43/3 London Country 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 1904. (Printed, by order of the Council, 31at October, 1905.) including medical officer (Education) 1905 PRINTED BV SOUTHWOOD, SMITH & CO., LTD., PLOUGH COURT, FETTER LANE, E.G. 6108 London Country Council. Report of the Public Health Committee submitting the report of the Medical Officer of Health of the County of London for the year 1904. We submit the Medical Officer's annual report for 1904, and observe that the London death rate, although it has risen from 152 per 1,000 in 1903 to 16.1 per 1.000 in 1904, is still very much below the average of the last 10 years. Notwithstanding the increase of organised effort to reduce the mortality of infants, the death rate of children under 1 year of age has risen from 180 per 1,000 births in 1903 to 144 per 1,000 births in 1904. The marriage rate has further declined from 17.5 per 1,000 persons living in 1903 to 17.0 per 1,000 persons living in 1904. The decrease in the birth rate has also continued, and the rate for 1904 (27.9 for 1,000 persons living) is the lowest recorded rate since the institution of civil registration. 489 cases of smallpox were notified in London in 1904, and 25 deaths were registered as due to this disease, as compared with 416 cases and 13 deaths in 1903. With the object of facilitating the detection of cases of the disease, which has frequently been incorrectly diagnosed as chickenpox, the Council, on 29th March, 1904, again made an order rendering chickenpox a notifiable disease in London, and this order was subsequently renewed and remained in force until 7th November, 1904. Medical experts were also appointed by the Council for the assistance of medical practitioners in diagnosing doubtful cases of smallpox, and special precautions were again taken to prevent as far as possible the spread of the disease in common lodging houses and seamen's lodging houses, frequent visits being made and all suspected cases being examined by the experts. We regret to observe that the number of deaths from measles has increased from 2,046 in 1903 to 2,256 in 1904. In the early part of 1903 an order was made by the Council extending to measles the more important sections of the Public Health (London) Act, 1891, except that requiring notification, and the Medical Officer's report contains particulars of the action taken by sanitary authorities to give effect to the order. It is too soon yet to expect that the order has attained its object of educating the public as to the dangerous character of the disease, but it is satisfactory to note that progress is being made in that direction. The number of cases of scarlet fever has increased from 12,531 in 1903, to 13,439 in 1904 ; but the number of deaths is practically the same (365 in 1904, as against 361 in 1903). Diphtheria was reponsible for 723 deaths in 1904, as compared with 740 in 1903, the number of notified cases having also decreased from 7,738 to 7,219. This disease proves much more fatal to children of tender years than to older children and adults. The number of deaths from whooping cough in 1904 was 1,495, as against 1,627 in 1903. The decline in the mortality from this disease, which appears to have begun in the decennium 1871-80, and was conspicuous in the decennia 1881-1900 and 1891-1900, has been since maintained. A further substantial reduction has taken place in the number of cases of enteric fever, and the case-mortality has also declined as compared with that in 1903. The medical officer points out that some London districts suffer from this disease practically twice as much as others, and he thinks this is more especially due to the fact that the habits of the population in poor districts give more opportunity for the spread of the disease from one person to another. Shellfish, fried fish, and watercress in a number of cases came under suspicion as the infecting agent. It will be remembered that the result of a careful enquiry by Dr. Hamer into localised prevalences of enteric fever in 1903 pointed to infection by fried fish.* As regards shell-fish, the Council has urged the Local Government Board to give effect to the recommendations of the Royal Commission on Sewage Disposal (fourth report), t The condition of watercress beds from which London iB largely supplied has recently been the subject of a special investigation by the Council's medical officer and chemist, and iu certain instances many causes of pollution were found. The Local Government Board has been furnished with copies of the report containing the results of the inquiry, as well as with details of the localities referred to therein. (Appendix II.) The deaths attributed to influenza which in 1903 numbered 644 rose in 1904 to 709. Bronchitis and pneumonia were together the cause of 12,982 deaths as compared with 11,066 in 1903. 7,526 persons died of phthisis in London in 1904 as against 7,124 in 1903. This increase is, however, slight compared with the marked decline in the mortality from this disease shown when a number of years is reviewed. There was a slight decline in the number of deaths due to cancer, the death rate for 1904 per 1,000 persons living, being 0 92 as against 0.96 in 1903. The medical officer points out that the incidence of cancer mortality in no way corresponds with the incidence of phthisis mortality, which appears to be largely governed by the social condition of the population. The arrangements made by the Council for dealing with persons coming into contact with cases of plague have been maintained, but fortunately there were no cases or suspected cases brought to its knowledge in 1904. * Enteric fever.—Report by the Medical Officer of Health, presenting report by Dr. Hamer on prevalences of Enteric Fever in London at the close of 1903 (No. 719). † Royal Commission on Sewage Disposal (Fourth Report) (Cd. 1883-1904). A 2 6108 iv. The Council has exercised such limited powers as it possesses in respect of the milk supply of London, and has availed itself of the provisions of its General Powers Act of 1904, to seize and slaughter cows suspected of having tubercular disease of the udder. It has also taken such steps as have been possible to prevent the sale of milk from cows certified to be suffering from that disease. It has, however, again failed to obtain from Parliament the legislation which it considers necessary with the object of preventing the sale in London of infected or filthy milk. The administration of by-laws respecting houses let in lodgings has been to some degree in abeyance owing to the decisions of the Courts that the by-laws were invalid, unless they provided for notice to be given to the landlord of a house before proceedings were taken. The result has been that in a large number of districts the by-laws have been under revision. We regard the efficient enforcement of these by-laws as of great importance to the public health, and have urged the sanitary authorities which have not already done so, to make the necessary amendments, so that the by-laws may again be put into effective operation as soon as possible. An important decision was given by the magistrate at the Woolwich Police Court on 16th December, 1904, to the effect that the supply of water from a tap in the yard waB not a proper and sufficient supply of water to a tenement house, and that there should be a separate supply of water to each floor of the house in question. We hope that, aB a result of this decision, steps will be taken by the sanitary authorities to secure a proper supply to all such houses in their districts. The inquiry made by Dr. Young on behalf of the Council showed that the arrangements for the supply of the upper floors of many of such houses were very inadequate.* We are glad to observe that a number of the sanitary authorities have during the year displayed considerable activity in the enforcement of the law which prohibits the separate occupation of underground rooms. It is interesting to note that at the end of 1904. 34,488 workshops in London were under the supervision of the local authorities, and 18,922 conditions requiring remedy were dealt with in that year. 84,600 inspections were made of premises subject to the Factory and Workshop Act, many of these being dwelling houses at which outworkers were employed. The number of outworkers on the lists supplied to sanitary authorities was 34,579. There were in London at the close of 1904, 2,802 bakehouses, of which 1,416 were underground. Among the workplaces inspected were those in which food is prepared for sale, and hence the kitchens of hotels and restaurants and other similar places came under observation. The enforcement of the law respecting the sale of unsound food appears to be beset with considerable difficulties owing to trade practices such as the removal of glands, tonsils, etc., from carcases, and the need for more extensive employment of special inspectors of food is emphasised in the report submitted herewith. The special powers conferred upon sanitary authorities by the London County Council (General Powers) Act, 1902, in respect of premises on which ice cream is manufactured are being actively exercised with good results. Investigation has been made by Dr. Hamer as to the conditions under which the ice trade is conducted (Appendix I.), and the Local Government Board has been informed of the result, and asked to consider whether premises used for cold storage should not be registered, and whether local authorities should not be empowered to make regulations with a view to preventing the manufacture and sale of ice under conditions likely to give rise to contamination. The Council obtained in its General Powers Act of 1904 legislation enabling sanitary authorities to deal with filthy, dangerous or unwholesome articles, houses infested with vermin, urinals so placed or constructed as to be a nuisance or offensive to decency, and fixed ashpits. In connection with the licensing of common lodging houses, we have devoted much attention not only to the sanitary condition of the premises, but also to the arrangements for the safety of the lodgers in the event of fire. The recent fatal fire at a lodging house in Glasgow has emphasised the need for precautionary measures. We are glad to say that the improvements considered requisite by the Council have now been completed at nearly all the common lodging houses in London. The administration of the Public Health (London) Act, 1891, and other matters affecting the public health, were the subject of an important conference of London sanitary authorities, held at the instance of the Council, on 7th and 18th July, 1904. A number of resolutions were passed in the interests of a more uniform administration, and are shown in a separate publication.! A conference of local authorities of England and Wales was also convened by the Council on the question of the agency of vagrants in the spread of disease and the remedial measures advisable. The proceedings of this conference, which met on 19th November, 1904, have also been separately published, t The arrangements for minimising the dissemination of infectious disease in schools and for improving the physical condition of school children have an intimate relation to the general health administration. In Appendix III. will be found Dr. Kerr's report, which gives an account of the work done in this direction. G. J. Cooper, Chairman. County Hall, Spring-gardens, S.W., 15th December, 1905. * Houses adapted as Tanemeut'Houses. Report b v the Medical Officer submitting Dr. Young's report (No. 706). † Conference on the administration of the Public Health (London) Act, 1891. Notes of proceedings (No. 799). ‡ Conference on the spread of infectious disease by vagrauts. Notes of proceedings (No. 811). THIRTEENTH 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 7 Rate of mortality in the several metropolitan boroughs 8 London mortality in 1901 compared with the mortality in the decennium 1891-1900 9 Infant mortality 11 From certain diseases and groups of diseases 13 Principal epidemic diseases 15 Smallpox and vaccination 16 Measles 12 Scarlet fever 16 Scarlet fever and elementary schools 28 Age and sex distribution 28 Diphtheria 29 Diphtheria and elementary schools 32 Age and sex distribution 33 Whooping cough 33 Typhus 35 Enteric fever 35 Age and sex distribution 38 D.arrhoea 39 Puerperal fever 40 Influenza, bronchitis and pneumonia 41 Phthisis 42 London death rates compared with England and Wales 43 In relation to overcrowding 50 Cancer 47 In relation to overcrowding 50 Bubonic plague 50 Anthrax 50 Glanders 50 Infectious disease in relation to the age of attendance at school 50 Meteorology 52 Part II.— Dairies, cowsheds and milkshops 53 Offensive businesses 57 Nuisances 60 Smole nuisances 60 Removal of offensive matter 61 Pollution of rivers and canals 61 Housing of the Working Classes Act 61 Proceedings under Part I. of the Act 62 Schemes undertaken by district authorities under Part 11. the County Council contributing to the cost 62 Proceedings of the County Council under Part III. of the Act 62 Re-housing by the Council in connection with street improvements 63 Proceedings in respect of houses represented under Part IV. of the Act at unfit for human habitation 64 Death rates of persons resident in the County Council's dwellings 64 Houses let in lodgings 65 Common lodging houses 66 Seamen's lodging houses 68 Customs and Inland Revenue Acts, 1890, 1891 69 Underground rooms 70 Overcrowding 71 Factory and Workshop Act, 1901 71 Unsound food 74 Sale of ice cream 75 Ice and cold storage 77 Pollution of watercress beds 77 Disinfection 77 Shelters 77 Mortuaries 78 Cleansing of Persons Act 78 Legislation in 1904 79 Midwives Act 79 Conference on the administration of the Public Health (London) Act, 1891 80 London Equalisation of Rates Act, 1894 83 Inter-departmental Committee on Physical Deterioration 84 Appkndices— I.—Report by Dr. Hamer on the use of ice and on cold storage in London. II.—Report on watercress and watercress-beds in the neighbourhood of London. III.—Report of the Medical Officer (Education) for the year eaded 31st March, 1905. LIST OF DIAGRAMS. FACING PAGE Diagram I.—Marriages, 1851-1904 5 II.—Births, 1851-1904 5 ,, III.—Deaths (all causes), 1841-1904 7 ,, IV.—Smallpox (deaths), 1841-1904 16 ,, V.—Measles (deaths), 1841-1904 22 ,, VI.— Scarlet fever (deaths), 1859-1904 26 ,, VII.—Scarlet fever (admissions to hospitals of Metropolitan Asylums Board, per cent, of the total cases in London), 1890-1904 26 ,, VIII.—Scarlet fever (monthly notifications and case mortality), 1891-1904 27 ,, IX.—Diphtheria and croup, 1859-1904 29 ,, X.—Diphtheria (admissions to hospitals of Metropolitan Asylums Board, per cent, of the total cases in London), 1890-1904 29 „ XI.—Diphtheria (monthly cases and case mortality), 1891-1904 30 ,, XII.—Whooping cough (deaths), 1841-1904 33 ,, XIII.—Typhus (deaths), 1869-1904 35 „ XIV.—Enteric fever, 1869-1904 36 ,, XV.—Enteric fever (weekly notifications, 1904, and mean weekly notifications, 1890-1904) 36 ,, XVI.—Enteric fever (monthly notifications and case mortality), 1891-1904 37 ,, XVII.—Diarrhoea, dysentery and cholera (deaths), 1841-1904 38 ,, XVIII—Phthisis (mortality, males and females), 1851-1904 45 ,, XIX.—Phthisis (seasonal mortality), 1895-1904 45 ,, XX.—Scarlet fever and diphtheria (notified cases), 1895-1904 50 Diagram I. -Marriages. - REPORT OF THE MEDICAL OFFICER OF HEALTH. 1904: PART I. The temperature of the year 1904 was slightly below the average in the first quarter, and slightly above the average in the remaining three quarters of the year. In the first quarter the rainfall was above and in the remaining three quarters below the average. The marriage rate (17.0) was only 0.1 per 1,000 living above the lowest marriage rate on record in London, viz., the marriage-rates of the years 1887 and 1888. The birth rate (27.9) was the lowest on record, and the death rate (16.1) was the lowest recorded in any year except 1903. The number of deaths from diseases of the respiratory system were below the average of the preceding ten years, and deaths from diarrhceal diseases were above the average. Smallpox of a mild type, as judged by the casemortality, maintained some degree of prevalence, especially in the eastern, central, and southern districts, and both scarlet fever and diphtheria manifested the diminished prevalence and case-mortality which has been conspicuous during recent year3. Measles mortality was below the average of the period 1841—1904, but exceeded the mortality in the previous year. The mortality from whooping cough was lower than in 1895, the mortality of that year being at that time the lowest on record. There was a slight increase in the mortality from phthisis over that of the previous year, but this increase was trifling in extent. The deaths attributed to cancer showed no sign of diminution, being in excess of the figures for the preceding year. Population. The population of the Administrative County of London estimated to the middle of the year 1904 was 4,648,950. The population of the City of London and each of the metropolitan boroughs, as constituted by the London Government Act of 1899, estimated to the middle of 1904, is shown in the following table— Sanitary area. Estimated population, 1904. Sanitary area. Estimated population, 1904. Sanitary area. Estimated population, 1904. Paddington 146,975 Stoke Newington.. 52,445 Bermondsey 129,397 Kensington 179,236 Hackney 226,266 Lambeth 310,359 Hammersmith 117,412 Holborn 57,161 Battersea 175,465 Fulham 152,482 Finsbury 98,958 Wandsworth 257,448 Chelsea 74,329 City of London 23,482 Camberwell 268,384 City of Westminster 177,321 Shoreditch 117,033 Deptford 113,509 St. Marylebone 130,337 Bethnal Green 130,207 Greenwich 101,651 Hampstead 86,663 Stepney 303,791 Lewisham 140,401 St. Pancras 235,936 Poplar 169,905 Woolwich 123,416 Islington 341,044 South wark 207,937 Marriages. The number of marriages in the Administrative County of London in 1904 (52 weeks) was 39,586, giving an annual rate of persons married of 17'0 per 1,000 living. The marriage rate in successive periods has been as follows— 1851-60 20.6 1901 17.6 1861-70 20.3 1902 17.8 1871-80 19.1 1903 17.5 1881-90 17.6 1904 17.0 1891-1900 17.8 The accompanying diagram (I) shows the marriage rate in each year since 1850, in relation to the mean marriage rate of the period 1851-1904. In the year 1904 among the males 3.7 per cent, married were under 21 years of age, and among the females 139 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— 6108 B 6 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 1891-1900 4.7 16.5 5.4 17.5 1901 4.4 15.0 5.0 16.0 1902 4.0 1.41 4.7 15.4 1903 3.8 13.7 4.5 15.2 1904 3.7 13.9 Births. The number of births registered in the Administrative County of London in 1904 (52 weeks) was 129,335, giving a birth-rate of 27-9 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 1904 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 1901 29.0 1861-70 35.4 1902 28.5 1871-80 35.4 1903 28.5 1881-90 33.2 1904 27.9 1891-1900 30.3 The corresponding figures for England and Wales are as follows:— 1851-60 34.2 1901 28.5 1861-70 35.2 1902 28.6 1871-80 35.5 1903 28.4 1881-90 32.5 1904 28.0 1891-1900 29.9 The accompanying diagram (II) shows the London birth-rate in each year since 1850, in relation to the mean birth-rate of the period 1851-1904. The following table shows the birth-rate in the several sanitary areas per 1,000 persons living and per 100 married females aged 15-45 in the period 1901-3 and in the year 1904:— Sanitary area. Births, 1904. Birth-rate per 1,000 persons living. Births per 100 married females aged 15-45. 1901-3. 1904. 1901-3. 1904. Paddington 3,295 22.8 22.5 19.9 19.6 Kensington 3,450 19.9 19.3 19.4 18.7 Hammersmith 3,146 26.8 26.9 21.5 21.9 Fulham 4,905 32.9 32.3 23.7 24.5 Chelsea 1,547 21.7 20.9 20.0 191 Westminster, City of 2,898 17.5 16.4 16.3 14.7 St. Marylebone 3,948 30.1 30.4 26.9 26.4 Hampstead 1,431 17.8 16.6 17.4 16.5 St, Pancras 6,116 27.0 26.0 21.2 20.2 Islington 8,892 27.0 26.1 21.2 20.4 Stoke Newington 1,139 21.5 21.8 18.3 18.5 Hackney 6,159 28.3 27.3 234 22.7 Holborn 1,628 28.1 28.6 23.7 23.1 Finsbury 3,593 37.0 36.4 28.5 27.2 London, City of 346 13.5 14.8 15.1 14.9 Shoreditch 3,744 34.0 32.1 26.5 24.4 Bethnal Green 4,526 35.4 34.9 28.0 27.3 Stepney 11,204 37.6 37.0 29.7 29.1 Deaths (All Causes.) Diagram HI. 7 Sanitary area. Births, 1904. Birth.rate per 1,000 persons living. Births per 100 married femalos aged 15.45. 1901-3. 1904. 1901-3. 1904. Poplar 5,543 34.4 32.7 27.7 26.0 Southwark 6,557 32.9 31.6 24.6 23.4 Bermondsey 4,192 33.2 32.5 26.5 25.3 Lambeth 9,059 29.7 29.3 23.6 23.3 Battersea 4,849 28.9 27.7 21.7 20.9 Wandsworth 6,928 26.4 27.0 22.3 24.0 Camberwell 7,242 27.9 27.1 23.0 22.5 Deptford 3,255 30.3 28.8 23.4 22.3 Greenwich 2,629 28.1 25.9 24.1 22.7 Lewisham 3,579 25.9 25.6 21.9 22.6 Woolwich 3,535 30.4 28.7 23.1 22.2 London 129,335 28.6 27.9 23.4 22.8 Deaths. The number of deaths in the Administrative County of London (52 weeks) was 74,555, giving an annual death rate of 16.1 per 1,000 persons living. The London death-rate in successive periods has been as follows:— All causes—Death-rates per 1,000 living. 1841-50 24.8 1891-1900 19.11 1851-60 23.7 1901 17.11 1861-70 24.4 1902 17.21 1871-80 22.5 1903 15.21 1881-90 20.5 1904 16.11 The death-rate in each year since 1840 in relation to the mean death-rate of the period 1841-1904 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 1904. Towns. Estimated Population middle of 1904. Crude death-rate per 1,000 living. Death-rate per 1,000 living (corrected for age and sex distribution). 1894-1903. 1904. 1894-1903. 1904. London 4,648,950 18-32 16.62 19.2 17.4 Liverpool 723,430 23.3 22.6 24.9 24.2 Manchester 557,938 22.6 213 25.2 23.8 Birmingham 537,965 20.1 199 21.6 214 Leeds 450,142 191 18.0 20.8 19.6 Sheffield 432,940 19.7 16.8 21.2 18.1 Bristol 343,204 17.1 15.6 17.5 16.0 West Ham 288,424 17.9 16.5 19.1 17.6 Bradford 285,089 17.6 17.6 19.5 19.5 Hull 253,865 18.7 18.6 19.2 19.1 Nottingham 248,811 183 17.7 193 18.6 Salford 228,983 22.6 21.2 25.0 23.4 Newcastle 225,362 20.8 19.4 22.4 20.9 Leicester 224,186 16.8 14.5 17.9 15.5 London had therefore (comparing the corrected death-rates) in the decennium 1894-1903 a lower death-rate than any of these towns except Bristol, West Ham, Hull and Leicester, and in 1904 a lower death-rate than any except Bristol and Leicester. 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. 6018 B 2 8 The following table enables comparison to be made of the death-rates of London with the death-rates of several foreign cities1:— Towns. 1894-1903. 1904. Towns. 1894-1903. 1904. London 18.32 16.62 St. Petersburg 26.7 23.7 Paris 19.5 17.4 Berlin 17.9 16.9 Brussels 17.1 14.5 Vienna 20.8 18.3 Amsterdam 16.3 15.1 Rome 19.2 18.7 Copenhagen 17.6 15.8 New York 20.0 22.6 Stockholm 16.8 14.4 It will be seen that in the period 1894-1903 the London death-rate exceeded that of any of these towns except Paris, St. Petersburg, Vienna, Rome and New York, while in 1904 it was lower than that of any except Brussels, Amsterdam, Copenhagen and Stockholm. i The following table shows the crude death-rates, and the death-rates corrected for differences in the age and sex constitution of the population of the several sanitary districts during the year 1904; the mean death-rates for the period 1901-33 are also shown for the purposes of comparison. Crude and corrected death-rates* per 1,000 persons living, in the County of London, and the several sanitary districts. Area. Standard deathrate. Factor for correction for ago and sex distribution. Crude deate-rato. Corrected death-rate. Comparative mortality figure (London, 1,000), 1901-3. 1904. 1901-3. 1904. 1901-3. 1904. England and Wales 18.19 1.0000 — — — — — — London 17-31 1.0511 16.5 16.1 17.3 16.9 1,000 1,000 Paddington 17.04 1.0677 14.0 13.8 14.9 14.7 861 870 Kensington 16.88 1.0778 14..8 14.3 16.0 15.4 925 911 Hammersmith 17.47 1.0414 15.8 15.7 16.5 16.3 954 964 Fulham 17.39 1.0462 15.6 15.4 16.3 16.1 942 953 Chelsea 17.56 1.0361 16.6 16.5 17.2 17.1 994 1,012 Westminster, City of 16.22 1.1217 15.2 13.5 17.0 15.1 983 893 St. Marylebone 17.08 1.0652 17.1 16.2 18.2 17.3 1,052 1,024 Hampstead 16.13 1.1280 10.5 10.2 11.8 11.5 682 680 St. Pancras 17.40 1.0456 17.7 17.4 18.5 18.2 1,069 1,077 Islington 17.51 1.0391 15.6 15.4 16.2 16.0 936 947 Stoke Newington 17.43 1.0438 13.1 13.3 13.7 13.9 792 822 Hackney 17.46 1.0420 14.9 14.9 15.5 15.5 896 917 Holborn 16.90 1.0766 20.0 18.5 21.5 19.9 1,243 1,178 Finsbury 17.57 1.0355 21.5 21.3 22.3 22.1 1,289 1,308 City of London 16.55 1.0993 18.4 16.7 20.2 18.4 1,168 1,089 Shored itch 17.34 1.0493 20.7 20.4 21.7 21.4 1,254 1,266 Bethnal.green 18.01 1.0102 19.8 19.3 20.0 19.5 1,156 1,154 Stepney 17.41 1.0450 19.8 19.4 20.7 20.3 1,197 1,201 Poplar 17.64 1.0314 19.2 18.6 19.8 19.2 1,145 1,136 South wark 17.41 1.0450 20.3 20.1 21.2 21.0 1,225 1,243 Bermondsey 17.76 1.0244 20.0 20.0 20.5 20.5 1,185 1,213 Lambeth 17.63 1.0320 16.6 15.8 17.1 16.3 988 964 Battersea 16.96 1.0728 15.2 14.5 16.3 15.6 942 923 Wandsworth 17.25 1.0547 13.1 13.4 13.8 141 798 834 Camberwell 17.54 1.0373 15.5 14.9 16.1 15.5 931 917 Deptford 17.31 1.0511 16.0 16.1 16.8 16.9 971 1,000 Greenwich 17.82 1.0210 14.6 14.4 14.9 14.7 861 870 Lewisham 17.46 1.0420 12.6 12.0 13.1 12.5 757 740 Woolwich 17.02 1.0690 14.4 14.3 15.4 15.3 890 905 1 All death.rates in this report relating to foreign cities are calculated upon figures published by the Registrar-General. 2 See footnote (2) page 7. 3 Owing to the changes consequent upon the London Government Act, 1999, the death-rates in tho present metropolitan boroughs cannot be shown prior to the year 1901. 4 All death-rates in this report relating to metropolitan sanitary districts are fully corrected for institutions (see footnote (1), page 7). 9 The following table shows the number of deaths1 occurring at several ages in each of the sanitary areas of the Administrate County of London during the year 1904 (36l> days) — Age period. 0- 1- 2- 3- 4- Under 5. 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 and up. All ages. Paddington 447 87 37 24 15 610 36 15 32 42 117 150 220 264 233 235 70 2,024 Kensington 522 148 56 33 21 780 34 22 40 41 134 217 293 297 355 261 98 2,572 Hammersmith 480 139 50 23 21 713 34 13 25 36 104 135 171 204 195 177 41 1,848 Fulham 756 191 64 33 23 1,067 42 29 27 47 131 212 200 217 190 150 44 2,356 Chelsea 244 64 22 10 7 347 22 11 7 24 79 98 135 147 184 145 34 1,233 Westminster, Citv of 361 66 30 13 9 479 33 17 32 58 161 231 297 350 381 272 73 2,384 St. Marylebone 380 116 41 21 11 569 30 24 27 49 130 199 236 235 319 248 65 2,131 Hampstead 162 37 15 9 4 227 18 5 13 20 56 71 94 110 122 108 42 886 St. Panoras 927 288 99 55 32 1,401 85 47 72 83 263 351 421 494 500 326 92 4,135 Islington 1,145 361 132 65 49 1,752 113 55 75 121 296 441 532 610 664 504 110 5,273 Stoke Newington 133 29 11 12 3 188 12 9 9 20 48 61 70 88 114 68 19 706 Hackney 878 204 68 66 29 1,245 72 45 55 52 192 215 315 393 419 309 76 3,388 Holborn 179 68 19 12 6 284 10 7 14 32 65 122 129 155 113 92 17 1,040 Finsbury 515 158 63 31 17 784 36 20 36 30 124 207 215 238 261 146 29 2,126 London, City of. 38 10 3 3 2 56 6 4 5 11 23 30 56 56 74 54 17 392 Shoreditch 715 219 74 40 25 1,073 41 35 35 42 130 182 227 239 225 147 28 2,404 Bethnal-green 716 212 79 49 26 1,082 55 29 33 47 145 191 227 252 227 i7<; 50 2,514 Stepney 1,756 536 155 97 67 2,611 103 77 75 129 316 491 577 595 515 350 70 5,909 Poplar 854 287 109 59 42 1,351 80 47 63 69 153 248 281 352 304 177 36 3,161 Southwark 1,152 387 138 60 45 1,782 87 41 68 68 220 347 400 412 421 277 53 4,176 Bermondsey 725 236 82 58 21 1,122 43 40 43 38 116 191 260 265 298 160 21 2,597 Lambeth 1,253 319 124 51 45 1,792 97 46 70 114 250 442 494 505 550 426 140 4,926 Battersea 717 144 61 24 15 961 48 37 40 71 137 183 284 282 271 196 43 2,553 Wandsworth 854 200 71 50 41 1,216 66 44 58 68 162 263 293 390 424 354 125 3,463 Camberwell 1,048 281 104 47 37 1,517 67 53 73 85 209 296 359 431 471 348 106 4,015 Deptford 477 148 50 33 19 727 47 22 30 40 89 125 158 178 230 160 38 1,844 Greenwich 376 104 29 26 8 543 26 23 21 35 89 124 140 158 163 105 37 1,464 Lewisham 445 78 33 20 8 584 28 13 47 36 71 117 135 151 226 213 70 1,691 Woolwich 483 94 41 22 18 658 53 25 26 44 108 143 159 183 184 170 26 1,779 London 18,738 5,211 1,860 1,046 666 27,521 1,424 855 1,151 1,552 4,118 6,083 7,378 8,251 8,633 6,354 1,670 74,990 London mortality in 1904 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 decennium 1891-1900 and in the year 1904. The figures for the year 1904 are fully corrected for institution deaths (see footnote —, page —), and the rates for the decennium 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. Death-rate 1904. Difference per cent. Mean deathrate 1891-1900. Death-rate 1904. Difference per cent. 0— 71.97 58.65 —18.5 61.99 49.72 —19.8 5— 4.97 3.20 —35.6 5.17 3.08 —40.4 10— 2.46 1.89 —23.2 2.48 2.09 —15.7 15— 3.47 2.76 —20.5 2.94 2.35 —20.1 20— 4.59 3.71 —19.2 3.46 2.72 —21.4 25— 7.36 5.78 —21.5 5.65 4.27 —24-4 35— 14.22 11.66 —18.0 10.68 8.58 —19.7 45— 23.14 20.23 —12.6 17.12 14.89 —13.0 55— 40.68 36.21 —11.0 31.01 26.62 —14.2 65— 77.78 72.06 — 7.4 63.44 57.35 — 9.6 75— 154.13 148.14 — 3.9 134.56 123.33 — 8.3 85 and upwards 284.10 310.92 + 9.4 265.77 265.98 + 0.1 All ages 20.88 17.61 —15.7 17.88 14.81 —17.2 It will be seen from this table that the rate of mortality in 1904 was considerably lower than that of the period 1891-1900 at each age period of life and for each sex, except at the period 85 and upwards. In previous annual reports it has been shown that a more accurate estimate of the effect on the community of fluctuations of mortality could be obtained by the use of a "life table," the method adopted being similar to that employed by Dr. Tatham in a report on the health of greater Manchester for the period 1891-3, The advantages of this method and the formulae used are set out in some (') See footnote (') page 7. 10 detail in the London life table appended to the annual report for 1901. It will be seen from the description therein contained that in order to apply this method of comparison it is necessary in the first place to ascertain from the life table the mean future life time of males and females in groups of ages corresponding to those age-groups to which the deaths relate. The following table shows the results thus obtained from the London life table, 1891-1900— Table I. Mean future lifetime of males and females in groups of ages, calculated from the London life table, 1891-1900. Age-groups. Males. Females. Age-groups. Males. Females. Years. Years. Years. Years. 0— 50.16 53.66 35— 23.98 26.89 5— 49.89 53.48 45— 17.75 20.04 10— 45.61 49.30 55— 12.35 13.93 15— 41.26 44.94 65— 7.98 8.90 20— 37.05 40.62 75— 4.91 5.37 25— 31.05 34.39 85 and upwards 3.02 3.19 In the following table the number of deaths occurring in the year 1904 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 1904. The number of lives gained in the latter period is also shown, and the figures in the last column of the table express this gain in terms of "life capital," these being obtained by applying the mean future lifetime figures given in Table I. to the number of lives gained at each age-group. Table II. Age-groups. Deaths calculated according to mean death-rates of 1891-1900. Peaths occuring in the year 1904. Oain(-)-)or loss (—) of lives in the year 1904, by fluctuation of mortality. Gain (+) or loss (—) of 'lifecapital" in the year 1904 by fluctuations of mortality. Males. 0— 18,284 14,900 +3,384 + 169,741 5 1,122 722 + 400 + 19,956 10— 524 402 + 122 + 5,564 15— 743 590 + 153 + 6,313 20— 1,022 827 + 195 + 7,225 25— 2,801 2,201 + 600 + 18,630 35— 4,090 3,355 + 735 + 17,625 45— 4,630 4,047 + 583 + 10,348 55— 4,949 4,405 + 544 + 6,718 65— 4,384 4,062 + 322 + 2,570 75— 2,690 2,586 + 104 + 511 85 and upwards 507 555 — 48 — 145 All ages 45,746 38,652 + 7,094 + 265,056 Females. 0— 15,735 12,261 + 3,114 +167,097 5— 1,178 702 + 476 + 25,456 10— 538 453 + 85 + 4,190 15— 702 521 + 141 + 6,337 20— 924 725 + 199 + 8,083 25— 2,535 1,917 + 618 + 21,253 35— 3,397 2,728 + 669 + 17,989 45— 3,830 3,331 + 499 + 10,000 55— 4,480 3,846 + 634 + 8,832 65— 5,056 4,571 + 485 + 4,316 75— 4,111 3,768 + 343 + 1,842 85 and upwards 1,114 1,115 — 1 — 3 All ages 43,600 36,338 + 7,262 + 275,392 Total 89,346 74,990 + 14,356 + 540,448 It will be seen from the preceding table that during the year 1904, compared with the decennium 1891-1900, there has been a saving of 14,356 lives, representing a gain to the community of 540,448 years of life capital. 11 Infant Mortality. The deaths of children under one year of age in the Administrative County of London during 1904 (52 weeks) numbered 18,600, being in the proportion of 144 per 1,000 births. Ihe proportion in succssive periods has been as loliows:— Period. Deaths under one year of age per 1,000 births. Period. Deaths under one year of age per 1,000 births. 1841-50 157 1891-1900 1581 1851-60 155 1901 1481 1861-70 162 1902 1391 1871-80 158 1903 1301 1881-90 152 1904 1441 The following table enables comparison to be made of the infant mortality in London and other large English towns. Deaths under one year of age per 1,000 births. Towns. 1894-1903 1904 Towns. 1894-1903  London 1542 1462 Bradford 163 166 Liverpool 184 196 West Ham 167 162 Manchester 185 187 Hull 172 178 Birmingham 184 197 Nottingham 184 176 Leeds 174 175 Salford 198 192 Sheffield 185 158 Newcastle 172 156 Bristol 142 134 Leicester 181 167 London had therefore both in the period 1894-1903 and in 1904 a lower infant mortality than any of these towns except Bristol. The following table shows the deaths under one year ot age and the number or these deaths per 1,000 births in each of the sanitary areas of the County of London for the period 1901-3, and for the year 1901— Sanitary aroa. Deaths under one year of age, 1904. Deaths under ono year of age per 1,000 births. 1901-3. 1904. Paddington 447 129 136 Kensington 519 152 150 Hammersmith 478 151 152 Fulham 752 142 153 Chelsea 242 142 156 Westminster, City of 361 131 125 St. Marylebone 373 103 94 Hampstead 161 93 113 St. Pancras 920 145 150 Islington 1,143 133 129 Stoke Newington 130 116 114 Hackney 876 124 142 Holborn 178 116 109 Finsbury 504 144 140 London, City of 36 146 104 Shoreditch 702 181 188 Bethnal-green 711 150 157 Stepney 1,741 149 155 Poplar 851 158 154 Southwark 1,143 161 174 Bermondsev 720 161 172 Lambeth 1,246 130 138 Battersea 713 141 147 Wandsworth 847 123 122 Camberwell 1,045 134 144 Deptford 471 139 145 Greenwich 373 132 142 Lewisham 440 115 123 Woolwich 477 121 135 London 18,600 1391 1441 1 See footnote (1 page 7. 2 See footnote (2) page 7. 12 The report of the Inter-departmental Committee on Physical Deterioration contains a table prepared by Dr. Tatham, Superintendent of Statistics in the General Register Office, showing the deaths in each month of the first year of life of infants in London in the year 1902. These figures are the only ones available, but they may none the less be conveniently stated in life table form showing the probability of living for one month and the number of survivors at the beginning of each month of age out of 100,000 born. The results thus obtained may be seen from the following table:— London, 1902. Infant Mortality. Life table for the, first 12 months of life (based on the mortality during the year 1902.) Age-period. X Registered deaths. Probability of living for ouo month. Px/1 Number living at the beginning of each month of age. lx_ 0—1 month 5,438 .95817 100,000 1—2 „ 1,979 .98412 95,817 2—3 „ 1,510 .98770 94,295 3—4 „ 1,379 .98864 93,135 4—5 „ 1,138 .99053 92,077 5—6 „ 1,028 .99136 91,205 6—7 „ 1,062 .99099 90,417 7—8 „ 1,011 .99138 89,602 8—9 „ 1,018 .99127 88,830 9—10 „ 918 .99206 88,055 10—11 „ 917 .99200 87,356 11—12 „ 909 .99201 86,657 0—1 year 18,307 — 85,965 The Annual Summary of the Registrar-General for the year 1904 shows that the deaths in 1904 of London children under one year of age were attributed to the following causes— Deaths1 under one year of age registered in London during the 52 weeks of 1904. Small-pox 4 Premature Birth 2,639 Cow-pox 2 Meningitis (not tubercular) 316 Measles (Morbilli) 553 Epilepsy 4 Scarlet Fever 17 Convulsions 1,120 Influenza 37 Paraplegia, Disease of cord 6 Whooping-cough 637 Nervous System (other diseases) 52 Diphtheria 62 Heart and blood-vessel diseases 17 Cerebro-spinal Fever 3 Croup (not spasmodic nor membranous) 6 Enteric Fever 2 Bronchitis 1,277 Epidemic Diarrhoea (infective Enteritis) 2,347 Pleurisy 3 Diarrhoea, Dysentery 1,374 Respiratory Diseases (other) 121 Tetanus 20 Tonsillitis, Quinsy 3 Venereal Disease 279 Enteritis (not epidemic) 362 Pneumonia 1,719 Gastro-Enteritis 344 Erysipelas 59 Peritonitis 11 Septicaemia 14 Cirrhosis of liver 2 Pyaemia 11 Liver Diseases (other) 2 Other infective conditions 87 Digestive Diseases (other) 355 Tuberculous Phthisis 71 Nephritis, acute 5 " Phthisis" 15 Bright's Disease, Albuminuria 3 Tuberculous Meningitis 270 Urinary System (other diseases) 5 Tuberculous Peritonitis 160 Generative organs (diseases of) 7 Tabes Mesenterica 142 Other Diseases 3,422 Tuberculous Diseases (other) 225 Suffocation in bed 533 Scrofula 5 Accident (other) 141 Rheumatic Fever 2 Homicide 26 Sarcoma 4 ' See footnote (2) page 7. 13 The annual reports show generally, increase of organised effort to reduce the mortality of infants. This includes the tendering of advice to mothers as to the feeding and care of their infants, the visitation of their homes by women inspectors who for this purpose must have training and knowledge different from, or beyond that, which is required for the purposes of sanitary inspectors, and the establishment in two districts of a depot for the supply of milk. In Battersea, milk is taken with due precautions from cows on farms which are open to the inspection of the medical officer of health, is modified at the depot of the borough council and supplied in bottles at prices which do not entirely cover the total cost incurred. Commenting on the incidence of infantile mortality in the four sub-districts of the borough, Dr. McCleary states: "There has been a great and progressive reduction in infantile mortality in North-west Battersea since 1901. The Council's Infants' Milk Depot is situated in that sub-district, and most of the babies fed on the milk live there. This has been probably an important factor in the reduction." In Finsbury a milk depot has been established by a voluntary society under the control of a small medical committee, of which Dr. Newman, the medical officer of health, is a member. The milk is received from a farm at Theydon Bois, Essex. The cows are milked with precautions to ensure cleanliness, and the milk is modified, sterilized and bottled on the farm. To begin with, it is not intended to supply more than fifty infants with this milk. Enquiry by Dr. Newman as to the method of feeding of a number of cliildren of the poorer classes of Finsbury enabled him to compare the mortality among children differently fed at four age-periods, viz., 0-3 months, 3.6 months, 6-9 months, and 9-12 months, and showed that the deaths from diarrhoea in artificially-fed children under three months of age "were nearly four times the number that ought to have occurred on the supposition of an average distribution of deaths from diarrhoea among infants fed in different ways. The same excessive mortality in the hand-fed continues up to the ninth month of life. In the last three months of the first year of life the diarrhoea mortality approximates to the average." This diminution in the deathsjfrom diarrhoea among children artificially fed after the ninth month of life appears, Dr. Newman states, to be due to the fact that many of these children had in the antecedent period been breast-fed and had thus acquired powers of resistance. The mortality of breast fed children after the ninth month is, however, comparatively high for the reason that "many of them obtain insufficient nourishment from the milk of mothers who are not equal to the strain of nine months' lactation." Referring to the mortality from diarrhoea among children fed on condensed milk, he found that in the first six months of life this is nearly three times the average mortality, while the mortality amongst those fed on cows' milk is less than twice the average. "Between the sixth and ninth months condensed milk still gives a high mortality but the discrepancy is less marked. The difference in the two mortalities admits of both the following explanations; one that fermentative changes in the condensed milk are more deadly than similar changes in cow's milk, and the other that children fed on condensed milk are virtually starved and are ready victims of diarrhoea.". Again: "Further evidence of the unfavourable influence of condensed milk is shown by the deaths from 'other causes.' Between the third and ninth months the deaths from 'other causes' among those fed on condensed milk is twice the average number, whilst the deaths among those fed on cow's milk are, in the first age period, equal to the average, in the second period only slightly above, and in the third age period actually below. The enfeebled constitution resulting from the use of condensed milk is the direct cause of this high mortality in the case of wasting diseases, and the indirect cause of the fatal termination of other ailments less intimately connected with feeding." He concludes : " It would thus appear that condensed milk is the worst food for infants, that cow's milk greatly increases their liability to death, and that all artificial feeding is attended by a high rate of mortality." In a paper read before the Derby Medical Society, Dr. Howarth, the medical officer of health of Derby, gives an account of the method of feeding and the mortality during the first year of life among over 8,000 children born during three years in that town, with the result that the mortality among the breast-fed children was 69.8 per 1,000, among the hand-fed 1975 per 1,000, and among children reared partly naturally and partly by hand 98.7 per 1,000. Of the hand-fed children, those fed on milk and water only, had a mortality of 177 per 1,000, those fed on condensed milk only, had a mortality of 255 per 1,000, and those fed on patent foods a mortality of 202 per 1,000. The increased incidence of mortality among the hand-fed infants as compared with breast-fed was manifested under various causes of mortality, including bronchitis, pneumonia, and convulsions, as well as gastric and intestinal maladies. Comparing the mortality of infants born in the different quarters of the year, he found that hand-fed children born in the second quarter show the highest mortality, that there is a progressive decrease amongst those born in the third, fourth and first quarters, and that "the high mortality among hand-fed children born in the second quarter is due to zymotic enteritis and diarrhoea," the result probably of less care being taken in preparing the food after the first month, and "as the resisting power of a child to attacks of zymotic enteritis is an increasing one, children of the age of two or three months at the time of greatest prevalence of this disease will show greater mortality than those who are older." How far it will be possible to increase the practice of the breast feeding of infants, or when this cannot be done, to ensure the provision of the best substitute for the mother's milk is the problem which has to be considered in the first instance, but obviously efforts in this direction give the largest promise of success. Deaths at " all Ages " 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 1904 under certain of the more important heading, in the list of causes of death, as compared with the corrected annual average of the preceding 10 years— C 6108] 14 Cause of death. Diminution in 1904. Excess in 1904. Smallpox 154 — Measles 330 — Scarlet fever 293 — Typhus 3 — Influenza 480 — Whooping cough 488 — Diphtheria 1,183 — Pyrexia (origin uncertain) 2 — Enteric fever 332 — Diarrhoea — 1,194 Pneumonia — 415 Phtliisis and other tuberculous diseases (including scrofula) .. 907 — Cancer — 408 Premature birth 23 — Diseases of nervous system ) 1,537 — Diseases of circulatory system Diseases of respiratory system 2,449 — Diseases of urinary system - 139 Childbirth and puerperal septic diseases 78 — « Accident 582 —1 Homicide 11 — Suicide — 22 All other causes 1,230 — Net diminution or excess 7,904 — _ | Comparison can be made of certain causes of death in sanitary areas by reference to the following table. The death-rates shown in the table are fully corrected for deaths in institutions (see footnote (1), page 7). In the case of phthisis and of "cancer" (inclusive of carcinoma, sarcoma, and cancer) "factors for correction for differences in age and sex constitution,' have been calculated, and these factors and the corrected death-rates are shown on pages 42 and 47. Death-rates "per 100,000 living from all causes, and from various causes, in each of the various sanitary areas, 1904 (366 days). Sanitary area. Measles Rheumatic fever. Cancer. Tabes mesenteric Tubercular meningitis. Phthisis. Other tuberCBlar and scrofulous diseases. Pneumonia. Other respiratory disease All other causes. All cause Paddington 29 4 109 4 18 122 12 88 152 839 1,377 Kensington 39 7 102 20 17 140 16 123 158 814 1,435 Hammersmith 92 2 101 9 20 136 13 146 129 927 1,574 Fulham 44 7 85 13 27 142 14 132 119 962 1,545 Chelsea 35 5 122 12 16 176 22 161 218 892 1,659 W estminster, City of 11 10 102 5 18 149 19 112 138 780 1,344 St. Marylebone 39 5 110 8 13 166 17 137 188 953 1,635 Hampstead 21 8 98 12 18 84 9 96 81 595 1,022 St. Pancras 54 8 97 17 19 189 20 164 153 1,031 1,753 Islington 53 7 96 11 22 156 16 132 152 902 1,546 Stoke Newington 13 6 103 10 19 170 23 97 95 810 1,346 Hackney 34 5 84 20 20 140 26 126 133 909 1,497 Holborn 77 9 94 10 18 276 19 163 217 936 1,819 Finsbury 60 8 83 17 31 247 27 204 285 1,186 2,148 London, City of — 9 141 13 17 153 17 145 217 958 1,669 Shoreditch 70 8 78 23 37 221 37 155 203 1,223 2,054 Bethnal-green 68 5 87 21 30 217 24 184 217 1,078 1,931 Stepney Poplar Southwark 57 9 76 11 36 213 20 200 199 1,124 1,945 54 6 71 14 19 174 22 155 211 1,135 1,860 92 10 85 17 32 241 22 227 302 1,080 2,008 Bermondsey 104 9 73 22 22 214 32 223 189 1,120 2,007 Lambeth 54 9 103 16 22 144 20 130 145 944 1,587 Battersea 33 12 95 11 13 142 17 109 142 882 1,455 Wandsworth 42 5 99 10 16 111 12 111 102 837 1,345 Camberwell 41 9 88 12 22 134 20 114 166 890 1,496 Deptford Greenwich 68 7 94 8 23 145 21 129 164 966 1,625 39 7 86 11 10 135 22 114 112 905 1,440 Lewisham 18 6 85 7 15 90 15 96 105 767 1,204 Woolwich 24 9 83 11 15 168 20 110 109 894 1,442 London 49 7 92 13 22 163 19 142 159 947 1,613 1 For purposes of comparison deaths from infective endocarditis are included under this heading. 15 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, fever (including typhus, enteric fever, and pyrexia1), and diarrhoea during 1904 (52 weeks) was 9,90G, giving an annual death rate of 2" 14 per 1,000 living. The death rates in successive periods have been as follows:— Period. Death rate from principal epidemic diseases. Period. Death rate from principal epidemic diseases. 1841-50 5.20 1891-1900 2.682 1851-60 5.13 1901 2.222 18G1-70 5.23 1902 2.212 1871-80 3.86 1903 1.752 1881-90 3.05 1904 2.142 It will be seen from the following table that London in the decennium 1894-1903 had a lower death rate from these diseases than any of the undermentioned English towns, except Bristol, Bradford Nottingham and Newcastle, and in 1904 had a lower death-rate than any except Bristol, Newcastle and Leicester:— Principal epidemic diseases—Death-rates per 1,000 living. Towns. 1894-1903. 1904. Towns. 1894-1903. 1904. London 2.513 2183 Bradford 1.93 2.42 Liverpool 3.28 4.66 West Ham 3.45 3.43 Manchester 3.20 3.09 Hull 2.93 3.52 Birmingham 2.93 3.42 Nottingham 2.45 2.58 Leeds 2.60 2.56 Salford 4.03 4.37 Sheffield 3.30 2.20 Newcastle 216 1.79 Bristol 1.93 1.64 Leicester 2.77 1.97 The. following table shows that the London death rate from the first six of these principal epidemic diseases, viz., smallpox, measles, scarlet fever, diphtheria, whooping cough, and fever (including typhus, enteric fever and pyrexia), was in the period 1894-1903 exceeded only by that of St. Petersburg, and in 1904 was higher than that of any except Amsterdam, St. Petersburg and New York. Sic principal epidemic diseases—Death rales per 1,000 living. Towns. 1894-1903. 1904. Towns. 1894-1903. 1904. London 1.733 1.143 St. Petersburg 3.22 2.33 Paris 0.88 0.69 Berlin 1.10 0.89 Brussels 0.73 0.40 Vienna 1.17 0.90 Amsterdam 0.77 1.40 Rome 1.04 1.03 Copenhagen 1.02 0.83 New York 1.43 1.39 Stockholm 1.03 0.54 The following table shows the deaths from the principal epidemic diseases and the death-rates per 1,000 living in each of the sanitary areas of the County in 1904, and the period 1901-3 :— Sanitary area. Deaths in 1904. Deatli-rate per 1,000 persons living. 1901-3. 1904. Paddington 229 1.60 1.56 Kensington 256 1.62 1.45 Hammersmith 296 2.11 2.53 Fulham 379 272 2.49 Chelsea 110 1.49 1.49 Westminster, City of 153 1.20 0.87 St. Marylebone 197 1.75 1.51 Hampstead 57 0.80 0.66 St. Pancras 474 2.26 2.01 Islington 596 1.72 1.75 Stoke Newington 59 1.29 1.13 Hackney 481 1.96 2.13 Holborn 102 2.06 1.80 1 Origin uncertain. Originally described as simpls continued fever. 2 See footnote (') page 7. 3 See footnote (2) page 7. 6108] v r o o 2 16 Sanitary area. Deaths in 1909. Death-rate per 1,000 persons living. 1901-3, 1904. Finsburyy 254 2.76 2.57 London, City of 14 1.10 0.60 Shoreditch 374 3.14 3.20 Bethnal-green 383 2.57 2.95 Stepney 859 2.74 2.84 Poplar gt 568 2.93 3.37 Southwark 649 2.69 3.13 Bermondsey 456 2.66 3.52 Lambeth 650 1.90 2.10 Battersea 353 2.24 2.02 Wandsworth 448 1.61 1.73 Camberwell 509 2.01 1.90 Deptford 278 2.36 2.46 Greenwich 229 1.84 2.26 Lewisham 198 1.46 1.41 Woolwich 295 1.52 2.40 London 9,906 2.061 2.141 It will be seen from the foregoing table that the death-rate from the principal epidemic diseases was in the period 1901-3, highest in Shoreditch (3.14) and lowest in Hampstead (080), and in the year 1904, was highest in Bermondsey (3.52) and lowest in the City of London) 0'60). The death rates from these diseases during each of the four quarters of the year were as follows, first quarter 1*61, second quarter, 1*71, third quarter, 4"20, and fourth quarter 1'04 per 1,000 persons living. Smallpox and Vaccination. The deaths from smallpox in the Administrative County of London numbered 25 in 1904 (52 weeks) and two deaths were attributed to cownox and effects of vaccination. The death rates from smallpox in successive periods have been as follows:— Period. Smallpox death-rate per 1,000 living. Period. Smallpox death-rati per 1,000 living. 1841-50 0.402 1891-1900 0.0101 1851-60 0.280 1901 0.0511 1861-70 0.276 1902 0.2821 1871-80 0.457 1903 0.0031 1881-90 0.145 1904 0.0051 The smallpox death.rate in each year since 1840 in relation to the mean smallpox death.rate of the period 1841.1904 is shown in diagram 1Y. 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. Uase.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 1904 489 0.105 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 decennium 1894-1903 the London death-rate exceeded that of any except Birmingham, West Ham and Hull, while in the year 1904 it was exceeded by the deathrates of Manchester, Hull, Nottingham, Newcastle and Leicester. See footnote (') page 7, Diag ram IV. Smallpox. 17 Smallpox death-rates per 1,000 living. Towns. 1894-1903. 1904. Towns. 1894-1903. 1904. London 0.041 0.01 Bradford 0.02 0.01 Liverpool 0.03 0.00 West Ham 0.08 0.00 Manchester 0.01 0.02 Hull 0.07 0.02 Birmingham 0.04 — Nottingham 0.00 0.05 Leeds 0.01 0.00 Salford 0.00 0.01 Sheffield 0.00 0.00 Newcastle 0.01 0.08 Bristol 0.01 0.00 Leicester 0.01 0.02 In this table 0.00 indicates that the deaths were too few to give a rate of 0.00; where no death occurred is inserted. The following table shows that the London smallpox death-rate was in the decennium 1894-1903 higher than that of any of the undermentioned foreign towns except Paris and St. Petersburg, and in the year 1904 was exceeded by the death-rates of Paris, Brussels and St. Petersburg. Smallpox death-rates per 1,000 living Towns. 1894-1903. 1904. Towns. 1894-1903. 1904. London 0.041 oor St. Petersburg 0'10 006 Paris 0.04 0'03 Berlin 0.00 — Brussels 0.03 0-02 Vienna 0.00 0.00 Amsterdam 0.00 0-01 Rome 0.00 0.00 Copenhagen 0.00 — New York 0.03 0.00 Stockholm 0.00 — In this table 0.00 indicates that the deaths were too few to give a rate of 0.00; where no death occurred is inserted. The following table shows the smallpox cases, deaths, case-rates, and death-rates in the year 1904, the case-rates in the decennium 1894-1903, and the death-rates in the period 1901-3 in the several sanitary areas of the Administrative County— Sanitary area. Cases, 1904. Case-rate per 1,000 persons living. Deaths, 1904. Death-rate per 1,000 persons living. 1894-1903. 1904. 1901-1903. 1904. Paddington 4 0.1 0.0 2 0.05 0.01 Kensington 3 0.1 0.0 1 0.02 0.01 Hammersmith — 0.2 — — 0.08 — Fulham — 01 — — 0.04 — Chelsea — 0.1 — — 0.03 — Westminster, City of 6 0.2 0.0 — 0.11 — St. Marylebone 8 0.5 0.1 — 0.08 — Hampstead 1 0.1 0.0 — 0.02 — St. Pancras 7 0.3 0.0 — 0.17 — Islington 18 0.2 0.1 1 0.06 0.00 Stoke Newington 8 0.2 0.2 — 0.07 — Hackney 13 0.3 0.1 — 0.11 — Holborn 6 0.8 0.1 2 0.43 0.04 Finsbury 15 0.4 0.2 3 0.14 0.03 London, City of 2 0.2 0.1 — 0.12 — Shoreditch 14 0.4 0.1 2 0.22 0.02 Bethnal-green 126 0.7 1.0 7 0.17 0.05 Stepney 89 0.7 0.3 3 0.31 0.01 Poplar 42 0.5 0.2 3 0.20 0.02 Southwark 28 0.4 0.1 1 0.15 0.00 Bermondsey 19 0.3 0.1 — 0.11 — Lambeth 27 0.2 0.1 — 0.07 — Battersea 7 0.2 0.0 — 0.05 — Wandsworth 6 0.1 0.0 — 0.04 — Camberwell 19 0.2 0.1 — 0.09 — Deptford , 11 0.2 0.1 — 0.10 — Greenwich 1 0.2 0.0 — 0.08 — Lewisham — 0.1 — — 0.03 — Woolwich 8 0.3 0.1 — 0.11 — Port of London 1 — — — — — London 489 0.3 0.1 25 0.113 0.012 In this table 0.0 indicates that the cases were too few to give a rate of 0.05; whore no cases occurred is inserted. 1 See footnote (2), page 7. 8 See footnote (1), page 7. 18 The following table shows the number of cases of smallpox notified in London in each week of the year 1904— Smallpox—Notified cases, 1904. Week ended. No. of cases notified. Week ended. No. of cases notified. Week ended. No. of cases notified. January 9 6 May 14 23 September 10 3 tt 16 3 tt 21 16 it 17 1 tt 23 5 tt 28 34 tt 24 — tt 30 3 June 4 9 October 1 Februan 6 7 tt 11 20 it 8 1 tt 13 1 ti 18 8 it 15 — ft 20 8 it 25 14 ti 22 ti 27 3 July 2 9 a 29 — March 5 7 it 9 9 November 5 — it 12 24 tt 16 9 t> 12 — It 19 22 tt 23 6 f 19 1 tt 26 53 it 30 8 it 26 3 April 2 37 Aug. 6 1 December 3 2 tt 9 25 )) 13 — tt 10 1 tt 16 37 it 20 1 ti 17 3 tt 23 26 a 27 1 ti 24 8 a 30 12 Sept. 3 1 it 31 4 May 7 14 Cases of smallpox had occurred in London in every week of the year 1903, 22 cases being notified in the five weeks ending the 2nd January. During the four weeks ending the 30th January, 1904, fourteen cases occurred. Three of these cases were persons residing in Westminster and were the last of a series of cases which had begun in the preceding year, due originally to infection from a bargeman who had been at a wharf adjoining Millbank. One case occurred in each of the following districts, Islington, Hackney, Bethnal Green and Stepney, and two in Lambeth and four in Southwark. The Lambeth cases were members of the family of a woman who had been attacked in the preceding month of December, and three of the Southwark cases were also known to have been in contact with cases of smallpox during that month. In February, seventeen cases occurred in nine districts, one of which deserves especial reference. This was the case of a cattleman F, who had arrived on the lGth February in Victoria Docks on board the ss. Austriana from Newport News, Virginia, U.S.A. Two days after his arrival he was found to be suffering from smallpox and removed to hospital. In the meantime, he had been staying at 144, High-street, Poplar, with two of his fellow cattlemen, of whom there had been eleven on board the vessel. These were searched for in all the seamen's and common lodging houses by the Council's inspectors, and all but one, who had returned to America, were found and vaccinated. Five days after the removal of F., one of his companions, C.P., a cattleman who had been staying at a common lodging house in Leman-street, Whitechapel, was found to be suffering from smallpox and removed to hospital. Between the 16th and 18th February, F. had visited the dispensary at the Victoria Seamen's Rest and on the 4th of March, a lodger and three servants of that institution were removed to hospital with smallpox. Another companion of F-, a man named K., had stayed one night at a common lodging-house in Thrawlstreet, Whitechapel, and a case of smallpox was subsequently removed from this house on the 6th March. This man had been an out-patient at the London Hospital. On the 8th March, a man living in Lower North-street, Poplar, was removed to hospital with smallpox. He had been in the habit of attending meetings at the Victoria Seamen's Rest. The same day four cases were removed from the common lodging house in Thrawl-street, having evidently been infected by C.P. and these were followed by two more on the 9th and 10th March. One of the latter had been drinking in a public house in Leman-street. In view of the probable extension of the disease in common lodging houses arrangements were made by which "contacts" should sleep in separate rooms and destitute "contacts" should be provided with board and lodging at the Council's expense so as to ensure that they should remain under observation, and Mr. Bingham, formerly medical superintendent of the Smallpox Hospital at Hampstead, was engaged by the Council to visit infected common and seamen's lodging houses in the early morning with the Council's officers, before the lodgers had left the houses. As a result several cases of smallpox were detected in an early stage of the disease, and the sufferers were removed to hospital without loss of time. Two cases thus dealt with were removed from the Victoria Seamen's Rest on the 18th March. On the 22nd March two more cases were removed from the common lodging house in Leman-street and another man, who had been a lodger in a common lodging house in Brick-lane, was removed from the Whitechapel Infirmary. Two further cases were removed from this common lodging house on the 23rd March, and two more on the 24th and 25th respectively. On the 23rd March, a foreign seaman who had been previously staying in High-street, Shad well, was removed from the Victoria Seamen's Rest and the same day a case of smallpox was removed from the Victoria Home in Commercial-street. This case was shortly followed by three others from the same home. On the 25th March, a seaman who had been staying at Medland Hall was removed and on the 27th March a man who had been staying at the common lodging house in Thrawl-street, already mentioned. This 19 man had been drinking in the "Frying Pan" public house at a time when he must have been infectious. The same day several other cases were removed, one from Victoria Home, Commercial-street, three who had been staying in the lodging house in Brick-lane, one of whom was a newsvendor at Liverpoolstreet Station, and another, a vanboy. Three other seamen's or common lodging houses also became invaded during the month of March, one in Tooley-street, one in Dock-street and one in Wentworthstreet, Whitecliapel. Smallpox had therefore made considerable progress in the common lodging house and seamen's lodging house population of Poplar and Stepney during March. During the same month smallpox spread rapidly in Bethnal Green, due in the main to infection from a man named H., employed as a bricklayer, who died in some model dwellings on the 23rd February in Corfieldstreet, of an illness which there is no reason for doubting was hemorrhagic smallpox, although the nature of his malady was not recognised during his lifetime. On the 4th March, Dr. Bate, the medical officer of Bethnal Green, found this man's wife, a baby and two sons, suffering from smallpox. Dr. Bate reports that the coffin of this man was opened at the time of the funeral and his mother and several other members of the family who came from Braintrec to attend the funeral subsequently developed smallpox, together with three other persons, two of whom were daughters of a woman who had assisted in nursing the first case H. Dr. Bate then investigated the illness of three families residing in the same block of buildings and who had been suffering from a pustular rash which had been thought to be that of chickenpox. Of these cases, Dr. Bate states, that he feels certain that the children had suffered from mild smallpox. Other cases occurred in the buildings and remote from them, including an employe of the undertaker who buried H. Moreover, during March cases of smallpox occurred among the inpatients of the London Hospital, due to infection from a patient suffering from smallpox, but whose malady had been thought to be chicken-pox. To what extent this man's illness was responsible for subsequent cases cannot be stated, but after his discharge from hospital a sanitary inspector of Bethnal Green found him wheeling a barrow while he was still in an infectious state. His children were then found to be suffering from smallpox, which had been thought to be chickenpox and his landlady was also subsequently attacked and removed to the Smallpox Hospital, as well as his brother, a resident of Stepney, who visited him in the London Hospital. Thus Bethnal Green, Stepney and Poplar were most severely attacked in March, the number of cases of smallpox removed to hospital during that month being respectively 40, 35 and 22 in those districts out of 131 in the total area of London. At this period one of the outbreak, with a view to the better control of smallpox, the Borough Council of Bethnal Green made an order requiring the notification of chickenpox in the borough; this order came into operation on the 26th March. The County Council made a like order requiring the notification of chickenpox throughout London, which come into operation on the 8th April Chickenpox was thus required to be notified in London until the 7th November. Moreover the County Council appointed as from the 1st April, Drs. Bingham and Wanklyn to visit at the request of any medical practitioner, any doubtful case of smallpox and continued their services for this purpose the former until the 7th August and the latter until the 7th November. In April, the number of cases of smallpox showed some diminution, 91 persons suffering from tliis disease being admitted into the smallpox hospital. These cases were widely distributed over London, but the main incidence was on the Eastern districts. Of these cases, ten were inmates of common lodging houses who were removed, two from Thrawl-street, one from Brick-lane, two from Tooleystreet, one from Essex-road, Islington, one from West India Dock-road, Stepney, one from Eagle Wharf road, Shoreditch, and two from Kingsland-road, Shoreditch. Two cases were also removed from the Sailors' Home in Dock-street. In May there was still further decline, 83 persons being removed from London to the smallpox hospital, 36 of whom were residents in Bethnal Green. The greatest number of cases removed from any other district was eight from the Borough of Southwark. The spread of smallpox among the inmates of common lodging houses and seamen's lodging houses was by this time nearly at an end, but three cases were removed from the common lodging house in Tooley-street, Bermondsey, and one from the common lodging house in Kingsland-road, Shoreditch, both of which had been infected in the preceding month. From the common lodging house in Tooley-street six cases of smallpox in all were removed during the months of March, April and May. Dr. Brown, the medical officer of health of Bermondsey, states in his annual report in reference to this house that " The London County Council kept a very close watch on the Southwark-chambers which are capable of accommodating upwards of 500 lodgers. The average number of lodgers on the night previous to the notification of the various cases was 395 ; of these 349 were vaccinated and none of them showed any symptom of smallpox. The premises were visited every morning by the special inspector of the London County Council, and during the day by our inspector and all suspicious cases were immediately sent to bed and isolated till one of the London County Council smallpox experts pronounced an opinion on them." In subsequent months of the year the number of cases occurring was markedly less; the number of cases removed to hospital being in June, 45, July, 31, August, 1, September, 3, October, 0, November 1, and December, 15. Of those occurring in December, 9 were removed from Deptford and 5 from Woolwich.—Dr. Roberts, the medical officer of health of Deptford, states that in the latter part of November and in early December, four cases were removed from a house in New Cross-road, viz., one adult, vaccinated in infancy, and three unvaccinated children, and later in December, two adults and three unvaccinated children from a house in Tanners-hill, the latter household having received infection from the former. The Woolwich cases were a series beginning with the attack of a man the nature of whose illness was not discovered until he had infected three neighbours, the fifth case being a sister of one of the latter who had visited the sick room after removal of the patient, but before the room was disinfected. 20 The measures adopted during the year included the speedy removal to hospital of ½ infected persons, inquiry into the circumstances of all cases of smallpox which had occurred especially with a view to the discovery of other cases at the time unknown, the keeping of "contacts" under observation and their vaccination whenever possible. Information was freely communicated by telephone by one medical officer of health to another whenever there was suggestion that it might be of value for administrative purposes, and the County Council received from medical officers of health particulars of cases of smallpox and the addresses of persons who had been in contact with them and communicated this information at once to all medical officers of health in London. As before, unrecognised smallpox, especially cases of this disease which were mistaken for cases of chickenpox, played large part in the dissemination of the disease. Of the care taken to search for unrecognised cases of smallpox in connection with each case notified the annual reports of the medical officers of health contain abundant evidence, and there can be no doubt that the thoroughness with which this was done was largely instrumental in controlling the spread of the disease. No better illustration of this work can be given than that contained in the annual report of the Medical Officer of Health of Finsbury, who thus reports his inquiries concerning an attack of smallpox in a man who he found had been employed in several printing works. Dr. Newman writes " On visiting one of these printing works in Goswell-road we learned that S.A.P. had worked there about a fortnight before, but that all the employees were well and there had been no illness. On pursuing the matter further, however, and pressing the point, six men out of some twenty employed were brought to me. After examination I found that the first was suffering from toothache and neuralgia, the second and third were suffering from smallpox in the acute stage; the fourth was recovering from smallpox, the fifth was affected with a minor skin disease on the face, and the sixth was suffering from what might be the premonitory symptoms of smallpox." Condition as to vaccination of patients admitted to hospital. The report of the Statistical Committee of the Metropolitan Asylums Board contains a tabular statement of the condition as to vaccination of persons suffering from smallpox received into their hospitals during 1904 from which the following table has been prepared :— Admissions. Deaths. A. Vaccinated class— (A1) Half and upwards of one half square inch total area of cicatrices 219 5 (A2) One third but less than half ditto 29 4 (A3) Less than one third ditto 39 3 (A') Area not recorded 2 2 T otal of vaccinated class 289 14 B. Doubtful class 21 3 C. Unvaccinated class— (C1) Not vaccinatcd successfully after having been infected with smallpox 111 10 (C'J) Successfully vaccinated after having been infected with smallpox 28 — Total of unvaccinatedclass 139 10 Grand totals 449 27 Of the above cases fourteen were stated to have been successfully re-vaccinated and in five of these cases the appearance of the vaccination cicatrices afforded presumptive evidence of re-vaccination. In three cases the patient was stated to have previously suffered from smallpox and in one of these cases scars were present, affording presumptive evidence of previous smallpox. The number of cases admitted in 1904 into hospital at several ages, classified according to their condition as to vaccination is as follows :— Ages. Vaccinated. . Unvaccinated. Doubtful. Cases. Deaths. Cast's. Deaths. Cages. Deaths. 0—5 0 — 33 7 1 — 5—10 3 — 49 1 — — 10—15 8 — 25 — 2 — 15—25 83 — 23 1 5 1 25 and above 195 14 9 1 13 2 Total 289 14 139 10 21 3 21 The proportion of cases of smallpox at these ages admitted into hospital in recent periods of epidemic prevalence is shown in the following tables. The small proportion of the vaccinated cases as compared with the large proportion of unvaccinated cases at the younger ages is conspicuous in each period. There is no doubt that the systematic re-vaccination in the later years of school age, of children vaccinated in infancy would largely protect against smallpox both the children of parents who do not object to vaccination, as well as the children of parents who have such objection. For the former children it would renew the protection against smallpox which is conferred upon them by their vaccination in infancy, but which in later years wanes. For the latter children it would reduce the opportunity of exposure to the infection of smallpox. Further it would effect a saving of a considerable amount of public money now expended upon the provision and maintenance of smallpox hospitals. Tn this respect the experience of Berlin furnishes a lesson which London might well learn. Cases of smallpox at several ages admitted into the hospitals of the Metropolitans Asylums Board per cent, of total cases admitted. Ages. 1893-4-5. 1901-2. 1903. 1904. 0—5 7.7 7.8 7.3 7.6 5—10 8.4 7.6 8.7 11.6 10—15 10.7 8.1 4.2 7.8 15—25 31.4 26.7 19.2 24.7 25 and above 41.8 49.8 60.6 48.3 Ages. Vaccinated. Unvaccinated. Doubtful. 1893-4-5 1901-2. 1903. 1904. 1893-4.5 1901-2. 1903. 1904. 1893-4.5 1901-2 1903 1904 0—5 0.4 0.3 0.8 0.0 32.2 31.1 27.6 23.7 1.3 2.0 0.0 4.8 5—10 2.8 1.6 1.6 1.0 25.6 25.2 29.9 35.2 7.1 6.6 4.3 0.0 10—15 9.2 5.0 2.0 2.8 15.2 17.3 10.3 18.0 10.9 6.9 4.3 9.5 15—25 37.9 30.5 17.5 28.7 16.2 16.6 24.1 16.5 20.0 21.3 17.4 23.8 25 & above 49.7 62.6 77.9 67.5 10.8 9.8 8.0 6.5 60.7 63.2 73.9 61.9 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 1902 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) per cent, of total births. Year. Children not finally accounted for (including cases postponed) per cent, of total births. 1872 8.8 1888 10.3 1873 8.7 1889 11.6 1874 8.8 1890 13.9 1875 9.3 1891 16.4 1876 6.5 1892 18.4 1877 7.1 1893 18.2 1878 7.1 1894 20.6 1879 7.8 1895 24.9 1880 7.0 1896 26.4 1881 5.7 1897 29.1 1882 6.6 1898 33.0 1883 6.5 1899 27.7 1884 6.8 1900 25.8 1885 7.0 1901 24.1 1886 7.8 1902 21.3 1887 9.0 Since, and including the year 189S, the vaccination returns have included a statement of the number of children in respect of whom "certificates of conscientious objection" have been obtained. The number of these children represent the following percentage of the births in the years 1898-1902, 1898, 1.4, 1899, 10, 1900, 10, 1901, 1 1, 1902, 0.8. 6108] D 22 During these years, the proportion of children exempted by certificate of conscientious objection, together with the proportion of children not finally accounted for in the several unions has been as follows A umber of certificates of conscientious objection and number of children not finally accounted for per cent of births. Metropolitan Union. 1898. 1899. 1900. 1901. 1902. Bethnal-green 67.0 48.2 49.2 52.2 44.1 Camberwell /">n i 41.2 29.7 23.0 20.0 21.4 Chelsea 17.3 14.9 16.0 13.4 14.9 Fulham 15.4 12.6 13.7 12.0 11.8 St. George, Hanover.square 11.1 9.0 7.1 5.8 7.5 St. George.in.the.East 34.6 35.0 33.5 30.6 29.7 St. Giles and St. George 32.5 33.0 33.6 30.7 27.1 Greenwich 17.2 14.2 13.8 12.6 11.1 Hackney 49.0 38.6 40.4 38.5 26.1 Hammersmith 13.8 11.7 9.1 8.3 9.4 Hampstead 15.4 10.3 11.0 10.0 9.2 Holborn 43.8 31.8 28.5 27.6 23.2 Islington 31.1 29.2 26.2 21.6 17.7 Kensington 13.5 10.2 9.2 9.0 7.2 Lambeth Lewisham 30.6 27.8 25.2 22.6 20.6 20.7 22.2 15.7 20.4 13.5 London, City of 25.4 18.3 14.2 11.3 11.3 Marylebone 18.0 20.9 17.7 14.6 12.5 Mile End Old Town 68.9 69.9 68.0 66.1 58.8 St. Olave (Bermondsey) 32.5 23.6 21.8 18.0 17.5 Paddington 14.7 14.6 13.5 11.0 10.1 St. Pancras 36.7 36.1 32.9 32.8 26.2 Poplar 63.6 50.1 49.0 49.1 44.2 Shoreditch 68.8 52.4 53.0 44.7 36.4 Southwark 32.6 30.3 27.6 26.8 25.4 Stepney 48.6 46.9 44.4 44.3 37.2 Strand 25.2 19.7 19.2 16.1 19.0 Wandsworth and Clapham 32.2 25.1 23.0 20.5 19.2 Westminster 17.4 14.8 12.2 13.3 13.4 Whitechapel 11.8 14.5 13.1 10.5 9.5 Woolwich 10.2 8.3 7.5 9.8 9.7 In no union has the proportion of children exempted by certificate of conscientious objection exceeded in 1898, 7'5 per cent., in 1899, 2.3 per cent., in 1900, 2.4 per cent., in 1901, 3.6 per cent., or in 1902, 2'2 per cent., and indeed in the unions with the largest proportion of children not finally accounted for, the proportion of children thus certified has been especially low, thus indicating laxity of administration rather than conscientious objection to vaccination. Nevertheless, the general trend of the later figures which have been hitherto published is in the direction of improvement in the proportion of children vaccinated, and it is noteworthy that the proportion exempted by certificate of conscientious objection has not increased. This improvement is probably in great part due to the presence of smallpox in London in recent years, leading to increased recognition of the need for the protection against this disease which vaccination affords. It is impossible to state how many of these children have been vaccinated at a time subsequent to that at which the return was compiled. Measles. The deaths from measles in the Administrative County of London during 1904 (52 weeks) numbered 2,256, as compared with 2,040 in 1903. lhe death-rates from this disease per 1,000 persons living in 1904 and preceding periods have been as follows :— 1841-50 0.62 1891-1900 0.581 1851-60 0.53 1901 04.31 1861-70 0.58 1902 0.511 1871-80 0.51 1903 0.441 1881-90 0.64 1904 0.491 The death-rate in each year since 1840 in relation to the mean death-rate of the period 1841-1904 is shown in diagram Y. The following table shows the deaths and death-rates from measles in 1904 (52 weeks) in each of the sanitary areas of the county :— 1 See footnote (1) page 7. Measles. Dig gramV. Mean-Death Rate 1841-1904. 568 per million. 23 Sanitary area. Deaths 1904. Death-rate per 1,000 persons living. 1901-3. 1904. Paddington 40 0.30 0.27 Kensington 68 0.38 0.38 Hammersmith 106 0.44 0.91 Fulham 64 0.62 0.42 Chelsea 25 0.40 0.34 Westminster, City of 23 0.27 0.13 St. Marylebone 50 0.36 0.38 Hampstead 17 0.09 0.20 St. Pancras 127 0.53 0.54 Islington 181 0.39 0.53 Stoke Newington 7 0.24 0.13 Hackney 76 0.43 0.34 Holborn 42 0.40 0.74 Finsbury 58 0.66 0.59 London, City of — 0.18 — Shoreditch 81 0.74 0.69 Bethnal-green 90 0.60 0.69 Stepney 174 0.57 0.57 Poplar 91 0.63 0.54 Southwark 191 0.65 0.92 Bermondsey 136 0.73 1.05 Lambeth 164 0.36 0.53 Battersea 59 0.66 0.34 Wandsworth 106 0.37 0.41 Camberwell 110 0.45 0.41 Deptford 76 0.56 0.61 Greenwich 40 0.42 0.39 Lewisham 25 0.23 0.18 Woolwich 29 0.24 0.24 London 2,256 0.461 0.491 In the distribution of measles mortality in London throughout the year 1904, the highest deathrate obtained in Bermondsey (1.05) and the lowest in the City of London, where no death was registered. For the period 1901-3, Shoreditch had the highest measles death-rate (0'74) and Hampstead the lowest (0.09). The death-rates from this disease in the four quarters of the year were as follows First quarter, 0.58, second quarter, 0.80, third quarter, 0.32, fourth quarter, 0.25 per 1,000 persons living. 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 decennium 1894—1903, the London death-rate exceeded that of any of these towns except Manchester, West Ham and Salford, while in 1904 it was exceeded by the deathrates of Liverpool, Manchester, Leeds, Bradford, West Ham, Hull and Salford. Measles—Death-rates per 1,000 persons living. Towns. 1894-1903. 1904. Towns. 1894-1903. 1804. London 0.562 0.492 Bradford 0.33 0.52 Liverpool 0.47 0.94 West Ham 0.65 0.60 Manchester 0.76 0.76 Hull 0.51 0.71 Birmingham 0.46 0.38 Nottingham 0.38 0.18 Leeds 0.47 0.76 Salford 0.87 1.11 Sheffield 0.55 0.08 Newcastle 0.48 0.25 Bristol 0.44 0.30 Leicester 0.37 0.14 The following table shows that in the decennium 1894-1903 the London measles death-rate was higher than that of any of the undermentioned foreign towns except St. Petersburg, and in 1904 it exceeded that of any except Amsterdam, St. Petersburg and Vienna. Measles—Death-rates per 1,000 persons living. Towns. 1894-1903. 1904. Towns. 1894-1903. 1904 London 0.56 0.492 St. Petersburg 0.60 0.59 Paris 0.29 0.24 Berlin 0.20 0.21 Brussels 0.23 0.10 Vienna 0.46 0.57 Amsterdam 0.25 0.85 Rome 0.31 0.36 Copenhagen 0.21 0.14 New York 0.21 0.26 Stockholm 0.19 0.07 1 See footnote (1) page 7. 2 See footnote (2) page7. 6108] D 2 24 The following table shows the number of deaths from measles at several age-periods in each of the sanitary areas. 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 (366 days). Age-period. 0— 1— 2 " 3— 4— Under 5. 5— 10— 15 and upwards. All ages. Paddington 12 12 4 5 3 36 4 1 1 42 Kensington 12 30 15 6 4 67 2 — 1 70 Hammersmith 27 47 18 6 6 104 4 — — 108 Fulham 19 28 10 6 3 66 1 — — 67 Chelsea 7 7 8 1 1 24 2 — — 26 Westminster, City of 7 10 2 1 — 20 — — — 20 St. Marylebone 9 22 11 4 2 48 2 — 1 51 Hampstead 5 8 3 — — 16 2 — — 18 St. Pancras 25 51 28 5 7 116 10 1 — 127 Islington ,50 76 24 12 8 170 11 1 — 182 Stoke Newington 1 3 — 2 — 6 1 — — 7 Hackney 21 31 8 10 3 73 3 — — 76 Holborn 6 21 10 5 1 43 1 .— — 44 Finsbury 12 25 12 5 2 56 3 — — 59 London, City of — — — — — — — — — — Shoreditch 10 42 17 8 5 82 — — — 82 Bethnal Green 21 45 12 8 2 88 1 — — 89 Stepney 57 77 20 15 3 172 2 — — 174 Poplar 21 42 19 5 3 90 2 — — 92 Southwark 45 86 34 12 12 189 2 — 1 192 Bermondsey 31 59 20 14 7 131 4 — — 135 Lambeth 46 64 30 15 8 163 5 — — 168 Battersea 21 23 9 4 — 57 1 — — 58 Wandsworth 20 37 20 14 9 100 8 — 1 109 Camberwell 28 47 19 7 7 108 2 — — 110 Deptford 21 27 17 7 2 74 2 — 1 77 Greenwich 9 15 7 5 36 3 1 — 40 Lewisham 7 10 4 2 1 24 1 — — 25 Woolwich 9 8 2 3 2 24 5 — — 29 London 559 953 383 187 101 2,183 84 4 6 2,277 The number of deaths from measles in London in 1904 (2,256) shows some increase upon the number of deaths in the preceding year. In 1903 the Order of the County Council came into force extending to measles all the more important provisions of the Public Health (London) Act relating to dangerous infectious diseases, except that requiring notification. These new powers were therefore in force during the whole of the year 1904. Jt is, of course, impossible to expect that the principal object of the Order, viz., the education of the public in the knowledge that measles is a dangerous infectious disease, will be attained for some considerable period, but already it is satisfactory to note that progress is being made in this direction. Thus Dr. Reginald Dudfield writes in his annual report relating to Paddington: "After a year's experience of the working of the Order it can be said that one effect has been to impress on the minds of a large section of the community the fact that measles is not a disease to be trifled with, and there is little room for doubt that greater care is now exercised in dealing with the disease." Again, Dr. Annis, the medical officer of health of Greenwich, writes; "I certainly think that the steps now adopted in reference to this disease will help to educate the public up to understanding that this disease is really one of a very dangerous character, for whilst the municipality took no steps to deal with this disease, the public very naturally were inclined to think that the disease therefore was of a very trifling character." In discussing the administration aiming at the limitation of measles, the desire that notification of cases should be required is expressed by some of the medical officers of health, but this desire is not unanimous. Information given by school teachers as to the absence of children from school on account of an attack of measles is necessarily imperfect, and is, of course, suspended during the holidays. Moreover, it is pointed out that there is difficulty in enforcing the provisions of the Public Health Act which apply to measles, for the reason that often when offences are committed the nature of the disease cannot be proved. Dr. Reginald Dudfield writes on this point: "A decision given in at the Marylebone Police Court has shown that the penal clauses of the Public Health (London) Act, cannot be enforced in the absence of medical evidence as to the nature of the illness. An admission on the part of the parent or guardian that he (or she) knew the patient had measles was held to be insufficient evidence for a conviction." In cases of measles, however, very frequently no medical man is in attendance. In the annual reports relating to the following districts the number of cases of measles brought to the knowledge of the medical officer is stated thus :—Paddington, 896; Hammersmith, 742; Fulham, 831; Chelsea, 251; City of Westminster, 181; St. Marylebone, 980; Hampstead, 741; Islington, 355; Hackney, 1,121; Holbom, 444; Finsbury, 802; Bethnal Green, 728; (Poplar, 868; Bermondsey, 1,089; Wandsworth, 2,291; Camberwell, 1,534; Deptford, 1,029; Greenwich, 1,185; Woolwich, 1,240. The part played in the dissemination of the disease by attendance at school is discussed in a number of the reports, and the desire expressed that children under five years of age should be excluded 25 from such attendance. Dr. Kerr reports that during the year ending March, 1905, 71 class-rooms and 14 departments were closed on account of measles in the provided schools, and one class-room and ten departments in the non-provided schools. All of these, except one in the Junior Mixed department, were in the Infants' departments. The system of observation of the behaviour of measles in schools in one group of which closure was practised and in the other group the schools remained open, was continued in Woolwich, the borough being divided into two districts for this purpose. Dr. Thomas, who has on behalf of the County Council studied the behaviour of measles in Woolwich under these conditions, states that the experience hitherto gained seems to justify the conclusion that " if children under five were excluded from school, closure for measles would not be necessary for some time in London, except in one or two special districts; if, however, this were successful in postponing attacks,the question would again become acute in a few years"; and again, "To effect any useful purpose, school closure must take place before the' first crop ' falls. The old practice of waiting until the attendance fell to a certain limit was useless in arresting the spread of measles and did absolutely no good." Apart from school closure, Dr. Thomas regards the provision of sanitary buildings and training of teachers as two. factors which " probably have the greatest effect of all in determining the extent of spread of an outbreak." He regrets the withdrawal by the Board of Education of Article 101, for the reason that the " average attendance " which determines the grant is affected by the closure of a class but not of a whole department, and he states that: "We thus have great difficulty in carrying out our measures, as much opposition is often encountered to the necessary closing of a single class, while the unnecessary closure of a whole department is gladly borne or even welcomed." See Appendix III. By direction of the Public Health Committee, inquiry was made in the early part of 1905 as to the steps taken by London sanitary authorities in connection with the disinfection of premises, and of bedding, clothing, etc., after occurrence of measles, and also as to the steps taken to impress people with the need of taking precautions as to measles. The replies of medical officers of health are embodied in the following tabular statement:— Sanitary areas. Is disinfection of infected premises carried out after all cages of measles which come to the knowledge of your authority ? Is disinfection of infected bedding, clothing, etc., carried out after all cases of measles which come to the knowledge of your authority? Has your authority taken any steps in the way of distribution of leaflets or otherwise with a view to impressing upon people the importance of taking precautions as to measles ? Paddington Yes Yes Yes Kensington Yes, (in a few instances objected to by occupiers) Yes, in infected rooms Only by posting at work, shops L.C.C. posters Hammersmith Yes Yes No Fulham Yes Yes Yes Chelsea No. Only at request of occupier No. Only at request of occupier Lady inspector has visited over 200 premises where measles existed Westminster, City of No reply received — — St. Marylebone Not in all cases, but in a good many Not in all cases, but in a good many No Hampstead No. In majority of cases As far as possible Yes St. Pancras Not in all cases, only when requested and permitted Not in all cases, only when requested and permitted Yes Islington No. Often do not hear of cases until after children are well No Yes Stoke Newington No No Yes, leaflets Hackney Yes, after most cases Yes, after most cases Yes Holborn Yes, with few exceptions, illness of mother, etc. Yes, except where dis infection is carried out to the satisfaction of the doctor Now under consideration Fins bury Yes Yes Yes, by card for distribution London, City of Yes Yes No Shoreditch Yes, in most instances Yes, in most instances Yes Bethnal-green Yes, with consent of occupants Yes, with consent of occupants No Stepney Only in cases which are early reported Only in cases which are early reported Yes Poplar Yes Yes No, sanitary inspector calls and leaves papers as in ordinary notifications Southwark Yes, in all cases where termination of cases becomes known Yes; in all cases where termination of cases becomes known Yes, leaflets and posters Bermondsey Yes, as far as possible Yes; as far as possible Distribution of leaflets contemplated Lambeth Yes Yes Yes, leaflets Battersea Yes Bedding, etc.,- is not removed, but disinfected in the home Leaflet left at infected house and special districts where measles is prevalent Wandsworth Yes No No Camberwell Yes Yes Not since 1900 Deptford Yes Yes Yes Greenwich Yes (exceptions in special circumstances) Yes (exceptions in special circumstances) Yes Lewisham Yes, only in small number of oases Yes Yes, leaflets Woolwich No No, only on application Yes, two kinds of leaflets 26 It is thus seen that in London generally methods of disinfection are being employed after many cases of measles, both in respect of premises and bedding and clothing, and effort has been made to educate the public to recognise the danger attending measles infection. With respect to Westminster, from the medical officer of which no reply was received, reference to his annual report shows that disinfection was carried out after 23 cases, presumably those cases in which death occurred. It would also appear that effort is being made by lady inspectors and other health visitors to ensure that proper care is taken by parents of children who are attacked, and especially of these children at a time when the rash has disappeared. Scarlet Fever. The cases of scarlet fever notified in the administrative county of London during 1904 (52 weeks) numbered 13,439, compared with 12,531 in 1903. The number of deaths registered from this cause was 365 in the vear 1904, compared with 361 in 1903. The London rates for 1904 and preceding periods are shown in the following table :— Period. Death-rate per 1,000 persons living. Case-rate per 1,000 persons living. Caso mortality per cent. 1861-70 1.13 3 3 1871-80 0.60 8 3 1881-90 0.33 3 3 1891-1900 0.191 4.8 3.9 1901 0.131 4.1 3.2 1902 0.121 3.9 3.1 1903 0.081 2.7 2.9 1904 0.081 2.9 2.7 The death-rate in each year since 1858 in relation to the mean death-rate of the period 18591904 will be seen on reference to diagram VI. The monthly case-rate and case-mortality in each of the years 1891-1904 in relation to the mean of the whole period is shown in diagram VIII. It will be seen from the following table that in the decennium 1894-1903 the London scarlet fever death-rate was exceeded by the death-rates of all the undermentioned English towns, except Bristol, West Ham, and Newcastle, and in 1904 was exceeded by the death-rates of all except Hull and Leicester :— Scarlet fever—Death-rates per 1,000 persons living. Towns. 1894-1903. 1904. Towns. 1893-1903. 1904. London 0.142 0.082 Bradford 0.18 0.15 Liverpool 0.30 0.20 West Ham 0.13 0.14 Manchester 0.22 0.15 Hull 0.15 0.05 Birmingham 0.23 0.12 Nottingham 0.16 0.11 Leeds 0.18 0.13 Salford 0.37 0.25 Sheffield 0.18 0.20 Newcastle 0.14 0.11 Bristol 0.11 0.11 Leicester 0.16 0.02 The following table shows that the London scarlet fever death-rate was, in the decennium 18941903, lower than the death-rates of the undermentioned foreign towns, except Paris, Brussels, Amsterdam, and Rome, and in 1904 was exceeded by the death-rates of Stockholm, St. Petersburg, Berlin and New York:— Scarlet fever—Death-rates per 1,000 persons living. Towns. 1894-1903. 1904. Towns. 1894-1903. 1904. London 0.142 0.081 St. Petersburg 0.56 0.45 Paris 0.06 0.03 Berlin 0.25 0.22 Brussels 0.04 0.00 Vienna 0.19 0.04 Amsterdam 0.03 0.02 Rome 0.01 0.02 Copenhagen 0.18 0.06 New York 0.22 0.25 Stockholm 0.15 0.12 The following table shows the scarlet fever cases, deaths, case rates, and death-rates for the year 1904, the case rates for the decennium 1894-1903, and the death-rates for the period 1901-3 in the several sanitary districts of the County :— 1 See footnote (') page 7. 2 See footnote (-) page 7. 3 The Infectious Desease (Notification) Act came into force in 1889. Scarlet Fever. Diagram VI. Mean, Death Rate /8591904 488 per million Number of admissions to Hospitals of the Metro Diagram VII. Asylums Board percent of to tat cases notified in London 1890~1904- Diagram VIII. Scarlet Fever 27 Sanitary area. Cases, 1904. Case-rate per 1,000 persons living. Deaths, 1904. Death-rate per 1,000 persons living. 1894-1903. 1904. 1901-3. 1904. Paddington 363 3.4 2.5 10 0.07 0.07 Kensington 265 3.0 1.5 5 0.10 0.03 Hammersmith .. 284 3.6 2.4 6 0.08 0.05 Fulham 295 4.7 1.9 4 0.11 0.03 Chelsea 108 3.6 1.5 6 0.07 0.08 Westminster, City of .. 313 2.9 1.8 9 0.06 0.05 St. Marylebone 294 3.3 2.3 9 0.12 0.07 Hampstead 169 3.1 2.0 2 0.06 0.02 St. Pancras 848 4.2 3.6 27 0.15 0.11 Islington 1,150 4.4 3.4 35 0.09 0.10 Stoke Newington 154 3.8 2.9 n 0.06 0.06 Hackney 858 4.8 3.8 20 0.09 0.09 Holborn 98 3.6 1.7 — 0.09 — Finsbury 330 4.5 3.3 17 0.15 0.17 London, City of 32 3.3 1.4 1 0.08 0.04 Shoreditch 343 3.9 2.9 13 0.10 0.11 Bethnal Green 661 5.0 5.1 18 0.19 0.14 Stepney 1,261 4.7 4.2 33 0.10 0.11 Poplar 548 4.2 3.2 24 0.10 0.14 Southwark 415 4.6 2.0 12 0.18 0.06 Bermondsey 454 5.0 3.5 18 0.22 0.14 Lambeth 658 3.9 2.1 16 0.12 0.05 Battersea 385 5.1 2.2 10 0.08 0.06 Wandsworth 772 3.8 3.0 14 0.08 0.05 Camberwell 956 4.3 3.6 17 0.13 0.06 Deptford 405 5.3 3.6 10 0.16 0.09 Greenwich 213 4.2 2.1 3 0.07 0.03 Lewisham 337 3.6 2.4 7 0.10 0.05 Woolwich 469 4.9 3.8 16 0.05 0.13 Port of London 1 – – – – – London 13,439 ' 4.2 2 9 365 0.ll1 0.081 It will be seen from the foregoing table that the scarlet fever death-rate in the period 1901-3 was highest in Bermondsey (0.22) and lowest in Woolwich (0.05), and in the year 1904 was highest in Finsbury (0.17) and lowest in Holborn, where no death was recorded. The scarlet fever death-rates obtaining in London during the four quarters of the year 1904 were as follows :—First quarter, 0.07; second quarter, 0 07 ; third quarter, 0'08 ; and fourth quarter, 010 per 1,000 persons living. With the continuance of diminished prevalence and of diminished severity of cases of scarlet fever occurring in London, the discovery of the source of infection in particular instances was especially difficult. Dr. Newman found it possible to trace to their probable source of infection 50 cases out of 148 occurring in Finsbury in the first six months of the year. Dr. Brown was able to attribute 53 cases out of 454 notified in Bermondsey to the following causes—Previous case in house or family 31, to friends (visitors 5,) o return cases 15, to playmates 2. In Battersea, of 385 cases notified, Dr. McCleary found in 78 cases a history of direct personal contact with a previous case in the district, while in 14 others infection occurred outside the district. Dr. Stevens comments on the exceptionally large number of cases in Camberwell, which must have been contracted from other children who had been playing about in the streets while suffering from a mild and unsuspected attack of the disease. No outbreak due to milk is recorded during the year. The following occurrences are notified in the annual reports—In Paddington there was an exceptional prevalence of this disease in August and September, all but four of 51 cases occurring in a comparatively small area of the district, and due to delay in the notification and, consequently, in the isolation of the earlier cases. In Chelsea 12 cases occurred between 28th October and lGth December among children attending the Oratory School. In Hampstead a number of cases occurred among children attending the Emanuel Schools, Mill-lane, which in consequence were closed for three weeks in October. Dr. Newman comments on a higher incidence of scarlet fever in Finsbury on children of the school age. Of 148 cases occurring in the first six months of the year, 19 were traced with some degree of probability to infection connected with school attendance, but in only six was there evidence of infection by previous cases or contacts attending the same class; the remaining 13 cases must have contracted infection in the playground or precincts of the school. Of the six referred to, one child was probably infected by a class mate, but " che remaining five cases were indirectly infected by third persons who carried the disease without themselves acquiring it. Of these five children who acted as carriers of infection, three had never had scarlet fever, and yet were not attacked.'' The child probably infected by a class mate continued to attend school for four weeks 1 See footnote (') page 7. 28 whilst actually suffering from scarlet fever, and only one case occurred in the school during his attendance and the week following his removal. In Battersea six cases occurred in a boarding school; the first child who was attacked and who infected the other five directly or indirectly, had sickened three days after receiving a parcel of pancakes from home ; from this home a case of scarlet fever had been removed before the child referred to sickened. In the borough of Wandsworth a slight outbreak occurred in November in Roehampton, due to one or two unrecognised cases infecting others at school or in the street after school hours. In Streatham there was local prevalence due mainly to infection at school. An outbreak also occurred in a convent school, due to infection from a child who was herself apparently infected during a railway journey from Bognor. In Holborn a small outbreak occurred among children attending the St. John School. In Shoreditch in October and November a series of 14 cases occurred among children attending the Catherine-street School. In Lambeth an outbreak occurred in the Stockwell Orphanage which began in 1903, and involved the attack of 70 boys ,41 girls, and three officers. Dr. Kerr's report shows that four class rooms and two departments were closed during the year on account of prevalence of scarlet fever among the children attending the schools. The annual reports show " return cases " to have occurred in Finsbury, 5 ; in Bermondsey, 15 ; Battersea, 20 ; Wandsworth 17 ; Woolwich, 18 ; Shoreditch, 7 ; and Greenwich, 3. The medical officer of health of Shoreditch gives a summary of return cases occurring during the years subsequent to 1893, and which amounted to 1*4 per cent, of Shoreditch children discharged from hospital. The occurrence of three cases in Poplar upon the return of a child from hospital, led the Poplar Borough Council, to communicate with other London sanitary authorities as to the steps taken by the hospital providing authority to ensure that patients are not discharged in an infectious condition.1 The summer holiday of the London County Council schools began in 1904 on Thursday, the 21st July, i.e., the latter part of the 29th week, and the schools re-opened on Monday, the 22nd 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 :— j Scarlet fever—Notified cases, 1904. 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) 126 839 139 — — — Four weeks of holiday influence (31s/ to 2>Uh) 98 638 144 —22.2 —24.0 + 3.6 Four week» following ueeks of holiday influence (35th to 38th) 145 967 164 + 48.0 +51.6 + 13.9 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 1904. 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 both males and females of two years of age. The fatality, it will be observed, was highest among males of one and among females under one vear of aere. Scarlet fever2, 1904. Age-period. Males. Females. Cases. Deaths. Case mortality per cent. Rates por 100,000 living. Cases. Deaths. Case mortality per cent. Rates per 100,000 living. Cases. Deaths. Cases. Deaths. All ages 6,365 201 3.2 290 9 7,074 173 2.4 288 7 0— 90 8 8.9 160 14 75 10 133 134 18 1— 285 35 12.3 571 70 257 26 10.1 515 52 2— 509 43 8.4 1,009 85 443 30 6.8 881 60 3— 652 31 4.8 1,327 63 709 28 3.9 1,425 56 4— 740 20 2.7 1,539 42 750 23 3.1 1,567 48 5— 2,664 45 1.7 1,180 20 2,988 40 1.3 1,311 18 10— 831 12 1.4 390 6 949 9 0.9 437 4 15— 259 3 1.2 121 1 323 — — 135 — 20— 155 1 0.6 70 0 284 4 1.4 106 1 25— 135 3 2.2 35 1 241 2 0.8 54 0 35— 34 — — 12 — 45 — — 14 — 45— 10 — — 5 — 9 1 Il.l 4 0 55 and upwards 1 — — 1 1 0 — 1 A report has been issued by the Metropolitan Asylums Board giving detailed information of the results of inquiry into return cases by Dr. A. G. R. Cameron. 2 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. Diphtheria. Diagram IX. Mean Deatti Rate /6JS-/304 273per million Mean Death Rate 1853-1904. 403per million Admissions lo Hospitals of the Metropolitan Asylums Diagram X Board per cent of total cases notified tn L ondon 1890-/904. 29 Proportion of cases admitted to hospital. It will be seen from diagram VII. that the proportion of cases of this disease admitted to the hospitals of the Metropolitan Asylums Board was slightly in excess of the proportion admitted during the preceding year. Diphtheria. The cases of diphtheria (including membranous croup) notified in the administrative county of London in 1904 (52 weeks) numbered 7,219, compared with 7,738 in 1903. The number of deaths registered from this cause in 1904 was 723, compared with 740 in 1903. The diphtheria case-rates, death-rates, and case mortality in 1904, and preceding periods, are shown in the following table :— Period. Death-rate per 1,000 persons living. Case-rate per 1,000 persons living. Case mortality per cent. 1861-70 0.18 2 2 1871-80 0.12 2 2 1881-90 0.26 2 2 1891-1900 0.491 2.6 19.0' 1901 0.291 2.7 10.9 1902 0.251 2.3 10.8 1903 0.161 1.7 9.6 1904 0.16 1.6 10.0 The death-rate in each year since 1858 in relation to the mean death-rate of the period 1859— 1904 is shown for diphtheria and for diphtheria and croup combined in diagram IX. The monthly case-rate and case-mortality in each of the years 1891-1904 in relation to the mean of the whole period is shown in diagram XI. 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 decennium 1894-1903 the London rate exceeded the rates of all these towns, except Sheffield, West Ham, and Leicester, while in 1904 it was lower than the rates of any except Leeds, Sheffield, West Ham, and Leicester. Diphtheria—Death-rates per 1,000 persons living. Towns. 1894-1903. 1904. Towns. 1894-1903. 1904. London 0. 423 0.163 Bradford 0.13 0.57 Liverpool 0.24 0.27 West Ham 0.63 0.15 Manchester 0.19 0.17 Hull 0.18 0.25 Birmingham 0.27 0.24 Nottingham 0.11 0.28 Leeds 0.34 0.10 Salford 0.32 0.49 Sheffield 0.44 0.11 Newcastle 0.16 0.22 Bristol 0.25 0.30 Leicester 0.50 0.03 The following table shows that the London diphtheria death-rate in the decennium 1894-1903 was higher than that of any of the undermentioned foreign towns, except Stockholm, St. Petersburg, and New York, and in 1904 was exceeded by the death-rates of St. Petersburg, Berlin, Vienna, and New York. Diphtheria—Death-rates per 1,000 persons living. Towns. 1894-1903. 1904. Towns. 1894-1903. 1904. London 0.421 0 .163 St. Petersburg 0.90 0.50 Paris 0.19 0.12 Berlin 0.33 0.18 Brussels 0.13 0.10 Vienna 0.37 0.21 Amsterdam 0.15 0.12 Bome 0.09 0.15 Copenhagen 0.22 0.08 New York 0.62 0.60 Stockholm 0.45 0.16 1 See footnote (') page 7. 2 The Infectious Diseases (Notification) Act came into foroe in 1889. 3 See footnote (2) page 7. 6108] E 30 The following table shows the diphtheria cases, deaths, case-rates, and death-rates for the year 1904, the case-rates for the decennium 1894-1903, and the death-rates for the period 1901-3, in the several sanitary districts :— Sanitary area. Cases, 1904. Case-rate per 1,000 persons living. Deaths, 1904. Death-rate per 1,000 persons living. 1894-1903. 1904. 1901-3. 1904. Paddington 143 2.1 1.0 19 0.21 0.13 Kensington 187 1.6 1.0 17 0.15 0.10 Hammersmith 204 1.8 1.7 22 0.22 0.19 Fulham 300 3.5 2.0 23 0.29 0.15 Chelsea 61 2.6 0.8 5 0.11 0.07 Westminster, City of .. 145 1.5 0.8 7 0.12 0.04 St. Marylebone 118 1.7 0.9 14 0.22 0.11 Hampstead 57 1.6 0.7 4 0.16 0.05 St. Pancras 349 2.5 1.5 38 0.36 0.16 Islington 347 2.2 1.0 29 0.27 0.09 Stoke Newington 61 2.0 1.2 8 0.17 0.15 Hackney 572 3.2 2.5 55 0.31 0.24 Holborn 46 2.1 0.8 4 0.19 0.07 Finsbury 145 3.0 1.5 16 0.28 0.16 London, City of 40 2.0 1.7 2 0.25 0.09 Shoreditch 188 2.5 1.6 18 0.22 0.15 Bethnal Green 425 3.3 3.3 47 0.32 0.36 Stepney . 821 3.2 2.7 90 0.24 0.30 Poplar 670 3.7 4.0 84 0.39 0.50 Southwark 281 3.2 1.4 26 0.22 0.13 Bermondsey 193 3.0 1.5 16 0.22 0.12 Lambeth 327 2.3 1.1 34 0.14 0.11 Battersea 227 2.7 1.3 14 0.13 0.08 Wandsworth 404 2.2 1.6 42 0.21 0.16 Camberwell 270 3.5 1.0 21 0.29 0.08 Deptford 1J5 3.6 1.7 16 0.31 0.14 Greenwich 152 2.7 1.5 11 0.22 0.11 Lewisham 130 2.6 0.9 12 0.22 0.09 Woolwich 161 2.3 1.3 29 0.16 0.24 London 7,219 2.6 1.6 723 0.231 0.161 It will be seen from the foregoing table that in the period 1901-3 the diphtheria death-rate was highest in Poplar (0 39), and lowest in Chelsea (0-11) and in the year 1904 was highest in Poplar (0 50) and lowest in the City of Westminster (0.04). The diphtheria death-rate in London in each of the four quarters of the year 1904 were as follows: first quarter, 018; second quarter, 014 third quarter, 0'13 ; and fourth quarter, 0-18 per 1,000 persons 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 1891-1904 inclusive, i.e., the case-rates of each borough are shown in relation to the London case-rate of the same year, the London rates being taken as 100 — Diphtheria. Comparative case rates (London taken as 100). Sanitary area. Comparative case rates (London case rates taken as 100). 1891. 1892. 1893. 1894. 1895. 1896. 1897. 1898. 1899. 1900. 1901. 1902. 1903. 1904. Paddington 104 77 73 117 74 66 91 98 68 44 89 65 59 63 Kensington 78 60 68 63 86 70 67 49 51 74 52 43 59 63 Hammersmith 195 164 87 72 77 67 49 58 58 85 74 70 82 106 Fulham 61 58 78 126 139 99 109 145 135 178 174 126 118 125 Chelsea 138 110 83 107 143 184 107 79 61 74 56 78 76 50 Westminster, City of 58 91 57 53 61 53 59 67 50 59 52 70 59 50 St. Marylebone 70 81 88 78 64 66 53 64 47 59 74 78 100 56 Hampstead 105 96 73 53 61 84 47 65 48 74 70 52 59 44 St. Pancras 89 95 103 83 90 64 76 78 79 93 148 152 129 94 Islington 152 119 86 103 70 106 73 60 68 70 100 113 82 63 Stoke Newington 83 113 97 77 70 70 52 59 34 111 104 83 47 75 Hackney 131 147 135 108 93 89 122 152 106 107 167 139 141 156 Holborn 52 89 79 61 66 61 104 102 46 70 104 87 53 50 1 See footnote (') page 7. Diagram XI Diphtheria. 31 Sanitary Area. Comparative case rates (London case rates taken as 100). 1891. 1892. 1893. 1894. 1895. 1896. 1897. 1898. 1899. 1900. 1901. 1902. 1903. 1904 Finsbury 118 82 130 81 86 112 170 163 93 74 107 100 76 94 City of London 59 130 60 49 51 74 71 60 68 89 96 161 65 106 Shoreditch 124 89 131 95 80 97 103 80 103 111 104 83 76 100 Bethnal Green 154 230 181 168 143 114 144 100 89 115 133 104 112 206 Stepney 106 132 112 123 157 150 128 93 89 107 104 113 106 169 Poplar 191 148 214 159 179 133 141 105 83 141 137 117 147 250 Southwark 71 72 116 113 86 106 102 151 207 141 100 113 100 87 Bermondsey 68 60 84 126 80 99 97 90 177 133 93 91 76 94 Lambeth 88 97 91 83 88 74 83 103 121 104 63 70 65 69 Battersea 144 123 132 122 97 81 125 178 116 70 59 74 106 81 Wandsworth 74 83 84 79 60 51 100 114 99 74 74 135 124 100 Camberwell 69 65 67 112 140 180 154 102 156 130 122 113 82 63 Deptford 72 68 86 153 225 113 141 132 121 111 144 104 241 106 Greenwich 60 43 84 85 137 189 82 105 122 89 74 78 124 94 Lewisham 48 74 82 70 57 122 85 127 170 126 85 130 118 56 Woolwich 32 68 66 66 81 96 91 86 100 115 67 91 88 81 London 100 100 100 100 100 100 100 100 100 100 100 100 100 100 These reports have for a number of years contained accounts of the evidence which London affords of the spread of diphtheria from one person to another by means of intermediary persons, who, although infective, are not themselves suffering from symptoms of the disease. In 1902 Dr. Brown, Medical Officer of Health of Bermondsey, made bacteriological examination of material from the throats of 259 persons of school age living in houses in which cases of diphtheria had occurred, and in 32, or 12.4 per cent., found the Klebs-Loeffler bacillus. The parents of these were informed that their child harboured diphtheria bacilli in its throat, and were advised to keep the child under the close observation of their medical attendant, and 16 of these later developed the clinical symptoms of diphtheria and were removed to hospital. "By this method," Dr. Brown states, "there is no doubt that the 16 cases notified were placed under treatment, and isolated much earlier than they would otherwise have been." In 1903 he examined material from the throats of 193 "contacts" in 64 families, and found that of this number 20 had diphtheria bacilli in their throats, and he states that 3 of the 20 subsequently developed sore throats and were notified as suffering from diphtheria. In his annual report for the year 1904, Dr. Brown states that he has continued to examine material from the throats of persons in contact with cases of diphtheria, and that in 1904 the number of contacts examined for the purpose of determining whether they should attend school was 145, being members of 60 families. of this number 12 had diphtheria bacilli in their throats, and of these 4 subsequently showed symptoms of diphtheria and were removed to hospital. One contact, whose examination gave a negative result, was subsequently removed to hospital with laryngeal diphtheria. "The bacilli were evidently confined at the time of the examination to the larynx, which cannot be reached by the ordinary throat swab." Dr. Brown makes it his practice to examine the children at the Town Hall in the second week after removal to hospital of the original case of diphtheria. If no diphtheria bacilli are found, the head master of the school and the parents are informed that the "contact" may return to school, but if diphtheria bacilli are found the head master is requested to exclude the child from school till further examination. The parents are also advised to take the child to their medical attendant for direct throat treatment. Only after subsequent examination of the throat at a fortnight's interval, and when the throat is found free of diphtheria bacilli, is the child allowed to return to school. So, again, Dr. Newman, the Medical Officer of Health of Finsbury, in discussing the part played by "carrier" cases in communicating disease, writes: "To discover such cases and prevent them infecting their neighbours is the business of preventive medicine. In accordance with this view we have in a number of cases made bacteriological examination of the throats of 'contact' persons." He gives account of a family attacked with diphtheria, some members of which, while harbouring the diphtheria bacillus in their throat, were not received into hospital, and he writes : "Probably it is desirable that the Metropolitan Asylum Board's hospitals should not admit as cases of diphtheria persons who, though they may have the bacillus in their throats, are not suffering from the clinical symptoms of the disease. But it will be evident that these persons are yet a danger to the community, and are in my opinion one of the chief causes of the spread of the disease in Finsbury. What is to be done with them? I think they should be isolated as much as practicable at home, and kept from school and their neighbours ; and also direct throat treatment should be adopted with a view of clearing their throats of the infective bacillus; and if any throat symptoms occur in addition to the presence of the bacillus, they should not only be notified, but admitted to hospital, and not discharged until it has been bacteriologically demonstrated that their throats are clear." The annual report of Dr. Kerr (See Appendix III.) contains accounts of the finding of " carrier " cases among the children attending numerous schools invaded by diphtheria, and the exclusion of which was attended by the termination of the outbreak. The need for careful inquiry for "carriers" among all "contacts" with cases of diphtheria, both in the home and in the school, is very obvious. 6108] E 2 32 The exclusion of such children from school and the adoption of suitable throat treatment promises to give better control over diphtheria prevalence. As pointed out in a previous report, this administration requires the unstinted use of the laboratory. The reports of medical officers of health include accounts of local prevalences. In Stoke Newington in 11 cases there was a history of antecedent recurrent sore throat in the person attacked, and in 2 cases the attack was preceded by sore throat in other members of the family. In Shoreditch in 27 instances antecedent sore throat was found in members of the family of the persons subsequently attacked, or in other persons resident in the same house. Dr. Allan gives the particulars of a limited outbreak among the children attending the St. George's School, Westminster, and Dr. Alexander of an outbreak among the children attending the girls' department of the Atley-road School, Poplar; Dr. McCleary records a small outbreak among the children in a boarding school in Battersea, and the finding of the diphtheria bacillus in the throats of two children in the school not previously suspected to be infectious, and one of whom had no clinical symptoms. Dr. Caldwell Smith gives account of the prevalence of diphtheria among children in the Eardley-road school and in the Immanuel-road school, Streatham Common. In both these schools children were found with the diphtheria bacillus in their throats, and in the former closing of the infant school and in the latter closing of the infants' and girls' departments was resorted to. Dr. Davies found in two houses in Woolwich, in which children were attacked, antecedent cases of diphtheritic nasal discharge, the nature of which had remained unsuspected until the subsequent cases occurred. In connection with the question of the relation of school attendance to the spread of infection, it has been thought well to include, as in previous reports, a table showing the reduction in the prevalence of the disease among persons of school age during the summer holiday when the schools are closed. The summer holiday of the schools of the London County Council began on Thursday, the 21st July, i.e., the latter part of the 29th week, and the schools re-opened on Monday, the 22nd 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 confined to the school age— Diphtheria—Notified cases, 1904. 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) 95 377 87 ... ... ... Four weeks of holiday influence (31st to 34th) 124 314 123 + 30.5 -16.7 + 41.4 Four weeks following weeks of holiday influence (35th to 38th) 124 366 107 0.0 + 16.6 -13.0 Many of the annual reports show the number of cases of suspected diphtheria in which material from the throat was submitted to bacteriological examination and the results obtained. This is shown in the following table :— Sanitary area. No. examined. No. positive. Sanitary area. No. examined. No. positive. Paddington 58 16 Shoreditch 27 6 Fulham 178 38 Poplar 178 52 Westminster, City of 47 10 Bermondsey 240 31 St. Marylebone 9 5 Lambeth 190 19 St. Pancras 92 25 Battersea 244 39 Islington 86 28 Wandsworth 112 23 Stoke Newington 16 5 Deptford 67 20 Hackney 87 27 Greenwich 127 31 Holborn 16 7 Woolwich 73 12 Finsbury 91 22 In only one report, that relating to Battersea, are return cases stated to have occurred. In this district there were two such cases. In many of the other reports it is stated specifically that none were found. DiagramXH Whooping C ough - 33 The use of antitoxin, both for curative and prophylactic purposes, is mentioned in some of the reports, and it is stated that a supply is kept by the Medical Officer of Health for the use of medical practitioners. Proportion of cases admitted to hospital. It will be seen on reference to diagram X. that the proportion of cases of diphtheria admitted to the hospital of the Metropolitan Asylums Board during 1904 was slightly less than the proportion admitted during 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 1904. The incidence of attack at " all ages" was, as in preceding years greater on females than on males. The incidence of deaths was the same on both sexes as "all age3," while the fatality was higher among males than among females. In the age groups adopted for the purposes of this table the greatest incidence of attack was upon males of three and females of four years of age; the greatest incidence of death was upon both males and females of one year of age. The fatality was greatest among males under one and females of one year of age. Diphtheria, 1904. Males. Females. Age period. Cases. Deaths. Case mortality per cent. Rates per 100,000 living. Cases. Deaths. Case mortality por cent. Rates per 100,000 living. Cases. Deaths. Cases. Deaths. All ages 3,340 359 10.7 152 16 3,879 385 9.9 158 16 0— 114 41 36.0 202 73 79 25 31.6 141 45 1— 286 59 20.6 573 118 249 87 34.9 499 174 2— 379 59 15.6 751 117 368 56 15.2 732 111 3— 407 56 13.8 828 114 366 47 12.8 736 94 4— 388 47 12.1 807 98 425 39 9.2 888 81 5 1,050 80 7.6 465 35 1,266 106 8.4 555 47 10— 328 7 2.1 154 3 419 19 4.5 193 9 15— 127 4 3.1 59 2 194 2 1.0 81 1 20— 91 1 1.1 41 0 190 1 0.5 71 0 25— 100 2 2.0 26 1 199 1 0.5 44 0 35— 49 2 4.1 17 1 85 1 1.2 27 0 45— 14 — — 7 — 25 — — 11 — 55 and upwards 7 1 14.3 4 1 14 1 7.1 5 0 Whooping-cough. The deaths from whooping-cough in the Administrative County of London in the year 1904 (52 weeks) numbered 1,495 compared with 1,627 in 1903. The death-rates from this disease in 1904 and preceding periods have been as follows— Period. Death rate per 1,000 persons living. Period. Death rate per 1,000 persons living. 1841-50 0.87 1891-1900 0.502 1851-60 0.88 1901 0.352 1861-70 0.88 1902 0.402 1871-80 0.81 1903 0.352 1881-90 0.69 1904 0.322 The death-rate in each year in relation to the mean death-rate of the period 1841-1904 is shown in diagram XII. The death-rate is calculated upon the population at all ages, but, as a matter of fact, comparatively few of the deaths occur amongst persons above five years of age, the greatest incidence of whooping-cough mortality, being upon the first year of life. It may be stated that although the decrease in the birth-rate has contributed to the relative reduction of the infantile population, this is insufficient to account for the fall in the whooping-cough death-rate which the diagram shows. It will be seen from the following table that the London whooping-cough death-rate was in the decennium 1894-1903 exceeded by the death-rates of Liverpool, Manchester, Birmingham,WestHam, Salford and Newcastle, and in the year 1904 was exceeded by the death-rates of all the undermentioned large English towns except Bradford and Hull 2 See footnote (2) page 28. 2 See footnote (1) page 7. 34 Whooping-cough—Death-rates per 1,000 persons living. Towns. 1894-1903. 1904. Towns. 1894-1903. 1904. London 0.43 0.33 Bradford 0.30 0.17 Liverpool 0.52 0.58 West Ham 0.48 0.35 Manchester 0.50 0.50 Hull 0.35 0.26 Birmingham 0.45 0.85 Nottingham 0.34 0.36 Leeds 0.37 0.47 Salford 0.60 0.62 Sheffield 0.43 0.34 Newcastle 0.45 0.58 Bristol 0.38 0.34 Leicester 0.28 0.39 The following table shows that the London whooping-cough death-rate was in the decennium 1894-1903 considerably higher than that of any of the undermentioned foreign towns, and in the year 1904 exceeded that of all of these towns except Copenhagen— Whooping-cough—Death-rates per 1,000 persons living. Towns. 1891-1903. 1904. Towns. 1894-1903. 1904. London 0.341 0.331 St. Petersburg 0.23 0.19 Paris 0.13 0.12 Berlin 0.28 0.24 Brussels 0.13 0.12 Vienna 0.10 0.05 Amsterdam 0.25 0.32 Rome 0.07 0.06 Copenhagen 0.31 0.52 New York 0.16 0.06 Stockholm 0.19 0.16 The following table shows the whooping-cough deaths and death-rates for the year 1904 and the death-rates for the period 1901-3 in the several metropolitan sanitary districts :— Death rate per 1,000 persons living. Sanitary area. Deaths, 1904. 1901-3. 1904. Paddington 16 0.30 0.11 Kensington 19 0.33 0.11 Hammersmith 36 0.40 0.31 Fulham 58 0.44 0.38 Chelsea 26 0.32 0.35 Westminster, City of 18 0.21 0.10 St. Marylebone 13 0.30 0.10 Hampstead 8 0.20 0.09 St. Pancras 82 0.41 0.35 Islington 84 0.39 0.25 Stoke Newington 12 0.25 0.23 Hackney 55 0.31 0.24 Holborn 9 0.31 0.16 Finsbury 28 0.55 0.28 London, City of 7 0.13 0.30 Shoreditch 63 0.51 0.54 Bethnal Green 52 0.43 0.40 Stepney 126 0.45 0.42 Poplar 81 0.51 0.48 Southwark 118 0.45 0.57 Bermondsey 69 0.43 0.53 Lambeth 109 0.39 0.35 Battersea 59 0.44 0.34 Wandsworth 50 0.30 0.19 Camberwell 99 0.33 0.37 Deptford 49 0.40 0.43 Greenwich 56 0.33 0.55 Lewisham 37 0.25 0.26 Woolwich 56 0.27 0.45 Port of London — — — London 1,495 0.37' 0.322 It will be seen from the foregoing table that in the period 1901-3 the whooping-cough death-rate was highest in Finsbury (0.55), and lowest in the City of London (0.13); in the year 1904 the highest rate 1 See footnote (2) page 7. 2 See footnote (1) page 7. Diagram XIII. Typhus Fever 35 was in Southwark (0.57), and lowest in Hampstead (0.09). The whooping-cough death-rate in each of the four quarters of the year 1904 were as follows: first quarter, 0.51; second quarter, 0.44; third, quarter, 0.21 ; and fourth quarter, 0.13 per 1,000 persons living. It is interesting to note that the decline in the mortality from whooping-cough, which appears to have begun in the decennium 1871-80, and was conspicuous in the decennia 1881-90 and 1891-1900, has been since maintained. Medical officers of health receive information from teachers of the absence of children from schools on account of whooping-cough, and in this way efforts are made to prohibit infectious children from attending schools. The number of cases which come to the knowledge of medical officers of health is thus stated in some of the annual reports : Paddington 196, of which 89 were reported by teachers ; Hammersmith 102, Westminster 62 (56 from teachers); Islington 1,293, from teachers ; Hackney 273, from teachers; Shoreditch, 159, from teachers ; Bermondsey 334 cases, and 92 contacts from teachers ; Lambeth 431, from teachers ; Wandsworth 163, from teachers ; Lewisham 173, from teachers, and 72 contacts. The Medical Officer of Health of Lambeth states that disinfection was carried out in 380 cases, all the cases being visited by women inspectors. Typhus. There were no deaths from typhus in the Administrative County of London during the year 1904. The death-rates from this disease in successive periods have been as follows— Period. Death-rate per 1,000 living. 1871-80 .055 1881-90 .008 1891-1900 .0011 1901 .0011 1902 .0001 1903 .0011 1904 1 In this table where — is inserted no death occurred. The death-rate in each year since 1868 in relation to the mean death-rate of the period 1869-1904 is shown in diagram XIII. During the year 1904 three persons were certified to be suffering from typhus, residing respectively in the City of Westminster, Islington, and Stepney. The only cases of typhus known to have occurred during the year were— 1. A man, aged 40 years, admitted into the Seamen's Hospital on the 9th March from Gravesend, where he had been working. 2. A grocer's traveller, aged 22 years. He was admitted from a house in Mile End, where he had been living for some time, into the Eastern Hospital on the 30th April. 3. A tailor, aged 19 years, admitted into the Middlesex Hospital on the 16th May, from Old Compton-street, Westminster. Dr. Allan expresses doubt as to this case being one of typhus. 4. A woodcarver and hawker, a Russian by birth, aged 24 years, admitted on the 7th September, into the Eastern Hospital from a house in Highgate-hill, where he had been resident for ten days. Prior to that period he had been living in Cotton-street, Stepney. Enteric Fever. The number of cases of enteric fever notified in the Administrative County of London during 1904 (52 weeks) was 1,896, compared with 2,339 in 1903. The deaths from this disease numbered 286 in 1904, compared with 368 in 1903. The rates per 1,000 persons living and the case mortality per cent, in 1904 and preceding periods were as follows— Period. Death-rate per 1,000 persons living. Case-rate per 1,000 persons living. Case mortality per cent. 1871-80 0.24 -2 2 1881-90 0.19 -2 2 1891-1900 0.141 0.8 18.2 1901 0.111 0.7 15.6 1902 0.121 0.7 15.8 1903 0.081 0.5 15.7 1904 0.061 0.4 15.1 The death-rate in each year since 1868 in relation to the mean death-rate of the period 1869-1904 13 shown on diagram XIV. 1 See footnote (1), page 7. 2 The Infectious Disease (Notification) Act came into forco in 1889. 36 The monthly case-rate and case mortality in each of the years 1891-1904 in relation to the mean of the whole period is shown in diagram XVI. The following table shows the enteric fever cases, deaths, case-rates, and death-rates for the year 1904, the case-rates for the decennium 1894-1903, and the death-rates for the period 1901-3 in the several sanitary districts— Sanitary area. Cases, 1904. Case-rate per 1,000 persons living. Deaths, 1904. Death-rate per 1,000 perliving. 1894-1903. 1904. 1901-3. 1904. Paddington 48 0.5 0.3 10 0.08 0.07 Kensington 47 0.6 0.3 6 0.07 0.03 Hammersmith 39 0.6 0.3 5 0.10 0.04 Fulham 39 0.6 0.3 6 0.10 0.04 Chelsea 13 0.6 0.2 2 0.07 0.03 Westminster, City of 51 0.6 0.3 10 0.10 0.06 St. Marylebone 50 0.7 0.4 3 0.09 0.02 Hampstead 27 0.6 0.3 5 0.08 0.06 St. Pancras 136 0.9 0.6 17 0.12 0.07 Islington 128 0.8 0.4 18 0.11 0.05 Stoke Newington 14 0.6 0.3 3 0.09 0.06 Hackney 185 1.0 0.8 26 0.13 0.12 Holborn 41 0.8 0.7 4 0.13 0.07 Finsbury 46 0.8 0.5 9 0.10 0.09 London, City of 14 1.0 0.6 — 0.10 — Shoreditch 48 0.9 0.4 8 0.12 0.07 Bethnal Green 58 1.0 0.4 6 0.12 0.05 Stepney 198 0.9 0.7 30 0.12 0.10 Poplar 93 1.2 0.5 13 0.14 0.08 Southwark 92 0.8 0.4 18 0.10 0.09 Bermondsey 73 0.9 0.6 16 0.12 0.12 Lambeth 100 0.7 0.3 11 0.09 0.04 Battersea 63 0.7 0.4 13 0.10 0.07 Wandsworth 71 0.5 0.3 11 0.09 0.04 Camberwell 78 0.6 0.3 16 0.09 0.06 Deptford 30 0.7 0.3 3 0.08 0.03 Greenwich 49 0.8 0.5 9 0.07 0.09 Lewisham 29 0.5 0.2 2 0.08 0.01 Woolwich 27 0.7 0.2 6 0.08 0.05 Port of London 9 — — — — — London 1,896 0.7 0.4 286 0.101 0.061 It will be seen from the foregoing table that among the several sanitary areas the enteric fever death-rate was, in the period 1901-3 highest in Poplar (0.14), and lowest in Kensington, Chelsea and Greenwich (0.07); in 1904, Hackney and Bermondsey had the highest death-rate (0.12), the City of London, where no death was recorded, the lowest. The death-rates from enteric fever in London in each of the four quarters of the year 1904 were as follows: first quarter, 0 05; second quarter, 0.04; third quarter, 0 07; and fourth quarter 0.09 per 1,000 persons living. The decline in the case-rate, death-rate, and fatality of enteric fever has been maintained, but some London districts suffer practically twice as much as others. This may in part be due to difference in the food supply, but in all probabilty it is especially dependent upon other conditions of life, and especially the habits of the population which give opportunity for the disease to be spread from one person to another. Thus it will be observed that districts which are especially occupied by poor persons suffer more than districts inhabited by persons better circumstanced. Efforts to secure greater reduction in the prevalence of this disease should therefore especially be directed to the discovery of persons suffering from this disease in so slight a degree that their illness escapes recognition and notification, but who may nevertheless be infective. When regard is had for the long period of time during which the bacillus of enteric fever often remains in the urine of a person who has been attacked by enteric fever, the frequency of the opportunity for infection can be appreciated. The annual reports contain numerous references to the spread of enteric fever by infection conveyed from one person to another. Dr. Brown gives the particulars of nine cases of this disease which occurred in one house in Bermondsey, eight of which were directly or indirectly infected by the first case, a man, the cause of whose own attack was unknown. In another house in this district three cases of undoubted enteric fever occurred, and other cases of less defined disease, but which was probably enteric fever, the disease being communicated by personal infection. Enquiry by Dr. Newman in Finsbury enabled him to attribute the source of infection to antecedent cases in ten instances. In Shoreditch, Dr. Bryett found four such cases. In Wandsworth, Dr. Caldwell Smith attributed the origin of eight cases to this cause, and Dr. Davies found three such cases in Woolwich. Again, Dr. Sykes gives account of the occurrence of a number of cases of enteric fever, occurring during 1 See footnote (1), page 7. Diagram XIV Enteric Fever. DiagramXV Enteric Fever. Diagram XVI Enteric Fever. 37 August and September in the neighbourhood of Ferdinand-place, St. Pancras, of which fourteen appeared to be due to infection from an antecedent case, but explanation, after careful inquiry, was wanting for the others. Dr. Reginald Dudfield states the number of instances in which multiple recognised cases occurred in houses. Thus, there were two houses with two cases in each, one house with three cases, one house with four cases, and one house with five cases. The statements made in the annual reports as to the number of persons attacked who shortly before their illness had eaten articles of food which come under suspicion as a possible cause may be thus summarised:— In Paddington, watercress and winkles in one case, and oysters in two cases. In Kensington, shellfish in a few cases, oysters in seven. In Fulham there was strong ground for suspecting shellfish in two cases. In Chelsea in one case the consumption of oysters at Yarmouth was regarded as the cause of the illness. In Westminster in four cases there was direct evidence of probable infection from shellfish, and Dr. Allan heard of persons in other boroughs attacked after eating shellfish in Westminster. In Stoke Newington in one case the evidence pointed to watercress. In Holborn one case was attributed to the eating of raw cockles at Whitstable, another to raw mussels, one was probably due to eating oysters, two had eaten fried fish, and one watercress. In Finsbury nine persons attributed their illness' to shellfish. In Shoreditch a woman developed enteric fever after eating cockles with a friend at Southend. This woman's husband was employed by the friend's husband in London, and the friend's husband and probably her son also subsequently developed enteric fever. In Bethnal Green eight persons who were attacked were in the habit of eating shellfish, seven fried fish, three ate watercress, three ice cream, one mussels and fried fish, and one watercress and fried fish. In Poplar, in twelve cases eating of shellfish was suspected, and in two of these cockles had been eaten at Southend. In Bermondsey shellfish had recently been eaten in three cases. In Lambeth in twenty-three cases there was a history of shellfish having been eaten from one to three weeks before attack. In Battersea there was reason for suspecting shellfish in six cases, viz., oysters in four cases, cockles in one, and mussels in one case. Of the above, two patients had eaten Emsworth oysters, and one mussels from Leigh-on-Sea. In Wandsworth shellfish had been eaten in eleven cases, watercress in five, and ice cream in two cases. In Camberwell it was possible in some instances to ascribe infection to cockles or other shellfish, and in others ice cream had been eaten. In Deptford, infection was thought to be due to the eating of oysters in two cases, and mussels in two cases. In Greenwich, suspected articles of food had been eaten at about the critical period in thirteen cases, viz., shellfish five (one oysters, and another cockles at Southend), one fried fish and winkles, one fried fish and stewed eels, two fried fish, three mackerel, and one eels and haddocks. In Woolwich one had eaten oysters at Dinard, one oysters and mussels, two mussels, three had eaten watercress, and two were in the habit of eating fried fish. The Widal test was employed with the results stated in the following districts— District. Examined. Positive. Paddington 19 10 Fulham 58 22 Westminster, City of 17 2 St. Pancras 72 26 Islington 53 14 Stoke Newington 5 4 Hackney 24 13 Shoreditch 7 2 Poplar 34 6 Bermondsey 17 6 Lambeth 60 11 Battersea 54 12 Wandsworth 9 1 Deptford 10 4 Greenwich 35 14 Woolwich 11 5 The seasonal prevalence of the disease in 1904 may be compared with that of the period 18901904 by reference to diagram XV. The sharp rise in the 34th-39th weeks in 1904 is largely due to increase in the number of cases of the disease in Hackney. Enteric fever—Age mid 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 1904. The case-rate at "all ages" was greater among males than among females, as were also the death-rate and fatality. In the age-groups adopted for the purposes of this table the greatest incidence of attack was upon both males and females aged 10-15. The greatest incidence of death was upon males aged 25-35 and upon females aged 20-25. The fatality was greatest among males aged 35-45 and among females aged 55 and upwards. 6108] f 38 Enteric fever 1904. 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. 1,036 180 17.4 47 8 860 121 14.1 35 5 0— 3 1 1 1— 1 — 1 — 2— 5 — 8.2 19 2 7 — 3.1 13 — 3— 20 2 7 — 4— 20 1 16 1 5— 127 8 6.3 56 4 110 7 6.4 48 3 10— 180 15 8.3 85 7 114 14 12.3 53 6 15— 148 17 11.5 69 8 109 12 11.0 46 5 20— 150 25 16.0 16.0 70 11 130 19 14.6 49 7 25— 200 54 27.0 53 14 201 28 13.9 45 6 35— 110 36 32.7 38 13 95 19 20.0 30 6 45— 47 15 31.9 23 7 49 12 24.5 22 5 55 and upwards 19 6 316 10 3 20 9 45.0 8 3 Diarrhœa. The deaths in the administrative county of London attributed to epidemic diarrhoea and infective enteritis numbered 2,856 in 1904 (52 weeks), while 1,945 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 diarrhœa (infective enteritis) 2,347 457 5 2 10 29 6 2,856 Diarrhœa and dysentery 1,374 250 15 41 80 147 38 1,945 Total 3,721 707 20 43 90 176 44 4,801 No accurate comparison of the deaths from epidemic diarrhœa for a long series of years in London can be made; diagram XVII., however, shows the deaths from cholera, dysentery, and diarrhœa combined, in relation to the mean of the period 1841-1904 in each year since 1840. The death rate from these causes was higher in 1904 than in any year since 1876, and the death rate of the third quarter of the year, the period in which the greatest proportion of the deaths occur, was higher than in any year since 1873. The following table shows that the London diarrhœa death-rate was in the decennium 1894-1903, lower than the death-rate of any of the undermentioned large English towns except Bristol and Newcastle and in the year 1904, was lower than that of any except Leeds, Bristol, Bradford and Newcastle. Diarrhœa—Death rates per 1,000 living. Towns. 1894-1903. 1904. Towns. 1894-1903. 1904. London 0.782 1.042 Bradford 0.80 0.83 Liverpool 1.42 2.52 West Ham 1.23 2.08 Manchester 1.34 1.37 Hull 1.46 2.08 Birmingham 1.27 1.76 Nottingham 1.18 1.37 Leeds 1.04 0.99 Salford 1.55 1.66 Sheffield 1.42 1.35 Newcastle 0.78 0.51 Bristol 0.62 0.51 Leicester 1.31 1.31 1 See footnote (2) page 28. 2 See footnote (2) page 7. Diarrhœa, Dysentery and Cholera Diagram XVII. 39 The deaths and death-rates from diarrhoea for the year 1904, and the death rates for the period 1901-3 in each of the sanitary areas in London are shown in the following table :— Sanitary area. Deaths, 1904. Death-rate per 1,000 persons living. 1901-3. 1904. Paddington 132 0.59 0.90 Kensington 139 0.57 0.78 Hammersmith 121 0.79 1.03 Fulham 224 1.12 1.47 Chelsea 46 0.49 0.62 Westminster, City of 84 0.33 0.48 St. Marylebone 108 0.58 0.83 Hampstead 21 0.19 0.24 St. Pancras 183 0.52 0.78 Islington 248 0.41 0.73 Stoke Newington 26 0.41 0.50 Hackney 249 0.58 1.10 Holborn 41 0.51 0.72 Finsbury 123 0.88 1.25 London, City of 4 0.24 0.17 Shoreditch 189 1.23 1.62 Bethnal Green 162 0.74 1.25 Stepney 403 0.95 1.33 Poplar 272 0.96 1.61 Southwark 282 0.94 1.36 Bermondsey 200 0.83 1.55 Lambeth 316 0.73 1.02 Battersea 198 0.78 1.13 Wandsworth 225 0.52 0.88 Camberwell 246 0.63 0.92 Deptford 124 0.75 1.10 Greenwich 110 0.65 1.09 Lewisham 115 0.55 0.82 Woolwich 159 0.61 1.29 London 4,750 0.68 1.021 It will be seen from the foregoing table that the diarrhœa death-rate was in the period 1901-3 highest in Shoreditch (1-23) and lowest in Hampstead (0-19); in the year 1904, Shoreditch had again the highest death-rate (1-62) the lowest obtaining in the City of London (0-17). The diarrhœa deathrates in London in each of the four quarters of the year 1904, were as follows: first quarter, 0-21; second quarter,0-21 ; third quarter, 3-39 ; and fourth quarter 0-29 per 1,000 persons living. The deaths from erysipelas in the Administrative County of London registered during 1904 (52 weeks) numbered 232. 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 persons living. Deaths.2 Death-rate per 1,000 persoEs 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 .5 1900 4,762 1.06 182 .04 1901 4,604 1.02 171 .4 1902 5,536 1.19 183 .04 1903 4,372 0.95 183 .4 1904 4,943 1.08 232 .05 1 See footnote (l) page 7. 2 See footnote (2) page 7. 6108] f2 40 The number of cases of erysipelas notified and the case-rate for the year 1904, together with the case-rate in the decennium 1894-1903, in the several sanitary areas are shown in the following table— Sanitary area. Cases 1904 Case-rate per 1,000 persons living. 1894-1903. 1904. Paddington 117 1.0 0.8 Kensington 141 1.2 0.8 Hammersmith 123 1.0 1.1 Fulham 130 1.0 0.9 Chelsea 45 0.9 0.6 Westminster, City of 126 0.8 0.7 St. Marylebone 187 1.6 1.4 Hampstead 56 0.7 0.6 St. Pancras 258 1.4 1.1 Islington 280 1.0 0.8 Stoke Newington 53 . 0.8 1.0 Hackney 266 1.3 1.2 Holborn 76 1.8 1.3 Finsbury 106 1.6 1.1 London, City of 21 0.9 0.9 Shoreditch 177 1.6 1.5 Bethnal Green 224 2.2 1.7 Stepney 467 1.5 1.5 Poplar 204 1.4 1.2 Southwark 298 1.4 1.4 Bermondsey 186 1.4 1.4 Lambeth 248 1.0 0.8 Battersea 160 1.3 0.9 Wandsworth 270 1.1 1.1 Camberwell 328 1.1 1.2 Deptford 151 1.3 1.3 Greenwich 86 1.2 0.8 Lewisham 83 0.8 0.6 Woolwich 75 0.8 0.6 Port of London 1 — — London 4.943 1.2 1.1 The following table shows the age and sex distribution of the notified cases of erysipelas in 1904— Ago. All ages. 0- 5- 10- l5 20- 25- 35- 45- 55- 65- 75 and upwards. Males 2,163 182 98 89 111 125 304 425 382 264 132 51 Females 2,780 202 123 131 180 187 384 445 497 332 198 101 Persons 4,943 384 221 220 291 312 688 870 879 596 330 152 The table shows, so far 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 female3 attacked exceeds the number of males attacked. Puerperal Fever. The deaths in the Administrative County of London in the year 1904 (52 weeks) attributed to puerperal fever 1 numbered 198. The number of cases notified and the number of deaths registered from this cause since the year 1890 have been as follows— Puerperal fever. Year. Notified cases. Deaths.2 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 1904 273 198 1 Including deaths from puerperal septicseinia and puerperal pyaemia. 2 See footnote (2), page 7. 41 If these cases and deaths are considered in relation to the total population and total births the following rates are obtained— Year. Case-rate per 1,000 living. Case-rate per 1,000 birth". Death-rate' per 1,000 living. Death-rate per 1,000 births. 1891 .05 1.64 .05 1.65 1892 .08 2.55 .07 2.37 1893 .09 2.98 .08 2.65 1894 .06 1.92 .05 1.60 1895 .05 1.76 .05 1.56 1896 .06 2.04 .05 1.66 1897 .06 1.98 .05 1.61 1898 .05 1.86 .04 1.39 1899 .07 2.45 .05 1.57 1900 .05 1.81 04 1.29 1901 .06 1.93 .04 1.40 1902 .07 2.34 .04 1.51 1903 .05 1.78 .04 1.30 1904 .06 2.11 .04 1.53 Influenza, Bronchitis and Pneumonia.j The deaths attributed to influenza, which in 1903 numbered 644, rose in 1904 to 709. The deaths from bronchitis in 1904 numbered 6,373, compared with 5,240 deaths in the preceding year. The deaths from pneumonia numbered 6,609 in 1904, compared with 5,826 deaths in the vear 1903. The deaths from these diseases since 1899 have been as follows- Year. Deaths1 from Influenza. Deaths1 from Bronchitis. Deaths1 from Pneumonia. 1890 652 12,448 6,224 1891 2,336 13,136 6,915 1892 2,264 11,183 6,164 1893 1,526 10,413 7,198 1894 750 7,816 5,321 1895 2,156 10,633 5,989 1896 496 7,558 5,537 1897 671 7,408 5,053 1898 1,283 7,779 5,440 1899 1,817 9,195 6,666 1900 1,950 8,699 7,189 1901 664 7,317 6,121 1902 1,073 7,901 6,788 1903 644 5,240 5,826 1904 709 6,373 6,609 The distribution of deaths from influenza throughout the year for each of the years 1890 to 1904 is shown in the following table:— Influenza—Deaths registered in London in four-weekly periods, 1890-1904. Number of weeks. 1890. 1891. 1892. 1893. 1894. 1895. 1896. 1«97. 1898. 1899. 1900. 1901. 1902. 1903. 1904. 1—4 303 9 1,308 52 272 59 37 40 244 66 1,016 57 77 141 67 5—8 167 7 637 96 96 164 58 55 368 259 298 75 224 103 62 9—12 75 8 119 162 69 1,343 61 94 193 430 130 134 298 89 74 13—16 39 29 42 180 56 257 50 121 140 302 172 102 89 54 62 17—20 13 770 33 125 32 106 50 96 61 121 105 81 58 46 40 21—24 5 1,044 22 72 27 35 33 54 51 82 57 30 35 37 21 25—28 6 242 15 49 19 28 17 26 25 42 16 21 20 25 17 29—32 6 51 7 23 17 14 15 18 27 27 12 18 7 18 5 33—36 3 32 9 23 20 17 10 13 10 11 11 11 16 6 9 37—40 6 13 6 18 14 15 12 19 17 19 15 12 13 17 24 41—44 5 15 20 28 29 22 27 29 46 55 17 23 35 13 92 45—48 13 35 18 152 41 47 56 35 49 61 55 44 65 44 98 49—522 6 81 28 546 58 49 56 71 52 342 46 56 99 51 138 1 Sec footnote (2) page 7. 2 The deathK occurring in the 53rd week of the yoars 1890, 1896 and 1902 aro excluded from these figures. 42 Phthisis. The deaths from phthisis in the Administrative County of London during 1904 (52 weeks), numbered 7,526, as compared with 7,124 in 1903. The death-rates from this disease in successive periods per 1000 living have been as follows:— 1851-60 2.86 1901 l.661 1861-70 2.84 1902 1.601 1871-80 2.51 1903 1.551 1881-90 2.09 1904 1.621 1891-1900 1.84 The following table shows the crude phthisis death-rate corrected for differences in the age and sex constitution of the various sanitary districts. The factors for correction, also shown in the table, have been calculated by applying the population at each age and for each sex of each of the London sanitary districts to the death-rates at each age and for each sex obtaining for London in the five years 1897-1901 — Crude and corrected Phthisis death-rates per 1.000 persons living, in the County of London and the several sanitary districts. Sanitary area. Standard death rate. Factor for correction for age and sex distritribution. Crude death-rate. Corrected death-rate. Comparative mortality figure. (London 1,000.) 1901-3. 1904. 1901-3. 1904. 1901-3. 1&04. London 1.74 1 .00000 1.60 1.621 1.60 1.62 1,000 1,000 Paddington 1.80 0.96659 1.07 1.20 1.03 1.16 644 716 Kensington 1.78 0.97419 1.30 1.44 1.27 1.40 794 864 Hammersmith 1.74 0.99600 1.44 1.38 1.43 1.37 894 846 Fulham 1.69 1.02786 1.38 1.43 1.42 1.47 887 907 Chelsea 1.83 0.95018 1.57 1.82 1.49 1.73 931 1,068 Westminster, City of 1.95 0.89205 1.79 1.52 1.60 1.36 1,000 840 St. Marylebone 1.85 0.93836 1.88 1.68 1.76 1.58 1,100 975 Hampstead 1.75 0.98862 0.83 0.83 0.82 0.82 512 506 St. Pancras 1.80 0.96551 1.86 1.88 1.80 1.82 1,125 1,123 Islington 1.75 0.99145 1.47 1.55 1.46 1.54 912 951 Stoke Newington 1.77 0.97914 1.28 1.72 1.25 1.68 781 1,037 Hackney 1.68 1.02969 1.41 1.39 1.45 1.43 906 883 Holborn 1.97 0.87894 2.99 2.86 2.63 2.51 1,644 1,549 Finsbury 1.72 1.01050 2.25 2.39 2.27 2.42 1,419 1,494 City of London 1.89 0.91946 1.86 1.58 1.71 1.45 1,069 895 Shoreditch 1.66 1.04206 2.12 2.18 2.21 2.27 1,381 1,401 Bethnal Green 1.59 1.08984 2.08 2.16 2.27 2.35 1,419 1,451 Stepney 1.65 1.05281 2.03 2.12 2.14 2.23 1,337 1,377 Poplar 1.66 1.04772 1.74 1.74 1.82 1.82 1,137 1,123 Southwark 1.74 0.99829 2.51 2.36 2.51 2.36 1,569 1,457 Bermondsey 1.65 1.05026 1.80 2.12 1.89 2.23 1,181 1,377 Lambeth 1.75 0.99258 1.58 1.45 1.57 1.44 981 889 Battersea 1.69 1.02483 1.35 1.42 1.38 1.46 862 901 Wandsworth 1.72 1.01050 1.00 1.12 1.01 1.13 631 698 Camberwell 1.68 1.03522 1.40 1.37 1.45 1.42 906 877 Deptford 1.69 1.02969 1.22 1.42 1.26 1.46 787 901 Greenwich 1.67 1.04143 1.16 1.33 1.21 1.39 756 858 Lewisham 1.69 1.02543 0.60 0.90 0.62 0.92 387 568 Woolwich 1.70 1.01881 1.57 1.67 1.60 1.70 1,000 1,049 The following table shows the number of deaths from phthisis at several age periods in each of the sanitary areas. For the purposes of this table deaths occurring in public institutions belonging to London have been distributed to the sanitary areas in which the ueceased had previously resided (see footnote(1), page 7). Phthisis (366 days). Age-period. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65 75- 85 and upwards All ages. Paddington 3 3 2 9 21 38 32 42 17 ll 1 - 179 Kensington 14 2 6 19 13 51 55 54 22 14 — 1 251 Hammersmith 6 2 4 9 15 37 45 29 12 — 1 — 160 Fulham 7 5 — 12 25 48 65 31 19 5 . — - 217 Chelsea 7 1 1 1 11 30 30 34 11 2 3 - 131 Westminster, City of 2 1 1 5 16 55 71 63 31 16 4 265 St. Marylebone 8 3 2 14 13 40 59 44 22 7 3 1 216 1 See footnote (1) page 7. 43 Age period. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 8aaud tipwards All ages. Hampstead — — 1 4 9 17 15 15 9 3 — — 73 Sc. Pancras 16 5 8 29 28 97 102 102 41 16 3 — 447 Islington 25 5 11 26 57 114 123 111 40 19 1 — 532 Stoke Newington 3 1 — 4 9 21 26 13 10 2 — — 89 Hackney 9 1 5 17 17 74 72 73 40 6 2 — 316 Holborn 1 — 1 3 13 27 33 46 26 7 1 — 158 Finsbury 9 3 1 14 16 53 72 47 26 3 — — 244 London, City of 2 1 — — 3 9 11 3 5 - 2 — 36 Shoreditch 18 2 5 11 21 58 63 48 23 8 2 — 259 Bethnal Green 13 5 4 14 23 64 58 58 33 8 2 - 282 Stepney 23 5 10 25 58 122 166 158 57 21 2 1 648 Poplar 10 3 9 20 35 57 70 51 37 3 — — 295 Southwark 25 5 4 21 30 95 135 102 60 19 4 1 501 Bermondsey 10 3 11 19 16 51 72 55 32 7 1 — 277 Lambeth 14 4 8 15 42 89 126 85 41 19 5 — 448 Battersea 6 3 7 15 31 54 50 51 25 7 1 — 250 Wandsworth 3 2 8 17 26 69 64 48 33 12 3 1 286 Camberwell 11 3 7 25 39 78 84 64 36 10 2 — 359 Deptford 9 4 4 8 19 30 42 32 14 2 — — 164 Greenwich 3 2 2 8 12 28 41 23 13 5 — — 137 Lewisham 2 1 2 19 13 18 36 16 11 9 — — 127 Woolwich 2 2 4 11 20 56 49 38 19 4 2 — 207 London 261 77 128 394 651 1580 1867 1536 765 245 45 5 7554 The annual death rates show a marked decline in the mortality from phthisis in London. To what extent these figures would require correction if allowance could be made for more exact diagnosis during later years it is impossible to say. In this connection it is well to remember that since Koch's discovery of the tubercle bacillus in the decennium 1881-90, the microscope has been increasingly used for the diagnosis of tubercular phthisis. There is, however, much reason for thinking that there has been substantial decline in the mortality from this disease. Accepting the figures obtained from registration of deaths, the following observations may be made. The London death-rate from phthisis at all ages has with but slight exception been greater than that of England and Wales, but at ages from 15-35 years among females, and ages 15-25 among males, with the exception of the decennium 1891-1900, has been less in London than England and Wales, and as will be seen from the following tables, has declined less both in males and in females in London than in England and Wales at each age shown. In both England and Wales and London the decline has been much greater among females than males but this has been specially marked in England and Wales where in 1851-60 and in 1861-70 the female mortality at "all ages" was greater than the male, and in 1891-1900 was lower, whereas throughout the whole period under review the male mortality in London has been higher than the female mortality. England and Wales. Phthisis. Death rates per 1,000 living at certain age periods. Males. Decennia. 0- 15- 25- 35- 45- 55- 65 + All ages. 1851-60 0.896 3.184 4.034 4.005 3.830 3.333 1.970 2.579 1861-70 0.693 2.985 4.094 4.166 3.861 3.297 1.644 2.467 1871-80 0.547 2.339 3.699 4.120 3.860 3195 1.562 2.209 1881-90 0.389 1.772 3.024 3.562 3.488 2.916 1.512 1.847 1891-1900 0.286 1.406 2.353 3.074 3.126 2.602 1.301 1.574 Females. Decennia. 0- 15- 25- 35- 45- 55- 65 + All ages. 1851-60 1.067 3.900 4.575 4.175 3.120 2.383 1.350 2.774 1861-70 0.821 3.533 4.378 3.900 2.850 2.065 1.001 2.483 1871-80 0.654 2.760 3.543 3.401 2.464 l.777 0.891 2.028 1881-90 0.510 2.050 2.787 2.730 2.053 1.512 0.807 1.609 1891-1900 0.373 1.432 1.909 2.106 1.633 1.232 0.670 1.209 44 London. Phthisis. Death rates per 1,000 living. Males. Decennia. 0- 15- 25- 35- 45- 55- 65 + All ages. 1851-60 0.947 2.874 4.530 5.953 6.096 5.116 3.173 3.290 1861-70 0.910 2.903 4.793 6.183 6.380 5.314 2.792 3.350 1871-80 0.658 2.295 4.494 6.035 6.114 4.958 2.303 3.002 1881-90 0.441 1.716 3.800 5.298 5.474 4.637 2.335 2.547 1891-1900 0.351 1.474 3.023 4.820 5.146 4.369 2.364 2.302 Females. Decennia. 0- 15- 25- 35- 45- 55- 65 + All ages. 1851-60 1.038 2.476 3.682 4.121 3.295 2.411 1.377 2.492 1861-70 0.970 2.331 3.698 4.097 3.208 2.299 1.165 2.397 1871-80 0.723 1.939 3.242 3.862 3.015 2.069 0.971 2.076 1881-90 0.511 1.416 2.595 3.241 2.582 1.819 0.910 1.659 1891-1900 0.407 1.073 1.853 2.747 2.293 1.596 0.900 1.355 England and Wales. Comparative phthisis death-rates. Death-rates of 1851-60 taken as 1,000. Males. Decennia. 0- 15- 25- 35- 45- 55- 65 + All ages. 1851-60 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1861-70 774 938 1,015 1,040 1,008 989 835 956 1871-80 611 735 917 1,029 1,008 958 793 857 1881-90 434 557 750 889 911 875 768 716 1891-1900 .. 319 442 583 768 816 781 660 610 Females. Decennia. 0- 15- 25- 35- 45- 55- 65+ All ages. 1851-60 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1861-70 770 906 957 934 914 867 741 895 1871-80 613 708 775 815 790 746 660 731 1881-90 478 526 609 654 658 635 598 580 1891-1900 350 367 417 504 523 517 496 436 London. Comparative phthisis death-rates. Death-rates of 1851-60 taken as 1,000. Males. Decennia. 0- 15- 25- 35- 45- 55- 65 + All ages. 1851-60 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1861-70 961 1,010 1,058 1,039 1,047 1,039 880 1,018 1871-80 695 799 992 1,014 1,003 969 726 912 1881-90 466 597 839 890 898 906 736 774 1891-1900 371 513 667 810 844 854 745 700 Diagram. XVIII. —Phthisis (Mortality). Phthisis (Seasonal mortality 1895.1904.) Diagram XIX. 45 Females. Decennia. 0. 15. 25. 35. 45. 55. 65 4. All ages. 1851.60 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1861.70 935 942 1,004 991 974 954 846 962 1871.80 697 783 881 937 915 859 705 833 1881.90 492 572 705 786 783 755 661 666 1891.1900 392 433 503 667 696 662 654 544 A table published in the sixtieth report of the Registrar.General enables comparison between the deaths at ages 10.15, 15.20, 20.25 and 25.35 in successive decennia, to be made for the provinces and London, and it is there pointed out that at each of these ages the death rates of females in the provinces was in excess of those in London, but that this difference was a decreasing one ; also that, in less degree, the same disparity attaches to young males. Explanation of the difference between the death rates at younger ages of the provincial and London populations is probably, as pointed out by Dr. Tatham, to be found in the tendency of persons of this age, when they are not tied to town by the responsibilties of a family to return to their homes in the country when failing in health from phthisis. Some further explanation is, however, necessary to account for the observed fact that the difference between the rates in the provinces and London at these ages is decreasing. Reference to diagram XVIII. shows the decline in the mortality from phthisis in the two sexes in London and the greater decline in the female mortality is conspicuous. The diagram also shows that the decline has been subject to slight interruptions to which climatic conditions may perhaps contribute this is especially suggested by diagram XIX. showing seasonal mortality, from which it will be seen that the maximum mortality occurs at the beginning and end of the year, the mortality being at a minimum in the summer months. The measures which are being adopted for the prevention of phthisis mortality include the adoption of such precautions as can be taken in view of the generally accepted opinion that the disease is communicable from one person to another by means of the sputum of those who are suffering from this malady. The County Council has made a by.law forbidding expectoration on the floors and walls of public conveyances, public halls, waiting rooms and places of entertainment. Efforts are being made to teach phthisical patients to expectorate into suitable receptacles, and sanitary authorities are encouraging the notification to their medical officers of health of cases of phthisis occurring in their districts. At a conference of sanitary authorities held at the County Hall in 1904, a resolution was adopted that a system of voluntary notification is desirable and should be made general throughout London. In London at the present time a system of voluntary notification of phthisis is established as follows— Districts in which phthisis is notified— Kensington St. Marylebone Southwark Hammersmith Islington Bermondsey Fulham Stoke Newington Lambeth Chelsea Holborn Wandsworth Westminster, City of Finsbury Greenwich Hampstead London, City of Woolwich Districts in which phthisis is not notified— Paddington Stepney Deptford Hackney Poplar Lewisham Shoreditch Battersea St. Pancras Bethnal Green Camberwell Thus in eighteen of the twenty.nine sanitary areas of London this system has been adopted. The sufferers thus notified are visited and advised as to the precautions which should be taken in their homes and when not objected to. disinfection of the premises follows removal or death. In many of the annual reports the number of cases notified during the year is stated, and the following figures are thus supplied— District. Number of cases notified. District. Number of cases notified. District. Number of cases notified. Kensington 203 Stoke Newington 53 Lambeth 306 Hammersmith 143 Holborn 344 Wandsworth 118 Fulham 165 Finsbury 210 Greenwich 123 Chelsea 16 Southwark 323 Woolwich 186 Westminster, City of 148 Bermondsey 128 In the annual reports relating to Stoke Newington and Finsbury the opinion is expressed that much of the value of notification is lost owing to the fact that notice of the existence of the illness is not given until it has reached an advanced stage. In some reports, moreover, the need for compulsory notification is urged. In 1903 Sheffieldeld obtained parliamentary powers for this purpose, and 6108] G 46 experience of the advantages and disadvantages of compulsory notification will thus eventually be available. In a few of the reports information is afforded as to association of the cases under consideration with antecedent cases of phthisis in such a way as to suggest infection of the former by the latter. Thus Dr. Allan analyses cases in Westminster which came to his knowledge and shows that of 18 cases with a history of tuberculosis in a previous generation 10 had been in contact with tubercular members of the family, and of 54 cases without history of tuberculosis in previous generations, 20 had been in contact with tubercular members of the family and 4 in contact with other tubercular associates. Dr. Newman, writing of deaths from phthisis is Finsbury, states that 111 out of 251 were infected by relatives, or 44.2 per cent. of the total. He adds :— " When it is considered that there may be no outward signs of early phthisis, that it is frequently to the patient's interest to conceal the disease, and that the greater number of cases go about for years without medical attendance, or are detected only in the later stages or at death, this percentage of casos where a definite history of personal contact was made out must be counted as high. In many of these cases the history indicated family infection through anveral generations. The number of casos with a history of probable infection by persons not related must always be small, since it is the cause of death among relatives which in the greator number of instances furnishes the clue to infection, and this clue is always wanting when the history of fellow workmen, lodgers, etc., in past years are inquired into. But there is abundant evidence to show that iufection may be dorivod from other sources." He gives, moreover, a table showing the number of previous cases of phthisis notified or having died in former years in the same house as those in which cases occurred which became known to him in 1904, and he points out that "79 deaths in that year occurred in houses already infected," and that " 18 cases occurred in houses where there had been no less than five previous cases." And again, Dr. Davies attributes the source of infection in 100 cases of 186 notified in Woolwich during the year as follows :—To relatives 41, lodgers 24, to infection in public houses 35, and suggests other causes for another eleven, and he points out that 30 per cent. of 140 adults were allowed by themselves or their friends to be intemperate. It should be pointed out that these observed facts as to sources of infection need to be considered in relation to the mathematical probability of their occurrence apart from some special cause. The insufficiency of provision for the reception of cases of phthisis when badly circumstanced at home is commented upon in some of the reports. Dr. Kenwood, writing on phthisis in Stoke Newington comments on the fact that it has often happened that a patient in the last stages of the disease has had to occupy a room shared by several others. In these cases, he says, " no suggestion which I was able to make could do away with the enormous risks the other occupants were daily called upon to face." Dr. Davies, discussing the same question, points out that " when the patient is the bread.winner, the illness means usually cessation of wages, and he consequently becomes destitute and goes to the infirmary as a matter of course. When, however, the patient is the wife of the breadwinner, and in other cases where there is no destitution, there is no legal claim on the Guardians for poor law relief; nevertheless, such cases may be, and frequently are, received into the infirmary, and often the cost of the maintenance is partly or wholly recovered from the persons responsible. In such cases, however, admission becomes a matter of special consideration; some cases are admitted and others refused, and unfortunately the worst cases from the public health point of view are sometimes refused admission." He suggests therefore, that until special provision is made, Boards of Guardians should assist sanitary authorities in providing facilities for the removal from their homes of advanced cases of this disease While it cannot be said that there is unanimity of opinion as to which are the principal factors concerned in the production of phthisis, there is no doubt a considerable consensus of opinion that cases of phthisis may act as sources of disease to those who are intimately associated with them, especially in crowded tenements where no separate sleeping accommodation can be provided for the sick. Certainly there is need for bringing the opportunities for institutional treatment into relation with the home necessities of the sufferers, and in so far as there may be dearth of accommodation in institutions, there is need for selection of the cases which most need to be removed from their homes, the object aimed at in dealing with advanced cases being rather to protect those associated with the patient in his home than to benefit the sufferer himself. If it be possible to express the relative value which is now deemed to attach to sanatorium treatment, which aims at cure, and institutional treatment, which aims at prevention of infection, it may be said that while many cases of phthisis undoubtedly derive benefit from treatment in sanatoria, the value of sanatoria in effecting permanent cure is regarded as less than it was thought to be some years ago, and indeed much of its value is now thought to depend upon the opportunity it gives for the education of the patient in habits which reduce the risk to his family on his return to his home. Treatment in institutions, on the other hand, in providing the means of isolation and of education in the sense mentioned, is now deemed to be of the first importance. Whatever view may be taken of the possibility of reducing phthisis prevalence by the segregation of persons whose expectoration is charged with tubercle bacilli, no doubt is entertained of the greater susceptibility of some persons than others to attack by phthisis, and while racial susceptibility and family susceptibility are recognised, the greater liability to attack of the badly housed and especially the badly fed is a factor which must be reckoned with in any attempt to reduce the mortality from this disease. Hence the need not only for attention to be directed to the care of the patient, but for the well.being of the family to be ensured, so far as that may be found possible, and for the organisation of philanthropic effort in such way that it may be brought into relation with the work of the medical officer of health and made available in suitable cases. Phthisis in large degree is a disease of poverty, and in so far as the social condition of the people is improved, the risk of attack by phthisis is lessened for all. 47 Cancer. The deaths from cancer in the Administrative County of London during 1904 (3G6 days) numbered 4.278. The death.rates of this disease per 1,000 persons living in successive periods have been as follows)— Period. Rate. Period. Rate. 1851.60 0.42 1901 0.881 1861.70 0.48 1902 0.931 1871.80 0.55 1903 0.961 1881.90 0.68 1904 0.921 1891.1900 0.85 For the purpose of enabling the incidence of cancer on the several populations of the sanitary areas to be more precisely stated, factors have been calculated for correcting the death.rates, 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 sanitary area, corrected by their application. Owing to the changes of area in the sanitary districts of London, caused by the London Government Act of 1899, the death.rates 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. Cancer. Crude and corrected death.rates per 1,000 persons living in the County of London and the several sanitary districts. Sanitary areas. Standard death. rate. Factor for correction for age and sex distribution. Crude death.rate. Corrected death.rate. Comparative mortality figure (London 1,000). 1901.3. 1904. 1901.3. 1904. 1901.3. 1904. London 0.87 1.00000 0.92 0.921 0.92 0.92 1,000 1,000 Paddington 0.98 0.89478 1.04 1.09 0.93 0.98 1,011 1,065 Kensington 1.02 0.85622 1.03 1.02 0.88 0.87 957 946 Hammersmith 0.90 0.96811 0.85 1.01 0.82 0.98 891 1,065 Fulham 0.77 1.13828 0.81 0.85 0.92 0.97 1,000 1,054 Chelsea 1.03 0.84874 1.07 1.22 0.91 1.04 989 1,130 Westminster, City of 0.96 0.91348 0.98 1.02 0.90 0.93 978 1,011 Marylebone 099 0.88571 1.16 1.10 1.03 0.97 1,120 1,054 Hampstead 0.92 0.94816 1.11 0.98 1.05 0.93 1,141 1,011 St. Pancras 0.92 0.95229 0.99 0.97 0.94 0.92 1,022 1,000 Islington 0.90 0.96704 0.99 0.96 0.96 0.93 1,043 1,011 Stoke Newington 0.98 0.89387 0.95 1.03 0.85 0.92 924 1,000 Hackney 0.88 0.99341 0.86 0.84 0.85 0.83 924 902 Holborn 0.95 0.91924 1.02 0.94 0.94 0.86 1,022 935 Finsbury 0.84 1.04071 0.83 0.83 0.86 0.86 935 935 London, City of 1.06 0.82316 1.29 1.41 1.06 1.16 1,152 1,261 Shoreditch 0.79 1.10518 0.90 0.78 0.99 0.86 1,076 935 Bethnal Green 0.78 1.12077 0.85 0.87 0.95 0.98 1,033 1,065 Stepney 0.74 1.17976 0.73 0.76 0.86 0.90 935 978 Poplar 0.81 1.08327 0.80 0.71 0.87 0.77 946 837 Southwark 0.82 1.06350 0.89 0.85 0.95 0.90 1,033 978 Bermondsey 0.81 1.08162 0.83 0.73 0.90 0.79 978 859 Lambeth 0.92 0.95333 1.01 1.03 0.96 0.98 1,043 1,065 Battersea 0.79 1.10798 0.84 095 0.93 1.05 1,011 1,141 Wandsworth 0.88 0.99116 0.95 0.99 0.94 0.98 1,022 1,065 Camberwell 0.87 1.00483 0.92 0.88 0.92 0.88 1,000 957 Deptford 0.81 1.07396 0.90 0.94 0.97 1.01 1,054 1,098 Greenwich 0.87 1.01064 0.77 0.86 0.78 0.87 848 946 Lewisham 0.92 0.95333 0.93 0.85 0.89 0.81 967 880 Woolwich 0.78 1.11933 0.78 0.83 0.87 0.93 946 1,011 The following tables (a), (b), and (c) show the deaths in each of the sanitary districts from cancer at several age-periods under three headings, viz., sarcoma, carcinoma, and cancer, deaths classified under the last named term being those for which the information given on the certificate of death was insufficient to further distinguish them for purposes of classification. (1) See footnote (1) page 7. 6108] G 2 48 (a) Deaths' from Sarcoma. Age period. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 and upwards All age«. Paddington 1 — — — — — 3 5 5 2 2 18 Kensington 1 1 — — 1 2 2 1 1 3 — 1 13 Hammersmith — — — — 1 — 1 1 — 2 — — 5 Fulham — — — — — 1 2 — 3 — — — 6 Chelsea 2 — — — — 3 — 1 — 1 — — 7 Westminster, City of — 2 1 — — 2 2 1 2 1 1 — 12 St. Marylebone 1 — — — 1 — 2 4 2 1 1 — 12 Hampstead 2 1 — — — 1 — — — 2 1 — 7 St. Pancras 1 — — — 1 — 1 1 6 1 2 — 13 Islington — 1 1 — 1 3 2 4 6 3 2 2 25 Stoke Newington — — — — — 1 1 — 1 2 — — 5 Hackney 2 1 — — 1 — — 2 2 — 1 — 9 Holborn — — — — — — 1 — 1 — — — 2 Finsbury — — 1 — — 1 1 — 1 — — — 4 London, City of — — — — — — — 1 — — — — 1 Shoreditch — — — 1 — — — 1 1 — 1 — 4 Bethnal Green — — — 1 — — — 1 1 2 1 — 6 Stepney 1 — 1 1 — 2 1 6 4 4 1 — 21 Poplar 1 — — 1 — 2 — 3 4 1 1 1 14 Southwark — 1 — 2 1 — 1 4 1 — — — 10 Bermondsey 3 — — '— — 1 2 1 1 — — — 8 Lambeth 2 1 1 — 2 1 4 3 5 5 2 — 26 Battersea 1 1 — — — — 1 — 1 1 1 — 6 Wandsworth 2 2 — — — — 4 2 5 — — 1 16 Camberwell — — 1 1 — — 2 4 3 4 — — 15 Deptford — — 1 — — — — 1 2 — 1 — 5 Greenwich — — — — — — 1 1 3 1 — — 6 Lewisham — — 1 — — — — 2 1 1 1 — 6 Woolwich — 1 — 2 2 — 1 1 1 1 — — 9 London 20 12 8 9 11 20 35 51 63 38 17 7 291 (b) Deaths1 from Carcinoma. Age period. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 and upwards All age?. Paddington — — — — — 2 6 22 27 17 15 — 89 Kensington — — — — — 2 9 20 27 24 13 2 97 Hammersmith — — — — 1 3 11 13 20 15 7 2 72 Fulham — — — — — 4 15 24 20 21 6 — 90 Chelsea — — — — — — 5 15 13 11 6 — 50 Westminster, City of — — — — 1 1 6 19 33 24 11 2 97 St. Marylebone — — — — 1 4 2 19 16 16 4 1 63 Hampstead — — — — — 1 8 5 16 18 9 — 57 St. Pancras — — — — — 3 9 41 30 37 16 3 139 Islington — — — — — 7 26 28 37 44 12 1 155 Stoke Newington — — — — — 1 2 3 9 11 1 1 28 Hackney — — — — — 4 12 25 37 22 9 — 109 Holborn — — — — — 2 4 6 9 6 1 — 28 Finsbury — — — — 1 2 3 15 13 11 2 — 47 London, City of — — — — — 1 2 3 1 8 2 — 17 Shoreditch — — — — — — 5 13 22 10 2 — 52 Bethnal Green — — — — — 2 12 15 20 12 3 1 65 Stepney — — — — — 4 17 34 48 19 17 1 140 Poplar — — — — — 4 12 18 26 15 3 2 80 Southwark — — — — 1 3 4 18 30 17 28 10 1 112 Bermondsey — — — — — — 8 13 22 12 6 — 61 Lambeth — — — — 2 5 22 52 51 49 23 2 206 Battersea — — — — — 4 10 23 26 23 6 — 92 Wandsworth — — — — 1 3 13 20 42 32 17 2 130 Camberwell — — — — — 1 10 32 28 35 14 2 122 Deptford — — — — — 2 11 14 23 20 7 — 77 Greenwich — — — — — 3 3 10 12 13 7 — 48 Lewisham — — — — — — 8 22 19 21 7 3 80 Woolwich — 9 7 12 11 7 1 47 London — — — 1 10 69 278 561 676 585 243 27 2450 (1) See footnote (1) page 7. 49 (c) Deaths1 from Cancer (otherwise undistinguished). Age period. 0- 5- 10 - 15- 20- 25- 35- 45- 55- 65- 75- 85 and upward s All ages. Paddington 2 — — — — — 5 13 17 13 3 — 53 Kensington — — — — — 1 8 17 21 18 5 2 72 Hammersmith — — — — — 1 4 10 11 9 5 1 41 Fulham — — 1 — — — 7 8 9 6 2 — 33 Chelsea — — — — — — 2 9 12 6 5 — 34 Westminster, City of — — — — — 1 3 13 26 18 9 1 71 St. Marylebone — — — — — 1 7 13 13 21 13 — 68 Hampstead — — — — — — 2 2 4 11 2 — 21 Pancras — — — 1 1 2 9 14 29 17 5 — 78 Islington 1 — — 1 — 2 11 32 43 46 9 2 147 Stoke Newington — — 1 — — — 3 3 6 6 2 — 21 Hackney — — — — 1 2 10 19 12 20 9 — 73 Holborn — — — — — — 3 1 9 7 4 — 24 Finsbury 1 — — — — 1 5 4 11 7 1 1 31 London, City of — — — — — 1 1 3 5 1 2 2 15 Shoreditch — — — — — — 2 11 13 6 3 — 35 Bethnal Green — — — — — 3 3 5 12 14 4 1 42 Stepney — — 1 — — 5 6 25 15 16 2 1 71 Poplar — — — — — — 3 10 6 5 2 — 26 Southwark — — — — — — 4 19 16 11 4 1 55 Bermondsey 1 4 6 5 6 2 1 25 Lambeth 1 1 — 1 — 3 11 15 27 19 10 l 89 Battersea — — — — 2 1 4 13 21 19 7 1 68 Wandsworth — — — — — 1 13 25 32 20 15 2 108 Camberwell — — — — — — 11 25 32 18 10 2 98 Deptford — — — — — 1 1 2 9 6 6 — 25 Greenwich — — — — — — 5 16 7 3 1 1 33 Lewisham 4 4 7 12 7 — 34 Woolwich 1 — — — 2 6 7 15 12 3 — 46 London 6 1 3 3 4 29 157 344 445 373 152 20 1537 The following table shows the proportional age-distribution of the deaths in London classified under the three headings— Deaths at each age period per 1,000 deaths at "all ages." Age-period. All ages. Under 35- 35- 45- 55- 65- 75- 85 and upwards. Sarcoma 1,000 276 120 175 216 131 58 24 Carcinoma 1,000 33 113 229 276 239 99 11 Cancer 1,000 30 102 224 289 243 99 13 Total 1,000 48 110 223 277 233 96 13 With a view to showing whether there is any tendency, such as is exhibited by phthisis, for cancer mortality to have special incidence upon poor populations as compared with populations better circumstanced, the sanitary districts in London have been arranged in groups on the basis of the population living more than two in a room in tenements of less than five rooms. No doubt this is not an absolutely precise index of poverty, but it is sufficient for the purpose in view, which is to enable comparison of cancer rates to be made among populations living under varying social conditions. The following table shows that the incidence of cancer mortality in no way corresponds to the incidence of phthisis mortality, which appears to be largely governed by the social condition of the population. As between the accuracy diagnosis of cancer among the rich and the poor there may, of course, be differences, due to the greater ability of the former class to pay for skilled advice ; but in this connection it may be recollected that in London, where public institutions are within reach of all, any difference of this sort must be largely compensated or more than compensated, by the greater use of such institutions by the poorer classes. For the purpose of comparison, the phthisis death-rates of groups of districts arranged in the manner stated above are shown in a corresponding table. 1 Sea footnote (1) page 7 50 London, 1901-4. Cancer death-rates in relation to overcrowding (1901 census). Percentage of overcrowding in each group of sanitary areas. 1901-4 crude canter death. rate per 1,000 living. Standard death. rate. Factor for age and sex correction. Corrected death. rate. Corrected death rate (London, 100). Under 7.5 per cent. .936 .883 .99003 .927 101 7'5 to 12.5 per cent. .907 .864 1.01180 .918 100 12.5 to 20 per cent. .958 .921 .94919 .909 99 20.0 to 27.5 per cent. .988 .904 .96704 .955 104 Over 27.5 per cent. .798 .774 1.12946 .901 98 London .920 .874 1.00000 .920 100 London, 1901.4. Phthisis death-rates in relation to overcrowding (1901 census). Percentage of overcrowding in each group of sanitary areas. 1901-4 crude phthisis death. rate per 1,000 living. Standard death. rate. Factor for age and sex correction. Corrected death. rate. Corrected death. rate (London, 100). Under 7.5 per cent. 1.12 1.718 1.00991 1.13 70 7.5 to 12.5 per cent. 1.42 1.705 1.01761 1.44 89 12.5 to 20 per cent. 1.54 1.771 .97969 1.51 94 20.0 to 27.5 per cent. 2.16 1.805 .96124 2.08 129 Over 27.5 per cent. 2.12 1.651 1.05090 2.22 138 London 1.61 1.735 1 00000 1.61 100 It will be seen that correction for difference in the age and sex constitution of the population in five groups of districts diminishes the difference between the cancer death-rates of these groups ; similar correction of the phthisis death-rates emphasises the differences, and in the case of phthisis, in marked contrast with the case of cancer, the incidence of mortality closely follows the overcrowding. Bubonic Plague. During the year 1904 in no instance was any case of suspected bubonic plague brought to the notice of the Public Health department of the Council. Anthrax. During the year four deaths were registered from this cause. Nine cases of this disease during the year occurred in Bermondsey, and all the sufferers but one were employed in work which brought them into relation with foreign hides, in two instances with Cape goat-skins. One man worked at a contractor's dealing mostly with provisions, and is not known to have been associated with hides. Glanders. Two deaths occurred from glanders. One of the deaths was that of a man who had been employed as a farrier at stables where 400 horses were kept. Ten days before his attack a horse in the stables, suffering from glanders, had been slaughtered. The other that of a horsekeeper. Infectious Disease in Relation to the Age of Attendance at School. Since attention has been directed to the extent to which infectious disease is spread by school attendance, suggestion has been made that young children should be protected against this risk by being excluded from school, and recently definite proposals have been put forward that children under five years of age should be excluded from public elementary schools. The extent to which exclusion from school of children under five years of age in London would reduce infectious disease in the London population may be considered in respect of two diseases to the prevalence of which school attendance undoubtedly contributes, and cases of which are notified, viz., diphtheria and scarlet fever. During the last ten years the decline in the prevalence of these diseases during the August holiday has been pointed out in these reports, a decline which was most marked among children of the school age, and which was often observed to be manifested among children in the pre-school age, and in persons above school age, a week later than it was manifested among school-attending children, suggesting that a considerable proportion of the persons who suffer from these diseases at those ages receive their infection from children who have themselves been infected in school. The diminution of these diseases in August at several ages will be seen by reference to diagram XX., which is based on the number of cases notified in London in the ten years 1895.1904. Notified Cases 1895-1904 51 This behaviour of the two diseases suggests that a statement of the number of cases notified at each age in the months of June, July, August, September, and October during ten years in London would provide material which would at least give some indication, so far as these two diseases are con. carned, of the effect of the exclusion from school of children of any particular age. The following table has therefore been prepared:— Diphtheria, 1895-1904. Age period. Actual notifications. August. Hypothetical notifications. August. Difference. Difference per cent. 0— 176 193 + 17 + 9.7 1— 580 561 . 19 . 3.3 2— 752 780 + 28 + 3.7 3— 909 1,039 + 130 + 14.3 4— 808 1,110 +302 + 37.4 5— 757 1,084 + 327 + 43.2 6— 589 864 + 275 + 46.7 7— 462 713 + 251 + 54.3 8— 359 485 + 126 + 35.1 9— 297 417 + 120 + 40.4 10— 1,076 1,318 + 242 + 22.5 15— 616 687 + 71 + 11.5 20 + 1,208 1,340 + 132 + 10.9 All ages 8,589 10,591 + 2,002 + 23.3 Scarlet fever, 1895-1904. Age period. Actual notifications. August. Hypothetical notifications. August. Difference. Difference per cent. 0— 239 220 -19 - 79 1— 587 700 + 113 + 19.3 2— 1,144 1,190 + 46 + 4.0 3— 1,490 1,627 + 137 + 9.2 4— 1,494 1,837 +343 + 23.0 5— 1,366 1,997 + 631 + 46.2 6— 1,202 1,703 + 501 + 41.7 7— 1,045 1,554 + 509 + 48.7 8— 881 1,212 +331 + 37.6 9— 739 1,029 + 290 + 39.2 10— 2,316 3,209 +893 +38.6 15— 930 1,004 + 74 + 8.0 20 + 979 1,104 + 125 + 12.8 All ages 14,412 18,386 + 3,974 +27.6 In explanation of this table it may be stated that column I. shows the actual number of cases notified at each age in the month of August during the decennium 1895-1904. Column II. has been obtained by estimating the number of cases by the method of finite differences i.e., by interpolating the figures for the month of August from the actual notifications in the two preceding months of June and July, and the two succeeding months of September and October. Column III. shows the differences between the figures in columns II. and I., which differences may be taken to represent approximately the reduction in the prevalence of these diseases due to the fact that during August the children were not exposed to infection in school. Column IV. shows these differences as percentages. In studying these figures the following points should be borne in mind:— (a) In view of the possibility of the disease not having the same degree of infectivity in different periods of the year, it cannot be affirmed that the same reduction as that observed in August would occur in the cases notified in other months of the year if the schools were closed in those months. In some months it might be greater, in others less, than in August. (b) The exclusion of children of particular ages would not be likely to effect the same reduction in the number of cases occurring at those ages as would be effected by the closure of the schools. (c) The exclusion of children of particular ages would not only reduce the prevalence of disease at those ages, but would affect in some degree the prevalence of disease at other ages, reducing them at once and probably in after years somewhat increasing them. (d) So far as increased opportunity for exposure to infection in the street or home would militate against the advantages gained by exclusion from school, this influence would have been operative in the month of August. 52 In considering the value which attaches to reduction of prevalence of infectious disease at a particular age, the fatality (case mortality) at the several ages is important. The following tables show the fatality of diphtheria and scarlet-fever at ages under ten years, in London during the period 1895.1904:. Ages in years. 1895-1904. Cases. Diphtheria. Scarlet fever. Deaths. Deaths per 100 cases. Cases. Deaths. Deaths per 100 cases. 0— 2,517 1,064 42.3 2,526 336 13.3 1— 7,407 2,729 36.8 1,825 801 11.7 2— 9,818 2,700 27.5 12,254 1,098 9.0 3— 11,989 2,588 21.6 16,766 1,040 6.2 4— 12,398 2,236 18.0 18,327 669 3.7 5—10 36,156 4,313 11.9 70,016 1,272 1.8 In the absence of a requirement that measles and whooping cough shall be notified, it is impossible to supply information concerning these diseases similar to that obtained from the records of notification of diphtheria and scarlet fever. There is, however, no question about the extension of the spread of these diseases by school attendance, but unfortunately only the age incidence of deaths can be given. The following table shows the number of deaths from these diseases in London at ages under ten years in the period 1895.1904. The deaths from diphtheria and scarlet fever are also shown. Mortality.—1895.1904. Ages in years. Measles. Whooping cough. Diphtheria. Scarlet fever. 0— 5,415 8,188 1,064 336 1— 10,375 6,218 2,729 801 2— 4,267 2,367 2,700 1,098 3— 2,400 1,251 2,588 1,040 4— 1,333 658 2,236 669 5—10 1,116 573 4,313 1,272 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 1904 was 49.8 deg. Fahrenheit, or 0.3 deg. Fahrenheit above the average of the 50 years 1854.1903. The rainfall during the year amounted to 20.67 inches, or 3.86 inches below the average of the preceding 50 years. The temperature and rainfall in each month of the year 1904 are shown in the following table— Month. Temperature of the air. Departure from average of 50 years, 1854.1903. Rain. Absolute maximum. Absolute minimum. Mean for month. Number of days it fell. Amount collected. deg. F. deg. F. deg. F. deg. F. Inches. January 54.8 23.8 38.7 +0.2 16 2.51 February 54.2 27.2 39.4 —0.1 19 2.55 March 59.1 26.4 40.5 —1.2 12 1.36 April 66.9 33.2 49.2 +2.0 13 1.01 May 75.1 34.2 53.7 +.0.6 14 1.92 June 76.1 43.9 58.5 —0.9 8 0.87 July 85.2 49.2 66.2 +3.8 14 2.23 August 91.0 43.5 62.4 +0.8 8 1.24 September 74.6 38.8 55.8 —1.4 11 1.34 October 66.5 31.9 50.6 +0.6 16 1.74 November 59.0 23.2 42.1 —1.1 11 1.65 December 56.0 24.8 40.3 +0.6 23 2.25 53 PART II. Dairies, Cowsheds and Milkshops. The County Council received during the year 266 applications for cowhouse licences, of which 259 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 received. No. of premises for which licences were 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 1904 266 259 In 1903 effort was made, in conjunction with the medical officers of health of London districts, to secure uniform statistical statement of the several proceedings of the authorities and their officers, which can thus conveniently be dealt with. Tables showing these proceedings have therefore, in the main, been compiled from tabular statements in the annual reports of medical officers of health or from figures otherwise contained in their reports, and are included in this report. The following table relating to cowsheds has been thus prepared. Cowsheds. Sanitary area. Number of cowsheds. Number of Inspections 1904. Number of notices 1904. Number of prosecutions 1904. On register at end of 1903. Added in 1904. Removed in 1904. On register at end of 1904. Paddington 2 1 1 4 Kensington 2 1 1 Hammersmith — — — — 2 — Fulham 3 — — 3 12 — — Chelsea 4 — — 4 65 1 — Westminster, City of 3 3 S. Marylebone 6 6 Hampstead — — — — — — — St. Pancras 13 3 10 212 Islington 12 — 2 10 139 — 1 Stoke Newington 2 2 Hackney 24 1 23 301 7 Holborn 1 — — 1 3 — Finsbury 7 — 1 6 42 7 — Shoreditch 8 — 1 7 64 — — Bethnal Green 15 — — 15 189 — — Stepney 41 1 40 Poplar 17 1 16 90 Southwark 5 5 136 Bermondsey 7 — — 7 2 — Lambeth 20 3 17 Battersea 3 — — 3 — — Wandsworth 16 1 2 15 64 4 — Camberwell 21 — 1 20 295 — — Deptford 7 — 1 6 53 Greenwich 4 — — 4 15 Lewisham 16 — — 16 138 6 Woolwich 18 — — 18 56 9 In one instance the borough council took proceedings against a cowkeeper for keeping cows in an unlicensed shed, and a fine was imposed. The Council's inspector attended the hearing of the case to give evidence in support of the prosecution. 6108] H 54 Tuberculosis of the udder in cows. London County Council (General Powers) Act, 1904 (Part F.). Under the Dairies, Cowsheds and Milkshops Order, 1899, the Council's powers were limited to taking proceedings for penalties only in the event of milk, from cows certified by a veterinary surgeon to be affected with tubercular disease of the udder, being either (a) mixed with other milk, or (b) sold or used for human food, or (c) sold or used for the food of swine without having first been boiled. In several instances it was found that cows, certified by the Council's veterinary inspector to be suffering from tubercular disease of the udder, were sold by their owners to cowkeepers outside the county, and, in order to avoid the possibility of the milk from such animals being sold for human food, the Council sought power to remove and slaughter any cows suspected to be suffering from tubercular disease of the udder. This authority was conferred upon them by Part V. of the London County Council (General Powers) Act, 1904. This Act came into force on 15th August, 1904. Section 27 provides that if a veterinary surgeon appointed by the Council for the purposes of the Dairies, Cowsheds, etc., Order, 1899, has reason to suspect, upon inspection, that a cow in any dairy, farm or cowshed in the county (outside the City) is suffering from tuberculosis of the udder, he may cause such cow to be removed from such dairy, farm or cowshed. Section 27 (1) requires the Council forthwith, after such removal, either to agree with the owner the full value of the cow at the time of removal, or in case of disagreement to cause the value to be ascertained by a valuer to be appointed on the Council's application by the Board of Agriculture. Such valuer is to give to the Council and owner a certificate of the said value. When the value has been agreed or certified, Section 27 (3) requires the Council to cause the cow so removed to be slaughtered and its carcase to be examined by a properly qualified and (if required by the owner) independent veterinary surgeon, who, failing agreement between the Council and owner, shall be appointed by the President of the Royal College of Veterinary Surgeons. Other provisions are— Section 27 (4). If such surgeon, after examination, certifies that the cow was not in fact suffering from tuberculosis of the udder, the Council is required to pay to the owner the value of the cow as agreed or certified, or £30 (whichever shall be the less), and a further sum of £1, and also to bear and pay the reasonable costs of any independent veterinary surgeon and valuer employed for the purposes of the section. Section 27. If, after examination, the veterinary surgeon certifies that the cow was in fact suffering as alleged, the Council shall pay to the owner one.third of the agreed or certified value of the cow or the sum of £22 10s. (whichever shall be the less), and shall also bear one.half of the reasonable costs of any independent veterinary surgeon and valuer employed for the purposes of the section, the remaining half being paid by the owner. Section 27 (6). The carcase of any cow so slaughtered shall belong to the Council, and shall be buried, sold or otherwise disposed of as the Council may direct and as the condition of the carcase and other circumstances may require or admit. Section 27 (8) provides a penalty upon conviction of a sum not exceeding £5 for obstructing any person duly employed in the execution of the section. Section 27 (9) provides for the expenses of the Council under the section being defrayed out of the Special County Account. 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 1904, there were three periodical inspections of alll 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 1904. Details of Examination. 1st period, 5th Deo. (1903)—27th April (1904). 2nd period, 28th April— 12th Aug. (1904). 3rd period, 13th Aug.— 20th Dec. (1904). Total number of cows examined 3,706 3,692 3,586 Affected with disease or defects of the udder 219 247 304 Affected with tubercular disease of the udder 3 — 3 Suspected cases of tubercular disease of the udder 8 6 8 Subjects of acute mastitis 27 17 37 Clinically affected with chronic induration of the udder 8 7 10 Atrophy of one or more quarters 70 108 106 Injuries, abscesses, simple eruptions, strictures and obliterations of milk ducts 27 53 67 Hypertrophied udders without induration 3 3 5 Giving milk of poor quality, dried.ofi cows 56 42 49 Recovered or removed from premises 18 17 22 Presenting symptoms of tuberculosis 6 2 3 Suffering from chronic diarrhœa — — 2 55 Mr. Shaw's reports also show the action taken for the elimination of tuberculous cows from the London cowsheds, thus— First period.—Three cows were affected with tubercular disease of the udder, and six presented symptoms of tuberculosis. Of the three cows affected with tubercular disease of the udder, one was sent to the knackers, one to the public slaughterhouse, where the whole carcase was seized and condemned, and the third cow was sold in the public market. Of the six cows presenting symptoms of tuberculosis, three were sent to the knackers' yards and three to the slaughterhouses in the Islington market. The latter, after death, were examined by the meat inspector and found to be locally affected. The parts so diseased were seized and condemned the remainder of the carcases being passed for food. Under the instruction of the Public Health Committee, samples of milk were taken from eight cows suspected to be suffering from tubercular disease of the udder and submitted to Dr. Houston for bacteriological examination. Three of the samples so submitted proved to be tuberculous. Twenty.seven cows which were affected with mastitis were kept under observation until they either recovered or were removed from the sheds for slaughter. Second period.—Samples of milk were taken from six cows suspe .ted to be affected with tubercular disease of the udder and submitted for bacteriological examination. Four of these were found to be free from tubercle bacilli. The animals from which the other two samples were taken were sent by order of the owners to the knackers before the results of the examination were known, but, upon postmortem examination of the carcases, Mr. Shaw was unable to discover any lesions of disease in the udder, although the lungs in each case were badly affected. Forty cows which were affected with mastitis were kept under observation until they either recovered or were removed from the sheds for slaughter. Third period.—Samples of milk were taken from eight cows suspected to be affected with tubercular disease of the udder and submitted for bacteriological examination. Three of them were found to be tuberculous, three gave negative results, and in the case of the remaining two the results of the examination were not then known. The three cows in respect to which the milk samples gave positive results were seized and slaughtered, the owners being compensated under the provisions of the London County Council (General Powers) Act, 1904. On a post.mortem examination being made of the carcases, the animals were found to have tubercular lesions of the udder and the carcases were destroyed. Thirty.seven cows which were affected with mastitis and ten affected with chronic induration of the udder were kept under observation until they either recovered or were removed from the sheds for slaughter. In summary it may be stated that during the year, 26 samples of milk were taken by Mr. Shaw from 22 cows suspected to be suffering from tubercular disease of the udder, and submitted to Dr. Houston for bacteriological examination. In the case of seven cows the samples taken proved to be tuberculous, negative results were obtained in respect to 14 cows, and the sample taken from one cow was unfit for inoculation purposes. It was not possible to procure a further sample in this instance, as the animal in question had already been sold to a butcher at Sittingbourne. Two of the tuberculous cows, a few days after the samples had been taken, were disposed of for human food (one being sent to the market and one to a butcher at Limehouse), one was sent to Messrs. Harrison, Barber and Co. and the carcase sold for cat's meat, one was sent to the market by the owner and the carcase destroyed ; while three seized by the Council's veterinary surgeon under the General Powers Act, were slaughtered and the carcases destroyed, compensation being allowed to the respective owners. Milkshop Premises. The following table shows the number of milkshop premises on the register at the end of 1904, the number of inspections of such premises made, the number of notices served, and the number of prosecutions. The table has been compiled from information given in the several annual reports. Sanitary Area. Number ef places. Number of inspections, 1904. Number of notices, 1904. Number of prosecutions 1904. On Register at end of 1903. Added in 1904. Removed in 1904. On Register at end of 1904. Paddington 174 3 11 166 Kensington 291 Hammersmith 269 23 17 275 1,100 64 1 Fulham 272 28 42 258 520 42 — Chelsea 123 10 — 133 315 16 — Westminster, City of 303 30 41 292 298 1 — St. Marylebone 323* * Including inspections of cowsheds. 6108] H 2 56 Metropolitan borough. Number of places. Number of inspections, 1904. Number of notices, 1904. Number of prosecutions 1904. On Register at end of 1903. Added in 1904. Removed in 1904. On Register at end of 1904. Hampstead 110 6 2 114 354 40 2 St. Pancras 466 895 Islington 674 30 — 704 1,112 98 5 Stoke Newington 51 Hackney 430 23 33 420 1,005 9 1 Holborn 107 18 14 171 1,160 12 —. Finsbury 261 15 6 270 348 58 — London, City of 553 29 30 552 Shoreditch 300 27 33 294 3,199 4 1 Bethnal Green 344 31 23 352 1,701 19 3 Stepney 1,017 8 Poplar 25 383 1,284 Southwark 84 379 594 — Bermondsey 286 18 3 301 444 15 — Lambeth 468 5 473 Battersea 225 43 22 246 583 79 — Wandsworth 286 31 31 286 590 48 2 Camberwell 574 35 27 582 1,339 23 1 Deptford 189 46 45 190 395 Gre nwich 161 29 — 190 275 — 1 Lewisham 148 48 44 152 371 30 — Woolwich 154 54 12 196 196 9 The tables are, in respect of some districts, imperfect, but they serve to make apparent the amount of work which devolves upon sanitary authorities and the extent to which inspection of milk premises is carried out in London. It is much to be hoped that in future years a complete statement for the whole of London will be possible. In many of the reports of medical officers of health, the desire is expressed for amended regulations for the control of milk premises, and the Lambeth Borough Council, during the year, communicated with other London sanitary authorities with a view to representation to the Local Government Board of the need for an amended Dairies and Cowsheds Order. This subject is remaining in abeyance until the Royal Commission, appointed to report on the relation of bovine to human tuberculosis, has finally reported* Among the suggestions made in connection with the amendment of the Order is the proposal that all milkshop premises should be annually licensed, or that no milkshop should be registered if the sanitary authority were of opinion that it was not fit for the storage and sale of milk. Concerning the action taken under existing powers may be mentioned the following. Dr. Newman, referring to the results of the issue of a circular to milk vendors in the beginning of the year, states: "That circular, which appeared in my report for 1903 (p. 177), laid emphasis upon the importance of cleanliness of milkshop furniture and fittings, the cleansing of milk vessels, the covering of milk pans, the storage of milk, and the freedom of milk from infection. I am glad to report that in all these respects there has been marked improvement, though there is much still to be done. Almost all milk dealers in Finsbury now cover, their milk pans and take increased precautions as to storage. In many of the little general shops which deal in milk there is still much dirt and mismanagement, and it is to be feared that persons obtaining milk at these shops cannot often receive a pure and clean article. A continual and steady enforcement of the law is, in my opinion, the effectual and equitable system of reform." In Hackney, Dr. Warry states, it was found that " in some cowsheds the cows were groomed and their udders cleaned before milking, but in the majority of cases this was not done. It was also observed that in some instances the cleanliness of the milker left much to be desired. In certain dairies and milkshops the milk was exposed on counters, etc., quite uncovered, and consequently exposed to pollution from falling particles and from air.borne matters and germs." A circular, which Dr. Warry says has had good effect, was issued to milk.vendors, recommending the grooming of the cow at least once a day, and the cleansing of the udder before each milking; also pointing out the need of cleanliness of the milker, the wearing of clean overalls and head covering, and urging the covering and straining of the milk and the maintenance of cleanliness in the cowshed. In Islington also, special action was taken to secure the cleanliness of the udders of cows in cowsheds. * The interim report of this Commission, published in 1904, states that they have made use of material taken from more than twenty cases of tuberculous disease in human beings, and that in the case of seven of the above "strains" the introduction of the human tuberculous material into cattle gave rise at once to acute tuberculosis; that other "strains" gave rise to tuberculous disease of less extent, but that tuberculous material taken from the bovine animal thus affected and introduced successively into other bovine animals or into guinea pigs from which bovine animals were subsequently inoculated, " has up to the present in the case of five of these remaining 'strains,' ultimately given rise in the bovine animal to general tuberculosis of an intense character." 57 In the circular letter addressed by the Lambeth Borough Council to other sanitary authorities, reference was made to the need of directing the attention of railway companies " to the need of more sanitary means of transit and storage of milk," The Islington Borough Council adopted resolutions that the County Council should obtain powers (a) to prevent the introduction into London of unwholesome milk, and for that purpose, to take samples outside London, (b) to enable the County Council outside London and the sanitary authorities in London to take immediate action when serious infectious disease is suspected, subject to proper compensation, and (c) to enable the county and metropolitan borough councils to require from purveyors of milk all necessary information. These resolutions were communicated to other sanitary authorities. During the year enquiry was made by the Corporation of the City of London as to the condition of milk supplied within the City, and thirty.nine samples of milk were sent to Dr. Klein for bacteriological examination. The results of Dr. Klein's examination were that nineteen were found clean and pure, in three the bacillus tuberculosis was found, in seven the staphylococcus pyogenes aureus, and in ten the bacillus enteritidis Gaertner were found. Writing of this last microbe, Dr. Klein says : " This splenic microbe being the real bacillus enteritidis Gaertner, the matter assumes a serious aspect, for this reason, viz., the bacillus gaertner is capable, when introduced in sufficient numbers by the digestive organs, of causing acute gastro-enteritis, and further, if this microbe be present initially in however small numbers in milk during the warm weather, or if kept for some time in a warm place, it would soon multiply—milk being a good soil for such multiplication— and the milk remaining unaltered to the eye, its consumption might cause serious intestinal disorders. How this microbe got into the milk cannot be said, but since the bacillus Gaertner, according to our present knowledge, seems to be generally derived from the bovine animal, it is probably also in our cases directly or indirectly referable to this animal, it certainly could not have got into the milk in transit. Whether directly from the udder of the cow, or with impurities in the cowsheds, or originally from ailing animals, must for the present remain unexplained." Dr. Collingridge gives the results of the inspection by the local medical officer of health and a veterinary surgeon of the farms from which these ten samples of milk were derived. Various insanitary conditions were found on some of these farms, and on one farm a cow with indurated udder, on another a cow " affected with catarrhal mastitis in one quarter, associated with an erythemal eruption of the skin of the udder." In a few reports reference is made to the question of sanitary authorities providing milk depots for the supply of infants with milk specially adapted to their age. In Battersea a milk depot has thus existed since 1902 ; in Finsbury a depot has been provided by philanthropic agency, and the Lambeth Borough Council decided in 1904 to establish a depot. Offensive Businesses. In the year 1904 the County Council received 338 applications for licences for slaughter.houses and granted 333. 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 premises for which licences were granted. Year. No. of applications received. No. of premises for which licences were granted. 1892 543 537 1899 419 411 1893 538 529 1900 405 393 1894 518 506 1901 384 381 1895 497 485 1902 371 362 1896 478 470 1903 350 346 1897 460 460 1904 338 333 1898 442 429 The number of slaughter.houses in each of the London sanitary areas and the frequency with which these slaughter.houses, in some of the districts, were inspected are shown in the following table- Sanitary areas. Number of Slaughter.houses. No. of Inspections 1904. No. of notices 1904. On Register at end of 1903. Removed in 1904. On Register at end of 1904. Paddington 8 — 8 659 Kensington 12 — 12 Hammersmith 12 — 12 104 27 Fulham 5 — 5 20 — Chelsea 6 — 6 71 — Westminster, City of 1 — 1 St. Marylebone 11 1 10 81 Hampstead 5 — 5 159 — 58 Sanitary areas. Number of slaughterhouses. No. of inspections 1904. No. of notices 1904. On Register at end of 1903. Removed in 1904. On Register at end of 1904. St. Pancras 21 — 21 504 Islington 40 — 40 2,242 — Stoke Newington 8 — 8 Hackney 29 2 27 396 2 Holborn 2 — 2 39 1 Finsbury 5 1 4 101 — London, City of * 8 — 8 Shoreditch 14 1 13 96 — Bethnal Green 6 — 6 47 4 Stepney 12 2 10 Poplar 20 — 20 30 Southwark 7 1 6 90 — Bermondsey 3 1 2 — Lambeth 32 2 30 Battersea 7 — 7 — Wandsworth 23 1 22 288 1 Camberwell 16 — 16 156 — Deptford 6 — 6 49 Greenwich 7 — 7 33 Lewisham 17 1 16 147 — Woolwich 11 — 11 83 6 The only change in the number of offensive trade premises, other than slaughter.houses, in London is a reduction in the number of manure manufacturers' premises, one of these businesses being abandoned. The number of authorised offensive businesses other than that of slaughterer of cattle in London, except those under the jurisdiction of the City Corporation, was at the end of the year as follows :— Fat melters 25 Tripe boilers 23 Glue and size manufacturers 5 Knackers 5 Fellmongers 6 Bone boilers 6 Manure manufacturers 3 Soap boilers 13 Tallow melters 10 Gut manufacturers 4 Gut scrapers 2 Animal charcoal manufacturers 1 103 In several instances more than one offensive business is carried on on the same premises, hence the number of premises used for the purpose of these businesses is smaller than the number of such businesses. The districts in which these premises are situated, the number of premises, and, for some districts, the number of inspections, are shown in the following table— Premises used for scheduled offensive businesses. No. on register at end of 1904. No. of inspections. No. on register at end of 1904. No. of inspections. Kensington 1 — Poplar 10 35 Hammersmith 4 104 Southwark 7 98 St. Marylebone 2 — Bermondsey 12 118 St. Pancras 2 19 Lambeth 4 Islington 7 202 Battersea 2 Hackney 2 41 Wandsworth 8 124 Holborn 1 Camberwell 4 Finsbury 1 Deptford 5 65 Shoreditch 1 Greenwich 2 \ Bethnal Green 2 — Woolwich 2 Stepney 7 — * The eight slaugnter-houses in tne City of London are not licensed by the London County Council. 59 One business, that of a manure manufacturer, in Poplar, was discontinued during 1904. In two instances proceedings were taken by the Council for permitting matter to enter the sewer to the injury of the workmen, in one instance a fine of £15 and £30 costs was imposed, and in the other instance the matter was adjourned to enable the Council and defendants to arrange for the treatment of such matter by chemical means in future. Under the powers obtained by the County 'Council in 1903, a man was convicted at the Clerkenwell Police Court for using premises for the reception of the carcases of dead horses without having previously obtained the Council's licence. During 1903 inquiries were made by the Council concerning nuisances from the trade of fish skin dressing carried on by a limited number of persons, principally on Hackney Marshes. In March, 1904, the Council adopted the following report of the Public Health Committee on this subject :— Our attention has been called to the fact that there is a number of premises in London, especially at the east end, upon which the business of dressing roker, skate, and other fish skins is being carried on. It appears that the skins are obtained from fishmongers, are then scraped and dried, and aftewards sold to be prepared for use as beer finings by brewers and for other purposes, and that during the whole of the process, and while the material is upon the premises, a most offensive smell is given off. It appeals to us that the circumstances justify the Council in making an order under section 19 of the Public Health (London) Act, 1891, declaring the business in question to be an offensive business within the meaning of that section. This would have the effect of subjecting to by.laws all such existing businesses, but would not prohibit them. No further business of this nature could then be established anew without the sanction of the Council under a penalty not exceeding £50 for the illegal establishment thereof, and any person carrying on business when established without such sanction would be liable to a fine not exceeding £50 for every day during which he carried on the same. Section 19 of the Act entirely prohibits the establishment anew in London of the business of a blood boiler, bone boiler, manure manufacturer, soap boiler, tallow melter, or knacker, and the following businesses may only be established anew in the County of London with the sanction of the Council, and in the City of London with the sanction of the City Corporation—fellmonger, tripeboiler, slaughterer of cattle or horses, or any other business which the Council may declare by order, confirmed by the Local Government Board, and published in the London Gazette, to be an offensive business. The businesses which have been so declared by Orders made by the Metropolitan Board of Works are as follows—fat-melter, blood-drier, animal charcoal manufacturer, catgut manufacturer, glue and size manufacturer, and gut scraper. We think that the Council should make a similar order, in the terms submitted with this report, with regard to the business of a dresser of fish skins, and that notice of the Council's intention to apply to the Local Government Board for confirmation of the order should bo advertised in some London newspaper. We recommend— That an order be made by the Council, in the form submitted in this report, declaring the business of a dresser of fish ekins to be an offensive business within the meaning of section 19 (1) (ft) of the Public Health (London) Act, 1891; that the seal of the Council be affixed to copies of such order; that application be made to the Local Government Board for confirmation thereof; and that the clerk of the Council do take the necessary steps to advertise the Council's intention to apply to the Board for its confirmation. The following order was therefore made by the Council:— Whereas by section 19, sub-section 1, of the Public Health (London) Act, 1891, it is enacted as follows — If any person— (a) Establishes anew the following businesses or any of them, that is to say, the business of blood boiler, bone boiler, manure manufacturer, soap boiler, tallow melter, or knacker, or (b) Establishes anew, without the sanction of the County Council, the following businesses or any of them, that is to say, the business of fellmonger, tripe boiler, slaughterer of cattle or horses, or any other business which the County Council may declare by order confirmed by the Local Government Board, and published in the London Gazette to be an offensive business; he shall be liable to a fine not exceeding £50 in respect of the establishment thereof, and any person carrying on the same when established shall be liable to a fine not exceeding £50 for every day during which he so carries on the same. and whereas it has been represented to the London County Council, being the County Council mentioned in the above section, that the business of a dresser of fish skins is an offensive business and ought to be so declared, and the said Council after due inquiry and consideration have determined to make an order accordingly; Now, the London County Council in pursuance of the provisions of the above.mentioned Statute do by this Order declare for the purposes of the said Statute that tho following business is an offensive business—that is to say, the business of a dresser of fish skins—that is to say, any business in which fish skins are trimmed, cleansed, scraped or dried. By-laws regulating the conduct of the business of a fish skin dresser have since been drafted by the Council. In October, 1904, the County Council made the following by.law, under Section 54 of their General Powers Act of 1903, prescribing the conditions of carriage of dead horses through the streets ;— Any person who shall convey the carcase of a dead horse through or along a public street in the County of London shall use for such purpose a vehicle constructed and closed in such manner that such carcase shall be completely concealed from public view, and the body of such vehicle shall be made of, or lined with, impervious material so as to prevent any liquid or discharge from the said carcase escaping from such vehicle. He shall so convey such carcase along the public streets with all reasonable despatch and so as to prevent any nuisance arising therefrom. Any person who shall offend against this by.law shall be liable for each breach of such by.law to a penalty of forty shillings. This by.law shall not extend to the City of London. Effluvium nuisances from other than the scheduled trades are referred to in some of the annual reports. Thus, in Kensington, nuisance was experienced from gas works in Kensal Green ; in Westminster, nuisance arose from effluvia given off in the preparation of acetylene gas from calcium carbide, from motor tyre works in which benzine and ammonium sulphide were used, and from the National Skating Palace, the oause of which was not obvious and for which a conviction was obtained, which was upheld on appeal. In Hampstead, nuisance was experienced from ammonia flues, from ballast burning and from fish curing, and in Lambeth, from dust destructors, from electric supply works and from ballast burning. 60 Nuisances. Smoke nuisances. In all the annual reports reference is made to smoke nuisances, and in a number of insiances particulars are given of the number of observations or inspections made during the year, the number of notices served or pautions given and the number of summonses issued. The following table has been compiled from the information contained in these reports. Smoke Nuisance. Sanitary Area. Observations and inspections. Nuisances and complaints. Notices. Summonses. Paddington 133 (23 premises) 5 Kensington In a few instances Hammersmth (50 premises) 17 Fulham 19 Chelsea 4 Westminster, City of 3,191 55 (nuisances 102) 168 5 St. Marylebone 259 26 19 Hampstead 16 4 2 St. Pancras 721 8 Islington 515 Stoke Newington (43 premises) 3 Hackney 1,590 62 Holborn 388 41 2 Finsbury 135 11 28 3 London, City of 1,202 (55 premises) 1 Shoreditch (13 premises) 24 Bethnal Green (786 premises) 36 Stepney 78 25 1 Poplar 176 160 7 Southwark 270 55 28 6 Bermondsey 148 48 Lambeth 540 (41 premises) 46 Battersea 72 79 5 Wandsworth 33 2 Camberwell 56 Deptford 193 40 Greenwich 369 11 1 Lewisham 199 25 30 1 Woolwich 136 29 29 Complaints as to smoke nuisances from railway locomotives are referred to in some of the reports (Greenwich, Wandsworth and Lewisham), and penalties were recovered by the Greenwich and Wandsworth Borough Councils. In Poplar proceedings were instituted and penalties recovered in rcspect of smoke nuisances from road traction engines. As the result of complaint from the Smoke Abatement Society, observation was made in Lambeth of the chimneys from various business premises on the river, but without ground for proceedings being found. Among premises which are specially commented on as giving rise to smoke nuisance are electric light stations. Proceedings concerning smoke nuisances from hotels were instituted in Westminster in five instances, and penalties were recovered. The Public Control Committee of the London County Council communicated 692 reports of smoke nuisance to the borough councils, with the result that notices were served in 309 cases, legal proceedings instituted in 43, and convictions obtained in 40. Nuisance from Stable Manure. Nuisance from stable manure is discussed in several reports of the medical officers of health, and the extent to which horses are kept in some parts of London may be gathered from the information which is thus supplied. In the City there are 432 horses in 31 stables, irrespective of those in a large horse repository in the Barbican, where the number of horses stabled is constantly varying In Finsbury, there are 5,519 horses in 494 stables, some of which have several hundred horses in them ; one as many as 470. In Wandsworth there are 7,000 horses approximately in the borough, 2,400 of which are owned by omnibus companies. In Southwark there are 521 stables accommodating 7,152 horses. In Battersea there are 570 stables in which were 3,065 horses and 18 donkeys. Dr. Millson, writing of the stables in Southwark, states that while firms employing a large number of horses are often found to provide 100 square feet of floor space per horse, others provide much less, especially omnibus and cab proprietors. Thus in 22 stables there was less than 50 square feet of floor space per horse, in 30 stables from 50 to 60 square feet, in 71 stables from 60 to 70 square feet, in 62 stables from 70 to 80 square feet, in 46 stables from 80 to 90 square feet, in 58 stables from 90 to 100 square feet, and in 232 stables over 100 square feet per horse. 61 With reference to the amount of manure produced, Dr. Caldwell Smith estimates that the 7,000 horses in Wandsworth would produce 95 tons per day or 34,216 tons per annum, and that of the 95 tons 63 tons accumulated in the stables and 31 tons were deposited on the public highways. Dr. McCleary estimates that 362 tons of solid matter and 23,377 gallons of liquid matter must be daily deposited in the streets in London, while the daily amount of manure deposited in stables is over 725 tons of solid matter and 76,131 gallons of liquid matter, if the horses in the total county are in the same proportion to population as he found in Battersea. The frequency of removal of manure from stables in Battersea and Southwark is stated to be as follows:— Frequency of removal. Daily. Three times a week. Twice a week. Weekly. Fortnightly. Monthly. Battened— No. of stables 78 52 148 267 17 8 Southwark— No. of stables 176 195* 93* 57 In Finsbury a notice was issued by the Borough Council requiring the daily removal of manure. Nuisance from the use of peat moss litter is less frequently mentioned in the annual reports than in previous years. The Fulham Borough Council, however, instituted proceedings against an omnibus company under Section 21 of the Public Health (London) Act, for nuisance caused by the removal of peat moss manure from receptacles in which it had first been deposited from the stalls, but withdrew the summons on payment of costs and on the company undertaking to deposit the manure directly from the stalls into the vans in which it was removed. Removal of offensive matter. Prosecutions for breach of the County Council's by.laws prescribing the hours and conditions of removal of offensive matter were instituted in Stepney, Poplar, Southwark, Bermondsey, Battesea, Wandsworth, Camberwell and Deptford. The Borough Council of Wandsworth had, in 1901, instituted a service for the collection of offal from fishmongers' and butchers' premises. In February of 1904 a letter was addressed by the borough council to fishmongers and butchers in Wandsworth stating that owing to the difficulty experienced in disposing of the offal the Council had been compelled to make other arrangements for the service. A contract had therefore been entered into, the Contractor undertaking to collect and dispose of trade refuse in a manner similar to that adopted by the Council, leaving the requisite number of empty tins when removing those containing waste upon charges practically the same as made by the Council, viz., not exceeding three tons per week, one shilling ; from three to six tons per week, two shillings ; from six to nine tons per week, three shillings ; from nine to twelve tons per week, four shillings ; and any greater number than twelve tons, the charge to be at the same rates. The medical officer of health states that the arrangements have worked satisfactorily. In Woolwich offensive trade refuse was regularly collected by the borough council from 55 tradesmen ; the number of receptacles thus removed was 9,581, a sum of £119 17s. 6d. being received for this service. Pollution of rivers and canals. The Medical Officer of Health of Hackney includes in his report analyses of samples taken in 1904 from sewage effluents as they were passing into the Lea and comments on the fact that nothing has since been done to reduce the pollution. The Medical Officer of Health of Lewisham gives account of pollution of the river Ravensbourne by crude sewage discharged at Mill Pond, Southend, from the storm overflows of the sewers of the West Kent Main Sewerage Board. As the result of representations by the Lewisham Borough Council these overflows were closed. He also states that the Local Government Board has sanctioned a loan for the improvement of the works at the Croydon Sewage farm, the effluent from which he found polluting the river Pool and then finding its way iuto the Ravensbourne, and that a judgment was obtained against the Crystal Palace District Gas Works Company, for polluting the rivers Pool and Ravensbourne with water.gas tar. Works were afterwards carried out by the Company, which will probably be sufficient to prevent recurrence of the nuisance. The Regent's Canal was kept under observation by the Council's inspectors and by the inspectors of the Sanitary Authorities concerned during the year, but no nuisance was reported. Housing of the Working Classes Act. The following is a summary of the principal proceedings in 1904 of the London County Council and of the Metropolitan Borough Councils under the Housing of the Working Classes Act. * Every two days and every three days. 6108] I 62 Proceedings under Part I. of the Act. Clare.market scheme.—On the 1st March the Council resolved to allocate to the Clare.market Improvement Scheme the following buildings on the Millbank site, viz., Rossetti, Ruskin, Morland, Millais and Reynolds.buildings accommodating 1,530 persons. Aylesbury.place, etc., scheme.—On the 17th May, the Council decided to apply to the Secretary of State for a modification of the London (Aylesbury-place, Clerkenwell, and Union.buildings, Holborn) Improvement Schcme 1899, so as to provide for(a) the inclusion in the scheme of so much of the site of Malory. buildings as is surplus land acquired in connection with the St. John.street improvement; (b) the reduction of the accommodation to be provided on the Aylesbury.place area for 200 persons to that for 164 persons; and (c) the increase of the accommodation to be provided on the Union.buildings area for 1,200 persons to that for 1,236 persons or such other number as the building will accommodate when erected in accordance with approved plans. Warner-street representation.—On the 21st June the Housing of the Working Classes Committee reported that the Holborn Borough Council being of opinion that the Warner.street area could not be effectively dealt with without an improvement scheme had requested the Home Secretary to order a local inquiry, but having regard to the action already taken by the freeholders and to a renewed expression of their intentions to re.develop the property at an early date, the Committee considered the previous decision of the Council should be adhered to. This view was communicated to the Secretary of State, who had since intimated that under the circumstances he did not propose to order an inquiry. Burfords-court scheme.—On the 5th July, the Housing of the Working Classes Committee reported that the erection of Ontario and Hudson.buildings of the Preston.road Estate, Poplar, was practically completed. This site was provided for the accommodation of persons displaced by the Burford's.court, etc., improvement scheme and to fulfil certain re.housing obligations of the School Board. The number of persons to be accommodated in Ontario.buildings is 250 persons in 25 tenements of two rooms and 25 tenements of three rooms, and in Hudson.buildings 110 persons in 20 tenements of two rooms and 5 tenements of three rooms. In October the Committee reported the completion of Quebec and Winnipeg.buildings on this site, each providing accommodation similar to that in Ontario.buildings. Brady-street area, Bethnal-green.—The Medical Officer of Health of Bethnal-green reports having made a representation as to an area comprising 226 houses inhabited by 1,286 persons. The Housing of the Working Classes Committee replied that having regard to the shortness of the period within which the leases of the property will expire and to the prospect of the area being re.developed by " private enterprise they did not see their way to recommend the Council to prepare a scheme for the improvement of the area under Part I. of the Act. Digby-street area, Bethnal-green.—The Medical Officer of Health of Bethnal.green reports concerning a representation he made as to this area that a deputation waited on the Housing of the Working Classes Committee of the County Council, and that subsequently the borough council surveyor prepared three alternative schemes for dealing with the area under Part II. of the Act and that these schemes were still under consideration. Schemes undertaken by district authorities under Part II. of the Act, the County Council contributing to the cost. King John's-court, Stepney.—In January the Housing of the Working Classes Committee reported that the Local Government Board had issued an amending order to enable the borough council to devote the whole of this area to dwellings providing accommodation for 132 persons in lieu of 56 persons as prescribed in the original order. Norfolk-square, Islington.—In January the County Council approved the application of the borough council for the whole of this area to be left as open space. Fulford-street and Braddon-street, Bermondsey.—The Housing of the Working Classes Committee reported in October that the Local Government Board had issued an amending order to enable the borough council to provide accommodation on this site for 980 persons in lieu of 550 persons. Part of Somers-town area, east of Charlton-street, St. Pancras.—The Medical Officer of Health of St. Pancras, reports that the Local Government Board held an inquiry in April for the purpose of amending the schemes for this area; (a) mainly for the purpose of including three houses in Chapel. street, at the north end of the Chapel.grove area so as to enable a long block of dwellings to be built down the centre of the area, and to enable the southern part of this area to be devoted to other purposes ; (b) for the purpose of including four more houses in Phoenix.street in the Eastnor.place scheme so as to enable a long block of dwellings to be constructed down the centre of the area. Prospect.terrace and Brantome-place Scheme, St. Pancras.—A confirming order was issued by the Local Government Board in February sanctioning this scheme The Medical Officer of Health of St. Pancras states that the following is the position of the three sites included in this order., (a) Great College.street site : Goldington buildings have been erected for 332 persons for housing persons to be displaced from Brantome-place and Prospect.terrace or ten more than required in the order. 63 (b) Brantome-place area : all the interests have been acquired and the demolition was proceeding (c) Prospect.terrace area : all the interests have been acquired, except those in the Prospect.terrace roadway which have been referred to arbitration. The number of persons to be displaced from these two areas is 1,165 and the number to be re.housed in 842. In February the County Council approved the plan of buildings to be erected on the Brantome-place site. Proceedings of the County Council under Part. 111. of the Housing of the Working Classes Act. Totterdown-fields estate.—In July the Council accepted a tender for the erection of 414 cottages on Section B of this estate and later in the month accepted an estimate for the erection of six cottages on Section C. In October the Housing of the Working Classes Committee reported that 20 first.class cottages in Section B were practically completed, providing accommodation for 200 persons, making in all provision for 1,992 persons on this estate. Wessex-buildings, Wedmore-street, Holloway.—In July the Council authorised the erection of the third block of Wessex.buildings for 340 persons, and in October the Housing of the Working Classes Committee reported the front block of Wessex.buildings nearly completed, providing accommodation for 360 persons in 60 tenements of two rooms and 20 tenements of three rooms.' A Raleigh-buildings, Hughes-fields, Deptford.—In November the Housing of the Working Classes Committee reported the completion of Raleigh-buildings providing accommodation for 280 persons in 18 tenements of two rooms, 24 tenements of three rooms and 8 tenements of four rooms. Caledonian-estate.—In November the Council approved working drawings of five.storey dwellings on this estate providing accommodation for 1,388 persons in six tenements of one room, 100 tenements of two rooms, 144 tenements of three rooms, four tenements of 4 rooms and 4 tenements of five rooms, and in December, accepted a tender of £36,465 for the erection of four of the five blocks. Re-housing by the Council in connection with street improvements. In connection with street improvements the following steps were taken for re.housing persons of the labouring class displaced. In the spring, the following buildings erected on the Herbrand.street site area were completed— Coram for 200 persons, Dickens for 220 and Thackeray for 260 persons displaced by the Holborn to Strand improvement. In May the Council accepted a tender of £10,398 13s. 4d. for the erection of Lennox-buildings and Clare.cottages in Wandsworth.road for re.housing persons displaced by the widening of Nine Elms. lane. Lennox.buildings will consist of five.storey block dwellings having four tenements of one room, sixteen tenements of two rooms, and twenty tenements of three rooms. The cottages are to accommodate 42 persons. In the same month the Housing of the Working Classes Committee reported the completion of a section of Durham.buildings in York.road, Battersea, providing in 28 tenements of two rooms and 28 tenements of three rooms accommodation for 286 persons displaced by the widening of Garratt-lane and Merton.road,Wandsworth. In June the Housing of the Working Classes Committee reported the completion of Darcy. buildings, London Fields, providing in 25 tenements of two rooms and 15 tenements of three rooms accommodation for 190 persons being a proportion of those displaced by the Mare.street improvement. The remainder of the persons displaced will be accommodated in Vallette.buildings, in course of erection in Jerusalem.square, Hackney. In October the following steps were taken :— The Council accepted an estimate of £46,100 for the erection of a lodging.house of the Rowton House type for the accommodation of 699 men in connection with displacements by the Holborn to Strand improvements. The Housing of the Working Classes Committee reported the completion of Drake. buildings on the Hughes-fields estate, providing in ten tenements of two rooms and 30 tenements of three rooms accommodation for 220 persons displaced by the erection of an electricity generating station at Greenwich. The Committee reported the completion of Brightlingsea.buildings at Ropemaker's. fields, Wapping, providing in five tenements of one room, 20 tenements of two rooms, 35 tenements of three rooms and five tenements of four rooms accommodation for 340 persons, being part of those for whom accommodation has to be provided on the north side of the Thames on account of displacements resulting from the construction of the Rotherhithe Tunnel. The Committee reported the completion of Barnaby.buildings (part) in Leroy. street, Bermondsey, providing accommodation in ten tenements of two rooms and ten tenements of three rooms for 100 persons displaced by the Long.lane and Tabard.street improvement. The annual reports for the following districts give account of proceedings of the Borough Councils under Part III. of the Act. Kensington.—The Borough Council has purchased " nearly all the houses in Kenley.street in the Notting-dale special area and some*others in the locality, upon terms which enabled them to provide lodging houses for a considerable body of the working classes at reasonable and reduced rents, and with but a small annual charge upon the rates." 6108] I2 64 Chelsea.—The borough council has erected Sir Thomas More.buildings, consisting of five blocks, providing in all 37 one.room tenements, 130 two.room tenements and 94 three.room tenements, the average rent per room being 3s. l½d. per week. Westminster.—The building by the borough council of three blocks of dwellings in Regency.street was finished in 1904 and were occupied by 344 families comprising 1,138 persons. The number of applicants was several times more than could be accommodated. Hampstead.—After inquiry into the character of the accommodation in the neighbourhood of the Fleet.road a piece of vacant land was purchased at the corner of Lower Cross.road and Upper Park.road, and plans approved for the housing of 248 persons in three blocks containing 12 tenements of two rooms, 20 tenements of three rooms and 10 tenements of four rooms. Greenwich.—The Medical Officer of Health gives account of proposals for the provision of dwellings for the working classes, which were before the borough council, but inasmuch as vacant accommodation was found to exist no action was taken in the matter. Proceedings in respect of houses represented under Part II. of the Act as unfit for human habitation. The following tabular statement shows the procedings of the district authorities concerning houses represented as unfit for human habitation, and in respect of which the Council has received copies of representations from the 1st January to the 31st December, 1904 :— Local Authority. Total number of houses concerning which the Council has received information that representations have been made from the 1/1/04 tn the 31/12/34 Number of houses dealt with by owners without Magisterial intervention. Number of houses for which closing orders were granted. Number of houses for which dosing orders were refused. Number of houses represented but subsequently dealt with under Public Health (London) Act, 1891. Still closed. Derno. lished. Improved. Total. Still closed. Demolished. Improved. Total. Battersea — — — — — — — — — — — Bermondsey — — — — — — — — — — — Bethnal Green — — — — — — — — — — — Camberwell — — — — — — — — — — — Chelsea — — — — — — — — — — — Deptford — — — — — — — — — — — Finskury — — — — — — — — — — — Fulham — — — — — — — — — — — Greenwich — — — — — — — — — — — Hackney 16 — 9 7 16 — — — . — — Hammersmith — — — — — — — — — — — Hampstead 8 — — — — — — — — — 8 Holborn 4 — — 2 2 — — 2 2 — — Islington — — — — — — — — — — — Kensington — — — — — — — — — — — Lambeth 15 5 — 10 15 — — — — — — Lewisham 1 1 — — 1 — — — — — — Paddington — — — — — — — — — — — Poplar 6 — — — — 2 4 — 6 — — St. Marylebone 1 — — — — 1 — — 1 — — St. Pancras 1 — — 1 1 — — — — — — Shoreditch . — — — — — — — — — — — Southwark 5 — — — — — — — — 5 — Stepney — — — — — — — — — — — Stoke Newington — — — — — — — — — — — Wandsworth — — — — — — — — — — — Westminster — — — — — — — — — — — Woolwich 10 — — 6 6 1 — — 1 3 — Total 67 6 9 26 41 4 4 2 10 8 8 Death-rates obtaining among persons resident in the Council's buildings. The following death-rates obtaining among tenants of the Council's dwellings relate to buildings which were occupied during the whole of the year 1904. The population thus dealt with comprised 15,667 persons, and the death-rate at " all ages " after correction for age and sex distribution was 14 0 per 1,000 living compared with 17.5 for London. The factor for age and sex correction has been calculated on the age and sex distribution of the population which obtained in 1903; it has been assumed therefore, for the purposes of the following table, that the age and sex constitution of the population in these buildings has remained unaltered since 1903 :— 65 Death-rates of persons resident in the County Council's dwellings. Cause of death. Death rate per 1000 living. Council's dwellings. London. All ages 14.0 16.1 Age 0—5 45.8 54.2 „ 5—20 2.4 2.6 „ 20 and upwards 10.6 15.7 Diarrhœa 1.53 1.02 Principal Epidemic Diseases (excluding Diarrhœa) 1.81 1.12 Phthisis 1.15 1.62 Tubercular diseases other than Phthisis 0.64 0.54 Bronchitis 1.15 1.37 Pneumonia 1.02 1.43 Houses let in Lodgings. In view of decisions in the courts referred to in the last annual report, in which by-laws requiring the annual cleansing of houses and of provision of a water closet for every twelve persons were held to be ultra vires for the reason that these by-laws did not require notice to be given to the landlord, the by-laws of the County Council and of a number of the sanitary authorities were amended to meet this objection. Opportunity was taken to amend the by-laws in other matters at the same time. Many of the annual reports of medical officers of health show the steps taken for this purpose during the year. Thus— Paddington.—Draft by.laws submitted to the Local Government Board. Kensington.—Proposals of borough council before the Local Government Board. Fulham.—The Local Government Board have expressed their willingness to confirm the by-laws submitted. Hampstead.—" The matter is still the subject of negotiation with the Local Government Board." Islington.—A new set of by-laws has been framed and is awaiting the confirmation of the Local Government Board. Stoke Newington.—Amended by-laws awaiting confirmation by the Local Government Board. Finsbury.—Amended by-laws were confirmed in July. City of London.—Amended by.laws were confirmed in January, 1905. Shoreditch.—Amended by-laws were submitted to the Local Government Board. Stepney.—Amended by-laws were confirmed by the Local Government Board. i' Poplar.—Amended by-laws were confirmed by the Local Government Board. Bermondsey.—The borough council agreed to amendment of the by-laws. Lambeth.—The borough council agreed to amendment of the by-laws. Battersea.—Amended by-laws were under the consideration of the Local Government Board. Wandsworth.—Amended by-laws were submitted to the Local Government Board. Deptford.—Amended by-laws have been confirmed by the Local Government Board. Greenwich.—Amended by-laws have been confirmed by the Local Government Board. Woolwich.—Amended by-laws were submitted to the Local Government Board. Owing to the decisions in the Courts referred to, the administration of the by-laws was in some degree in abeyance in London. Referring to the by-laws in Stepney which were confirmed in 1904, Dr. Thomas, the medical officer of health, writes : " Since the new by-laws have been in operation, a vast improvement has occurred in the houses, which is due to the action of the owners as well as of the tenants themselves. A higher standard of cleanliness has been established and overcrowding has been lessened. Notices under the by.laws were served and overcrowding was abated in 614 registered houses. In only a few instances was it found necessary to take police court proceedings." Again, Dr. Collier, medical officer of health of Hammersmith, states : " The registered premises were visited as often as time would allow by the special inspector appointed for that purpose. There can be no doubt that the official influence obtained by registration has a very good effect in improving the sanitary condition of the premises." Insufficiency of staff for the purpose of administration of the by.laws is mentioned in one report, that of the medical officer of health of Greenwich. Dr. Annis thus writes : "No special work has been carried out under these by.laws during the year, and although we are now fully aware of a large number of properties which come within the scope of these by.laws, in many of which cases the occupiers would be considerably benefitted by the imposition of the requirements specified under the by.laws, yet with the present staff, I do not see how any of this very necessary work can be attempted, much less carried out satisfactorily." The following tables based upon information contained in the reports of medical officers of health, gives particulars as to proceedings in the several districts under by.laws for houses let in lodgings. 66 Houses let in lodgings. Number of places. Inspections, 1904. Notices, 1901. Prosecutions, 1904. On register at end of 1903. Added in 1904. Removed in 1904. On register at end of 1904. Paddington 851 185 6 1,030 3,501 148a Kensington 2,050 992 4 Hammersmith 1,630 378 45 1,963 1,595 1,828* 204 — Fulham 329 — — 329 720 Chelsea 602 — — 602 180 Westminster, City of 2,004 81 426 1,659 987 St. Marylebone Hampstead 908 — — 908 — — — St. Pancras 1,814 188 2 2,000 2,652 5,552* Islington 655 93 1 749 9,189 51a 455b Stoke Newington 180 39 219 Hackney 435 Holborn 775 28 36 707 1,228 67a 117b lla 15b Finsbury 1,079 52 — 1,131 9,036 131a 883b —a 4b London, City of 360 425 Shoreditch 233 24 — 257 272 29 — Bethnal Green 365 112 32 445 1,453 6a 4a 3b 5b Stepney 614 Poplar 564 204 768 709 1,510* 20a 384b Southwark 1,100 105 63 1,142 Bermondsey 207 11 — 218 462 2a 91b — Lambeth 372 — — 372 — — Battersea 121 — — 121 79 — Wandsworth 200 30 13 217 491 13a 347b — Camberwell 300 — 72 228 149 35a 101b — Deptford — 189 — 189 553 105b — Greenwich — — — — Lewisham 15 4 2 17 43a — Woolwich 123 116 4 235 371 8a 225b Common Lodging Houses. The administration of the Common Lodging Houses Acts devolved upon the Council in 1894. New bv-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 infectious disease. £ s. d. 1895 626 29,574 — — 16 12 37 6 0 51 99 1896 596 29,140 28,331 — 31 30 115 16 0 65 71 1897 581 28,718 26,121 — 31 30 95 11 0 59 48 1898 560 28,332 27,658 — 29 29 167 6 0 87 44 1899 544 28,448 28,229 1,162 25 22 183 9 0 96 54 1900 528 28,311 28,428 668 16 13 105 15 0 91 40 1901 514 28,037½ 35,225 2,133 16 15 96 3 0 102 166 1902 491 28,970½ 40,512 1,449 22 21 98 4 0 120 684 1903 470 28,893 33,402 4,790 6 6 26 11 0 98 53 1904 451 28,896 27,501 2,970 15 14 62 6 0 74 66 * He-inspections. (a) For overcrowding. (6)For other causes. † The number of deaths stated in the above table includos only those deaths brought to the knowledge of the inspectors as actually occurring in the houses, and not those occurring in infirmaries aud other institutions to which the lodgers were removed when attacked with fatal illness. 67 The decrease in the number of common lodging houses shown above is in part explained by the fact that in some degree small houses are being replaced by large and in part by the inclusion in one licence of two or more houses orginally separate, but which have had communications made between them, practically making them into one building. In the year 1904 proceedings before the magistrate were instituted in 15 instances, resulting in 14 convictions, the penalties amounting to £47 18s. Id., with costs amounting to £14 83. In addition to the number of inspections mentioned in the table, there were 1,196 day and 112 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, 45; erysipelas, 11; diphtheria, 5; scarlet fever, 4; enteric fever, 1; total, 66. In my annual reports for the years 1902 and 1903 I have referred to the passing of the London County Council (General Powers) Act, 1902, of which Part IX. gave power to the Council to license common lodging houses annually. During the year 1904 the work of inspecting these houses, and reporting upon the adequacy of means of escape in case of fire, has made considerable progress, and at the end of the year practically every house had been dealt with and lists of requirements served upon the respective keepers. Thes3 requirements in many instances were not completed at the time of the adjourned licencing meeting on 13th October, 1904, and consideration of the matter was further adjourned until January 27th, 1905, in order to give keepers the opportunity of carrying out the work. The following table shows the total number of licensed and unlicensed common lodging houses, and the authorised accommodation for the different classes of lodgers in the several sanitary districts of London, other than that of the City, on December 31st, 1904. Total number of licensed and unlicensed common lodging houses in the several sanitary districts of London on December 31st, 1904:— Sanitary district. No. of houses. Authorise 1 accommodation. Men. Women. Couples. Total. Battersea 9 177 76 23 299 Bermondsey 6 889 — — 889 Bethnal Green 16 737 — — 737 Camberwell 6 543 — — 543 Chelsea 9 339 52 — 391 Deptford 7 450 — — 450 Finsbury 7 503 — — 503 Fulham 2 GO — — 60 Greenwich 5 175 — — 175 Hackney 6 397 — — 397 Hammersmith 9 454 9 4 471 Hampstead — — — — — Holborn 39 1,965 403 — 2,368 Islington 42 1,175 217 16 1,424 Kensington 28 383 268 76 803 Lambeth 10 739 — — 739 Lewisham 1 30 — — 30 Paddington 8 195 31 19 264 Poplar 11 1,250 — — 1,250 St. Marylebone 20 1,518 7 — 1,525 St. Pancras 15 892 144 — 1,036 Shoreditch 12 734 — — 734 Southwark 51 3,658 429 4 4,095 StepDey 72 5,700 697 228 6,853 Stoke Newington 1 37 — — 37 Wandsworth 10 164 — 27 218 Westminster, City of 21 1,924 75 — 1,999 Woolwich 28 514 42 25 606 London—excluding the City 451 25,602 2,450 422 28,896 With a view to comparing the mortality of the male inmates of common lodging houses with that of the male population of London, the following Table I. has been prepared. For this purpose the deaths of persons removed from common lodging houses to infirmaries and other like public institutions have been included with those which actually occurred in these houses. The population of common lodging houses is, however, variable, and rates calculated upon it are necessarily open to objection. Table II. has therefore been prepared showing the proportion of deaths from several causes of mortality per 1,000 of total deaths and in common lodging houses, the corresponding figures for London being shewn for comparative purposes. 68 Table I. Common Lodging Houses. Death-rates per 1,000 males living at five age periods from certain causes in London (1903) and in licensed common lodging houses 1903 and 1904. Cause of Death. Age 25 to 35. Age 36 to 45. Age 45 to 55. Age 55 to 65. Age 65 and upwards. London, 1903. C.L.H 1903. C.L.H. 1904. London, 1903. C.L.H. 1903. C.L.H. 1904. London, 1903. C L H 1903. C. L. H 1901. London, 1SW3. C.L H. 1903. C.L.H 1904. London, 1903. C.L.H. 1903. C.L.H. 1904. Phthisis 2.34 6.89 6.86 4.01 12.49 15.13 4.92 20.27 21.16 4.03 16.29 16.51 2.51 11.49 11.50 Other tubercular 0.17 0.21 0.21 0.18 018 018 0.22 0.22 0.67 0.21 0.76 — 0.15 1.23 — diseases Alcoholism (includ. ing cirrhosis of the liver) 0.16 1.04 0.62 0.62 1.27 1.98 1.09 1.78 1.80 1.28 3.79 3.07 1.15 5.11 5.75 Urinary diseases 0.19 1.26 0.83 0.55 1.09 1.62 1.31 3.57 112 3.09 4.17 3.46 7.17 14.05 13.79 Violence 0.61 0.63 — 0.89 0.72 1.26 1.34 1.78 0.67 1.67 1.89 0.77 2.57 5.11 1.15 Cancer 0.17 0.21 — 0.61 0.72 0.18 2.37 2.23 1.57 5.04 7.20 4.99 8.1.2 21.72 17.24 Circulatory diseases 0.51 1.46 1.87 1.47 2.35 3.96 3.34 4.16 5.62 8.26 7.58 9.60 21.00 24.27 36.78 Nervous diseases 0.21 — 0.42 0.50 — 1.08 0.88 1.78 1.1.2 1.42 2.27 3.46 3.76 5.11 8.05 Bronchitis 0.07 0.21 0.42 0.25 1.00 2.52 0.68 2.01 3.82 2.97 11.36 11.90 11.98 30.66 48.28 Pneumonia 0.49 1.26 1.04 0.92 1.81 2.34 1.60 2.01 4.27 2.70 6.44 6.14 4.85 12.77 13.79 Other causes 1.06 2.07 0.21 1.43 0.90 1.03 2.31 2.45 2.70 4.23 4 55 3.46 21.04 12.77 36.78 Total (all causes) 5.99 15.24 12.48 11.43 22.62 31.33 19.98 42.56 44.50 34.90 66.30 63.35 84.30 144.30 193.10 Table II. Common Lodging Houses. Table showing the number of deaths of males at five age periods from certain causes per 1,000 deaths from all causes in London (1903) and licensed common lodging houses 1903 and 1904. Cause of death. Age 25 to 35. Age 35 to 45. Age 45 to 55. Age 55 to 65. Age 66 and upwards. London, 1903. C.L.H. 1903. C.L.H. 1904. London, 1903. C.L.H. 1903. C.L H. 1904. London, 1903. C.L.H. 1903. C.L.H. l»04i London, 1903. C.L.H. 1903. C.L.H. 1904. London, 1903. C.L.H. 1903. O.L.H. 1904. Phthisis 390 452 550 351 552 483 246 477 475 115 246 261 30 80 60 Other tubercular diseases 29 14 17 16 8 6 11 5 15 6 11 — 2 9 — Alcoholism (including cirrhosis of the liver) 27 68 50 54 56 63 50 42 41 37 57 48 14 35 30 Urinary di eases 32 82 67 48 48 52 66 84 25 89 63 54 85 97 71 Violence 102 41 — 78 32 40 67 42 15 48 29 12 31 35 6 Cancer 28 14 — 53 32 6 119 52 35 144 109 79 96 150 89 Circulatory and heart disease 86 96 150 128 104 126 167 105 126 237 114 152 249 168 190 Nervous diseases 36 — 33 44 — 34 44 42 25 41 34 55 44 35 42 Bronchitis 12 14 33 22 48 81 34 47 86 85 171 188 142 213 250 Pneumonia 81 82 83 81 80 75 80 47 96 77 97 97 58 89 71 All other causes 177 137 17 125 40 34 116 57 61 121 69 64 249 89 191 Total (all causes) 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 Seamen's Lodging Houses. Under the provisions of Section 214 of the Merchant Shipping Act, 1894, the Council has made bylaws for the regulation of houses accommodating seamen. laws for the regulation of houses accommodating seamen. These by.laws came into force on the 1st October, 1901, At the end of 1903, there were 133 houses on the register ; in 1904 houses were added to and removed from the register, leaving 90, which were situated in the following metropolitan boroughs:— Metropolitan Borough. Houses. Lodgers. Poplar 30 434 Stepney 59 1,125 Woolwich 1 26 Total 90 1,585 69 During the year 1,298 day visits were made to these houses by the Council's inspectors, and in four instances notices were served for the remedying of dirty or defective conditions. Proceedings before the magistrate were instituted in three instances; the fines amounting to £6 13s., with costs amounting to £4 14s. The number of cases of notifiable infectious disease reported in seamen's lodging houses was as follows:—Smallpox, 10; total, 10. Customs and Inland Revenue Acts, 1890 and 1891. The Customs and Inland Revenue Act, 1890, Section 26, provides that the assessment to inhabited house duty of any house originally built or adapted by additions or alterations, and used for the sole purpose of providing separate dwellings for persons at rents not exceeding for each dwelling the rate of seven shillings and sixpence per week, and occupied only by persons paying such rents, shall be discharged by the commissioners, provided that a certificate of the medical officer of health for the district in which the house is situate shall be produced to them to the effect that the house is so constructed as to afford suitable accommodation for such of the families or persons inhabiting it, and that due provision is made for their sanitary requirements. The medical officer of health of a district, on request by the person who would be liable to pay the house duty on any house in the district, if the duty were not discharged a3 aforesaid, shall examine the house for the purpose of a3certaining whether such a certificate can be properly given, and if the house be constructed so as to afford such accommodation and due provision be made as aforesaid, shall certify the same accordingly. The Revenue Act, 1903, Section 11, provides that— (1) 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 which is of an annual value below £20 shall be excluded from the annual value of the house for the purposes of inhabited house duty; and (b) The rate of inhabited house duty in respect of any dwelling in the house of an annual value of £20 but not exceeding £40 shall be reduced to three pence; and (c) The rate of inhabited house duty in respect of any dwelling in the house of an annual value exceeding £40 but not exceeding £60 shall be reduced to sixpence. (2) The provisions of this section as respects dwellings of an annual \alue not exceeding £40 shall not take effect with regard to any such dwelling, unless such a certificate as to accommodation and sanitary condition is produced to the general commissioners as defined by Section 5 of The Taxes Management Act, 1880, as is mentioned in sub-section (2) of section 26 of the Customs and Inland Revenue Act, 1890, and the provisions of that subsection as to the certicfiate shall apply for the purpose. The question of defining the minimum requirements which should be made by medical officers of health in London in this connection was considered by the Metropolitan Branch of the Incorporated Society of Medical Officers of Health and it was decided on the 27th January, 1905, to recommend the adoption of the following:— (1) That a definite minimum height for living and sleeping rooms is provided, as defined by the London Building Act, 1894, together with a definite minimum area (superficial) of 96 ft. for each of such rooms. (2) That a fireplace and chimney flue are provided for each living and sleeping-room. (3) That every living or sleeping room is sufficiently lighted by daylight and properly ventilated. (4) That each dwelling is so arranged as to be through-ventilated. (5) That each dwelling is provided with a properly ventilated food cupboard (or recess), or larder, properly protected against flies and effluvia; and also a proper range or stove for cooking purposes. (6) That there is a proper and sufficient supply of water available on each floor. (7) That there is, at least, one w.c. properly supplied with water for every twelve occupants (or less), on each floor, each w.c. being disconnected aerially from any dwelling in the interior of the building. (8) That on each floor a sufficient space or open lobby is provided, accessible to, and for the use of, the families on each floor, for the deposit of refuse, etc. (9) That every common staircase is permanently ventilated at each floor level, or by through-ventilation so as to break the common air connection. (10) That corridors, or lobbies within the building, whether external or internal to the dwellings, are all properly ventilated and sufficiently lighted as far as practicable. (11) That every internal court, open at the top and surrounded on all sides and situated wholly, or in part, within the building, is ventilated by a permanent opening, or openings, to the external air at the lower end, such opening, or openings, being of an area at least equal to one-twentieth the internal area of the court. (12) That the drainage of the premises is in accordance with the regulations and by-laws recognised by the authority within whose jurisdiction the premises are situated. (13) That accommodation for clothes washing is provided, sufficient for the number of persons inhabiting the house. 6108] K 70 In some of the annual reports it is stated that alterations were made in houses and tenements to bring them into compliance with the requirements which medical officers of health made before they would grant certificates. In numerous instances certificates were refused. Thus, in Paddington, one application was refused on account of the very small dimensions of the living rooms and the absence of suitable or separate scullery accommodation; in Wandsworth a certificate was refused because separate sanitary arrangements had not been provided for each family; in Bethnal Green the certificate was refused because only two water-closets were provided for three tenements; and in Greenwich one application in respect of 14 tenements was refused because there was a lack of proper ventilation for a room in each tenement which contained a gas stove not provided with any hood or other means for allowing the escape of the fumes which were found to pervade the various rooms of the tenements. Another application relating to 30 tenements in Greenwich was refused because of the "totally inadequate accommodation provided for washing or laundry purposes, such provision being almost of a dangerous character at the present time, on account of the small floor space, so that the garments of the person standing at the wash-tub would be very liable to catch fire at the copper provided for boiling purposes. Some of the bedrooms also appeared to be deficient so far as ventilation was concerned and very inadequate in size." The number of premises dealt with under the Acts is shown in some of the annual reports, and the information contained therein is stated in tabular form as follows. The proceedings in Hammersmith, which include the granting of certificates for various premises after they had been put into proper condition, do not lend themselves to the form of tabular statement adopted. Revenue Acts. Sanitary District. No. of houses for which applications were received during year. No. of tenements comprised therein. No. of Tenements for which certificates were granted. Certificates were refused. Certificates were deferred. Paddington 204 1 Fulham 94 487 304 46 137 Chelsea 13 190 11 2 .. Westminster, City of 29 603 462 15 45 Hampstead 20 168 102 Jslington 31 290 176 114 — Hackney 181 181 Holborn 8 614 566 48 Bethnal Green 18 63 — 51 12 Poplar 7 206 206 Bermondsey 227 Lambeth 141 494 338 119 37 Battersea 232 214 244 — — Wandsworth 754 1,120 962 18 140 Camberwell 24 74 16 58 — Deptford 3 95 95 — — Greenwich 44 — 44 — Lewisham 81 175 175 — Underground Rooms. It is specifically stated in the annual reports relating to Paddington, Fulham, Deptford,Wandsworth and Camberwell, that no underground rooms were dealt with during the year. In Kensington, in a number of instances the occupation of such rooms was discontinued after notice. The number of proceedings in some other districts is shown in the following table :— Sanitary District. No. of underground rooms illegally occupied Sanitary District. No. of underground rooms illegally occupied. Dealt with. Occupation discontinued. Dealt with. Occupation discontinued. Chelsea 2 2 Shoreditch 7 — Westminster, City of 26 26 Bethnal Green 6 6 Hampstead — 9 Stepney 107 107 St. Pancras 60 — Lambeth 26 26 Islington 67 57 Battersea 5 5 Hackney 4 4 Greenwich — 2 Holborn 13 11 Woolwich 6 3 Finsbury 20 3 71 Overcrowding. Information contained in many of the annual reports of medical officers of health shows the number of instances in which overcrowding was found, the number in which this overcrowding was abated, and in respect of a few districts, the number of cases in which proceedings before the magistrate were instituted on account of overcrowding. The following table has been prepared from the information supplied:— Overcrowding. No. of dwellingrooms overcrowded. No. romodied. No. of prosecutions. Paddington 518 227 Fulham 88 88 — Chelsea 11 11 Hampstead 11 11 — Islington 159 159 — Hackney 33 33 Holborn 123 123 11 Finsbury 250 250 — Shoreditch 132 132 — Bethnal Green 108 105 8 Stepney 1,489 Poplar 138 South wark 480 Bermondsey 10 Lambeth 48 48 Battersea 58 58 1 Wandsworth 107 107 — Camberwell 131 131 7 Deptforcl 22 22 Greenwich 20 — Lewisham 23 Woolwich 178 178 Factory and Workshop Act, 1901. Under the provisions of Section 132 of the Factory and Workshop Act, 1901, the medical officer of health of every district is required to report, in his annual report, specifically on the administration of this Act in workshops and workplaces, and to send a copy of his annual report, or so much of it as deals with this subject, to the Secretary of State. A form of table has been prepared for the guidance and convenience of medical officers of health in the preparation of this part of their report and forwarded to them by the Local Government Board, at the request of the Secretary of State. A note on the table points out that "it is not intended to supersede the fuller statement which is desirable in the text of the report, but to provide for uniformity in the presentation of such particulars as lend themselves to statistical treatment." From the tables thus supplied by the medical officers of health of the London districts the summary table shown on pages 72 and 73, has been prepared. The reports for the year 1901 show development of the administration under the Factory and Workshop Act. The requirement that the medical officer of health should report specifically on this administration and the provision of tables for statistical statement no doubt tends to emphasise the importance of the sanitary supervision of places where work is carried on and to stimulate the efforts of sanitary authorities to cope with it. The records show that at the end of 1904, 34,488 workshops in London were under the supervision of the local authorities, and that 18,922 conditions needing remedy were dealt with, 17,959 under the Public Health (London) Act, and 963 under the Factory and Workshop Act. Of the various premises subject to the latter Act, 84,600 inspections were made, many of them, as will be seen by the table, being inspections of home workers' premises and hence the Act has in addition to factories and workshops ensured the inspection of many dwelling houses, the number of outworkers on the lists supplied to the sanitary authorities being 34,579. The improvement that has been effected is commented on in some of the reports and it is further stated that employers are found to co-operate willingly with the local authorities in the remedy of faulty conditions. Conditions of overcrowding which were found are stated to be fewer, although, as the table shows, overcrowding was from time to time met with in most of the districts. In Wandsworth, the distribution among the employees of workroom cards has been found to have a useful effect in this matter. In respect of ventilation it is pointed out that the objection of the employees to the use of means of ventilation is often the greatest difficulty. Inasmuch as this objection is largely dependent on habit and custom it may be expected that this difficulty will gradually decrease. In connection with this subject it may be mentioned that Dr. Newman gives the results of the estimation by Dr. Haldane's apparatus of the 6108J K 2 72 73 TABLE SHOWING PROCEEDINGS OF LONDON SANITARY AUTHORITIES UNDER THE FACTORY AND WORKSHOP ACT. Premises, Particulars, Class, &c. Paddington. Kensington. Hammersmith. Fulham. Chelsea. Westminster. St. Marylebone. Hampstead. St. Pancras. Islington. Stoke Newington. Hackney. Holborn. Finsbury. City of Londcn. Shoreditch. Bethnal-green. Stepney. Poplar. Southwaik. Bermondsey. Lambeth. Battersea. Wandbworth. Camberwell Deptford: Greenwich. Lewisham. Woolwich. Inspection. Factories (including factory laundries, 346 162 278 102 11 - 4 128 98 290 16 47 1,189 917 160 53 31 15 214 93 47 6 705 381 128 46 126 22 Workshops (including workshop laundries) 3,223 3,935 1,772 401 995 2,039 1,046 1,547 589 5,1831 178 1,969 2,153 4,505 4,681 3,037 2,382 868 1,529 264 169 3,008 2,87 3,168 752 377 814 107 Workplaces 53 22 264 380 182 578 810 1,272 25 1,030 8 1,046 708 1,558 539 17 55 1,125 376 645 1,449 233 79 43 120 4 Homeworkers' premises 269 73 102 101 94 1,543 823 72 77 960 117 798 125 489 4 651 1,125 - 1,253 654 274 277 343 237 784 359 141 55 3537 Total 3,891 4,192 2,416 984 1,282 4,160 3,283 3,019 789 7,463 311 2,822 2,360 4,267 6,227 5,388 4,732 2,414 2,390 3,401 931 452 4,701 4,946 4,308 1,236 687 989 529 Defects Found. Nuisances under the Public Health Acts. Want of cleanliness 118 368 144 148 10 171 119 74 19 427 38 350 128 128 385 324 396 547 210 571 180 186 192 192 64 93 48 98 24 Want of ventilation 10 52 - 5 3 88 20 12 13 7 - 62 4 42 250 2 14 60 2 90 11 1 17 13 2 4 8 1 6 Overcrowding 16 24 - 8 6 48 9 10 - 4 6 27 12 7 72 7 7 66 11 18 3 11 9 19 5 4 - 1 3 Want of drainage of floors 1 23 4 2 - 20 2 1 2 4 5 7 - 2 1 - - - 1 10 23 - 31 3 2 1 - 1 Other nuisances 78 295 66 - - 70 55 294 36 488 480 27 277 1,564 67 311 179 139 975 213 63 350 247 74 54 34 45 11 Sanitary accommodation insufficient 2 18 12 8 2 56 2 17 1 11 4 3 57 12 16 4 39 20 39 15 - 9 21 17 13 5 - 1 unsuitable or defective 36 133 73 1 3 445 44 13 13 208 30 144 48 451 1,053 37 143 43 8 112 81 138 175 98 48 14 6 47 not separate for . sexes 4 13 1 2 1 67 2 7 1 9 4 6 5 83 4 5 40 2 13 10 1 3 10 10 3 - 2 Total 265 926 300 174 25 965 253 428 85 1,158 79 1,078 228 969 3,420 457 880 974 393 1,828 536 400 786 603 222 85 102 194 46 Offences under the Factory and Workshop Act. Illegal occupation of underground bakehouse (S. 101) - - - 1 - - - - - - - - 2 2 8 - 1 2 1 - - - - - - 4 - Breach of special sanitary requirements for bakehouses (SS. 97-100) 1 11 67 2 - 2 32 1 - - - 35 - - 4 - 3 - 1 - - - 68 7 89 - - Failure as regards lists of outworkers (S. 107) - 59 - 32 - 20 4 - - - - 140 106 61 8 18 11 - 8 - - - - - - 1 - - Giving out work to be done in premises which are 1 unwholesome f (S.108) - - - - - - - - 1 - - - - - - - 1 - - - - - - - - - - 1 infected (S. 110) - 9 - - - - - - 3 - - - - - - - - - - - - - - - - 1 - - Allowing wearing apparel to be made in premises infected by scarlet fever or smallpox (S. 109). - - - - - - - - - - - - - - - - - - - - - - - - - 1 - - Other offences 5 - - - - - - 7 - - - - - 120 - - - - - - - - 3 - - - - Total (all defects found) 271 1,005 367 209 25 987 289 436 89 1,158 79 1,253 336 1,152 3,440 475 896 976 403 1,828 536 400 857 610 311 188 16 194 46 Other Matters. Matters notified to H.M. Inspectors of Factories. Failure to affix abstract of the Factory and Workshop Act (S. 133) 05 57 - 80 16 30 39 54 20 130 2 73 48 85 44 1 60 24 33 6 2 31 69 79 31 9 10 14 1 Action taken in matters referred by H.M. Inspectors as remediable under the P. H. Acts but not under the Factory Act (S. 5) Notified by H.M. Inspector 6 16 8 5 9 - 43 1 7 10 1 86 7 19 31 122 18 166 5 2 1 13 6 3 11 4 1 4 2 Reports (of action taken) sent to H.M. Inspectors 7 12 1 5 11 - 38 2 7 10 1 6 - 19 31 16 18 (spl.) 1 10 2 1 13 6 3 4 4 1 3 Other 3 4 0 4 1 28 - 3 - 2 - - - 35 4 - - - - 11 - - 3 - - 19 50 - Underground Bakehouses (S. 101). In use during 1903 65 95 42 55 .. 96 27 136 115 20 32 46 44 46 33 63 39 42 33 79 49 61 72 34 33 23 24 Certificates granted in 1903 29 10 12 32 - - 77 11 - 69 20 7 33 19 46 9 63 33 - 33 72 29 48 27 27 2??? 24 ,, ,, in 1904 32 67 26 18 2 1 5 12 93 33 - 20 7 8 1 18 - 3 42 - - 4 - 39 1 18 - In use at the end of 1904 62 78 38 50 43 79 86 23 128 104 20 50 27 40 27 46 28 63 36 41 33 72 33 48 66 28 20 23 24 Homework. Number of lists received S. 101 83 95 58 29 53 491 112 114 47 201 18 403 116 168 272 42 35 531 63 147 24 2 10 36 373 95 66 135 81 Number of outworkers 414 599 124 94 548 7,268 1,315 341 290 1,759 274 3,476 739 4,089 3,457 791 645 2,464 1,352 1,188 363 17 174 375 1,407 204 194 265 353 Addresses of outworkers Forwarded to other authorities 253 415 34 49 408 734 69 277 152 886 206 1,579 119 3,891 3,334 601 298 432 497 693 169 - 37 249 613 314 29 132 38 Received from other authorities 156 151 124 158 67 341 76 14 362 875 200 1,228 68 152 123 680 1,073 1,375 563 394 283 277 175 96 311 280 122 59 41 Notices prohibiting homework in unwholesome premises (S. 108) - - - - - - - - - - - - - - 1 - - - - - - Cases of infectious disease notified in homeworkers' premises 4 9 - - - 15 1 3 12 - 67 - 9 - 45 - 19 - - - 12 34 4 Orders prohibiting homework in infected premises (S. 110) - - - - 1 - - - - - - - - - - - - Workshops on the Register (S. 131) at the end of 1904. Bakehouses 71 97 58 69 43 97 86 36 165 255 28 111 33 61 34 76 84 180 78 108 105 207 89 159 169 77 72 92 62 Laundries 143 255 - 60 35 30 6 86 171 116 19 24 3,030 32 33 2,106 22 74 476 1,139 41 130 86 12 37 123 17 Other Workshops 1,117 1,189 836 251 543 2,357 2,612 631 434 1,852 311 922 746 1,721 1,101 1,217 272 1,414 363 1,360 1,221 1???6 212 373 162 Total Workshop 1,331 1,541 894 380 621 2,484 2,698 673 685 2,278 339 1,149 798 1,806 3,064 1,209 1,334 2,286 372 1,596 581 1,346 493 1,649 1,476 255 321 588 241 74 amount of carbonic acid in the air of 12 workshops and factories and found the atmosphere highly polluted in seven of them, the air of one room containing no less than 48 parts of carbonic acid in 10,000 of air. "The high results obtained," he says, "were all due to the combustion of large quantities of gas and the failure to put in use means of ventilation which were available, and would have been adequate if employed." Unventilated gas stoves are, the medical officer of health of Paddington states, being banished from workshops of all classes. Laundries are mentioned among premises which are reported to be in better condition, and small laundries where unsatisfactory conditions were often found are gradually giving way to large laundries in which steam power is employed. In the same way the inspector of Islington states that it may be expected that work now done at home will be increasingly done in workshops owing to the larger use of mechanical power for sewing machines and the employment of more elaborate machinery. At the end of 1903 the standard of cubic space per head required in bakehouses was raised by order of the Secretary of State to 500 cubic feet in underground bakehouses, and to 400 cubic feet in other bakehouses where work is carried on at night by artificial light other than electric. The number of underground bakehouses is reported to be decreasing, and great improvements have been effected in those which have been certified; in numerous instances certificates were refused for those which were not improved. At the end of 1904, there were in London 2,802 bakehouses, of which 1,416 were underground. Among the workplaces inspected were those in which food is prepared for sale, and hence the kitchens of restaurants and other similar places came under observation. In many districts women are now employed as inspectors, evidently with good results and, further, the practice of allotting one or more of the male inspectors solely for duties under this Act has made progress. An arrangement of this sort undoubtedly gives better results than where the duties of workshop inspections is shared by inspectors who are employed in districts in all the duties which have to be undertaken under the Public Health Act. The Medical Officer of Health of Westminster states that since the appointment of two women inspectors in the autumn, it was possible for him to overtake the work; and the Medical Officer of Health of Hackney mentions the appointment of a woman inspector in 1904. In two annual reports the insufficiency of the staff of inspectors is pointed out, thus the Medical Officer of Health of Islington urges the appointment of another inspector for duties under the Factory and Workshop Act, and the Medical Officer of Health of Bermondsey states that his application for the appointment of a female inspector for this purpose was not adopted by the borough council. Unsound Food. In his report to the Corporation of the City of London on the meat supplied to the Central Market, Dr. Collingridge states that "the home-produced supplies continue to diminish and we are more than ever dependent upon Colonial and foreign meat." Meat, moreover, is brought longer distances and has, therefore, in larger proportion than before arrived at the market in an unsatisfactory condition. He comments, also, on the large export to foreign countries of the finest breed of cattle in this country, and quotes a statement of "The Meat Trades Journal" that the beef cattle of England itself wants "grading up." There has been, he says, a superabundance of second-class and imperfectly prepared meat in the market and a lessened demand for the home-grown product. The seizure of diseased and unsound meat during the year amounted to 1,156 tons, 2 cwt. and 1 qr., including 440 tons, 10 cwt., 3 qrs. and 10 lbs. of imported frozen and chilled meat Among the seizures made during the year were that of 10,322 rabbits brought from Australia in the s.s. Medic and most of which were seized in the Union Cold Air Stores beneath Cannon-street Station. A box of immature kids was also brought to the notice of the inspector by a salesman in the Central Meat Market. The box was labelled "rabbits" and was sent by a small trader who resided at Baarle-Nassau who had the intention of sending a hundred weekly to the market. There were nine prosecutions during the year and eight convictions. Concerning the case in which the summons was dismissed, that of a butcher who dressed and sent to market the carcase of a sheep belonging to a farmer and which had died in a field, the ownership of the meat by the butcher was not proved. Dr. Collingridge remarks that "at present the owner escapes because he has no knowledge and the butcher because he is not the owner," and he suggests that "the person or persons under whose control the meat was" should be made liable under Section 47 of the Public Health (London) Act. In Finsbury is situated the "Extra Metropolitan Meat Market," a market carried on in streets bordering on the City market, and in which a large amount of meat is sold. An inspector is appointed especially for the inspection of food in this market and in other parts of the borough. Inspection of food in other parts of the borough is also made by the " district inspector," and during the year 76 tons, 19 cwt., 3 qrs. and 13 lb. of meat were seized; 60 tons, 5 cwts., 1 qr. and 13 lb. being decomposed and 16 tons, 14 cwts. and 2 qrs. being diseased meat, besides other articles of unwholesome food, poultry, cheese, eggs, vegetables, etc. There were 17 prosecutions and 16 convictions during the year. Three of the convictions related to the sale of tuberculous pork—in one instance a pig's head. In Islington, where a special food inspector is also employed, the slaughterhouses were visited at the time of slaughter. The weight of unsound meat destroyed during the year was 3 tons, 2 cwt. 11 lbs., and that of unsound fruit, etc., 2 tons, 6 cwt., 3 qrs. and 3 lbs., and in three cases there were prosecutions and convictions. In Paddington, where meat is inspected in slaughterhouses, food stuff was seized or surrendered as follows, 1,740 lbs. in slaughterhouses, 2,348 lbs. in butchers' shops, 218 in fishmongers' shops, and 75 7,026 lbs. in fruit and greengrocery shops. Of the meat, 22i pigs and 8 pigs' heads were seized on account of their being tuberculous, and Dr. Dudfield states that a practice has been adopted which renders it impossible, except on rare occasions, to say whether the "dressed" carcase of pigs are or are not tuberculous. "The lymphatic glands, tonsils, etc., are usually so minced up—when not cut out—that it is impossible to form any opinion as to their freedom from disease." "Carcases for delivery in Paddington are almost always held back for special inspection, but where the 'stripping' takes place is not definitely known. It is not done in the borough." Summonses were taken out in eight instances under section 47 of the Public Health (London) Act in respect of unsound food, in five instances the food was unsound pork, and all the summonses in respect of pork were dismissed. In connection with some of these cases Dr. Dudfield writes that "In May of last year summonses were heard at the Guildhall Court touching pigs which were purchased at the Central Meat Market, and condemned on inspection by the Council's staff after delivery at the local shop. He states that the facts of the case have been laid before the Local Government Board, who have decided to enquire into meat inspection in the metropolis. In Hackney the slaughterhouses were inspected as far as possible at the time of slaughtering, and the whole or parts of carcases unfit for food were seized. In a preserved meat factory, of whic h there are six in the district, a pig's head was found to be badly affected with tuberculosis. The head wa3 seized, and the firm in Wiltshire which had sent the pig's head to the local manufacturer was summoned and convicted. Other articles of food were also seized in this district during the year. Among various articles seized in Shoreditch were a number of tins of condensed milk which were said to have been machine skimmed and prepared in Holland. These tins were found to be blown and their contents to be unfit for human food. The condition of the tins was brought by the owner to the notice of the Shoreditch Sanitary Authority. He had purchased them from a man in West Ham who had previously carried on business in Stepney, where he had been convicted of selling condensed milk unfit for human food. Dr. Bryett says: "It appears that he was in the habit of buying damaged stocks of tinned foods of various descriptions, such as meat, fish, fruits, etc., with a view to separating what was fit for food and rejecting what was unfit." With respect to the tins found in Shoreditch, it was impossible to prove their condition when they were received by the Shoreditch tradesman, as they had been in his possession for some time and it was therefore not deemed advisable to institute proceedings. In Stepney, 735 tons, 3 cwt., 1 qr. and 10 lbs. of food stuff were destroyed during the year, mostly vegetables and fruit. A difficulty met with in the inspection of food is commented on by Dr. Thomas as due to the sale on the same premises of food which is sold for human food with that which is used as cats' meat. It is claimed if diseased meat is found that it is intended for cats' meat, and it is impossible to go behind this statement, although in particular instances no reliance can be placed on the intention of the vendor. In one case diseased livers were found on a butcher's premises, who pleaded that they were intended for sale to a tripe dresser, who selected those which were fit for human food. The summons was dismissed by the magistrate, but the matter being brought before the Licensing Committee of the London County Council, who had cautioned him but three years before, the Committee refused to renew the licence for his slaughterhouses. In Poplar several pigs' heads were surrendered owing to being diseased, but the carcases belonging to the heads were not upon the premises, as the heads had been purchased separately. In one instance diseased lungs were found in a sausage factory and the butcher was prosecuted and convicted. Prosecutions for the sale of unsound food were instituted in some of the other London districts. In Battersea and in Bethnal-green there were ten prosecutions, in Bermondsey nine, and a smaller number in Fulham, Chelsea, Westminster, St. Pancras, Stoke Newington, Southwark, Lambeth, Wandsworth and Woolwich. Both in Bermondsey and Westminster pigs' heads were seized. In the former district the vendor of five pigs' heads, four half-pigs' heads and one piece of bacon was sentenced to three months' imprisonment, and in the latter district the vendor of a tuberculous pig's head and pork was fined £10. The need for the employment of special inspectors for inspection of food has been previously pointed out in these reports, and the results obtained in those districts where the inspection of meat in slaughterhouses is thus undertaken shows the advantage of such employment. This need for more thorough inspection of meat in London districts is now emphasised by recent seizures of pigs or parts of pigs found to be tuberculous. The observations of Dr. Reginald Dudfield show that tuberculous glands are removed from the head before it arrives on the local vendors' premises, equivalent, as he points out, to the stripping of the tuberculous pleura from the carcases of cattle. The extent to which the meat of tuberculous pigs is supplied to the consumer cannot be stated, but in the absence of public slaughterhouses where all animals killed would be examined at the time of slaughter and of the systematic inspection of all carcases, it is obvious there can be no adequate control over the sale of tuberculous pork. The Sale of Ice Cream. The conditions of premises on which ice cream is manufactured is controlled under the provisions of the London County Council (General Powers) Act, 1902, which conferred special powers upon London sanitary authorities for that purpose. The annual reports of medical officers of health show that these powers are being actively exercised, and thus a number of premises have been brought under inspection. Some of these places were obviously unsuitable for the purpose. Thus, in Hackney, in five instances living rooms were found to be used for this purpose contrary to the provisions of the Act. The medical officer of health, however, states that the premises were mostly found to be clean, and in 70 only a small proportion of cases were structural defects discovered. In Islington all the premises, 234 in number, were visited in the second quarter of the year, prior to the commencement of the summer season, and Dr. Harris reports that the proprietors, for the most part foreigners, have generally obeyed the law, and have manufactured the ices under conditions that are a great improvement on those which obtained some years ago. Dr. Bond, the Medical Officer of Health of Holborn, in the Italian quarter of which ice creams are largely manufactured for sale in the streets of London, reports in a similar sense. He writes: "On account of the increased powers which we have by the London County Council (General Powers) Act, 1902, the premises where ice cream is manufactured or sold are now in better condition. Many rooms and bedrooms which, before the Act came into force, were used for the manufacture, sale or storage of ice cream are no longer used for the purpose, and many rooms or other places have been specially fitted up and prepared for this business." In several districts, in addition to premises in which ice cream sold in the street is manufactured, other premises where the ice cream is sold only in a shop have been brought underinspection. In some districts there were prosecutions under the Act, for the most part for neglect of the itinerant vendor to exhibit on his barrow the name and address of the manufacturer of the ice cream which he was selling. In Deptford a manufacturer was fined £2 and £'3 3s. costs for kesping his premises in a filthy condition. Information as to the number of premises under inspection is given by all the medical officers of health except those of the metropolitan boroughs of Kensington, Westminster, St. Marylebone, Stepney and Lewisham, and the following table has thus been compiled:— The sale of ice cream. Sanitary Area. Number of places. No. of inspections 1904. No. of natices 1904. No. of prosecutions under Act, 1904. On register at end of 1903. Added in 1904. Removed in 1904. On register at end 1904. Paddington 21 135 91 Hammersmith 141 32 1 172 344 18 1 Fulham 117 9 5 121 264 15 - Chelsea 60 - 5 55 68 - - Hampstead 09 2 2 69 118 3 - Islington 183 51 - 234 280 75 - Stoke Newington 35 1 Hackney 107 Holborn 32 13 2 43 144 6 - Finsbury 101 - 1 100 206 48 5 London, City of 239 237 Shoreditch 64 11 6 69 196 23 - Bethnal Green 65 - - 65 33 13 - Poplar 134 206 4 1 Southwark 83 83 31 2 Bermondsey 68 1 - 69 285 14 - Battersea 115 116 267 22 - Wandsworth 158 49 15 192 333 30 - Camberwell 258 29 66 221 535 22 4 Deptford 98 23 27 94 272 1 Greenwich 118 5 7 116 122 - Woolwich 64 20 1 83 151 3 An outbreak of illness occurred in Battersea in July among a number of people who had eaten ice cream purchased at a particular shop. The number of persons attacked was evidently considerable, extending beyond 54 people of whose illness particulars were obtained by Dr. McCleary. The symptoms in all these cases were similar and appeared within 24 hours after the ice cream was eaten, the usual period being from eight to fourteen hours."The symptoms," Dr. McCleary states, "began with violent abdominal pain, followed by severe diarrhoea and sickness. The temperature was raised in most cases, varying from 101 deg. Fahr. to 103 deg. Fahr. The pulse was rapid and feeble, and in most or the cases the patient soon became collapsed. No case was fatal." The ice cream which caused this outbreak was all consumed and could not therefore be examined, but ice cream taken from the premises immediately afterwards was bacteriologically examined. The specimen was found to contain 10,000 coliform organisms per cubic centimetre, the typical Bacillus Coli Communis being apparently only present in small numbers and the Bacillus Enteritidis Sporogenes probably entirely absent." Dr. McCleary found the premises clean and well kept, but he states: "I have no doubt that one of the receptacles used for storing the ice cream was contaminated by bacteria—containing dust from a dust-bin on premises in the neighbourhood—that the ice cream stored in this receptacle also became contaminated, and that the consumption of this ice cream gave rise to the outbreak." 77 Ice and Cold Storage. Inquiry was made during 1903 and 1904 by Dr. Hamer into the question of the use of natural ice and its manipulation in London and, further, into methods adopted in the manufacture of artificial ice. In the report which he prepared and which I presented to the Committee at the end of 1904 (See appendix I.), account is given of the growth of the ice industry within recent years (in 1899 more than 500,000 tons of natural ice were brought to this country from Norway) and of a feature more remarkable than the extended use of natural ice, namely, the great development in the last fifty years of the use of refrigeration in various industries, a development which has clearly by no means reached its limit The report deals further with the records of ice-borne disease and the bacteriology of ice, and incidentally reference is made to the important conclusion arrived at by Professor Abba to the effect that the water bacteria in ice are not so much destroyed as extruded in the process of freezing. In Germany twenty years ago Professor Fraenkel urged that only ice made from distilled water should be allowed to come in contact with beverages and with food and, inasmuch as the source from which natural ice is derived can never be known with certainty by the consumer, this recommendation is undoubtedly sound. In America it has been suggested that there is need of supervising cold stores in the interests of public health, and Dr. Hamer gives account of the vast extension of the application of cold storage methods in recent years and points out that consideration should be given to the need of securing that questions of structure and arrangement which are of importance for ensuring freedom of food stuffs from contamination should be duly considered in designing cold stores. By the direction of the Public Health Committee, a copy of Dr. Hamer's report was forwarded to the Local Government Board. The Pollution of Watercress Beds. Attention has from time to time been directed to possible risk of spread of disease, and more particularly of enteric fever, by consumption of uncooked vegetables which have come in contact with sewage-contaminated water. Watercress has more than any other vegetable fallen under suspicion in this connection; and indeed, in London, Dr. Verdon, in 1894, and Dr. Warry, in 1903, have specially drawn attention to excessive prevalence of enteric fever, in Lambeth and in Hackney respectively, which may conceivably have been associated with watercress eating. The question of risk to health associated with use of raw vegetables and fruit produced on sewage farms was made the subject of study by a French Commission in 1902. The most interesting point brought out by their investigations was the absence of any evidence that certain pathogenic organisms can grow in living vegetable tissues. If cress acts merely as a carrier of sewage-contaminated water it must necessarily be a less serious source of danger than would be the case if the enteric fever bacillus found opportunities for development in the stalk or leaves of the cress. With the object of gauging the extent to which the watercress consumed in London is exposed to risk of contamination, the Council's Inspectors have visited all the known watercress beds within 50 miles of the county supplying the London market, and samples of the water supplying the beds and in some instances samples of the cress have been examined chemically and bacteriologically. The results of the topographical examination of the watercress beds correspond fairly closely with the results obtained by chemist and bacteriologist. Particulars concerning those beds to which objection might specially be taken have been communicated to the Local Government Board. In the report presented to the Public Health Committee in connection with this inquiry the beds have been broadly grouped in four classes according to their extent of departure from a satisfactory standard and particulars concerning them are appended. The report also contains the Chemist's report and a report by Dr. Houston giving the results of his bacteriological inquiry. It should be borne in mind that, as Dr. Houston observes, danger accruing to the consumer of unwashed watercress is enormously reduced by careful washing of the cress, but, he adds, "even an excess of care devoted to the washing of cress from polluted sources does not always entirely free the cress from objectionable microbes." (See Appendix II.) Disinfection. In the last annual report, it was pointed out that of all the London sanitary authorities only those of Kensington and Paddington had no disinfection station of their own, but relied on the services of a contractor for the purpose of disinfection of infected articles. The council of the borough of Kensington has now decided to provide a station at Wood-lane, Shepherd's Bush. The council of the borough of Paddington has been represented to the Local Government Board by the County Council as making default in respect of this duty under the Public Health (London) Act, and has since submitted to the Local Government Board plans of a disinfecting station in their district. A new disinfecting station has been provided in Bethnal Green and in Wandsworth. The Medical Officer of Health of Westminster states that the disinfecting station in Denzil-street has been acquired by the County Council for the purposes of the new street from Holborn to the Strand, and the Medical Officers of Health of Southwark and Battersea urge the need of a laundry in connection with the work of disinfection of clothes. In the City of London the disinfecting station was destroyed by fire in October, 1904, and plans for re-arranging the buildings on improved lines have been prepared. Shelters. The shelter in Battersea, which in 1903 was in course of erection, was ready for occupation at the end of the year. The shelter comprises two tenements, each containing two rooms and a scullery, and one tenement containing three rooms and a scullery. No shelter had been provided for the use of 6106] L 78 the inhabitants of Kensington. The number of persons accommodated in the shelters of some of the other sanitary authorities was as follows:—Chelsea, 191; Westminster, 39; St. Marylebone, 18; St. Pancras, 32; Islington, 14; Hackney, 104; Holborn, 6; Finsbury, 86; the City, 33; Shoreditch, 43; Bethnal Green, 86; Poplar, 159; Wandsworth, 6; Camberwell, 7; Deptford, 9; Greenwich, 13. In Paddington, Lambeth and Woolwich the shelter was not used during the year. Mortuaries. With the improvement in the accommodation provided for the temporary deposit of the dead, London mortuaries are being increasingly used, and some eleven per cent, of the dead bodies of the deceased inhabitants of London were in 1904 received into these buildings. A new mortuary has been provided on a site adjacent to the Coroner's Court in Greenwich. Dr. Annis describes it "as having its accommodation divided into two portions, one for the reception of infectious bodies, the other for the reception of general cases. The infectious diseases department is provided with catacombs for the reception of six bodies and is adjacent to the common viewing corridor, being provided with a large glass-plate window, so that the jurymen and others whose duty it is to view the bodies need not come into contact therewith, nor run any risk of infection thereby. The general mortuary is provided with catacombs for the reception of 12 bodies, also with an air-tight container for the reception of any decomposing bodies and this mortuary is provided with a plate-glass window looking into the viewing corridor. . There is also a well-lighted post-mortem room provided with two post-mortem tables and all appurtenances, a room for the use of the medical men who may be called upon to carry out their duties in this connection, accommodation for a small hand ambulance, and the usual offices. The walls of the building are faced internally with opalite tiling, the floors are of terrazo paving, the corners and angles are all rounded, hence the whole of the building can very readily be kept clean. It is well lighted by electricity, and ventilated by louvres alongside the lantern lights in the roof. The council of tho-borough of Deptford has been unable to use the land originally purchased for the purpose of erection of a mortuary and therefore other arrangements have had to be made. The council of the borough of Poplar has decided to erect a mortuary in Glaucus-street. This mortuary will be associated with a Coroner's Court. The Medical Officer of Health of Lambeth has called attention to the inadequacy of the mortuary in High-street, and states that a letter was received from the Guardians drawing attention to the need of additional mortuary accommodation in the district, "not necessarily for the reception of bodies awaiting inquest, but where bodies of poor people, whose friends or relatives are unable to make adequate and sanitary arrangements at home, mav be taken pending interment." The extent to which mortuaries were used in the London districts, other than in Stepney and Lewisham, for which the information is wanting, is shown in the following table:— Sanitary Area. Total number of bodies removed. Number of infectious bodies removed. Sanitary Area. Total number of bodies removed. Number of infectious bodies removed. Paddington 293 London, City of 184 Kensington 334 3 Shoreditch 460 4 Hammersmith 216 2 Bethnal Green 376 Fulham 211 3 Poplar 476 Chelsea 112 2 Southwark 557 6 Westminster, City of 388 Bermondsey 178 St. Marylebone 408 4 Lambeth 373 1 Hampstead 82 1 Battersea 221 6 St. Pancras 432 9 Wandsworth 197 - Islington 660 3 Camberwell 302 Stoke Newington 58 Deptford 76 1 Hackney 436 5 Greenwich 170 Holborn 135 1 Woolwich 164 2 Finsbury 437 15 The Cleansing of Persons Act. As yet but little provision has been made in London under the Cleansing of Persons Act for the cleansing of persons who may be in need of such assistance. At the time of the last report adequate provision had been made only in St. Marylebone. In this district 8,465 persons were cleansed, a large increase above the number of men and especially of the women cleansed in the preceding year. In St. Pancras a room adjoining the Contact Shelter has now been fitted with a couple of baths for men, and accommodation has also been provided for women and children. Dr. Sykes' annual report shows that in the four quarters ending March, 1905, 2,630 persons presented themselves for cleansing. In Hackney special provision has been made and has come into use during the present year. In other districts the accommodation hitherto provided consists as a rule only of the use of the baths at the casual wards, and only trifling use has been made of such accommodation. In Finsbury, however, arrangements are almost completed for providing more satisfactory accommodation, and in the City of Westminster it is intended to make suitable provision at the proposed central disinfecting station. 79 The Medical Officer of Health of Islington says the council of that borough has decided to erect suitable buildings, and the Medical^Officer of Health of Woolwich states that the borough council has decided to'erect a bath or baths adjoining the {disinfecting station in White Hart-road. The need of such accommodation is pointed out by the Medical Officer of Health of Southwark. Legislation in 1904. In addition to the powers conferred upon the Council with respect to tuberculosis of the udder in cows referred to on page 54, the London County Council General Powers) Act of 1904, Part IV. deals with various sanitary matters in respect of which new powers are conferred upon sanitary authorities. These powers may be thus summarized.— Filthy, dangerous or unwholesome articles.—Section 19 (1) provides that where on the certificate of the medical officer of a sanitary district, it appears to the sanitary authority that any articles in any house in their district are in such a filthy, dangerous or unwholesome condition that health is affected or endangered thereby, or that the cleansing or purifying or destroying of any such articles is requisite to prevent risk of or to check infectious disease, the sanitary authority may, at their own expense, cause any such articles to be cleansed or purified or destroyed. The sanitary authority is required by Section 19 (2) to compensate the owner for any unnecessary damage and reasonably compensate him for any articles destroyed. Houses infested with vermin.—Section 20 provides that where on a similar certificate it appears to the sanitary authority that any house or part thereof in their district is infested with vermin, the sanitary authority shall give notice in writing to the owner or occupier, requiring him within a specified period to cleanse such house or part thereof, and if so required to remove the wall paper and to take such other steps as they may require for the purpose of destroying and removing vermin. Section 20 (2) provides a penalty upon conviction, not exceeding 10s. per day during^default in compliance with the notice, and in the event of non-compliance the sanitary authority may, after the period specified in the notice, themselves do any work required by the notice, and summarily recover the reasonable costs and expenses as a civil debt from the person making default. In the event of proceedings under the Section the court is empowered by Section 20 (3) to inquire whether the requirements of the sanitary authority contained in the notice were reasonable and whether the costs, etc., incurred by the sanitary authority in doing the work, or any part thereof, ought to be borne wholly or in part by the person to whom the notice was given, and the Court may make such order as to the costs and expenses as appears to the court to be just and reasonable. The provisions of Section 59 of the Public Health (London) Act, 1891, as to provision of means for disinfecting bedding, etc., are made applicable by Section 21 of this Act to the provisions of Sections 19 and 20 above referred to. Removal or alteration of sanitary conveniences.—Section 22 empowers the'sanitary authority by notice to require the owner of any sanitary convenience, which is now or may hereafter be erected in or accessible from any street, and so placed or constructed as to be a nuisance or offensive to public decency, to remove such convenience or otherwise to reconstruct the same in such manner and with such materials as may be required to abate the nuisance or remove the offence. A penalty upon conviction of not exceeding £5 and a continuing penalty of not exceeding £1 per day is provided by the Section for default in compliance with the notice. Fixed ashpits.—Section 23 provides that where in connection with a building a movable ashpit contorming with the sanitary authority's requirements has been provided, the sanitary authority may, by notice, require the owner of such building within a reasonable period to remove or fill up any fixed ashpit in or about such building, and restore to a good and sanitary condition the site of such ashpit. A penalty of not exceeding £1 and a continuing penalty of 10s. per day is provided for default in complying with the notice. The Section empowers the sanitary authority themselves to bear any reasonable costs and expenses or part thereof in executing works under the Section, if they think fit. Section 24 gives the sanitary authority power to enter any house or part thereof, if they have reasonable cause to suppose that there are any filthy, dangerous or unwholesome articles therein which require to be purified or that the house or part thereof is infested with vermin. Section 25 incorporates various sections of the Public Health (London) Act, 1891, for the purpose of enabling sanitary authorities to enforce the provisions of this part of this Act, and Section 101 of the 1891 Act, which empowers the Council in the event of a sanitary authority making default in executing any provisions of the Act to make a complaint to the Local Government Board, is also incorporated. Dr. Kerr states in his annual report (see appendix III., page 18), that in connection with the observations made as to the condition of children in the Council's schools, information has been furnished to sanitary authorities regarding houses suspected to be verminous, and some authorities have done a great deal in effecting cleansing, while others have apparently done little. Midwives Act. The Midwives Act came into operation on 1st April, 1903, and the Central Midwives Board was constituted thereunder. Later in 1903 the Board framed its rules and began to issue certificates to midwives. The London County Council is the local supervising authority for London under the Act, and as a preliminary measure information was obtained by the Council from various sources as to women said to be practising midwifery in London. In April, 1904, a circular letter was sent to some 550 of these women pointing out the provisions of the Act and directing what steps 6108] L2 * 80 should be taken to secure certification, and notices were inserted in several daily and weekly newspapers. A list of midwives certified under the Act and living in London was compiled from the roll of the Central Midwives Board, steps were taken to ascertain whether these women were actually practising as midwive3, and inquiries were made into any cases of puerperal fever, still births, etc., occurring in the practice of such women. In November, Miss V. E. M. Bennett, M.B., B.S., was appointed inspector under the Act, and a systematic inspection of certified midwives practising in London was begun with a view to ensuring that they observed the rules of the Central Midwives Board. At the end of 1904 there were 972 certified midwives in London, and 150 of these had notified the Council as the local supervising authority under the Act of their intention to practise. Conference on the Administration of the Public Health (London) Act, 1891. On the 6th October, 1903, the following resolution was passed by the London County Council:— "That in view of tho different standards of thoroughness adopted bv the various medical officers of health in London, in their administration of the Public Health Act, it be an instruction to the Public Health Committee to consider as to convening: a Conference of representatives and medical officers from the metropolitan boroughs to consider the advisability of a more uniform administration." On this instruction the Public Health Committee on the 10th May, 1904, reported as follows:— " From information which has been placed before us it is evident that there is considerable want of uniformity in the enforcement by the sanitary authorities of London of their various statutory duties and powers, and we think that it would be of advantage if a conference were convened by the Council at which the undermentioned subjects might be discussed." 1. Houses let in lodgings. 2. Overcrowding. 3. Underground rooms. 4. Sanitary condition of factories, workshops and workplaces. 5. Enforcement of by-laws under the Public Health and Metropolis Management Acts. 6. Inspection of food and of places where food is prepared. 7. Inspection of offensive trades, slaughterhouses, cowhouses, dairies and milkshops. 8. Precautionary measures against measles and phthisis. 9. Methods of disinfection and the provision and use of shelters for persons during disinfection. 10. Number of sanitary inspectors. 11. Employment of female inspectors. The conference was held on the 7th and 18th July, 1904, under the presidency of Mr. Jephson, chairman of the Public Health Committee, and the following resolutions were adopted:— Housing. Houses let in Lodgings. 1. That the efficient administration of Section 94 of the Public Health (London) Act, 1891, relating to the registration and regulation of houses let in lodgings is a matter of extreme importance to the public health of London. 2. That it is advisable that in by-laws made in respect of houses let in lodgings there should be no rental limit of exemption, but that they should be so framed as to apply only to such houses as are registered by the sanitary; authority. 3. That the efficient enforcement of by-laws relating to houses let in lodgings is the most effective method of dealing with overcrowding, but that inspections should from time to time be made during the early hours of the morning at other houses where overcrowding within the meaning of Section (2), (1), (e) of the Public Health (London) Act, 1891, is suspected. Underground Rooms. 4. That a single angle of light and air to underground dwelling rooms should be adopted in the enforcing of Section 90 of the Public Health (London) Act. 5. That this Conference is of opinion that no underground room not complying with the conditions laid down by Section 96 of the Public Health Act, 1891, should be used for sleeping. Water Supply. 6. That a draw-off tap from the rising main and a sink should be provided on every floor of a tenement-house. Factories and workshops. 7. That it is desirable that the sanitary authorities in enforcing Section 38 of the Public Health (London) Act 1891, should adopt the following standards:— I. In factories and workshops where females are employed or in attendance there shall be one sanitary convenience for every 25 females, provided that in factories or workshops where the number of females employed or in attendance does not exceed 75 the following shall be the standard:— One sanitary convenience where no more than 15 females are employed or in attendance. Two sanitary conveniences where from 15 to 40 females are employed or in attendance. Three sanitary conveniences where from 40 to 75 females are employed or in attendance. II. In factories or workshops where males are employed or in attendance there shall be one sanitary convenience for every 25 males; provided that— (а) in factories or workshops where the number of males employed or in attendance does not exceed 50, and sufficient urinal accommodation is also provided there shall bo one sanitary convenience where no more than 20 males are employed or in attendance, and two sanitary conveniences where from 20 to 50 males are employed or in attendance; (b) in factories or workshops where the number of males employed or in attendance exceeds 100, and sufficient urinal accommodation is also provided, it shall be sufficient if there is one sanitary convenience for every 25 males up to the first 100, and one for every 40 after; (c) In factories or workshops where the number of males employed or in attendance exceeds 500, and the district inspector of factories certifies in writing that, by moans of a check system, or otherwise, proper 81 supervision and control in regard to the use of the conveniences are exercised by officers specially appointed for that purpose, it shall be sufficient if one sanitary convenience is provided for every 60 males, in addition to sufficient urinal accommodation. Any certificate given by an inspector shall be kept attached to the general register, and shall be liable at any time to be revoked by notice in writing from the inspector. (In calculating the number of conveniences required, any odd number of persons less than 15, 20, 25, 40. or 60, as the case may be, shall be reckoned as 15, 20, 25, 40, or 60). Shops. 8. That it is desirable that power should be given to local authorities to inspect the sleeping accommodation in shops where the assistants are boarded in. Food. Premises where food is prepared for sale. 9. That the London County Council be requested to insert in their General Powers Bill for the Session of 1905 a clause enabling them to make by-laws for the regulation of the structure of premises where food is prepared for sale and that no such premises should be used unless certified by the Borough Council to be suitable for the purpose, 10. That the London County Council be requested to insert in their General Powers Bill for the Session of 1905 a clause enabling them to make by-laws for the regulation of the conduct of the business carried on in premises where food is prepared for sale, such by-laws to be enforced by the Borough Councils. Abolition of private Slaughter-houses. 11. That the time has arrived when private slaughter-houses should cease to exist in London. Inspection of meat killed in private Slaughter-houses. 12. That it is desirable that Borough Councils should endeavour to have all meat that is killed inspected. Inspection of Slaughter-houses, Cow-houses, Dairies, Milk-shops, and Milk-stores. 13. That slaughter-houses, cow-houses, dairies, milk-shops and milk-stores should be frequently inspected. Registration of Milk-shops. 14. That the London County Council be requested to take powers to enable the Metropolitan Borough Councils to refuse registration of promises as milk-shops where, in their opinion, the promises are unfit for the purpose. Sale of Milk. 15. That the London County Council bo requested to introduce legislation providingfor thepenalising of persons selling filthy milk in London. Municipal Milk Depots. 16. That, having regard to the declining birth rate and the large infantile mortality rate of the Metropolis, it is desirable that the Metropolitan Borough Councils should be empowered, at their discretion, to provide in their respective districts depots for the preparation and sale of sterilised and humanised milk for the food of infants, and that the London County Council be requested to insert a clause in its General Powers Bill for the Session of 1905 to confer such power upon the said Borough Councils. Sale of Food and Drugs Acts. 17. (a) That, in the opinion of this Conference, the provisions of Section 25 of the Food and Drugs Act, 1875 and of Section 20 of the Food ^ind Drugs Act, 1899, operate to the prejudice of the purchaser and of public health, and should be repealed. (6) That the London County Council be requested to make a communication, conveying the resolution of the Conference, to the President of the Local Government Board,with a view of his promoting legislation for this purpose. 18. That the Local Government Board and the Board of Agriculture be asked to take such steps as may be necessary in order that a limit may be fixed as to the amount of boracic acid—that is free or combined boracic acid— or other preservatives which may be mixed with food other than milk. t 19. That every registered milk seller in a borough shall have his milk tested frequently. Cisterns. 20. That, in cases where there is a constant water supply, cisterns should only be used in connection with hot water services and sanitary conveniences. Prevention of Disease. Disinfection. 21. That this Conference is of opinion that disinfection should be carried out by the responsible officers of the sanitary authority without the intervention of a contractor. 22. That the London County Council be asked to take measures to amend the law with regard to disinfection, so that disinfection should be carried out by the responsible officers of the sanitary authority without the intervention of a contractor, and that in all cases the disinfection should be to the satisfaction of the medical officer of health. Provision of Laundry. 23. That the provision of a laundry for use in connection with the disinfection of infected articles is essential. Provision of permanent shelter accommodation. 24. That at least one permanent shelter for temporary use should be provided in each borough for the accommodation of persons during the disinfection of their homes. 25. That the word "accommodation" mentioned in Section 60, sub-section 4 of the Public Health (London) Aot, 1891, should, if and when necessary, include the expense of the supply of food. Precautionary measures against phthisis. 26. That the system of voluntary notification of phthisis is desirable, and should be made general throughout London. 27. That the sanitary authorities should disinfoct the premises in which a person suffering from phthisis has died, or from which such a patient has removed or has been removed. Hospital Accommodation. 28. That it is desirable to make provision of sanatoria for the isolation and treatment of persons suffering from consumption, for the Metropolis as a whole, and under one authority; and that, in the opinion of this Conference, the Metropolitan Asylums Board should be such authority. 29. That the foregoing resolution be sent to the Local Government Board with the request that they give the matter their immediate consideration. Offensive Trades. 30. That the business of a marine store dealer should be added to the list of offensive businesses specified in Section 19 of the Public Health (London) Act, 1891. 31. That the business of a fried fish shop keeper should be added to the list of offensive businesses specified in Section 19 of the Public Health (London) Act, 1891. 32. That the London County Council be requested to make an order to carry out these resolutions. 82 House Refuse. 33. That this Conference is of opinion that dust^collection should be carried out by the responsible officers of the sanitary authority without the intervention of a contractor. 34. That the daily removal of house refuse in suitable districts is advisable. 35. That improved dust carts should be adopted^so covered as to minimise annoyance caused to passers-by during collection of house refuse, especially in crowded thoroughfares. 36. That the method of destruction of house refuse by fire should be universally adopted in London. Collection of fish offal and other offensive trade refuse. 37. That the collection of fish offal and other offensive trade refuse should be undertaken by the sanitary authorities at the expense of the producers. Sanitary Inspection 38. That female inspectors should be employed in each borough. Miscellaneous. Municipal Creches. 39. That, having regard to the declining birth-rate and the large infantile mortality rate of the metropolis, it is desirable that the metropolitan borough councils should be empowered at their discretion to establish creches for the reception of young children during the hours their mothers are employed in work away from home, and to make reasonable charges for the accommodation so provided and for the food of the children, and that the London County Council be requested to insert in their General Powers Bill for the session of 1905 a clause to confer such power upon the said borough councils. Smoke nuisances. 40. That in the opinion of thi3 Conference it is desirable that the provisions of the Public Health (London) Act, 1891, as to nuisances arising from the emission of smoke, should be applied to property in the possession of the Crown. Metropolitan Ambulance Service. 41. That the Conference, taking note that the Metropolitan Asylums Board are prepared to extend the operations of their ambulance service so as to include the transport of medical, surgical, and mental cases, respectfully requests the Local Government Board to obtain for the Managers the requisite legal authority to enable them to do so. 42. That the Conference desires to express the opinion that should the London County Council not be able to provide for a street ambulance service, the duty should be undertaken by the Metropolitan Asylums Board. Application of Acts to Government Prop rty. 43. That all provisions of the Public Health and Sanitary Acts should apply to Government property. Conference on the Spread of Disease by Vagrants. The attention of the Council having been drawn by the Corporation of Newcastle-upon-Tyne to the spread of small-pox throughout England and Wales through the agency of vagrants, and the suggestion having been made that a conference of the sanitary authorities of England and Wales should be convened to consider the question, the Public Health Committee advised the Council to accede to the suggestion of the Corporation, and a resolution was passed by the Council convening a conference in the autumn of 1904. Invitations were issued to the Councils of counties, county boroughs, and metropolitan boroughs asking each to appoint a member together with the medical officer of health of each authority to meet in conference on the subject at the County Hall on 10th November, 1904. Invitations were also issued to the Local Government Board, the Corporation of the City of London and the Metropolitan Asylums Board. The chair of the conference was taken by Mr. Henry Jephson, the chairman of the Public Health Committee, and after discussion the following resolutions were adopted:— General Measures for the Prevention of the Spread of Infectious Disease by Vagrants. (1) (a) That this conference of urban and sanitary authorities of England and Wales recognises the increasing amount of habitual vagrancy as the cause of wide-spread and disastrous consequences to the public health, and is of opinion that much more effective measures than are at present adopted should be taken for preventing the spread of infectious disease by vagrants, and for effectually dealing with this great and growing danger. (b) That the evil can only be met by conferring further powers upon the local authorities, viz., the sanitary authority, the board of guardians, and the magistracy. (2) That means should be provided for the detention and isolation of any vagrant found wandering in a public place, if reasonably suspected of being liable to convey infectious disease. (3) That this conference is of opinion that it is desirable that (а) Parliamentary powers should be sought for the compulsory vaccination and re-vaccination of all vagrants unable to produce proof of being sufficiently protected against smallpox on entering casual wards or common lodging houses, who, in the opinion of the sanitary authority, have been exposed to the infection of smallpox, and also that sanitary authorities should have power to grant such compensation as they think necessary to persons vaccinated or re-vaccinated at their request who may be prevented on that account from work ; (b) It should be an offence to withhold information or make false statements to the sanitary authority in carrying out its powers with respect to the disease. (4) That in order to deal effectually with the transmission of notifiable infectious disease by tramps, power should be given to county councils to enforce the existing laws in all cases where sanitary authorities in the county refuse or neglect to do so. (5) That the Loal Government Board should obtain powers to secure weekly returns of all cases of infectious disease from all central authorities throughout the country, and circulate the same. (6) That it is desirable that in districts comprising groups of counties and county boroughs, intelligence bureaux should be established, to which information should be sent from sanitary authorities and workhouses in the district, of persons of the wandering class who have been exposed to the infection of smallpox; and that a printed copy of such information should be distributed from the bureau to every sanitary authority and board of guardians in the district, and that the expense of working the bureau should be met by contributions from the county councils and county boroughs forming the district. (7) That this Conference is of opinion that the port sanitary authorities should be authorised to take more stringent precautions to prevent the importation of disease by persons arriving by vessel at the ports who are suffering from small-pox, or who have been exposed to infection by that disease. 83 Common Lodging Houses and Casual Wards. (8) That the local authority should have increased control over common lodging houses, their keepers, and occupants. Thus the local authority should have power— (а) To medically examine the inmates. (b) To detain and isolate persons exposed to infection and to disinfect them and their clothes. (e) To temporarily close a common lodging-house in whole or in part, compensation to be given to the keeper of the house. (9) The local authority should have power to order the keeper of a common lodging-house in which there has been infectious disease to refuse fresh admissions for such time as may be required by the authority. (10) That the local authority should be empowered to require medical examination and disinfection of all persons entering casual wards. (11) That the local sanitary authority should have power to require the removal and isolation of any inmate of a casual ward who may reasonably be suspected of being liable to convey infectious disease. (12) That the local authority should have full power to require the cleansing of the person and the disinfection of the clothes of any person in a casual ward, whether infected or exposed to infection. Labour Bureaux. (13) (a) That the time has arrived when the Local Government Board should promote legislation for the establishment of labour bureaux in the areas of every county council and every county borough council. (b) That this Conference is also of opinion that it is desirable that a national voluntary agency should be formed for assisting bona fide working men while travelling through the country in search of work, and that such agency should be worked on the same lines as the Inter-Cantonal Union of Switzerland for the relief of poor travellers. (14) That the unemployed travelling bona fide in search of work, not being habitual vagrants, should not be treated as vagrants, but as far as possible be assisted to obtain employment. Labour Colonies. (15) That the time has arrived when the Local Government Board should promote legislation for the establishment of labour colonies for the compulsory detention of habitual vagrants until they have acquired power to work and self restraint. (16) That this Conference approves and affirms the resolutions passed by the executive council of the Association of Poor Law Unions in England and Wales at their meeting in September, 1003, as follows:— (а) That boards of guardians should be grouped in suitable areas to provide labour colonies for vagrants. (b) That such colonies should be established and governed by the joint committees of the boards of guardians of the unions in the said areas. (c) That habitual vagrants should be sent to such labour colonies by magistrates. (d) That the expenses of each colony should be spread over the unions in the areas served by such colonies. Children of Vagrants. (17) That the powers of the poor law guardians under the Poor Law Acts of 1889 and 1899 to assume and exercise, in certain circumstances, parental rights over the children of pauper parents, should be extended so as to confer similar rights over the children of habitual vagrants. Generally. (18) That, in order to give practical effect to the foregoing resolutions, this Conference is in favour of uniting with the County Councils Association, the Association of Municipal Corporations, the Association of Metropolitan Borough Councils, the Magistracy, and the Association of Poor Law Unions of England and Wales for the following purposes, viz.: (a) To enlist the sympathy and co-operation of members of Parliament; (b) to appoint representatives to wait on the Local Government Board; (c) to give evidence before the Inter-Departmental Committee of the Government on the Vagrancy Question; (d) to take such other measures as may be thought desirable in support of the resolutions arrived at by the Conference. That a Committee be appointed to give effect to this resolution. 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 abovementioned 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, 84 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, 1904, 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, 1905— District. Estimated population, 6th April, 1904. Equalisation charge, being excess of contribution over grant. Net grant, being excess of grant over contribution. £ s. d. £ s. d. Paddington 150,367 3,342 4 9 - Kensington 179,026 17,047 4 4 - Hammersmith 114,765 - 7,545 13 8 Fulham 149,090 - 12,516 9 0 Chelsea 71,332 4,721 14 8 - Westminster, City of 174,271 99,232 3 1 - St. MaryleboDe 130,589 14,469 11 1 - Hampstead 84,895 6,085 19 - - St. Pancras 233,099 - 6,744 14 - Islington 336,932 - 26,544 1 - Stoke Newington 51,810 - 2,897 13 4 Hackney 220,773 - 19,367 4 3 Holborn 56,612 11,213 9 11 - Finsbury 102,025 1,862 8 8 - London, City of 25,523 118,811 7 6 - Shoreditch 116,608 - 6,335 8 8 Bethnal-green 129,118 - 15,554 2 6 Stepney 293,318 - 29,126 18 9 Poplar 169,227 - 17,178 11 9 Southwark 202,144 - 13,402 16 7 Bermondsey 129,856 - 5,701 8 1 Lambeth 305,029 - 20,192 18 2 Battersea 169,770 - 12,159 1 1 Wandsworth 275,009 - 18,290 7 1 Camberwell 263,611 - 26,177 9 2 Deptford 111,060 - 9,432 11 7 Greenwich 99,383 - 7,257 - 3 Lewisham 148,419 - 9,166 19 1 Woolwich 132,070 - 12,149 18 8 Inner Temple 127 596 13 2 - Middle Temple 107 358 10 6 - Inter-Departmental Committee on Physical Deterioration. As a result of representation made concerning the unfitness of army recruits, this Committee was appointed and its report appeared in the year 1904. The finding of the Committee was that there were really no data enabling comparison to be made between an earlier and a later period, but that certain indirect evidence suggested that no progressive physical deterioration of the population had occurred; indeed, the indications are quite in a contrary direction. The Committee made, however, a number of recommendations, some of which have an important bearing upon questions immediately concerning the public health. Thus the Committee recommended the institution of a permanent anthropometric survey of the population, to be extended in the first instance to young persons in schools and factories, with a view to providing data for comparison of the physical state of the population at different times. Such survey would be of great value in measuring the effects upon the population of various conditions to which they are subject. The Committee consider it "in the highest degree desirable that a register of sickness not confined to infectious diseases should be established and maintained." The idea has long been entertained, and the time appears to have now arrived for carrying such a scheme into effect. If it were thought well to make a beginning by dealing with the figures of a compact and more or less homogeneous area, such as the County of London, there should be no difficulty in making arrangements for communication to a central authority of weekly statements of sickness of certain special kinds brought newly under treatment in infirmaries, hospitals and dispensaries. Such returns would probably be of value, and if this fact were demonstrated in London, an extension of the system to the rest of the country could later readily be made. Among other questions considered were, the need of taking systematic action with a view to abatement of overcrowding; the desirability of encouraging the teaching of infant management 85 in municipal creches (where such establishments exist) to girls by making this branch of teaching eligible for aid from the grant for public education; the need for strengthening the inspection and supervision of workers in factories and workshops: the need of "bringing home to men and women the fatal effects of alcohol on physical efficiency"; the desirability of requiring in tenement houses that proper provision should be made of the cooking apparatus necessary for the preparation of food; the need of strengthening existing powers for control of milk supplies, etc. These questions have from time to time been before the Council and its Committees, and the policy followed with regard to them has, generally speaking, been entirely in accord with the recommendations of the Inter-Departmental Committee. The Medical Supervision^of School Children. The year 1904 will always be notable in the sanitary history of the Metropolis for the reason that by the transfer of the administration of the Education Acts to the London County Council, a health authority is brought into direct relation with a large proportion of the child population of London. This change in administration gives opportunity for the study by a health authority of the conditions which affect the growth and development of the young, and for the application of measures which tend to promote improvement in their physical condition. It gives greater opportunity, moreover, for the study of the behaviour of communicable maladies which affect the whole population, but which have their greatest incidence upon children, and for the application of knowledge thus obtained to the limitation of risks which are inseparable from the aggregation of young and susceptible persons, and which have in the past been productive of regrettable results upon the prevalence of disease, not only among school children but among the population at ages other than those of school life. There is, therefore, much reason for anticipating that as the outcome of the change referred to, a higher standard of health will eventually be attained, and that this benefit will be shared by the London population as a whole. The London County Council has recognised the intimate relation existing between its medical supervision of school children and its health duties in respect of the population as a whole, and for administrative purposes has associated these two branches of its work. The annual report of Dr. Kerr, the medical officer specially appointed for the supervision of children in its schools, is appended to this report (see Appendix III.). As already stated (page 84), the Inter-departmental Committee on Physical Deterioration recommended the institution of an anthropological survey of the population, especially of children, and Dr. Kerr is able to present figures showing weights and heights of a limited number of children at several ages, and to discuss the effect of home conditions upon the physical development of children, and also the relation between this development and the infant mortality rate of the year in which they were born. Obviously, more complete data are necessary for drawing reliable inferences and it is much to be hoped that these will eventually be forthcoming. Dr. Kerr gives account of the steps taken to ensure the cleanliness of children attending school. The action which is thus being taken will do much to improve the condition of that part of the population which is subject to verminous infection. The cleansing of the people in this respect would be more successfully attained if sanitary authorities would adequately exercise the powers conferred upon them by the Act of 1897. There would further be advantage in educating children in the habit of bathing. Mention was made in the annual report for the year 1897 of the provision of baths made in the public schools of some continental cities and in which children periodically bathed. With reference to the prevalence of infectious disease among school children, Dr. Kerr's report shows the steps taken during the year for limiting the spread of such disease, and he discusses the part played by unrecognised or "carrier cases" in the dissemination of diphtheria. In this connection reference may be made to the method adopted by the Medical Officers of Health of Bermondsey and Finsbury for dealing with such cases occurring in houses invaded by this disease (see page 31 ante). It is obviously important that as complete steps as possible should be taken to exclude from attendance at school, children who are harbouring the bacillus of diphtheria in their throats, though not suffering from any clinical symptom of disease. There is much reason for thinking that systematic enquiry for such cases in connection with recognised cases of diphtheria and their exclusion from association with schoolattending children would limit the extension of the disease. In judging of any results obtained at the present time it must be borne in mind that diphtheria is now declining in London. Appended to Dr. Kerr's report is a report by Dr. Thomas, who is working with Dr. Da-vies, the Medical Officer of Health of Woolwich, in an attempt to determine experimentally the amount of value which attaches to school closing in arresting the spread of mearles. The extent to which children at the several ages are found to have been protected by previous attack is of much interest. There is reason for hoping that parents who now disregard the occurrence of measles in their families will later strive to extend to their own children and to those oi their neighbours a protection which would at least tend to postponement of the age of attack when the fatality is lower. The Order made by the Council, extending to measles certain provisions of the Public Health (London) Act, which came into operation in 1903 appears to be already having some influence in impressing the public with the dangers attending exposure of young children to measles contagion (see pages 24 and 25). Dr. Thomas, moreover, points out the value of sanitary buildings and training of teachers for arresting the spread of measles, in both of which improvement may be expected in the future; but there is no doubt need for those who have control over children gathered together on Sunday to be imbued with the same spirit as those in charge of week-day schools. While noting that recent legislative changes have increased the probability of better control of 6108 M 86 infectious disease, it needs to be pointed out that the withdrawal of Article 101 of the Education Code, relating to the epidemic grant, is generally regarded as a retrograde step by medical officers of health. The question of the postponement of the age of school attendance is also discussed by Dr. Kerr. In considering the value attaching to the exclusion from school of children under five years of age, regard must necessarily be had for the conditions to which children thus excluded would be subject. So far as infectious disease is concerned, some indication of the reduction in the prevalence of the two notified diseases, viz., diphtheria and scarlet fever, which would be effected by exclusion of children of particular ages will be found on pages 50-52 of this report. Shirley F. Murphy, Medical Officer of Health. December, 1905. To the London County Council. 87 Medical Officers of Health of London Sanitary Districts in 1904. Sanitary area. 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. Fins bury 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. (since deceased). Holborn W. A. Bond, M.D. Islington A. E. Harris, L.R.C.P Kensington T. O. Dudfield, M.D. I^ambeth J. Priestley, M.D. Lewisham A. W. Harris, M.D. Paddington R. Dudfield, M.B. Poplar F. W. Alexander, L.R.C.P. St. Marylebone A. W. Blyth, M.R.C.S. St. Pancras J. F. J. Sykes, M.D. Shoreditch L. T. F. Bryett, M.D Southwark G. Millson, L.R.C.P. Stepney D. L. Thomas, M.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. London 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 20M, 1904.) On the 16th July, 1908, the Committee had under consideration a letter from the Town Clerk of Bermondsey 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. Hamer'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 as 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 should 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. Dr. Hameb'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./13010 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 tlic lee 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 maybe 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. Autobiography. Vol. II., p. 398. 3 Thus 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 was 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 jjound. 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 Strathleven fitted with coldair machinery, arrived in London with 34 tons of frozen meat on board ; in 1881 the Dunedin, with Bell-Coleman 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. Carr6 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.5 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] k 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,5 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 iiir 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-Viehhofe by Dr. Oscar Schwartz, p. 185. 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 iti 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 iee 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, 1903, 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 infection 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 Repor^ of the Medic al Officer of Health of the County of London, 1898. 3 Arbelten aus dem Kaiserlichen Qesundhoitsamte, 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 Ice. 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 has 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 ly lee.—Dr. Prudden, in reporting on the ice Bupply 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 on the small ends, as 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 describes 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. Hey roth4 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 caBts 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 paramcecium aurelia (93"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—" Krystalleis-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, Hoft 2. 2 Nansen eays ("Farthest North," Vol. I., p. 220): " As soon as ice is formed in this temperature tho 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 ico which had boen exposed to the cummer sun, and consequently freed from salt.—Ibid, Vol. II., p. 137. 4 Arbeiten aus d'm Kaiserlichen Gesundheitf suite, 1888. Annual Reports of the State Board of Healtn 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 such 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 Belli'1, 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 8 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 homo ice-box. It melts there, and the same heat whioh melts it lets loose its tenors into the meats, butter, and other food substances whioh form the contents of the refrigerator. Half the time the ice-box is neyor scalded or sterilised."—Oold Storage, 15th August, 1904. 2 Uebor dem Mechanismus der biologischen Selb»trei*igung des Eises."—Zeitschrift fur Hygiene und Infectionskrankheiten. Band 45, Heft II. 3 Biforma Mtdica, 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 80,000 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 Ihe 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 must 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. 1 Further details with regard to these systems will be found in " Mechanical Refrigeration," by Hal Williams, Whittaker A 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 iB circulated in pipes through the cold rooms. This system readily adapts itself to the production of varying temperatures. (8.) 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, and great difficulty has been experienced in dealing with the same; indeed, atFrankfort-onMaine and at Cologne it was found necessary to " change the insulation" on this account. The relative 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 bofore guests with a view to their using the liquified air at discretion as a refrigerant for drinks, possibly alsu for viands. The cost of each charge, it was stated, would be less than a penny. 740] c Appendix II. London County Council. WATERCRESS. Report by the Medical Officer, to which are appended reports by Dr. Frank Clowes, the Council Chemist, and by Dr. A. C. Houston, on Watercress and Watercress beds in the neighbourhood of London. (Printed by order of the Council, 7th February, 1905.) According to Mr. Shirley Hibberd, the cultivation of watercress* is a comparatively modern industry. He notes that the plant, the wmtiirtiiim officinale of botanists, was first grown at Erfurt by Nicholas Meissner about the middle of the sixteenth century ; while in this country Mr. Bradbury, in 1808, commenced to grow watercress at Springhead, Northfleet. Mr. Bradbury described three varieties of the plant, and Mr. Hibberd claims to have secured five really distinct varieties; among them he includes the Erfurt variety (Erfurt sweet, Erfurt green or "Meissner's cress), the "brown cress of Springhead," and the "Newington purple cress." At the present time watercress dealers speak of the " small brown," the "large green," and the "large brown" varieties, but there appears to be no doubt that various "sports" may be developed, as the result of manner of cultivation and other local circumstances ; indeed Mr. Hibberd states that "the beautiful brown cress of Springhead when planted in clay land, where the water is often turbid when charged with the washings from meadows, will soon lose its fine colour and become more or less bronzy or purplish green;" while "in like manner the robust and handsome Newington purple cress will, if taken from its native loam, and planted in poor gravel or chalk, lose much of its vigour and fatness and of its purple colour also, and become in a few years a brown cress." Mr. Henry May hew caused enquiries to be made in 1851 at various markets in London from which he concluded (" London Labour and the London Poor"') that some 15,000,000 bunches of watercress were sold in London in a year; again, Mr. Hibberd quotes a statement, relating apparently to about the same period, made in " Wynter's Curiosities of Civilization," to the effect that" the consumption of watercress in London averages from three to four tons per week." Of course, much more is consumed in summer than in winter. It appears certain that the actual amount of watercress sold in London has considerably increased of late years, though it is open to question whether very much more watercress is eaten per head of population than was the case 30 years ago. On watercress farms of a total extent of some 20 acres the output in 1903 amounted to upwards of 200 tons, say ten tons per acre. Again, the total acreage of farms visited by the Council's inspectors within 50 miles of London works out at over 200 acres. If it be assumed that the total yield of, say, 75 per cent, of this acreage, i.e., of 150 acres, finds its way to London, this would give a total consumption of 1,500 tons in the year, which is probably not an excessive estimate, for in the height of the season particular farms of about ten acres in extent are known to have dispatched as much as three or four tons in a day to London, while farms of some 40 acres in extent sent to London in the course of last year nearly 350 tons of watercress. Watercress has been regarded in the past as being not merely a food, but as possessing also medicinal properties. Mr. Shirley Hibberd cites Lemery, who wrote in 1704 to the effect that" there is no herb whose virtues are more conspicuous and great than those of cresses"; the garden cress was even deemed to give "sharpnesse and readinesse to wit"; the watercress, according to a medical authority quoted by Mr. Hibberd, was "vaunted for its efficacy in all cases in which the digestive organs are weak, in cachexia, in scurvy, in scrofula, and lymphatism," and, indeed, watercress is said to have entered largely into the composition of the "sirop antiscorbutique" of the French pharmacopoeia. According to Culpeper (The Complete Herbal) watercress "is an herb under the dominion of the moon." He holds it to be "powerful against the scurvy, and to cleanse the blood and humours." He recommends the juice of the leaves for application to freckles, pimples, etc., and admixed with vinegar for application to the foreheads of those "that are dull and drowsy." "Watercress pottage," he says, "is a good remedy to cleanse the blood in the spring, and help headaches, and eradicate the gross humours winter lias left behind; those that would live in health," he adds, "may use it if they please; if they will not, I cannot help it." It was no doubt the discovery that certain forms of disease are spread by the agency of water which first caused attention to be directed to the conditions under which the growth of watercress was carried on. Mr. Shirley Hibberd declares that " the finest cresses supplied to the markets, and especially to the London markets, are for the most part produced in the purest water and the purest air. The rills that flow cold and bright through pure and purifying chalk strata produce the best brown cresses; those of a dark green or purple colour are, generally speaking, the produce of waters originating in and flowing through alluvial strata and the more likely to be tainted with sewage." The same writer points out that " there is something to be said against sewage-grown water plants that * Home culture of watercress. F. W. Allen. London, 1878. 4058—1,000-8.7.05] S.S./17.58 2 Cannot be said against sewage-grown land plants," for in the former the whole plant is liable to be bathed in the sewage and "may even become encrusted with a deposit that careless washing will not wholly remove." Again, he quotes the statement of Mr. Alfred Smee, who found that "watercresses act as a scrubbing brush to the sewage and remove all the solid flocculi from the water, which adhere to the stalks." Some growers of watercress use artesian well water, and this not only on account of its purity, but also because the warmth of the water enables cress to be grown and gathered in the winter months, for brown cresses grow best in water having a temperature of 50° to 55° Fahr., and thus, provided water of this temperature can be obtained all the year round, winter and spring cresses can be produced. Sewage cress and impure river cress, on the other hand, grow best in water having a temperature of 60° Fahr., and upwards, i.e., only in the summer months. "Summer cress" is, as a rule, planted in April and early May, winter or spring cress in September, or, in sheltered positions, even earlier. Sewage cress is not available for cutting during the early months of the year. Enteric fever, is of course, the disease which is especially apt to be spread by sewage-contaminated water in this country, and the suspicion that uncooked vegetables have been instrumental in promoting infection has from time to time been entertained both here and on the Continent, more particularly in France and Germany. Watercress has apparently in particular instances come into question in this connection. The only observations bearing upon the matter, so far as the London population is concerned, to which I am able to refer, are those made by Dr. Verdon, the medical officer of health of Lambeth, in 1894, and by Dr. Warry, medical officer of health of Hackney, in 1903. Dr. Verdon in the former year found that " a number of persons who were suffering from the disease (enteric fever), in one of its severest types had, during the days coming immediately before the advent of the earliest symptoms, eaten watercress on one or more than one occasion." Analysis of the water supplying the beds from which some of the watercress in question had been supplied showed that it had " all the chemical characteristics of liquid sewage." The evidence in this case, to quote Dr. Verdon's own words, " begins with the incidence of typhoid, proceeds by indicating the consumption of watercress at a period when infection must have taken place, continues by tracing the article under suspicion to the shop of a local tradesman, and thence to the place of its growth, and ends by demonstrating the existence of a connection of contact between the watercress consumed and sewage, with its complement of living microbes." This evidence is no doubt suggestive, but in the absence of material for precise statistical study is not, of course, conclusive. The results of Dr. Warry's enquiry I am able to give in some detail. He noted the existence of an unwonted prevalence of enteric fever in June, 1903, that is to say, before the time of year when the usual autumnal increase would be expected; the cases notified were, moreover, for some weeks "mostly localised within a circle of one-third mile radius." "These circumstances," he says, "led me to think that some special agent was responsible for the unusual prevalence of this disease in the borough which required special investigation." On further enquiry it transpired "that the outbreak took the form of two waves or outbursts, the first extending from the second week in June to the week ending the 25th July, and the second from the first week in August to the week ending the 29th August, both of these outbursts showing a different localisation." These outbursts Dr. Warry distinguishes by the letters A and B. Outbreak A included 48 cases in 45 households; 29 of the patients, i.e., 64 4 per cent., had partaken of watercress, in most cases more than once during the three weeks prior to the onset of illness. Outbreak B included 62 cases in 57 households; 28 of the patients, i.e., 48.2 per cent., certainly partook of watercress during the three weeks prior to the onset of the disease. In order to test the value of this evidence Dr. Warry caused enquiries to be made at 124 houses "in those parts of the borough invaded by enteric fever," and ascertained " that the inmates of 34 only were watercress eaters." "Thus," he says, "the watercress eaters may be taken at 27.5 per cent., and non-watercress eaters at 72.5 per cent, of the population; but the incidence of enteric fever on watercress eaters compared with non-watercress eaters during this epidemic was as the figures 64: 36." He further calculates "that watercress eaters suffered 4.6 times more than non-watercress eaters during the A period, more than twice as much during the B period, and over three times as much during the whole epidemic." Upon these statistical data and in the absence of evidence implicating milk, water, shell-fish, ice-creams, and fried fish, concerning all which possible sources of infection careful enquiry was made, Dr. Warry concluded that the watercress was at fault. The apparent undue incidence of enteric fever on watercress eaters during the periods in question is undoubtedly suggestive, but in considering how far the evidence available must be regarded as proof that the watercress was the cause of the disease, the following considerations must be borne in mind. In the two outbreaks 110 cases of this disease occurred in the areas in question. The number of cases which would have occurred in the areas in the absence of an exceptional cause would be very few, probably less than half-a-dozen. If this estimate be correct, this would still leave, after deducting the cases occurring in watercress eaters as well as the half-a-dozen cases, an excess of some fifty cases not explicable on the watercress hypothesis, unless, indeed, they could be regarded as secondary cases, i.e., caused by personal infection from cases directly due to the consumption of watercress. In this connection, it may be noted that so far as persons in invaded houses are concerned, only in two or three instances were more than one person in the household known to be attacked. The rarity of multiple attacks in houses, whether due to primary or secondary infection, is noteworthy when it is recollected that if watercress is eaten in a household it is usually shared 3 among the majority of the family. There is therefore, on the facts so far as they could be ascertained, reason for regarding the eating of watercress as not explicable of the whole of these outbreaks, and if this position be accepted an additional factor must have been operative having the ability to cause a number of cases not strikingly less than those which are associated with the eating of watercress. All, therefore, that can be deduced from Dr. Warry's interesting enquiry is that in this particular outbreak the incidence of attack upon watercress eaters was greater than would have been anticipated from the proportion which he found watercress eating families bore to the total families in 124 houses in the infected area, and indeed Dr. Warry does not himself suggest that the evidence against the watercress derived from incidence of attack is of a more conclusive nature than that stated. On making enquiry as to the sources from which the watercress consumed was obtained, it was ascertained that that eaten by sufferers in the A outbreak had been purchased in twenty-one instances from hawkers, and in eight instances from a particular shop, while that eaten by sufferers in the B outbreak was obtained from hawkers in twenty cases, in three cases it came from various sources, and in two others the source was not known. Dr. Warry states that his suspicion was directed to watercress beds in West Ham, "as being chiefly concerned in the unusual incidence of enteric fever," and on visiting these beds he found that they were " fed by almost undiluted sewage." Seventeen samples of watercress were obtained from various sources in Hackney, and all of these on bacteriological examination were found to contain bacillus coli. The question of the risk to health associated with use of raw vegetables and fruit produced on sewage farms was made the subject of study in 1902, in France, by a Commission (Messieurs Roux, Ogier and Wurtz), who reported to the Comity Consultatif d'Hygiere Publique. For particulars of this report I am indebted to Monsieur Masson, of the Prefecture of the Seine. This Commission quoted experiments made by Messieurs Wurtz and Bourges (Archives de Mudecine Experimentale, July, 1901), who grew cress, radishes and lettuce in earth watered with cultures of the bacilli of anthrax, enteric fever, and tubercle. The pathogenic germs in question were found to be present on examination of portions of the stalk of the plants at a height of even three decimetres (twelve inches) above ground level. Again, potatoes coated over with anthrax bacilli and planted at a depth of a decimetre were allowed to sprout, and as long as 101 days afterwards the anthrax organism was recovered from the stalk of the growing plant. The experimenters note that laboratory conditions may differ from those existing on the sewage farm; for instance, there is the bactericidal action of sunlight to take into account, and the cleansing effect of rain. Furthermore, in heavy storms mud may be splashed, as they note, to quite a remarkable distance above ground level, and so contaminate the stalk or leaves of plants. The Commission conclude that it is advisable, in the light of their experiments, that the cultivation of vegetables and fruit intended to be consumed in the raw state should not be allowed upon land fed with sewage, and that the Paris municipal authority should take steps to have a stipulation to this effect in contracts entered into in the future with cultivators of such lands. It is not quite clear whether or not the observations just referred to must be held to indicate that the bacillus typhosus may grow and multiply in vegetable tissues. If this were proved to be the case the difficulties which acceptance of Jan hypothesis of watercress causation of enteric fever entails would be materially lessened. Dr. Houston has carefully considered this matter so far as bacillus coli is concerned, and has made bacteriological examination of cress after repeated washings. If bacillus coli multiplied to any great extent within the plant, the number of these organisms in cress grown in sewage-polluted water ought to have been greater than in corresponding amounts of circumfluent water. Dr. Houston's results on the whole do not seem to support this hypothesis. Further, on the foregoing assumption, the number of bacillus coli in initially impure, but well washed cress, should have been much greater than Dr. Houston's analyses show, as it is inconceivable that his washings would remove all germs interiorly situated.* If it be assumed that the cress is a source of danger merely by virtue of the fact that it acts as a carrier of sewage-contaminated water, it must be admitted to be unlikely that a marked outbreak of enteric fever due to consumption of polluted cress would occur. In all outbreaks of waterborne enteric fever which have been made the subject of investigation, only a comparatively small percentage of those drinking the water have been attacked by the disease, and if cress has been subjected to preliminary washing, the actual amount of polluted water, consumed by the eater of the cress, must be very small in comparison with the amount swallowed in the case of a contaminated drinking water supply. On the other hand, however, the watercress in some instances grows in water which is very grossly polluted, far more grossly polluted than an ordinary drinking water supply could be. With a view to determining the actual conditions under which the watercress sold in London is grown, the Council's inspectors, Messrs. Harrison, Lewis, Tuck and Williamson, have visited some 120 watercress beds, ranging from less than a quarter of an acre to nearly 40 acres in extent, and comprising all the known beds within some 50 miles of the county supplying the London market. Samples of the water were taken in the majority of cases, and these samples have been, on the results of chemical examination (see Report by the Chemist), divided into four classes. The inspectors have also classified the beds under four headings, according to the degree to which in their estimation there was risk of pollution. The following statement gives particulars concerning the beds coming under each of the four headings, A, B, C, D, of the inspectors' classification. It further shows the group to which the samples from these beds must be relegated on the result of examination by the chemist, and in the case of groups B, C, D, the nature of the pollution to which the beds were exposed is also specified, the particulars for each bed being given on a separate fine. If the results of Dr. Houston's investigations are accepted as evidence against the multiplication of li. coli in living cress tissues, it is most unlikely that the less robust and highly specialised B. typhosus would grow and multiply under parallel conditions. Moreover, it is worth noting that the coli-like microbes isolated from cress and the "washings" of cress were less typical than tho coli-like microbes isolated from the circumfluent water. 4058] A. 2 4 CLASSIFICATION OF WATERCRESS BEDS. Samples of water were taken from the "beds" except those marked * which were taken from "water supplying the beds." CLASS A—No probable pollution. Beds inspected—Samples sent to Chemist for analysis. 27 samples. 1 sample. Beds inspected—No samples sent to Chemist for analysis. 35 beds. Chemist's report —Standard. A B VI., VII. VIII., XII., XIII. † CLASS B—Probable pollution. Beds inspected—Samples sent to Chemist for analysis. Nature of probable pollution in each instance. Chemist's report -Standard. In time of drought water is obtained from a canal A In time of drought water is obtained from a canal A Proximity to dwellings and surface water from grazing lands B Proximity to dwellings and surface water from gracing lands B Proximity to village dwellings and surface pollution from grazing lands A Proximity to village dwellings and surface pollution from grazing lands A Proximity to dwellings and flooding from a river to which sewage effluent has access A Proximity to dwellings and flooding from a river to which sewage effluent has access A Surface washings from grazing lands and flooding from a river A Proximity to a dwelling, and flooding from a river to which house drainage has access. B Proximity to a sewage farm just above the beds, and flooding from a river to which sewage effluent has access... A *roximity to a sewage farm just above the beds, and flooding from a river to which sewage effluent has access A Flooding from a river to which sewage effluent has access A Proximity to village dwellings above, and flooding from a river B * Proximity to village dwellings above, and flooding from a river B Proximity to town dwellings, and the occasional use of river water flowing through a town A *Proximity to town dwellings and surface washings from grazing lands A Water is obtained from a canal B Water is partly obtained from a canal B Proximity to town dwellings and surface washings from a highway A Proximity to village dwellings ; the lower ends of the beds abut, moreover, on a town sewage farm A Proximity to village dwellings ; the lower ends of the beds abut, moreover, on a town sewage farm A Stubble lying on the sides of the beds. Surface washings from roads adjoining have access to river above beds A *eds situated below a village. Surface drainage reaches stream during rains. Possible overflow from cottage cesspools *Beds situated below a village. Surface drainage reaches stream during rains. I'ossiblo overflow from cottage B cesspools B *eglected condition of beds and surroundings A Neglected condition of beds and surroundings B Large quantity of stubble lying on the sides of the beds. Surface washings of locality appear to reach the stream A Stubble on sides of beds. Cattle grazing on the banks A Proximity of houses not having an organised system of drainage A Proximity to dwellings and liability to floodings B *roximity to dwellings and large numbers of waterfowl on moats from which water is taken C Liability to flooding from grazing land. Very little watercress grown B *iability to flooding from grazing land. Very little watercress grown. Owner stated that he did not intend to grow any more B Surface water from grazing land B Surface water from grazing land B *urface drainage and from sewage higher up the river C Surface drainage and from sewage higher up the river B Prom a farmyard in close proximity, and surface drainage from grazing land B Prom a farmyard in close proximity, and surface drainage from grazing land B Subject to flooding from river and grazing land B Subject to flooding from river and grazing land B Subject to flooding from river and grazing land B Subject to flooding from river and grazing land B *roximity to dwellings, and surface pollutions from grazing lands B Proximity to dwellings, and surface pollutions from grazing lands B Proximity to farm buildings and surface drainage C Proximity to farm buildings and surface drainage A *rom surface drainage and grazing land B Proximity to dwellings, amTfrom decomposed refuse left on banks A Proximity to sewage farm A Beds situated near the road where the stream supplying them is frequented for drinking purposes by cattle A Proximity to farmyard and surface drainage of grazing land A From tannery adjoining the beds B From surface drainage of farmyard B From dwellings in close proximity to the beds and surface drainage C From surface drainage of agricultural land and dwellings near the stream B From surface drainage of land, and fouling of stream by cattle B From surface drainage of agricultural land B From surface drainage of agricultural land B From surface drainage of farm land B *From surface washings of locality B Below point of discharge of sewage effluent into river C †The figures indicate samples of water (Table I.) sent to Dr. Houston for bacteriological examination. According to Dr. Houston's classification, sample VI. was a water of the second class, and samples VII. VIII.. XII. and XIIIaters of the first class. 5 Beds inspected—No samples sent to the Chemist for analysis. Nature of probable pollution in each instance. Not in cultivation. Liable to flooding from a river which flows through grazing lands Proximity to a farmyard, and flooding from a river to which sewage effluent has access Situated below a village, surface washings from which during heavy rainfall reach the stream. Possibility of overflow from the cesspools in the neighbourhood on to the surface of the ground near the stream Proximity to dwellings CLASS C—Actual pollution (not considerable). Beds inspected—Samples sent to the Chemist for analysis. Nature of probable pollution in each instance. Chemist's report —Standard. Polluted by drainage from a farm and surface washings from grazing lands. Water taken from a canal in time of drought B Polluted by drainage from a farm and surface washings from grazing lands. Water taken from a canal in time of drought B *Deposits of manure and decaying vegetable matter ; the beds, moreover, are in proximity to town dwellings B Deposits of manure and decaying vegetable matter ; the beds, moreover, are in proximity to town dwellings B Water from a river to which sewage effluent has access B Beds polluted by cattle, and water fouled by dung C Beds polluted by cattle, and water fouled by dung B House drainage discharges into top ends of beds A *Situated in a locality which is being rapidly built over. Adjoins a sewage farm. Effluent from other sewage farms has access to the river several miles up stream. There are several leather mills and much market garden land on the river. The river receives the surface washings of a large area B Situated in a locality which is being rapidly built over. Adjoins a sewage farm. Effluent from other sewage farms has access to the river several miles up stream. There are several leather mills and much market garden land on the river. The river receives the surface washings of a large area B River receives sewage effluents up stream, and a short distance above the beds there is a by-stream which is often very foul. Large quantity of filth comes down stream during the cleansing of the bed, and from the banks of the river and from by-streams B 'River receives sewage effluents up stream, and a short distance above the beds there is a by-stream which is often very foul. Large quantity of filth comes down stream during the cleansing of the bed, and from the banks of the river and from by-streams C Stubble lying on the sides of the beds. By-stream supplying the beds consists largely of sewage effluent C Stubble lying on the sides of the beds. By-stream supplying the beds consists largely of sewage effluent C River receives sewage effluent up stream. Leather mill on stream. Large quantity of manure deposited on adjacent market garden land C *Rivet receives sewage effluent up stream. Leather mill oil stream. Large Quantity of manure deposited on cent market garden land C By-stream supplying the beds is partly fed by sewage effluent C *By-stream supplying the beds is partly fed by sewage effluent C River receives sewage effluents higher up stroam on both sides. Vegetable matter deposited in the branch stream on the premises; adjacent land is used as a market garden B Surface drainage of farmyard and cesspool overflow B V.t *Surface drainage of farmyard and cesspool overflow C *Surface drainage of agricultural land and cesspool overflow C Surface drainage of agricultural land and cesspool overflow C Beds in dirty condition. They receive surface drainage from farmyard and agricultural and grazing land ... D The beds receive surface water from piggeries and stables in close proximity to beds, the drainage from which flows over ground towards the beds C IX.t From manure deposited near the beds, and from houses and factory on the stream C *Stream coming from land used as sewage farm C Beds inspected—No samples sent to the Chemist for analysis. Nature of probable pollution in each, instance. Beds not in cultivation, the proprietor stating that the water was too polluted by sewage effluent CLASS D -Actual pollution (gross). Beds inspected—Samples sent to the Chemist fcr analysis. Niture of probable pollution in each instance. Chemist's report —Standard. Tidal river water is used, to which sewage effluents have access. Also surface washings from noxious trade premises. There is also aerial pollution of the cress from effluvium nuisances D Tidal river water is used, to which sewage effluents have access. Also surface washings from noxious trade premises. There is also aerial pollution of the cress from effluvium nuisances D & iv.t Tidal river water is used, to which sewage effluents have access. Also surface washings from noxious trade premises. There is also aerial pollution of the cress from effluvium nuisances D Tidal river water is used, to which sewage effluents have access. Also surface washings from noxious trade premises. There is also aerial pollution of the cress from effluvium nuisances o) *he only water used is the effluent water from a sewage farm D 1 III.+ The only water used is the effluent water from a sewage farm D J *roximity to piggeries and surface drainage C *ater from a ditch which comes from a dairy farm; washings, urine, etc., from a cowshed D *Effluent from large sewage works enters the stream C Occasional deposit of human excreta near the intake to beds. The effluent from a sewage farm enters the stream two miles above the bed C Xl.t Ths cress is grown in surface water into which the effluent from the sewage plant situated in close proximity to the beds percolates B X.t Beds inspected—No samples sent to the Chemist for analysis. Nil. † The figures indicate samples of water (Table 1.) sent to Dr. Houston for bacteriological examination. According to Dr. Houston's classilication, samples V". and IX. were waters of the 5th class; sample I. was a water of the 3rd class; samples II., IV., and X. were waters of the 7th class ; and samples III. and XI. were waleis of the 8th class 6 I may summarise as follows the results of the topographical enquiry made by the Council's inspectors. The best beds were, generally speaking, found upon a bottom of hard clean gravel. Such beds are regularly cleansed, and in some instances a light dressing of lime is used at each cleansing in order to destroy organisms deemed to be injurious to the watercress. On the other hand, there were beds found in sluggish streams or backwaters having muddy bottoms and receiving the drainage of grazing lands. The water supply was found to be derived from various sources, such as rivers, canals, natural springs and artesian wells. In one case, however, the effluent from a sewage farm provides the only water supply.* Some beds receive their water from a combination of any two or more of the abovementioned sources of supply. The condition as regards maintenance of the several beds varies considerably, and in one or two instances it was found that altogether exceptional precautions were taken to prevent risk of contamination. As an illustration of a case of this kind the following extract from the inspector's report may be cited— Case 1.†—"The sides of all the beds are boarded, and the paths between covered with clean gravel. The farmhouse and workmen's cottages are provided with earth closets. Slop water is discharged into the stream below and clear of the beds. The drainage of the surrounding fields is carried away by a separate channel The stubble and refuse from cleansing are at once removed by a cart to the fields, and are chain-harrowed into the ground. It is worthy of note that the workmen are not allowed to smoke on the premises so as to keep down the habit of spitting." These precautions are quite exceptional, though in a number of instances the position of the beds is such as to render it unlikely they can be exposed to pollution. As a typical instance of such watercress beds, the following extract from the inspector's report may be given c— Case 2.—" On the high ground on a hillside where a tiny stream is formed by springs, the watercress is grown in the bottom of the stream. The sloping sides of the hills are hopfields. The sides of the cleft and the bottom of the beds are steep. To dam up the water a little and prevent the cress from being washed away, rows of stones are placed at intervals across the beds. The conditions are the most primitive possible, but there is nothing to suggest pollution." The causes of pollution were found to be many and various. Surface drainage from grazing lands is often allowed to enter the beds. In some instances, too, house drainage and the drainage from trade premises are allowed to aggravate the mischief caused by want of proper cleansing, and the unchecked growth of rank vegetation. Even the process of cleansing itself contributes to pollution when the scum and weeds drawn from the beds are left to decompose upon their banks. The rapid growth of large towns, too, is another factor tending towards possible pollution. In a case to be mentioned hereafter, it was found that a bed had been laid down some twenty-five years ago in a rural district under altogether favourable conditions, but the neighbouring town had expanded, extending its area of smoke, sewage, contaminated watercourses, and noxious businesses until the rural district was wholly absorbed. Under these circumstances the carrying on of the business of a grower of watercress had necessarily become increasingly difficult. It does not follow in all cases where the watercress is grown under conditions which render it liable to pollution that analysis of the samples of water taken by the Council's inspectors revealed in marked degree the presence of deleterious matter; it is, however, an open question whether the unfavourable surroundings would not under particular climatic circumstances cause serious pollution, especially in low-lying beds. As examples of some of the defective conditions found I append some extracts from the reports of the Council's inspectors. Case 3.‡—" These beds cover an area of about three acres At the north end of the beds is a small engine-house in which a steam pump is worked, pumping about 400 gallons of water per minute near high tide from the river The water is discharged into an open ditch reservoir from whence it is conveyed to the beds by pipes and open channels. At low tide the river is nothing less than semi-liquid black filth giving off sickening and offensive odours Within 20 yards of the north-west portion of the beds is situated an artificial manure works, which gives off most unpleasant odours, polluting the atmosphere. Within 200 yards of the beds a gut-scraper's business is carried on Within 300 yards of the beds fish-skin dressing is carried on and the waste liquids from these various premises drain into the river. Within 10 yards house refuse of all kinds is deposited. There is also a piggery in the brickfield attached to this rubbish shoot. There are some 25 or 30 houses in the neighbourhood for which there is said to be no sewer accommodation. The effluents from two sewage farms also discharge into the river. The storage reservoir and channel are lined with black putrescent mud, and the beds are almost in the same condition The cress has a bright green appearance, and looks even better than that grown under more favourable conditions. The proprietor states that he has cultivated these beds for upwards of 25 years, and that the surroundings when he established the beds were of a totally different character from the existing conditions" * This bed has since gone out of cultivation. † From these beds samples of water VII. and VIII. (Table I.) were taken for bacteriological examination, ‡ Samples of water I., II. and IV, (Table I.) were taken from the beds for bacteriological examination. 7 Case 4*.—" The beds show evidence of careful cultivation, but I was informed that the water is frequently so dirty that it has to be shut oft from the beds. There is evidence of occasional contamination due to deposit of human excreta near the intake The effluent from the sewage farm is discharged into the river about 2 miles above the beds." Case 5†.—" The beds are situated in meadow land There are two sets of beds, one of which is supplied entirely by water from deep borings into the chalk. The second set of beds adjoin the river from which water is directly received. There was evidence of occasional contamination of the river and the second set of beds from cesspool overflows." Case 6†.—" The beds lie in a deep hollow, and are supplied with water principally from a spring rising at the head of the beds, but a ditch on the north side conveys a,quantity of surface water to the beds. The ground sloping to the beds on either side is cultivated as a market garden ; in close proximity are piggeries and stables, the drainage from which flows over the ground towards the beds. The contents of the cesspool are used on the land for manurial purposes." Case 7§.—" These beds are situated on a market garden and fruit farm. There are two sets of beds: No. 1 set is supplied with water from a watercourse which is principally surface water supplemented in time of drought by a little water from borings ; this is used for growing summer and autu'i n cress. No.2 set of beds is supplied by a series of deep borings into the chalk. This set is used for the cultivation of spring cress. On the farm, and in close proximity to the beds, is the septic tank sewage plant of the village. The effluent from th-s plant is allowed to run into shallow trenches near to, and at a higher level than, No. 1 set of beds, into which it eventually percolates; or it is run on to the land for manurial purposes in connection with the cultivation of salads, celery, etc." Case 8.—" No manure is used on the beds, it is said, but a few cattle graze in the field around them. On 29th July, 1904, the sides and bed of the river were being cleansed just above these watercress beds. The water was very dirty, with much floating scum in it. It was flowing into the watercress beds and I called Mr. 's attention to it, upon which he closed the intake" Case 9.—" These beds are low-lying the top beds are supplied partly by spring water and partly from a ditch. I traced this ditch and found that some of the water was quite black. I afterwards found that it came from a farm in the immediate neighbourhood, where cows are kept; the cowshed drains and the whole of the washings from carts and dairy utensils run into this ditch, and eventually into the watercress bed." Case 10||.—The beds form part of a sewage farm, and the sewage effluent was by agreement supplied for the purpose of growing watercress in them. The practice has now been discontinued, and the beds are not at the present time in use." The bacteriological enquiry carried out by Dr. Houston strikingly confirms the evidence yielded by topographical investigation; indeed, he found that four samples, taken from beds the topographical conditions of which were satisfactory, were at least ten million times purer (bacteriologically) than samples from two of the beds most open to objection, and at least one million times purer than samples from three other beds in which the topographical conditions were noted as being unsatisfactory. Dr. Houston reports that any danger accruing to the consumer of "unwashed watercress is enormously reduced by careful washing of the cress," but that "even an excess of care devoted to the washing of cress from polluted sources does not always entirely free the cress from objectionable microbes." He remarks on the "question of standards" that a bacteriological classification of the affluent waters supplying watercress beds—a classification which, he suggests, should be based on lines already tentatively brought forward by him in reports to the Local Government Board and Royal Commission on Sewage Disposal —would be of value particularly when coupled with the observations of the chemist and topographist. It is quite clear from the inspectors' inquiries and from Dr. Houston's results that cress of the best quality can be grown under conditions to which, from a public health point of view, no exception can be taken ; and, again, having in view the extent to which careful washing eliminates impurity, it may be assumed that there is under existing circumstances no material risk in consuming the watercress supplied from the majority of the beds sending watercress into London. Objection must, however, be taken on topographical, chemical, and bacteriological grounds to certain beds, especially those in class D in the table on page 5, and effort should be made to prevent the consumption of watercress from these beds in their present condition. To this report is appended the reports of Dr. Clowes, the Council's chemist, and of Dr. Houston, who has made bacteriological examination of samples of water and of watercress. Shirley F. Murphy, Medical Officer of Health. Puhlic Health Department, 8, St. Martin's Place, 23rd March, 1905. * Sample of water XI. (Table I.) was taken from these beds for bacteriological examination, 4 Sample of water V. (Table I ) was taken from these beds for bacteriological examination. ‡ Sample of tprlug water VI. (Table I.) was taken from these beds for bacteriological examination. § Sample of water X. (Table I.) was taken from these beds for bacteriological examination. ||Sample of water III. (Table I.) was taken from these beds for bacteriological examination. 8 REPORT ON THE RESULTS OF THE ANALYSIS OF SAMPLES OF WATER FROM WATERCRESS BEDS IN AND AROUND THE COUNTY OF LONDON. By Dk. Frank Clowes, Chemist to thk London County Council. In accordance with the order of the Committee, samples of water from the watercress beds in and around the County of London have been collected under the supervision of the Medical Officer of Health, and forwarded to me for analysis. Between 6th May and 27th August, one hundred and twenty-nine samples have been received. These have been submitted to chemical, microscopical and physical examination. The results obtained are stated in grains per gallon and are set out in the table* accompanying this report, together with the dates, times and places of collection. They include the amounts of albuminoid ammonia, which is a measure of the nitrogenous organic matter present in the water ; and the oxygen absorbed in 4 hours, which is a measure of the total organic matter. For convenience of comparison, I have grouped the results as follows:— Group "A," including 53 samples, in which the nitrogenous organic matter present was about the same as the nitrogenous organic matter present in the Thames-derived filtered water as supplied to the County of London. Group "B," including 47 samples, in which the nitrogenous organic matter present was about the same in quantity as that present in the water of the river Thames at Hampton and Sunbury, above the intakes of the various district works supplying London. Group "C," including 22 samples, in which the nitrogenous organic matter was large in quantity. Group "D," including 7 samples, in which the nitrogenous organic matter was very large in quantity. With a few exceptions, the samples in Groups "A" and "B" may be considered fairly satisfactory in chemical character. The microscopical examination of some of the samples showed, however, the presence of matter of an undesirable character. The samples in Group "C" contained a large quantity of nitrogenous organic matter, and in four of them a slight odour of sewage was detected when they were heated to 100 deg. F. From the results of my examination I am of opinion that some of the samples in this group were contaminated with sewage matter. The samples in Group "D" were organically of very bad quality, and six of them were, in my opinion, undoubtedly polluted with sewage. All the samples in Group "D," except No. 3, gave a distinct odour of sewage when they were heated to 100 deg. F. Frank Clowes, Chemist. *It lias been thought unnecessary to publish this table, inasmuch as the classification by the Chemist of the waters examined into four groups is sufficient for the purposes of this report. 9 REPORT ON TIIE BACTERIOLOGICAL EXAMINATION OF SAMPLES OF WATER AND OF WATERCRESS. By. Dr. A. C. Houston. SUMMARY OF CONTENTS. Methods—Page 9. Section I.—Results of the quantitative and qualitative bacteriological examination of the water "feeding" watcrcress beds in localities (1) free, from objection on topographical grounds, and (2) open to condemnation as the result of local inspection.—(Table I.). Page 11. Section II.—The comparative bacteriological examination of the water representing the first and final "washings" of cress obtained from pure and impure, beds.—(Table II.). Page 13. Section III.—The results as regards subsequent isolation of B. coli or coli-like microbes of the addition of cress in known quantities directly to liquid culture media both before and also after prolonged ivashing.—(Table III.). Page 13. Section IV.—Comparative bacteriological examinations of the leaf and the stalk of watercress.—(Table IV.). Page 10. Section V.—The question of standards. Page 16. Section VI.—Summary and conclusions. Page 17. Appendix A.—Analysis of the biological attributes of the B. coli or coli-like microbes isolated, from the various waters (Section I.). Page 18. Appendix B.—Analysis of the biological attributes of the B. coli or coli-like microbes isolated from the "washings " of the cress.—(Section II.). Page 18. Appendix c—Analysis of the biological attributes of the B. coli or coli-like microbes isolated from the primary medium into which the cress had been previously directly introduced.—(Sections III. and IV). Page 18. The circumstances which have brought watercress into some disrepute during recent years need not be described in this report. Bu the trade is undoubtedly at present suffering from the effects of a "watercress scare" somewhat analogous to the "oyster scare" now on the wane. This report is not concerned with the epidemiological evidence implicating watercress as a possible means of spreading disease nor with the topographical conditions of the watercress beds in the vicinity of London or elsewhere. No attempt will be made, therefore, otherwise than incidentally, to correlate the bacteriological facts with epidemiological experience and the results of topographical observations. The matter is important because, although the facts of the competent bacteriologist may be accepted without hesitation, the proper interpretation to be placed on the facts is matter for conjecture. The administrator is faced with the dilemma of how best to safeguard the interests of public health without causing injury to trade. In carrying out the investigation I have ventured to exceed to some extent my original instructions, which had reference only to the bacterioscopic analysis of water. The reason was that certain preliminary experiments showed that the bacteriological examination of the cress was likely to be as important as the examination of the water " feeding " the beds. METHODS. (1.)—Water. The various waters were examined by the B. coli, B. enteritidis sporogenes and streptococcus tests. It is unnecessary to enter into any detail as the methods employed were those described in my reports on the subject to the Local Government Board and Royal Commission on Sewage Disposal (2.)—Watercress. (A) The bacteriological examination of the first and final " washings " of the cress. One hundred grammes of watercress1 are weighed out and transferred bit by bit by means of a sterilised forceps and scissors into a flask containing 900 c.c. of sterile water. The flask is vigorously shaken for some time and then cultures are made of the " washings " of the cress as follows:— (а).—One hundred c.c. are transferred into a flask containing 100 c.c. double strength bile-salt glucoso peptone medium. (This culture is to be thought of as representing the first " washings " of 10 grammes of the cress.) (b).—Ten c.c. are transferred into a tube containing 10 c.c. of double strength bile-salt glucose peptone medium. (This culture is to be thought of as representing the first " washings " of 1 gramme of the cress.) (c).—One c.c. is added to a tube containing 10 c.c. single strength bile-salt glucose peptone medium. (This culture is to be thought of as representing the first "washing" of 0.1 gramme of cress.) Dilutions are made as follows :— Ten c.c. of the washings are added to 90 c.c. of sterile water in a flask called (2). Ten c.c. of (2) are added to a second flask containing 90 c.c. of sterile water called (3). Ten c.c. of (3) are similarly added to a third flask called (4), 10 c.c. of (4) to (5), and, lastly, 10 0.0. of (5)i to a fifth flask called (6). One c.c. from flasks (2), (3), (4), (5) and(6)2 are added to tubes containing bile-salt glucose peptone, and they represent the first washings "of .01, ".001. "0001, .00001, and .000001 gramme respectively of cress. 1 One hundred grammes by weight of watercress were found by volume to measure in each case about 120 o.o. A similar result was obtained with a sample of cress boughtfromashop. Cresstends to float, otherwise it would be more accurate to add the 100 grammes to an empty sterile 1,000 c.c. measuring cylinder and fill up with sterile water to the 1,000 c.c. mark. For all practical purposes the gramme by weight of cress and the cubic centimetre by measure of water may be considered identical. 2 Called (2), (3), (4), (5), (6), because 1 c.c. represents respectively the " washings" of .01, .001, .0001 .00001, and .000001 gramme of cress. 40581 B 10 To make the matter quite clear I give the following table:— Mixture of 100 grammes by weight of cress with 900 c.c. by measure of sterile water. Culture. Represents the following fractions of the whole mixture. Represents the "Washings " of:— Direct primary cultures A ... 100 c.c. of the mixture of cress and water. One-tenth 10 grammes of cress B ... 10 „ One hundredth. 1 gramme „ C .. 1,, One thousandth 1 ,, ,, Dilution cultures in successive tenths 1 c. c. of flask (2) .1 c.c. of the mixture of cress and water. One ten-thousandth. .01 ,, ,, „ „ „ (3).01 One hundred-thousandth .001 ,, ,, „ „ (4) .001 One millionth .0001 ,, ,, „ „ „ (5) .0001 One ten-millionth .00001 ,, ,, „ „ (6) .00001 One hundred-millionth .000001 „ „ The foregoing cultures are called primary cultures. They are incubated for 48 hours at 37 deg. C. The primary cultures which, after incubation for 48 hours at 37 deg. C., fail to develop "gas" are discarded because this negative result conclusively proves the absence from such cultures of glucose fermenting coli-like microbes, of any kind. On the other hand, the occurrence of gas in the primary cultures constitutes the prima facie or presumptive test for B. coli, and indicates the necessity for making from the liquid primary cultures secondary cultures on solid media. Surface gelatine plate cultures are, I think, the best for this purpose. Usually, it is advisable to inoculate one to three loopfuls of the primary culture into 10 c.c. of sterile water, and then to spread one to three loopfuls of this inoculated water over the surface of a gelatine plate by means of a sterile glass rod previously bent to an angle of about 45 deg. at one end. The gelatine plates are incubated for two days at 20 deg. C., and the coli-like colonies (filmy in preference) sub-cultured into gelatine and "shake" cultures made. If "gas" is developed in the gelatine " shake culture without any liquefaction of the gelatine within the first few days, the micro-organism is classed as a coli-like microbe. Further tests are then applied, and if these yield negative results the symbol 0 is applied to the microbe in question. The further tests are— Neutral red broth cultures (for greenish yellow fluorescence, symbol "fl"). Lactose peptone cultures (for acid and gas formation, symbol "ag"). Broth cultures (for indol formation, symbol "in"). Litmus milk cultures (for acidity and clot, symbol "ae "). If a microbe fulfils all these tests, it is termed a "flaginac" B. coli. Failure to yield a positive result as regards any of the tests is indicated by the omission of the corresponding letters. For example, a "flagac" B. coli would mean a B. coli typical except as regards indol production. A "weakness" of attribute is indicated by placing the corresponding letters in brackets. For example, a flag(in)(ac) B. coli would mean B. coli typical except that the attributes of indol production and acid clotting of milk were feebly displayed. The original gelatine "shake" culture is kept preferably for one month for observation as regards liquefaction. If slow liquefaction occurs, the letters S.L. are appended. [L.Y. = a liquefying chromogonic (yellow) microbe]. Reverting to the stage of the process at which the primary cultures representing the first "washings" of the mixture of cress and water have been made: The next step is to pour off the remaining water in the flask, to add fresh clean water, shake the flask, then pour off the water, again to add fresh water and again to pour off the water. Repeat this procedure several times; then add to the flask sterile water, shake the flask and pour off the water. This should be repeated several times. Finally add 900 c.c. of sterile water to the flask, Bhake it repeatedly, and proceed on exactly the same lines as before to examine the liquid (called the final "washings"). During the process of washing, any simple device, such as holding a piece of sterile wire gauze over the mouth of the flask will prevent loss of small floating pieces of cress. As the final "washings" liquid is examined in exactly the same way as the first washings, it is unnecessary to repeat what has been already described. Mention has only been made so far of the B. coli tests, but of course the first and final "washings" of the cress may be examined by the streptococcus, B. enteritidis sporogenes, or other tests. (B)—The results, as regards subsequent isolation of B. coli or coli-like microbes, of the addition of cress in known quantities directly to liquid culture media both before and also after prolonged washing. Several methods have been tried, but the following will be found satisfactory:— Unwashed cress. (a).—Weigh out 1 gramme of cress, cut it up into small pieces with a sterile pair of scissors, and drop the pieces with a sterile pair of forceps into a wide tube (8 in. by 1J in.) containing at least 30 c.c. of bile-salt glucose peptone medium. Incubate for two days at 37 deg. C.; and if there is aeid and gas production make secondary plate cultures and proceed on the lines explained in the preceding paragraphs. It is desirable to make several cultures. (b).—As above, but weigh out 10 grammes instead of 1 gramme of cress, use 100 instead of 30 c.c. of bilesalt glucose peptone medium and a wider tube (8 in. by 1£ in.). It is desirable to make several cultures. Washed cress. (c).—Weigh out 1 gramme of cress and affix a thin strip of sterile sheet lead for sinking purposes. (d).—Weigh out 10 grammes of cress and fasten the pieces together with a thin strip of sterile sheet lead. In either case wash first in clean water and finally in sterile water, then cut up the cress with sterile scissors and add the pieces to culture tubes with a sterile pair of forceps, as previously explained. Incubate at 37 deg. C., and proceed as under (a), (6). (C).—Comparison as regards the B coli test between the leaf and the stalk of cress. With a sterile pair of scissors and a pair of forceps separate the leaves from the stalk. (а).—Introduce 1 gramme by weight of the leaves into a wide-mouthed tube containing 30 c.c. of bile-salt glucose peptone medium. (б).—Ditto with the stalk. (c).—As in (a), but weigh out 10 grammes. (d).—As in (b), do. Some experiments were also carried out in which 1 leaf, 10 (leaves, and 100 leaves were severally introduced into wide-mouthed tubes (e, f, g), containing each 30 c.c. of bile-salt glucose peptone medium. Cultures (a, b, c, d, e, f, g) are incubated at 37 deg. C. If no gas develops the results are negative ; if gas formation occurs, secondary plate cultures are made in the ordinary way. 11 SECTION I. Results of the bacteriological examination of the water in connection with watercress beds. The results of the bacteriological examination of the samples of water collected either from the watercress beds or in connection with them are set forth in Table I. It is to be noted that the local conditions were found to be eminently satisfactory in connection with samples VI., VII., VIII., XII., and XIII. All the other samples (I., II. III. IV., V., IX., X., XI.) were obtained from situations considered unsatisfactory, in some cases highly unsatisfactory, as the result of local inspection. B. Coli Test. As judged by the total number of coli-like microbes, the two worst samples (III. and XI.) contained 10,000 coli-like microbes per c.c. (Water of the VIII. class.)3 Three samples (II., IV. and X.) contained 1,000 coli-like microbes per c.c. (Water of the Vll. class). Two samples (V. and IX.), contained 10 coli-like microbes per c.c. (Water of the V. class). One sample (I.) contained coli-like microbes in 10 c.c. but not in 1 c.c. (Water of the III. class). One sample (VI.) contained coli-like microbes in 100 c.c., but not in 10 c.c. (Water of the II. class) Four samples VII., VIII., XII., XIII.), contained no coli-like microbes even in 100 c.c. (Water of the I. class). Reviewing the results as a whole, there can be no question that with the notable exception of samples VI., VII., VIII., XII., and XIII. (possibly also sample I.), all the waters were outside the pale of recognition as judged by drinking water standards. Samples II., III., IV., X. and XI., indeed, resembled sewage effluents, bacteriologically. Great stress should be laid on the negative results afforded by the bacteriological examination of samples VII., VIII., XII. and XIII. It has been asserted that impure water is advantageous, if not necessary, for the successful cultivation of marketable cress. Yet cress grown in water of the greatest purity commands justly a ready sale. On the basis of the B. coli test, samples VII., VIII., XII. and XIII. were at least ten million times purer (bacteriologically) than samples III. and XI., and at least one million times purer (bacteriologically) than samples II., IV. and X.4 Preventive medicine is based largely on recognition of the importance of presumptive evidence. The bacteriologist can do no more than present his facts affording evidence of the numerical abundance of objectionable microbes in such a way as to allow the administrator to measure the relative value of such facts and by correlating them with topographical observations and epidemiological considerations to form a reasonable estimate of the degree of potential danger to health. As regards the biological attributes of the coli-like microbes, it will be noticed that above each sign † there are certain letters indicating the biological characters of the microbe representing the cultures. The significance of these letters is explained under " methods." B. Enteritidis Sporogenes Test. Two samples (II. and IV.) gave a positive result with .01 c.c. Two samples (III. and XI.) gave a positive result with .1 c.c. One sample (X.) gave a positive result with 1 c.c. Three samples (I., V. and IX.) gave a positive result with 10 c.c. Five samples (VI., VII., VIII., XII. and XIII.) gave a negative result with 10 c.c. With the exception of VI., Vll., VIII., XII., and Xill., all the samples would, I think, be condemned on bacteriological grounds and on a drinking water basis.5 Samples II., III., IV., and XI. failed to pass my primary standard for sewage effluents. Streptococcus Test. As regards samples I., VI., VII., VIII., IX., X., XI., XII., and XIII., either no microbes resembling in any way streptococci, or no microbes indubitably belonging to the streptococcus class were found in 0.1 c.c. of the respective waters. In respect of samples II., III., IV., and V., the diagnosis was uncertain. In all these samples there were present, in greater or less number, microbes concerning which I was left in much doubt even after a careful study of their morphological and biological characters. I could not, in brief, come to a final decision whether or not these microbes should be classed as streptococci of human faecal origin, nor indeed was I wholly convinced that they merited inclusion in the streptococcus group. As judged by the streptococcus test, the waters seemed less objectionable than was to be anticipated from the results of the B. coli and B. enteritidis sporogenes tests. Nevertheless, there are technical and other difficulties in connection with the streptococcus test which cause the observer to hesitate to pronounce too dogmatic an opinion. 3 That is, on the numerical abundance of coli-like microbes irrespective of their biological attributes not necessarily on the " flaginac," B. coli basis. Subject to fulfilment of positive confirmatory tests and considered on the basis of drinking water, ali the samples except VI , VII. and VIII. (possibly also I.) would be condemned without hesitation on bacteriological grounds. Samples II., III., IV., X. and XI. failed to pass my primary standard for sewage effluents. See page 107 et seq. of my report to the Royal Sewage Commission (Fourth Beport, Volume III.). 4 These are mathematical and biological distinctions. The measurement of the " disease value " of a given pollution unfortunately cannot be estimated by the topographist, epidemiologist, nor bacteriologist. 6 It is doubtful if drinking water standards could be applied to the water feeding watercress beds without serious injury to trade. Nevertheless, with the exception of VI., VII., VIII., XII. and XIII., all the samples submitted to me for bacterioscopic analysis were obtained from beds which, I am informed, could not on topographical grounds be considered as other than unsatisfactory. .1058] E2 12 Table I.—Showing the results of the Bacteriological Examination of Tarious samples of water collected in connection with different watercress beds. Number of Sample. B. Coli test. Number of b. coli or coli-like II icrobes. B. enteritidis sporogenes test. " Enteritidis change" in anaerobic spore-milk cultures. Remarks. 100 c.c. 10 c.c. 1 C.C. .1 c.c. *.01 c.c. .001 C.C. .0001 C.C. .00001 C.C. 10 c.c. 1 C.C. .1 C.C. .01 c.c. .001 c.c. *I. aginac + L Y flagina† + _ ... ... ... ... ... + - ... ... ... No streptococci found in 0.1 c.c. (D and C plates). * II. flaginac + flaginac + flaginac + flaginac + flaginac + flaginac + - ... + + + + ... Streptococci (?) in .001 c.c. Doubtfully of human fæca origin. (D and C plates). *III. flagac + flaginac + flaginac + flaginac + [ + f] flaginac + flaginac + — + + + - ... Streptococci (?) in .01 c.c. Doubtfully of human ffecal origin. (D and C plates.) IV. aginac + SL flaginac + fl(ag) + flaginac + flag + flaginac + ... ... + + + + Do. do. * V. flaginac + flaginac + flaginac + flaginac + - ... ... ... + - ... ... ... Streptococci (?) in .1 c.c. Doubtfully of human fsecal origin. (D and C plates.) § VI. flaginac + ... ... ... ... ... ... ... ... ... No streptococci in .1 c.c. (D and C plates.) § VII. - ... ... ... ... ... ... ... - ... ... ... ... Do. do. § VIII. - ... ... ... ... - ... ... ... Do. do. * IX. A (ag) + (in) + flaginac + flaginac + ... ... ... ... + - ... ... ... Do. do. * X. flaginac + flaginac + flag (ac) + flaginac + flaginac + flaginac + — ... + + — ... ... Do. do. * XI. (fl) aginac + .flaginac + flaginac + flaginac + aginac + flaginac + flaginac + - + + + - ... Do. do. § XII. - ... ... ... ... ... ... ... - ... ... ... ... Do. do. § XIII. - ... ... ... ... ... ... ... - ... ... ... ... Do. do. * Topographical conditions unsatisfactory. § Topographical conditions satisfactory. [ +¶] Signifies that acid and gas formation occurred in the primary medium, but that na coli-like microbes could be found in the secondary plate cultures. † The significance of these letters is explained under " methods." 13 SECTION II. The comparative bacteriological examination of the water representing the firtt and, final " washings" of watercress obtained from pure and impure beds.6 The results expressed in terms of B. coli or coli-like microbes in the "washings" of ten grammes, one gramme, or fractions of a gramme of watercress are set forth in detail in Table II. It is to be noted that, practically speaking, the results per gramme of cress are comparable with the results per cubic centimetre of water (Table I.). See page 12. In summary of the results set forth in Table II., See page 14, the following points deserve consideration:— In the first place it is clear that, as judged by the B. coli test and on mathematical lines of comparison, any danger accruing to the consumer of "unwashed" watercress would be enormously reduced by careful washing of the cress. It may be objected that my process of washing was, perhaps, more thorough than could be expected in practice, and that for the final "washings "sterile water was used. But as regards the former point, I was dealing with a principle, not with the notions of cleanliness of the average "washer" of watercress, and in respect of the latter point, the biological purity of the water used for washing purposes has nothing to do with the biological quality of cress, as cress. Secondly, it is to be noted that even an excess of care devoted to the washing of cress from polluted sources does not always entirely free the cress from objectionable microbes. Thirdly, it is apparent from a comparison of Tables I. and II., that there is usually a broad parallelism between the degree of the impurity of the water and the degree of impurity of the cress obtained from corresponding localities. At the same time, there is some indication that a cress grown in polluted water need not always reflect, as it were, its objectionable entourage. It is possible that the cress from ill-tended and the cress from well-tended beds may exaggerate and "mask" respectively the biological quality of the surrounding water. Fourthly, the results show quite conclusively that there may be as remarkable a distinction biologically between the first ''washings" of the cress from polluted and the first "washings" of the cress from non-polluted areas as was shown to be the case when the waters derived from pure and impure localities were compared. Fifthly, comparing the number of coli-like microbes per gramme of cress (washings) with the number of coli-like microbes per cubic centimetre of corresponding water, it is apparent that sometimes the cress and sometimes the water was, of the two, the more impure. Lastly, it was observed that the results of the first and final washings of the cress usually bore some relation to each other. For example, the more impure the first " washings," the less effective as a rule was the washing in removing the objectionable bacteria from the cress. As regards the biological attributes of the B. coli or coli-like microbes isolated from the cultures, it is to be noted that above the sign + there occurs in each case certain letters indicating the biological characters of the microbe representing the culture. The significance of these letters is explained under " methods." SECTION III. The results, as regards subsequent isolation of B. coli or coli-like microbes, of the addition of cress in definite quantities directly to liquid culture media both before and also after prolonged washing. These experiments were undertaken because the "washings" series of experiments, although dealing with the bacteria adhering to the cress and capable of being detached by a first or final process of washing, did not show whether or not the stomata or ducts of the leaf or stalk could harbour objectionable microbes. Obviously, even if the final "washings" of cress were sterile, the cress might still contain interiorly, or so firmly attached to it exteriorly as to be incapable of being washed away, undesirable microbes. The results are set forth in detail in Table III. See page 15. Generally speaking, it was found more difficult to isolate B. coli from, say, 10 grammes of cress directly introduced into the culture medium than from the washings of a similar or even smaller quantity of cress. It is possible that the presence of the cress in the medium may have a slight inhibitory action on the development of B. coli, whilst not restraining to a like extent the multiplication of other bacteria. This would account for the difficulty sometimes experienced in isolating B. coli from the secondary plate cultures. The results interpreted in a broad and general way indicate that cress grown in polluted waters both before and even after washing harbours as a rule undesirable microbes. As regards the biological attributes of the B. coli or coli-like microbes isolated from the cultures, it is to be noted that above the sign + there occur in each case certain letters indicating the biological characters of the microbe representing the culture. The significance of these letters is exolained under " methods." 6 Tho question of the possibility of the spread of entozoic diseases by means of watercress lies outside the scope of this report. 14 Table II—Showing the results of the Bacteriological Examination of (11 the first "washings," and (2) the final "washings" of watercress obtained from various localities. Mixture of 100 grammes by weight of cress+ 900 c.c. by measure of sterile water. Number of Sample. B. Coli test. Number of B. Coli or coli-like microbes. First "Washings." Final "Washings." "Washings"of:— "Washings" of:— 10 grammes of cress. 1 gramme of cress. .1 gramme of cress. .01 gramme of cress. .001 gramme of cress. .0001 gramme of cress. .00001 gramme of cress. .000001 gramme ot cress. 10 grammes of cress. 1 gramme of cress. .1 gramme of cress. .01 gramme of cress. .001 gramme of cress. 100 C.C. of mixt. 10 c.c. of mixt. 1 c.c. of mixt. .1 c.c. of mixt. .01 c.c. of mixt. .001 c.c. of mixt. .0001 c.c. of mixt. .00001 c.c. of mixt. 100 c.c. of mixt. 10 c.c. of mixt. 1 c.c. of mixt. .1 c.c. of mixt. .01 c.c. of mixt. * I. flaginac + flaginac + flaginact + — flinac + [+¶] — * II. flaginac + flaginac + flaginac + flaginac + flaginac + flaginac + flinac + — flaginac + flaginac + flaginac + — * III. [+11] [+11] — — * IV. flin(ac) + flaginac + flagin(ac) + flaginac + flaginac + — flaginac + flaginac + — * V. flaginac + fl(ac) + SL flag(ac) + SL fl(ag)in(ac) + SL — fl(ag)(ac) + SL flag(ac) + SL fl(ac) + — § VI. — — [* VII.] [ + ¶] flaginac + flaginac + inac + flaginac + — fl(ac) + flag(ac) + — § VIII. [ +¶] 0 + LY — — * IX. flaginac + flaginac + flaginac + flaginac + — [+¶] [+¶] — * X. flaginac + flaginac + (fl)aginac + (fl)ag(ac) + LY flag(ac) + LY flag + LY — fl(ag) + fl + fl(ag) + (fl)aginac + — * XI. flaginac + [+¶] [+¶] (fl)agac + — (fl)inac + — * Topographical conditions unsatisfactory. † The significance of these letters is explained under "methods." § Topographical conditions satisfactory. [+¶] signifies that acid and gas formation occurred in the primary medium, but that no coli-like microbes could be found in the secondary plate cultures. ║ The numbers correspond with those given in Table I. except as regards sample No. VII. (Table II.), which was from same source as No. III. (Table II.). Sample No. VII. (Table I.) was from same source as sample No. VIII. (Table I.). 15 Table III.—Showing the results as regards the B. coli test of the addition of cress in known quantities directly to liquid culture media both before and also after prolonged washing. Number* of Sample. Topographical Classification. Chemist's Report Standard. Unwashed Cress. Washed Cress. 10 grammes. 1 gramme. 10 grammes. 1 gramme. VII. and VIII. A. A. — No record No record No record — „ „ „ „ „ „ — „ „ „ „ „ „ — „ „ „ „ „ „ — „ „ „ „ „ „ IX. C. C. — „ „ — „ „ — „ „ — „ „ — „ „ — „ „ X. d. B. (fl) aginac † + „ „ flaginac + „ „ flagag + „ „ flagac + „ „ flaginac + „ „ flaginac + „ „ XI. D. C. — „ „ — „ „ (fl) aginac + „ „ flaginac + „ „ — „ „ flaginac + „ „ — „ „ (fl) (ag) (ac) + SL „ „ III. d. d.d. (fl) (ac) + „ „ flaginac + „ „ — „ „ flaginac + „ „ flagac + „ „ flaginac + „ „ flaginac + „ „ fl (ag) ac + SL „ „ I., II. and IV. d. d.d.d.c. No record No record — — „ „ „ „ flaginac + No record „ „ „ „ — „ „ „ „ „ „ flaginac + „ „ „ „ „ „ flaginac + „ „ „ „ „ „ — „ „ fl + — fl (ag) + flagac + fl + flag + — agac + flaginac + (fl) ag + SL flaginac + — (ag) ac + — — — fl (ag) + — — — (ag) inac + flaginac + flagac + flaginac + flaginac + (fl) aginac + flaginac + flinac + flag (in) + flaginac + flag + — flag + flaginac + flagac + — flag + flaginac + flin + — — — flagac + flag (ac) + flaginac + flag + — flagac + flag (ac) + flaginac + ag + — in + flaginac + (fl) (ag) inac + — flaginac + flaginac + flagac + — * The numbers given in this column correspond with those given in Tables I. and II. with the exceptions noted at foot of Table II. † The significance of these letters is explained under "methods." 16 SECTION IV. Comparative examinations bacteriologically of the leaf and stalk of watercress. These experiments were undertaken because it might be asserted that as it is the leaf of the cress that is largely eaten, the inclusion of any greater proportion of the stalk in the quantitative analyses than is likely to be consumed in practice is not quite fair.7 A strict comparison of the bacterial flora of the leaf and stalk of cress would be a most difficult task. A broad comparison only can be attempted here. The results are shown in detail in Table IV. It is quite clear from the results that both the stalk and leaf of cress may harbour objectionable microbes. As regards the biological attributes of the B. coli or coli-like microbes isolated from the cultures, it is to be noted that above the sign+there occur in each instance certain letters indicating the biological characters of the microbe representing the culture. The significance of these letters is explained under "Methods." Table IV.—Showing, as regards the B. coli test, a comparison between the leaves and stalk ol watercress. Number. Description of sample. 1 leaf. Leaf of Watercress. Stalk of Watercress. 10 leaves. 100 leaves. 1 grm. 10 grms. 1 grm. 10 grms. 1 19.8.04 No. I.watercress (Topographical conditions unsatisfactory) — — O + (ag)inac + fl(ag)ac* + flag + SL flagac + 2 23.8.04 ditto flaginac + flaginac + flag + SL flaginac + flagac + flaginac + flagac + 3 25.8.04 ditto fl(ag)in + (fl)ag + SL fl(ag) + flaginac + flaginac + aginac + flaginac + * The significance of these letters is described under "methods." SECTION V. The question of standards. This subject is one of such grave importance to the watercress industry that it is felt that at the present time only tentative suggestions should be made. It is difficult to decide whether or not any standards, provisional or otherwise, should be of a two-fold character. That is, whether they should take note of the biological quality both of the water and the cress. Inasmuch as, generally speaking, the results show that the cress is apt to reflect bacteriologically its aqueous environment, there would seem to be an advantage in reducing the question to one of water. Whether the affluent, circumfluent, or effluent waters should be chosen for investigation is matter for conjecture." On the whole, perhaps, the examination of the affluent water should form the basis for judgment. Strictly speaking, drinking water standards are applicable to the water "feeding" watercress beds. But the imposition of such standards would press, it is to be feared, rather heavily on the watercress industry. The responsibility of correlating the bacteriological and chemical facts and topographical observations with epidemiological experience must rest with the administrator. In this connection the following observations may be of some value. In the first place it is noteworthy that the best samples of water (VII., VIII., XII. and XIII.) were ten million times purer bacteriologically than the worst samples of water (III. and XI.), and one million times purer bacteriologically than samples II., IV. and X. This per se affords a reasonable and definite basis for objecting to the worst cases of pollution. Yet these cases, it may be contended, hardly need the confirmatory evidence of the bacteriologist. When we step inside a narrower circle the bacteriological facts remain none the less definite, but their interpretation in relation to potential danger to health is apt to grow more nebulous. Not, perhaps, on a purely mathematical basis, but from an added sense of responsibility, and an increased conviction that the bacteriological facts afford no direct indication of the "disease value" of a given pollution. Secondly, treading on safer ground, it may be said that it is desirable that all watercress beds should, on the basis of the biological qualities of their affluent waters, be divided into separate classes. This does not involve necessarily the question of bacteriological standards or of legislative condemnation. It merely means that the affluent waters to all watercress beds should be classified. It is not suggested that the bacteriological results should be used necessarily as a lever for condemnatory purposes, but rather that a bacteriological classification would, particularly when coupled with the 7 That is, on the assumption that per gramme of weight the stalk would be more impure than the leaf. This point, however, has yet to be established. 8 The affluent, circumfluent and effluent waters are the waters "feeding," flowing round the watercress, and leaving the watercress beds respectively. 17 observations of the chemist and topographist, aid the administrator in a progressive attempt to remedy pressing evils. In this sense, and with the modifications which the circumstances of the case demand, I would suggest a broad classification on the lines already tentatively brought forward in reports to the Local Government Board and Royal Commission on Sewage Disposal, as follows:— CI.ASS.* Standard based on numerical abundance of B. coli (or nonliquefying, gas-forming coli-like microbes). Numerical standard confirmed or modified according to response of the coli-like microbes in pure culture to certain well-known biological tests. Provisional bacteriological conclusions confirmed or modified by topographical observations. Provisional bacteriological & topographical conclusions confirmed or modified by epidemiological & administrative considerations. I. A water showing no evidence (bacteriologically) of objectionable contamination No B. coli in 100 c.c. For example:— (1) Neutral-red broth test— Greenish-yellow fluorescence (48 hrs. at 37° C.) For example:— Degree of cleanliness of watercress beds. Source and probable nature of the pollution and its proximity to the beds. Local arrangements for washing the cress in pure water before being dispatched to market. Relative volumes of the different waters "feeding" the beds, etc. For example:— Questions of practicability ; whether the contaminating material is likely to have a high or a low enteric morbific value; past epidemiological experience in circumstances broadly parallel, etc., etc. II. A water showing appreciable, although slight, evidence (bacteriologically) of objectionable contamination B. coli present in 100 c.c., none in 10 c.c. (2) Lactose peptone test— Gas and acid production (48 hrs. at 37° C.) (3) Indol test—Indol in broth cultures (5 days at 37° C.) III. A water showing definite signs (bacteriologically) of pollution, and therefore to be viewed with some degree of suspicion B. coli present in 10 c.c., none in 1 c.c, (4) Litmus milk test—Acid clotting of milk (5 days at 37° C.) Of course, the more tests applied the better, but the above are all tests of known value. IV. A water showing such obvious signs (bacteriologically) of objectionable pollution as to be condemned† on the basis of results B. coli present in 1 c.c., none in 0.1 c.c. (1 not 10) [4s regards tests (1), (2), (3) and (4), my work for the Local Government Board on the B. coli of recentlyvoided normal human faeces shows that of 101 B. coli, 98, 92, 98 and 92 per cent. respectively yielded positive results to one or other test. As regards all four tests (taken in conjunction), 85 per cent. yielded positive results.] V. B. coli present in 0.1 c.c. None in 0.01 c.c. (10 not 100) VI. B. coli present in 0.01 c.c., none in 0.001 c.c. (100 not 1000). [Primary standard for sewage effluents; nondrinking-water streams] VII. B. coli present in 0.001 c.c., none in 0.0001 c.c. (1000 not 10,000). [Secondary standards for sewage effluents; non-drinking-water streams. * It must, of course, be definitely understood that I am not prepared to say that a water of Class III., II., or even I. is necessarily always "safe," much less that a water of Class IV.—VII. has a definite "disease value." † This does not mean necessarily administrative practical or legislative condemnation, but rather that the evidence of pollution is sufficiently defined to merit objection from the bacteriologist's point of view. [This standard is intended to apply primarily only to potable waters.] N.B.—The B. enteriditis sporogenes test is not dealt with here. Perhaps the safest standard to suggest is that a water should yield a negative result when using 10 c.c. for cultural purposes. [This standard is intended to apply primarily only to potable waters.] SECTION VL Summary and condusions. The best waters contained no coli-like microbes of any sort, and no spores of B. enteritidis sporogenes when 100 c.c. and 10 c.c. respectively were used for cultural purposes. The least satisfactory waters contained from 1,000 to 10,000 B. coli or coli-like microbes per c.c. and yielded positive results with the B. enteritidis sporogenes test with from 1/10th to 1/100th of a cubic centimetre. On the basis of the B. coli test the best waters were from one million to ten million times purer than the least satisfactory waters. Generally speaking, watercress reflects bacteriologically its aqueous environment. That is, the more polluted the water the less pure is the cress, and the purer the water the cleaner is likely to be the cress. But the results were sometimes (partly, perhaps, for technical reasons) inconclusive and not in entire correspondence. It is possible that cress grown in well tended beds may escape in some measure the contamination by an impure circumfluent water. The importance of thoroughly washing watercress is shown by the fact that the final as compared with the first " washings " of impure cress was usually found to contain a much smaller proportion of objectionable microbes. But the results seem to indicate that no ordinary amount of washing could be relied on to rid cress grown in polluted waters of all undesirable microbes. This may be due either to bacteria so firmly adhering to the exterior of the plant as to resist being swept away during the washing process, or to the cress harbouring microbes within its structure, or to a combination of these causes. The results appear to prove that both the leaf and the stalk of cress may foster undesirable bacteria. 4058] C 18 As regards standards, this aspect of the question has been dealt with in a previous section (Section V.). In conclusion, it is desirable to lay stress on the biological attributes of the B. coli or coli-like microbes isolated from the water and cress. The results are shown in Tables I., II., III., IV., and in Appendices A, B, C. It should be noted that a larger proportion of the B. coli isolated were atypical than is found in the case of normal human faeces, sewages, and sewage effluents. The greater the percentage of a typical B. coli, the less obvious is the danger. Unfortunately, it is impossible to lay down any formula to link together the biological attributes and numerical abundance of B. coli or coli-like microbes. It is specially to be noted that the number of "flaginac" B. coli isolated from (a) the waters, (b) the first and final washing of the cress, and (c) the cress was 76, 54 and 40 per cent. respectively. This circumstance ought to be borne in mind in judging the wholesomeness or otherwise of cress. A. C. Houston. Appendix A.—Analysis of the biological attributes of 42 B. coli or coli-like microbes isolated from the waters.— (Section I.) Flaginac B. coli, about 76 per cent. Aginac B. coli, about 7 per cent. (in) B coli, about 2.4 per cent fl (ag) „ 5 „ flag(ac) „ 2.4 „ flagac „ 2.4 „ (fl)aginac „ 2.4 „ flag „ 2.4 „ [Slow liquefiers about 5 per cent.] Appendix B.—Analysis of the biological attributes of 52 B. coli or coli-like microbes isolated from the first and final "washings" of the cress.—(Section II.) Flaginac B. coli, about 54 per cent. flag(ac) B. coli, about 8 per cent. fl(ag)(ac) B. coli about 2 per cent. fl(ao) „ 6 „ inac „ 2 „ rlinac „ 4 „ 0 „ 2 „ fl)aginac „ 4 „ (fl)ag(ac) „ 2 „ fl(ag) „ 4 „ flag „ 2 „ din(ac) „ 2 „ fl „ 2 „ flagin(ac) „ 2 „ (fl)agac „ 2 „ fl(ag)in(ac) „ 2 „ (fl)inac ,, 2 „ [Slow liquefiers about 18 per cent.] Appendix C.—Analysis of the biological attributes of 81 B. coli or coli-like microbes isolated from the primary medium into which the cress had been previously directly introduced.—(Sections III. and IV ) Flaginac B. coli, about 40 per cent. dagac B. coli, about 14 per cent. (ag)ac B. coli, about 1.2 per cent. flag „ 8 „ agac „ 1.2 „ (fl)aginac „ 3.7 „ 0 „ 1.2 „ fl(ag) „ 3.7 „ flag(in) „ 1.2 „ fl(ag)ac „ 2.4 „ flin „ 1.2 „ fl „ 2.4 „ flinac „ 1.2 „ (fl)ag „ 2.4 „ in „ 1.2 „ (ag)inac „ 2.4 „ ag „ 1.2 „ flag(ac) „ 2.4 „ (fl)(ag)inac „ 1.2 „ (fl)(ac) „ 1.2 „ aginac „ 1.2 „ (fl)(ag)(ac) „ 1.2 „ fl(ag)in „ 1.2 „ [Slow liquefiers about 18 per cent] Appendix III REPORT OF THE MEDICAL OFFICER (EDUCATION) FOR THE YEAR ENDED 31st MARCH, 1905. Two Reports were written by me as Medical Officer to the late School Board for London. It will be to the advantage of the Educational Authority to have an Annual Review written of the work done by the officers of the Educational Branch of the Public Health Department. This review is of use as a kind of annual stocktaking of the gains in knowledge which the year has brought and also of the things left undone. The present report being the first under the Council includes, for the sake of completeness, a short résumé of the work presented in the previous Reports to the late School Board. The expansion of the Department under the late School Board was exceedingly rapid, and continues under the Council. The continuous press of work to be done accounts for the Report being this year delayed in appearance for several months. EXAMINATION OF CANDIDATES. Candidates for employment under the Council must be certified as to their health by the Council's Medical Examiner. In the case of candidates who will be engaged in the Schools the examinations are, however, done in this Department, and in addition all successful candidates for the Council Scholarships have to be examined here. Subjoined is a return of candidates medically examined during 1904:— Candidates. Number who applied for examination and reexamination. Number outstanding from 1903. Number examined and reexamined. Passed. Subject to re-examination before termination of Probationary Period. Rejected. Withdrawn, etc. Outstanding at end of 1904. Unconditionally. Subject to Oculist's Report. Subject to Aurlst's or Surgeon's Report. Subject to Dentist's Report. Subject to Successful Vaccination. Head and Assistant Teachers— Males 280 ... 244 235 9 ... ... ... ... ... 28 8 Do. do. Females 887 4 820 743 42 1 28 ... 8 2 57 14 Pupil Teachers Males 328 6 315 282 13 3 ... 3 3 11 14 5 Do. Females 1799 51 1758 1526 91 8 50 45 27 21 69 23 Cookery and Laundry Instructresses, Clerks, Visitors, and others Males 125 1 119 116 1 ... ... ... 1 1 5 2 Do. do. Females 53 ... 51 50 1 ... ... ... ... ... 2 ... Totals Males 733 7 678 633 23 3 ... 3 4 12 47 15 Females 2739 55 2629 2319 134 9 78 45 35 23 128 37 Grand Total 3472 62 3307 2952 157 12 78 48 39 35 175 52 The number of candidates examined in recent years has been:— Candidates examined. References as to health of Employes. 1901 1789 — 1902 2738 207 1903 2846 247 1904 3307 244 4 A considerable increase in the number of children examined at the Education Offices has taken place, owing to the fact that all children nominated tor admission to Residential Homes are examined in this Department. Cases requiring detailed examination, more particularly in regard to Blindness or Deafness referred from the admission examinations, and certain cases referred by Magistrates and Committees, are also seen at the offices. VISITS TO SCHOOLS. The average number of visits to schools made each week for examinations and inspections by officers of the Public Health Department is as follows:— Special Schools. Ordinary Schools. Domiciliary and Special Inquiries. Medical Officer and four Assistants 10 5 Not noted Six Oculists — 18 ,, Twelve Nurses 119.4 125 Each of the Residential Schools has now to be visited at least once a quarter by the Medical Officer (Education). PHYSICAL CONDITIONS. Measurements.—We have no trustworthy measurements of the development of London children. A scheme was put forward in November, 1903, for an inquiry into the relations between (1) Educational status, (2) the physical condition, (3) the social position of about 50,000 London children. The cost of this work stood in the way, and even a more modest scheme which would not cost more than £300 has been felt to be inopportune, and at present is in abeyance. Much care and expense is involved in the recording and analysis of mortality statistics concerning those whose lives have ceased. The vitality statistics of those who are about to enter on active service in the affairs of life, and whose energy is the chief of the national assets, is surely worth the cost of collection. The children whose measurements will form the units in the inquiry are not interfered with in any way; their self-respect will rather be increased, their sense of belonging to the community heightened by their participating in such measurements, and although the benefit to any individual is scarcely worth considering, yet the results to be hoped for are such that some effort must be made to conduct this inquiry, tedious though it may be, to those who do the work. In accordance with the method advocated for a general survey, and chiefly to gain experience in working it, a few measurements have been taken. Dr. Frances M. D. Berry has investigated the conditions of 1,612 girls at Capland Street, Honeywell Road, Prospect Terrace, and Victory Place Schools; and Dr. C. J. Thomas 1,861 boys, at the "Chaucer," Capland Street, Honeywell Road, Leipsic Road, "Michael Faraday," and Victory Place Schools. The numbers are insufficient to base any standards upon, but give some indication of conditions of cleanliness, health, and nutrition among the scholars. These have been charted as regards ages, sex, heights, and weights. In the case of one school, where the Head Master has taken great pains to investigate the Home Conditions, Dr. Thomas reports that one of the dominant characteristics of the population around it is its stationary habit as opposed to the migrating tendencies of some other districts on the one hand and its steady poverty on the other. Amongst the staple industries of the neighbourhood is the making of baskets and brushes, although the osier beds have years since departed, and the raw material has to be imported from outside London. The object of the inquiry was to discover the causes of variation in the physical condition of children within the limits of this single school. Each of the 405 boys was carefully weighed and measured without boots, a note was made of the 5 Diagram I. (See page 6.) 6 condition of the teeth and a general estimate of the personal cleanliness and sufficiency of clothing as a basis for determining the home conditions of neglect or otherwise from external evidence. The teacher of each class added an estimate of mental capacity. Each case which after the determination of the primary inquiry showed any marked deviation from the normal was specially investigated with the help of the Head Master. The results of the measurements are given in the following table:— Age. Date of Birth. Year and Quarter. No. Combined Weight. Average Weight. Combined Height. Average Height. Kilogrammes (1 Kilo—2.2lb.). Centimetres (2.5=1 inch). 7—7⅓ 1.1897 & 4.1896 15 292 19.4 1748 116.5 7½—8 3 & 2, 1896 23 461 20.6 2562 111.4 8—8½ 1.1896 & 4.1895 24 520 21.7 2766 115.3 8½—9 3 & 2, 1895 38 859 22.6 4417 116.3 9—9½ 1.1895 & 4.1894 29 668 23 3482 120.1 9½—10 3 & 2, 1894 33 816 24.7 4098 124.2 10—10½ 1.1894 & 4.1893 33 853 25.8 4139 125.4 10½—11 3 & 2, 1893 38 1007 26.5 4797 126.2 11—11½ 1.1893 & 4.1892 29 794 27.4 3726 128.5 11½—12 3 & 2, 1892 32 953 29.7 4243 132.6 12—12½ 1.1892 & 4.1891 34 1031 30.3 4570 134.4 12½—13 3 & 2, 1891 22 681 31 2954 134.3 13—13½ 1.1891 & 4.1890 30 986 32.8 4147 138.2 13½—14 3 & 2, 1890 20 707 35.4 2829 141.5 14 1.1890 4 147.9 ... 576.5 ... For Diagram I, see page 5. Taking clothing as the best indication, from external evidence, of poverty grading, the boys were given marks from 1 to 5, according as conditions passed from the very worst to the very best. No. Percentage. 1. The clothing of the scantiest possible—e.g., one ragged coat buttoned up and practically nothing found beneath it, and boots either absent or represented by a mass of rags tied upon the feet 30 7.4 2. Clothing insufficient to retain animal heat, and needing urgent remedy; boots leaking 141 34.8 3. Clothing poor, but passable ; an old and perhaps ragged suit, with some attempt at proper underclothing—usually of flannelette 187 45.9 4. Well clad. Stuff suit, good boots, with a flannel under-garment, or a guernsey; poor, but sufficient 48 11.8 5. Very well clad 1 — The 30 boys of the first class showed considerable failure to reach the average weight for their age of the school; the average shortage per boy for his age being as much as .7 kilogram. The effect upon weight was more striking than upon height, as the average failure in height was 1 centimetre. The 141 boys of the second class worked out at exactly the average. The well-clad boys of the 4th and 5th class (49) showed an average excess per age-weight of .54 kilogram and age-height of 1.8 centimetres. Cleanliness.—Want of cleanliness may be next taken as evidence of home neglect. The marking again was from 1 to 5, as from the very worst to the very best. No. Percentage. 1. Very dirty and verminous 45 11.0 2. Clothes and body dirty, but not verminous 141 34.7 3. Passably clean for boys 172 42.5 4. Clean, above the average, for boys 48 12.0 5. Unexceptionable — — Here, again, the very lowest class fell distinctly short of the average age-weight for each boy. The 45 verminous boys averaged less by .55 kilos, and 1.1 centimetres than the average weight and height for each age of the school. The second class worked out to exactly normal, while the 48 clean boys were considerably above the average height—to as much as 1.7 centimetres. The above results tend to show perhaps no more than the effect of poverty, although the excessive shortage of weight in the worst clad class suggests that insufficiency of clothing is a 7 definite factor in producing mal-nutrition, the insufficient food-energy being first taxed to keep up the animal heat. Mental capacity as affected by physique.—The mental capacity was gauged by the class teachers. The marks 1 to 5 were given in the following manner:— No. Percentage. 1. Very dull and backward 23 5 2. Below the average 70 17 3. Average intelligence 173 43 4. Above the average 98 24 5. Brilliant 41 10 It must be remembered that the actual mentally defective were already weeded out and sent to special schools. No correlation can be established between mental capacity and physique in this school; the 93 below average intelligence correspond with the average age, weight, and height for the school. The 98 boys given as above the average (class 4) have a decided advantage in physique, 1.5 centimetres in height and .5 kilos, in weight, the exceptionally brilliant boys (numbering 41), however, are actually slightly below the average physique—a quarter of a kilogram in weight and .4 centimetres in height. The effect of overcrowding upon physique.— No. of rases. Average divergence from normal age physique of the Schcol, Weight (kilos). Height (cms.). Living in 1-roomed tenements 15 —1.3 —2.6 „ 2 „ „ 70 0 —1 „ 3 „ „ 35 0 +1 „ 4 „ „ 84 +1.3 +2 Here, again, we see that only at the extremes can any effect be made out upon the physique; more important than the number of rooms of course is the number of occupants per room:— No. per room. No. of cases. Average divergence. Weight. Height. 1—2 41 +.5 +1.5 2—3 66 0 0 3—4 39 0 —.3 4—5 16 0 —.7 More than 5 10 —3.5 —7.6 There is seen here a slight effect only until we reach the serious overcrowding of more than five to a room, when the divergence becomes startling. It may be of some interest to give full particulars of these ten cases:— No. Mental. Age. standard. Height. Weight. Father. Mother. 1 Average 10.2 II. —5.5 cms. —2 kil. Asphalter Brush Maker 2 Below average 10.2 I. —10.5 „ —3.5 „ Fruit Seller Paper Bag Maker 3 Very dull 8.6 I. —10 „ —5 „ Tin Can Maker Onion Seller 4 Excellent 7.6 I. —9 „ —3 ,, ? Fish Seller 5 „ 7.0 I. —12 „ —4.5 „ General Dealer At home 6 Average 11.0 III. —5 „ —4 „ „ „ „ 7 Excellent 10.3 II. —7 „ —3.5 „ Dying Invalid Hawker 8 Very good 9.1 I. —1.5 „ —1.5 „ Bootblack. Dead 9 „ 9.2 I. +3 „ +0 „ Carman At home 10 Average 9.8 I. —12 „ —6.7 „ Hawker ? ■ No. Teeth. Cleanliness. Sufficient Clothing. Children in Family Alive. Remarks. No. in Room. 1 Bad, 2 Verminous Insufficient 3 Rickety 5 2 Bad, 2 Average Insufficient 6 — 8 3 Useless, 1 Dirty Average 3 — 5 4 Poor, 3 „ Insufficient 4 — 6 5 Poor, 3 Average Average 10 — 6 6 Very bad, 2 „ „ 10 Brother of No. 5 6 7 Good, 4 Verminous Insufficient 5 — 7 8 Poor, 3 „ Very bad 22, 16, 15 (girls) and 18, 9 (boys) One ragged coat 6 9 Poor, 3 Dirty „ 3 Chronic Bronchitis 5 10 Poor, 3 Verminous Very good 10 Chronic Blepharitis 6 8 Nineteen boys in the school were the sons of widows. They nevertheless showed somewhat better physique than the average, being on an average 1.4 centimetres taller and .3 kilos. heavier. In many cases, unfortunately, it must be observed that the father is a parasitic member of the family, accounting for more than he brings in, and taking the food out of the children's mouths. Another point of interest tending to show that it is necessary to look far back in the life-history for the causes of poor physique is the fact that where the parents are reported to have sunk from a higher stratum of the community the children are usually of excellent physique compared with the aboriginal denizens of the neighbourhood. One of the most potent causes of ill-nutrition is undoubtedly the necessity for mothers to leave their homes to go out to work. The added income of the family thus obtained is not repaid by increased physique of the children, who practically never get a properly prepared meal. Diagram II. (See page 9.) Note.—In this diagram the fine vertical lines should be disregarded. The upper curve gives yearly infantile mortality; the dotted curve the average European heights (Axel Key), and the lower curve, heights from table on page 6. Of 124 boys who were conspicuously above the average in physique, the figures were:— Mother works. Mother keeps the house. Mother dead. 13 109 2 Of 110 boys conspicuously below the age average, a similar inquiry gave this result:— Mother works. Mother keeDS the house Mother dead 57 44 9 Thus of the well-nourished children 87.9 per cent. had the benefit of maternal care, while of the ill-nourished 40 per cent. only were in like case. The probability is that the damage is to a great extent done in the first year of life, the percentage of mothers who go out to work probably 9 closely approximating to those who fail to suckle their children, as the following consideration also helps to emphasise. It may be noted in the heights and weights for each age that the curve is not a continuous line of growth, but that at some ages it springs nearer to, and at others sinks further from, the normal. The greatest effect upon the life capital of the population is produced by the infantile mortality, which in some years actually kills off during the first year one in five of all children born; the question naturally arises what is its effect upon the survivors—do the weakly ones get killed off and only the strong muddle through, or does the adverse environment which slaughters one in five have a maiming effect upon those left ? First, the London curve of infantile mortality was obtained and superimposed upon the physique curve, but the result gave little indication of any effect. When, however, the infantile Diagram III. (See page 11.) mortality for the parish in which the school is situate was charted above the physique curve, an absolute correspondence is to be observed (see diagram II., page 3). The children born in a year when infantile mortality is low show an increased physique, rising nearest to the normal in the extraordinarily good year 1892; and those born in the years of high mortality show a decreased physique. This, then, gives an indication of great importance to those engaged in anthropometric surveys; the year of birth should be carefully noted; hitherto the age has been alone noted, and children measured in different years at the same age have been charted together, and thus the effects of such 10 conditions have been smoothed out and lost. The infantile mortality varies in the same year very considerably, even in neighbouring parishes, and in this particular parish is dissimilar from any other in London. In the same manner, by taking the weights of the Sharp Street boys in Manchester given by an independent investigator to the Royal Commission on Physical Deterioration and placing above them the Manchester Infantile Mortality for the years in which they were born, we get diagram (IV.) Diagram IV. The Leipsic Road School Boys also show a slight increase in height when they are born in a year of lower mortality—these boys come from three neighbouring districts, Newington, 11 well, and Lambeth, and the infantile mortality curve is the combined one of those districts (see diagram III., page 9). It appears certain, therefore, that in years of high infantile mortality the conditions, to which one in five or six of the children born are sacrificed, have a maiming effect upon the other four or five. What these conditions are requires the fullest investigation; and whether they be dependent on climate, custom, ignorance, the laws of the land or conditions of labour, they are of interest not merely to educational authorities but to every right-minded citizen who has the welfare of his country at heart, and the urgency of bringing all the forces at our disposal to play upon this, the ugliest blot on our civilisation, is more than ever apparent. Table of Infantile Mortalities. 1802. 1893. 1894. 1806. 1806. London 154 163 143 165 161 St. Saviour's 187 154 145 205 213 St. George's 174 206 186 198 181 Newington 172 176 158 201 184 Camberwell 155 161 148 164 156 Lambeth 135 149 133 152 136 In compiling curves to bring out these and similar facts, it is necessary to make certain that one is dealing in the first place with a stationary population, and in the second place that the infantile mortality figures used should be those of the area corresponding to the district from which the school draws its pupils, conditions which at present it is very difficult to satisfy except in a few localities. Care of the Teeth.—The importance of this subject is not likely to be overestimated. Apart from local conditions giving rise to pain or abscess, septic mouths sometimes requiring prolonged treatment, so that many candidates for admission as teachers have to have their certificates of fitness suspended till they have been through the dentist's hands, defective teeth are the source of many serious general diseased conditions. Such septic conditions are an exceedingly common cause of irritation and inflammation of lymphatic glands, which often become tubercular. They are a fruitful cause of gastric and intestinal troubles in later life, of chronic anaemia and of severe and persistent neuralgia and headaches. It is asserted that severe scarlatinal angina is ten times more common in cases with septic than with healthy mouths. The difficulty is in applying remedies. It is difficult to suggest practical treatment. During the past year the following returns have been made as regards dental conditions of elementary school children, expressed in percentages: Examiners —Dr. F. M. D. Berry (Girls). Dr. C. J. Thomas (Boys). Standards. I. II. & III. IV. & V. VI. & VII. I. to VII. Numbers examined 124 441 330 226 406 No decayed teeth 11.0 15.0 17.0 22.0 9.6 One decayed tooth 19.0 19.0 20.0 25.0 20.0 Several—not seriously impairing bite 47.0 47.0 54.0 41.0 50.0 Several—seriously impairing bite 23.0 21.0 9.0 11.0 18.0 Practically all affected .3 ... ... ... 2.5 In the case of the boys a very serious state of things was shown, 90 per cent. of the boys having caries, and 70 per cent. to a serious extent. The boys who had insufficient grinding surface were below the average in physique. Of the 83 boys in this category the average weight was half a kilogram below the school average for their age, and the height 1.3 centimetres lower. The 39 boys who had perfect teeth worked out exactly to the average for height and weight. It appears, therefore, that caries must be severe to produce an effect on nutrition. PHYSICAL EXERCISES. The necessity pointed out two years ago for increased precautions to obtain better physique is obvious to anyone visiting the schools. The recommendations as to the exercises in the Infants' Departments never being slow, being of simple and automatic nature, easily learned and massive in character, very intermittent and accomplished without regard to detail; the use of music in aiding Infants' exercise, the rhythm diminishing fatigue, the necessity 12 of short lessons in the Infant school broken up by a few quick movements, or, if feasible, a very few seconds run, are all points which have been borne out by the syllabus of Physical Exercises for Schools. No formal syllabus has been set forth for use in Infant schools; but what has been attained in London schools is wholly good, and, with trifling modification in some of the commands will fit in as introductory to the syllabus devised for the Standards. These exercises, for the sake of uniformity, will be required as a minimum in all the Standards, and will be adopted in London from the beginning of the autumn session of this year. The most common danger seems to be the case of children with chorea (St. Vitus' Dance). In some districts of London this disease appears more prevalent than elsewhere, and the teachers should be able to recognise the meaning of the facial twitches and jerky finger or shoulder movements. Such children should not only not be exercised, but the teacher would be exercising a wise discretion who refused to allow them to continue school attendance. It would be as well also that a special squad should be formed in large schools of children who present defects or deformities, often comparatively slight in nature, which interfere with their being properly looked after if exercised in large classes. Such children should be presented to the Medical Officer on his school visits for his opinion and advice as to exercise. In pupils above the Standards the need for exercise is just as urgent and imperative as in younger children. Candidate pupil teachers frequently, more especially in the case of the girls, give evidence of being much in want of exercise. The heart muscles being out of tone and flabby, and acting sometimes in such a way as to give rise to suspicions of actual disease. Reserve powers are at a low ebb. Liability to diseases, particularly of the catarrhal type, is increased, and mental receptivity is diminished, and liability to show signs of comparative over-pressure, exhaustion, or even neurasthenia is almost to be expected. THE FEEDING OF SCHOOL CHILDREN. This is a matter in which it is quite impossible to attain an opinion of any real scientific value without the expenditure of time and money on observations of the physique of sufficient children to establish standards. The following report was made to a Sub-Committee considering the matter:— "The following are general impressions; definite statements could only be made on exact facts being ascertained for the purpose. "The question should be stated, not as 'underfeeding,' but as' ill-nutrition. "Ill-nutrition is most obvious in the youngest children at school and in 'slum' districts. Among the older children it is not so common, and is expressed chiefly by anæmia, and by development being less than would be expected for age. "The most typical children who present 'simple ill-nutrition' are of a fine textured constitution, frequently with long delicate hair and thin smooth skins, and often present a mentally sharp appearance even when dull. In better social position they form the class of ' delicate' children. "The majority of 'ill-nourished' children are so from a complexity of causes, of which want of food during school life is a comparatively trivial one. "Frequently they seem the offspring of people who from inherent want of efficiency, mental or otherwise, have gone to the wall. These most often present evidences of mental slackness, and with this is associated in great measure alcoholism and its associates, want of regular employment, and poor housing. Insufficient rest for the young children is a frequent contributory cause due to housing. "The married women also have to work, and infants are artificially fed; a want of cheap milk supply leading to the use of tinned milks deficient in fat, and also of preparations of various foods. 'The children are frequently fed on foods which are savoury from containing stimulating extractive matters their debilitated condition leading to their passing over wholesome food which is not tasty. The want of a sufficiency of fat and perhaps sugar is the chief defect noticeable in children's diets. "Ill-nutrition associated with heredity and home conditions is due to deeper causes than any school feeding yet attempted is likely to materially relieve. "In addition, when the child comes into school several new factors come into play, the chief being the foul atmosphere of most schoolrooms—the importance of this can scarcely be over-estimated; the deprivation of free spontaneous muscular movements; the contagions of infant life which in large towns play a considerable part in depressing vitality; the unnecessary strain on immature structures of much of the work in infant schools. The exclusion of children under 5 would only relieve the last of these causes. 13 "What can be done? "General.—Experimental observation ia most wanted—standards of age, weight, height, &c., are an urgent necessity. "The amelioration of the unhygienic conditions of school life—the only remedy for this being efficient knowledge on the part of teachers. "The ultimate diffusion of knowledge of child-life through the teachers to the homes. "Immediate.—Feeding in two or three schools under observation, with control observations of children in similar but unfed schools would be advisable to gain knowledge. "At present, excepting the blind and deaf specially exempted in their Elementary Education (Defective and Epileptic Children) Act, 1899, any legal relief to children means pauperisation of the parents. The recent order to Guardians is cumbrous and likely to become a dead letter, and any experimental feeding will best be done in association with voluntary agencies. "I do not think there are sufficient grounds for asking parliamentary powers at present." A limited experiment in feeding in certain centres has been determined on, the Cookery Centres being utilised for this purpose. THE AGE OF ATTENDANCE OF SCHOOL CHILDREN. Considerable attention is now being paid to this subject, which first sprung from a paper read before the Childhood Society by Dr. Newsholme about three years ago. The control of schools coming under the Sanitary Authorities, the Medical Officers of Health have turned to the question of whether considerable reductions in the incidence of disease and in certain death rates could not be effected by excluding children from school till comparatively late ages. The subject is likely to come up for further consideration, as the Board of Education have altered their regulations and given Educational Authorities a free hand as regards school attendance between the ages of 3 and 5. In country districts, and more especially in the winter season, it may be very advisable that young children should not be sent to school; but the criticism of school attendance for children, under 7 is the age often discussed, has been chiefly directed against children in towns, and has been altogether destructive and not constructive. The age for school attendance in England is earlier than any other civilised country; the usual age for compulsory school attendance on the Continent is the end of the sixth year, earlier generally in the northern lands, a trifle later in the south. Kindergartens are, however, recognised for earlier ages, and creches are common in the larger towns. It is said that the infant school is chiefly responsible for the diffusion of such diseases as measles and whooping cough. The natural history of these diseases has not yet been sufficiently studied to deny the truth of this statement, but the greater part of the mortality of whooping cough occurs at ages before school life begins, and from our experience in the past three years 25 per oent. of the infants entering school at three years of age have already had measles. If the prevention of contagion can be accomplished in the case of these diseases, and for measles probably no practical means of doing this is possible in large towns, it has to be done by isolating the children as much as possible, and with the number of women who work nowadays this means, if not school, some kind of creches. The next reason put forward is that children at early ages cannot learn efficiently; but this is entirely wrong. It is only really directed at the want of intelligence in the curriculum hitherto prevailing under official sanction, but which now is being amended. Children learn more in the years from 3 to 5 than they will learn in the same period at any time subsequently; but if it is attempted to get work out of non-existent organs, there will be failure, and even immature tissues may and do suffer. But this is merely a reason for improving the kind of education and instructing the teachers. The last argument is entirely short-sighted, and points out that much room is taken up by these children in schools, and the accommodation which has cost much money would be set free by excluding infants, and could be used for other children—but if these children are to be excluded from school they must be accommodated elsewhere. There is no room in the homes, no one to watch them, the older girls will be kept from school to do this. In the earlier days of the late 14 School Board, creches were actually started to avoid this cause for non-attendance of the older children. The infants cannot be tolerated in the streets, kindergartens or creches must be provided. To accomplish what is required the crèche must at least come up to the standard of the Austrian laws regulating creches promulgated thirty-three years ago. These allow not more than twenty-five children in a crèche, and do not take them before their third birthday. All schooling is forbidden in the creche; they are washed, exercised in coarse movements, and taught to speak and sing. We would want at least this in London, twenty-five would be the maximum number allowable if localisation of measles outbreaks was looked for. Such a crèche for twenty-five children will be required in almost every street, it will want a manageress of some kind, and as she cannot be left alone with twenty-five infants she also must have an assistant. Whilst the isolation would do something to prevent measles and other infantile contagions, the real evil of the infant school, unhygienic surroundings, foul air, and constant sensory stimulation, would probably persist unchecked in the creches. The cost would be very considerable. A first cost of £100 per head might be suggested, and an annual cost for maintenance of building, teacher, and assistant would make it much dearer than any infant school. It is doubtful whether there would be any substantial gain in the prevalence of infectious disease, which if postponed till later ages would certainly be a gain hygienically, although a great disturbance educationally, in the upper schools. Educationally, over-pressure only results in Infant Departments as one of the evils which the country has to suffer from want of a medical department for education, and financially exclusion of children at present in the infant school would call for more costly treatment in small creches. The real question then is narrowed down to whether the ratepayers are prepared for the additional call on the purses involved in the treatment of children between 3 and 5 in small creches instead of in the present large schools. Should the question come into practical politics, it should be first tried in a limited district. THE WORK OF THE INFANT DEPARTMENT. In the Infant Departments children are admitted from the age of 3. The Board of Education have lately made it permissible for an authority to refuse children under the age of 5, at which age compulsory school attendance begins. Reasons have already been given (p. 13) for admitting children from the age of 3. The Infant Department takes the children from the time they are admitted until the end of the school year in which they attain the age of 6, when they are supposed to go into Standard I. In London Standard I. is generally located in the Infant Department, and in a few cases Standard II also. During the time it is in the Infant Department the child has chiefly to grow. Nutrition and sleep are its chief functions. Education, which is mainly a matter of training of nerve cells by making them act in certain ways, is more active in the Infant Department than at any later period, but it is not necessarily education of a literary character. Generally speaking, the child, on admission to the lowest Infant class, can walk but some cannot even do that properly ; some can run, but many fall in the attempt; few dare jump off a chair; many have dirty habits; and each Infant school should have a woman attendant to look after the children with regard to this matter alone. All these are matters which should receive attention during the first six months at school. The majority require teaching to march, walk and run, hence some simple drill is necessary; and as such movements are best done rhythmically and automatically, the rhythm of music should be used with all exercises in the Infant Department. Although in the syllabus of physical exercises issued by the Board of Education no scheme for Infant schools is laid down, and only games asked for, it is to be remembered that this is the minimum demanded from all schools, and that in large towns more than this is necessary. It would be practically impossible to do the physical work which ought to be done in a large Infant Department solely by games, though games should predominate in the lower classes to encourage spontaneous movements. 15 In schools where exercises and simple drills, using movements of massive character, are already practised, it would be a very great mistake to abolish such work. The only proviso about physical exercises in the Infant school is that they should not be done slowly, and no finished execution in movement be expected. With a caution in regard to these two points the present syllabus of work for the Infant schools should be maintained. I have seen the exercises in an Infants' Department carried out so slowly as to call for very carefully graduated movements, and thereby become so exceedingly fatiguing that the children were yawning. This is the danger to be avoided. Most children can speak, but as a rule imperfectly; this must be developed, as it is of great importance to the physical well-being of the child. The value of a good and correct vocabulary cannot be over-estimated. Simple things and simple happenings in his daily life will provide material enough, but care should be taken with articulation. Children see and hear much automatically or subconsciously. They see and hear, but the amount of reasoning from things seen and heard is much less than would at first sight appear probable. This becomes very evident in testing vision or hearing in very young children. They classify things in large groups, very often according to slight characteristics only. Much detail is wasted on children, and the difficulty of learning letters and words becomes a mental one from want of evolution in the higher centres. The teacher says the child has no memory for these things, whereas it is really the learning that is premature, and therefore often fatiguing and very objectionable to him. Learning to write with a pencil is also exceedingly tiring and exhausting, as is, in fact, any fine work in which the finger muscles are involved. Such fine finger work should be eliminated under six years of age. Pens, pencils, paper, pins and needles should not be handled in school by children below six. As regards omission of sewing, after years of discussion, this is still allowed by the recent Code of the Board of Education, but with permission to omit if wished. Children of three will spontaneously attempt drawings, and after spoken language the spontaneous drawings of the children should be one of the chief means of expression in the Infant Department. This faculty appears to furnish a considerable indication as to the child's mental possibilities. Such drawing should be taken frequently in the course of lessons, and is best done with chalks, with a child standing at a large blackboard, or at a large stretched canvas on the wall; in practice the last is best. It should not be attempted sitting in the desk with a six or eight inch piece of cardboard leaning up in front of it. The value of real freearm drawing (not this spurious desk work attempt at it) is quite settled, and it must be looked on as a subject which will take a large part in Infant school work in the future. It is suited to the stage of nervous development of the child in the Infant school, and at first the use of both hands may be even encouraged as helping the establishment of a muscular sense of space. This is quite different from ambidexterity, which, as an educational gospel, is to be deprecated. This idea of training both hands to do similar work can only be described as an educational crank. Almost every action performed involves the use of both hands, part is done by the right, part by the left. Tie up the left hand and most individuals will find themselves much incommoded. When learning the letters, as the first step towards writing, the letters shown should be of a large size ; they should be drawn in sand; they should be modelled in clay, laid with sticks or shells, or bent with wire to fix their structure indelibly in the muscular sense of the child, for it seems very probable that the child visually remembers them to some extent by the movements of its eye muscles caused by focussing the yellow spot in the optical axis of the eye on each part of the letter separately. It is important to fix these movements by the early use of large letters, to magnify, as it were, the movements made. Most children will learn to read almost unconsciously if letters are employed in naming the drawings they make on the blackboard, and each child should first be taught to print its own name on its work. As far as possible, all work in the Infant Department should be distant work; there should be nothing that requires the child to bend its head over, and it should learn the letters so perfectly that it could write any letter as large as its hand on the blackboard with its eyes shut. The majority of Standard I. children cannot do this with their eyes open. If this is aimed at, there will be little difficulty later about teaching writing in copy-books, and the cases of nervous strain from school work will enormously diminish. The young child has an undeveloped eye which is shorter in the length of its axis than it will 16 be later. To see any object clearly within a yard of the eye needs a very much greater muscular effort of accommodation than in an adult, and as these fine muscles are not mature and this effort cannot be kept up by the child it sacrifices clearness to get a larger image by bringing the eye close up to the work, thereby learning the worst of school habits. A habit that, with the present Infant school curriculum, even the best teacher is powerless to prevent. The child bends over its work, straining itself to do this, and contracting its chest. The evil the school originates in this way can in great measure be prevented by requiring all work in the Infant Department to be large and at a proper distance from the eyes. The greatest evil to the child in the Infant Department falls, not on the eye, but on the brain, which is overstrained in maintaining that accommodation and convergence of the eye which is possible, and in the fatiguing movements of the fingers required for the fine work demanded in school. PERSONAL CLEANLINESS. The majority of cases of injury to health among children may be traced originally to a want of cleanliness. For some years nurses had been provided by voluntary means to visit a few schools, and about three years ago the late Authority appointed a nurse to visit schools in the Southwark, Tower Hamlets, and Hackney Divisions. After a year's experience (8.1.03) they appointed three nurses, and immediately after the summer vacation of 1904 the Council raised the number to 12. This number is quite insufficient for the work wanted. The nurses provided by the voluntary associations attended a few schools frequently; they examined children with cuts, sores, abscesses and bruises, and applied dressings, or other treatment. The work done appealed at first glance as a work of kindness and charity, but it was neither educational nor really of serious use, yet for sentimental reasons it was much appreciated by teachers, managers, and others. The nurses working under the late School Board, and continued by the Council, give no treatment, but are accomplishing a highly important work of considerable educational value. They were appointed first to examine cases of ringworm, and were, in fact, termed ringworm nurses; then their duties were extended to all forms of obvious uncleanness and disease. They also follow up their school work in many cases by home visits, and there is a noticeable tendency, both among the teachers and school attendance superintendents, to utilise the nurses' visits as a means of securing better school attendance. The method of working which the nurses adopt is to pay single visits here and there to different schools in their district, but every third week begin a very thorough examination of one school, and pay several visits at short intervals till it is deemed sufficiently cleansed. The teachers should then endeavour to maintain the results of the nurse's work for weeks or months. Managers do not realise the amount of work a nurse has to do, and in many instances have sent in requests for more frequent visits from the nurse, or for greater attention to their particular school, which at present it is quite impossible to afford. The following table shows the results obtained from the cleansing scheme:— Departments. Number of Children Examined. Clean. Partially Cleansed. Verminous. White Cards. Red Cards. Proposed for Exclusion. Excluded for Prosecution. Boys 34,345 32,726 847 1,139 657 105 22 5 Girls 36,445 22,476 4,426 12,003 9,197 3,114 838 329 Infants 42,140 6,675 2,661 29,675 5,552 1,501 387 126 Mixed 5,855 4,886 298 897 562 161 49 32 Special 977 624 133 296 206 108 51 23 Total 119,762 67,387 8,365 44,010 16,174 4,989 1,347 515 The parents of 78 children have been prosecuted, and fines imposed varying from 1s. to 20s. 17 Ringworm.—This disease is comparatively common all over London. An estimate over a considerable area showed about one-ninth of the loss of attendance due to this disease, so that in this respect it is a very formidable item. For the individuals affected the absence from school may be prolonged over many months, and sometimes runs into years. In many cases the absolute neglect by the parents is such that it would be well to consider the question of a number of ringworm classes, and after a certain time of absence compel the attendance of ringworm cases there. Experience has made the judgment of the nurses very accurate. In 235 doubtful cases stumps were sent to this department for microscopical examination. The stumps are washed with ether, and then examined microscopically in potash solution, and unless the fungus is actually seen ringworm is not diagnosed. Over 60 per cent. of the cases thus submitted present small spored endothrix as the common variety. Very many medical certificates are submitted in cases where the head can scarcely have been looked at, and in others when certainly stumps had not been sought. During the past year 51 medical certificates were so submitted in reference to cases diagnosed as ringworm by the nurses; the fungus being found on microscopical examination in 47 cases, and in some of these cases given a clean bill of health by their doctors, the clinical appearances were quite typical. The anxiety of teachers to get children back to school is a matter of considerable difficulty in so chronic a disease as some cases of ringworm—the nurse attempting to obtain exclusion from school, whilst the teachers are striving to secure attendance again. Favus.—Favus, which may be regarded as a variety of nearly-allied disease to ringworm, occurs chiefly in the East End, and in a very few isolated cases in other parts. It does not seem highly contagious, but whilst recent cases appear, under treatment, to be apparently cured, almost every one relapses in a few weeks. It is quite easy to miss the fungus when only a few hairs are submitted for an opinion. In such a case the absence of the disease might be wrongly assumed, but where its presence is noted after microscopical examination the diagnosis is positive and conclusive. In a small district embracing about one square mile (St. George's-in-the-East, Stepney, and Whitechapel) we know of at least 79 cases of favus. Outside this area we have also found 34 other cases. This disease tends to spread in the family, and in the class of persons mostly affected, its cure in a well marked case is a matter of very great difficulty. By keeping it under observation and treatment the infectious qualities can be much lessened, and in order that education may not suffer from prolonged school exclusion it has been decided to open an elementary school for favus cases only. This will accommodate 80 children in two classrooms, and a separate nurse's room will also be provided. The question of blight and external ocular diseases comes under the work of the Oculists. Unclean Heads.—The majority of these cases are due to vermin. Their number is continually diminishing. Formerly many children were out of school for weeks or months untreated, and in my first Report to the late School Board it was suggested that exclusion and prosecution would be a good policy to adopt. An unclean head due to vermin can be cleansed in a week, or less. The cause of the trouble is obvious, and these cases have therefore, for the past year and a half, been used as an object lesson in cleanliness. The nurse adopts this Cleansing Scheme in a school: she examines every child, noting all that have verminous heads. The parents are notified by a white card, on which is also printed directions for cleansing. Yiddish cards are used in the East End. At the end of a week, if not cleansed, the child is made to sit separately from the rest of the class, and the School Attendance Officer serves a more urgent warning, red card, at the home. The nurse, too, often visits to offer advice, and then if in another week the child is still unclean, it is excluded after having been seen by the Medical Officer, and the parent is prosecuted for not sending the child in a fit state to school. Only an outline of the principles followed is given—the method is very cumbersome and slow, but the results most excellent, and powers for a more rapid method of dealing with objectionable cases are required. The powers to be sought should be on the lines of the Glasgow Police Act, so that if a child 18 is found by a duly-appointed officer of the Council (Medical Officer or Nurse) to be in school in an objectionable state, notice may be served on the parents to cleanse the child within 24 hours, or it may be cleansed at the public expense and the cost recovered from them. So far as concerns the Educational Authority, their officers alone should deal with the matter up to the serving of the notice, and their part should cease with the serving of the notice. The following up of this should lie with the local Sanitary Authority, but power should be reserved by the Council to take action on default by the Sanitary Authority. The examination of the heads has led to the discovery that the clothes and bodies of many children are infested. And here a considerable difficulty arises, for whilst it is a comparatively easy matter to cut a child's hair and get rid of the trouble (and one headmaster has adopted the very sensible policy of providing a clipping machine and making his boys keep each other's hair well clipped), in the case of clothing there is no ready means of cleansing. There is often no accommodation in the houses, and one cannot say this child must be cleansed or turned out of school, as it is not reasonable, with the means at the disposal of most of these people, to expect them to be able to disinfect clothing. The pressing need of one sanitary administration in London in place of the numerous borough authorities is nowhere better exemplified than in this question of personal cleansing. The Cleansing of Persons Act, passed in 1897, was permissive, and excepting Marylebone, St. Pancras, Hackney, and Finsbury, is practically ignored. For the present the experiment will be tried of working in conjunction with the borough of Marylebone to effect cleansing of verminous children. In cases under the General Powers Act of 1904 information has been furnished to sanitary authorities regarding houses suspected to be vermin infested, and some authorities have done a great deal in effecting cleansing; others have apparently done little. Baths.—Complaints have been received, chiefly from teachers, of children with both clothes and bodies verminous using public baths, and in some instances children from clean houses are alleged to have become infected by this means. There are two purposes for which baths are useful to school children, one is for cleansing purposes, the other for educational and recreative purposes. For cleansing, the proper use of the bath has not been attempted as yet, but it is very essential in a large city. The problem can be reduced to very simple factors: How little space is required and how little heat and how little water is necessary to effectively cleanse a child twice weekly. There is no reason why such baths should not be used all the year round. School baths are the best provision to be recommended, quite apart from the question of the more costly swimming baths. For cleansing purposes a very shallow tank six inches deep, with a rose for a shower over each child is used, worked by a chain which the child pulls when under the rose. In some German schools the shallow tank is provided, others have a somewhat raised flat part with a gutter of white tiles round about a foot broad and six inches deep. In a recently provided school the bath room was square, with a sloping concrete edge run round, and on this twenty ordinary galvanized iron slipper baths arranged, into which each child got before working the shower. All these devices are intended to economise room, to save expense in heating and in cost of water. With the campaign now being carried on in favour of personal cleanliness in schools, the provision of school washing baths, as distinct from swimming arrangements, is becoming increasingly necessary in many parts of London. Diving is so notorious as a cause of danger that even healthy children ought not to be allowed to dive from any height without protection for the ears. Mr. Cheatle called attention during the year to the considerable numbers who appear at hospitals at the beginning of every bathing season, where diseased ears have had violent and dangerous inflammation set up from bathing or swimming. For these reasons it, is advisable that all children with aural disease or discharge should be refused admission to the swimming baths. INFECTION IN SCHOOLS. Before 1891 there was no attempt on the part of the late School Board to organise a systematic means for prevention of the diffusion of diseases by the schools. The Public Health (London) Act, 1891, made it compulsory for the Medical Officer of Health to send a copy 19 of notification relative to smallpox, diphtheria, erysipelas, cholera, membraneous croup, scarlatina, scarlet fever, typhus, typhoid, enteric and relapsing fever to the teacher of any school attended by children from infected houses. The head teacher should receive a copy of the notification certificate within 12 hours of its receipt by the Medical Officer of Health. These arrangements have during the past year also been supplemented by a voluntary arrangement extended to the various districts bordering on London, and which send pupils into our schools. On receipt of the notification from the Medical Officer of Health the following action is taken:— (а) The head master sends the notice to the head teachers of the other departments. (b) All affected children (whether suffering or coming from the home in which the disease exists) are excluded from school. (c) Head teachers of all departments forward on the same day the names and addresses of all children affected by the notice, to the Divisional Superintendent and the Medical Officer (Education) on a form specially provided for the purpose. (d) The notification is then filed at the school until the end of the school year. In addition to the notifiable diseases there are the following non-notifiable diseases, which are dangerous to school children:—Measles, mumps, whooping-cough, and chicken-pox. If a child shows symptoms of any of these diseases, or comes from a home where such a disease is known to exist— (а) The child is excluded. (b) The head teachers of the other departments are informed. (c) The head teachers of all departments forward on the same day the names and addresses of all affected children to the Divisional Superintendent, Medical Officer o Health and Medical Officer (Education) on a form provided for the purpose. The average number of these forms received weekly is 1,200, relating to 3,500 children excluded. A record book is kept in this department, and each school department is credited with all cases occurring therein. Notifications.—Charts are appended showing the weekly numbers of cases of diphtheria and scarlatina notified. For Diagrams V., VI, VII., and VIII., see pp. 20—23. The returns are also shown as a percentage above and below the mean. School Closure.—There has been no general outbreak to record. The number of schools under observation has been variable, as during the autumn the medical oversight of infectious diseases was extended to non-provided ("voluntary") schools. The following Table shows the closures during the year:— Department. DISEASE. DIPHTHERIA. SCARLET FEVER. MEASLES. MUMPS. WHOOPING COUGH. No. of classrooms closed. No. of departm'ts closed. No. of classrooms closed. No. of departm'ts closed. No. of classrooms closed. No. of departm'ts closed. No. of classrooms closed. No. of departm'ts closed. No. of classrooms closed. No. of departm'ts closed. Boys' P. ... ... ... ... ... ... ... ... ... ... N.-P. ... ... ... ... ... ... ... ... ... ... Girls' P. ... ... ... ... ... ... ... ... ... ... N.-P. ... 1 ... ... ... ... ... ... ... ... Sen. Mxd. p. ... ... ... ... ... ... ... ... ... ... N.-P. ... ... ... ... ... ... ... ... ... ... Jun. Mxd. p. ... ... ... ... ... 1 ... ... ... ... N.-P. ... ... ... 1 ... ... ... ... ... ... Infanta' p. ... 1 4 ... 71 13 ... ... 1 ... N.-P. ... 1 ... 1 1 10 ... ... 2 1 20 Diagram V. 21 Diagram VI. 22 23 24 In the case of measles, which is the disease for which most frequent class closure is required, the cases in infant schools were distributed through the year as follows:— 19 0 4. 1 805. From 26th Mar. to 30th April. May. June. July. Aug. Sept. Oct. Nov. Dec. Jan. Feb. March. Class-rooms Prov. 8 16 14 4 ... 4 5 6 ... ... 7 7 N.-P. ... ... ... ... ... ... ... 1 ... ... ... ... Departments Prov. 2 4 ... ... ... 1 2 ... 2 ... 1 1 N.-P. ... ... ... ... ... 1 3 ... ... 1 2 3 Schools affected Prov. 8 18 11 3 ... 5 7 5 2 ... 7 8 N.-P. ... ... ... ... ... 1 3 1 ... 1 2 3 School or class closure, in each case, is decided on individually and on its merits. We can now get the returns from the school so quickly that it is safe to judge as to school infection from these returns. As a rule, when measles appears in a single class of an infants' school closure is applied, but where several classes are affected from the first, and especially where several schools in a district are affected, it is held that the district is generally affected, and experience has shown that school or class closure is of no benefit. Excepting the Borough of Lewisham the method of closing a school on account of the prevalence of measles, and because the attendance has dropped 10 or 20 per cent., has now been abandoned throughout the Metropolis. It is to be noted that one of the consequences of the abolition of the Article marked 101* in the late Code of the Board of Education is that, not only is the grant for absentees lost, but in cases of severe epidemics authorities are actually fined for keeping schools open, and it would be almost worth while defining what percentage attendance is required to prevent loss of grant arising from counting the school as open and marking the registers. The reinstatement of this Article 101* has been urged on the Board of Education by many educational and sanitary authorities in the country, but their entreaties are made to those whose training has not been such that they can appreciate the enormous importance of keeping infectious and convalescent children out of school without penalising teachers and school authorities. The value of the regulation was so great that efforts should be continued to have it re-enacted. Average absence in six schools from various diseases of a contagious nature (1905):— Disease. SUFFERING. IN HOUSE. Boys. Girls. Infants. Boys. Girls. Infants. No. of Children affected. Av. No. of Att. lost. No. of Children affected. Av. No. of Att. lost. No. of Children affected. Av. No. of Att. lost. No. of Children affected. Av. No. of Att. lost. No. of Children affected. Av. No. of Att. lost. No. of Children affected. Av. No. of Att. lost. Diphtheria 3 75.0 6 59.2 16 55.3 20 19.1 13 21.7 12 32.5 Scarlet fever 9 69.7 23 77.9 90 75.6 83 21.8 72 23.3 53 28.8 Measles 10 40.6 38 30.1 350 38.1 289 21.9 277 25.3 158 28.3 Mumps 3 157 5 43.8 17 29.4 8 18.6 2 19.5 9 16.9 Whooping-cough ... ... 7 55.1 90 76.1 27 22.7 20 32.6 29 20.1 Chicken-pox 7 40.4 21 25.9 85 41.8 49 22.2 41 20.1 44 27.4 Ringworm 33 36.4 30 50.7 66 58.6 No exclusions for disease in house. Blight 3 24.3 20 20.3 70 33.6 25 Diphtheria returns are kept under continuous observation, and on any suspicion of school influence showing itself my Assistant visits the school, and all children giving any sign of ill-health, such as aural or nasal discharge, enlarged glands, undue pallor, or a history of recent absence, have a small portion of mucus removed from throat or nose by a sterilized platinum wire, and placed on the surface of a tube with sterile blood serum. This is then cultivated in an incubator at 98° F. for 15 to 18 hours. The cultures are then examined microscopically, and any showing suspicious forms are then stained with Neisser's stain. Except in very rare cases this is deemed sufficient. Only cases showing Klebs-Loeffler bacilli are counted as diphtheria, the pseudobacilli we neglect. Where a doubt arises, the Medical Officer of Health is communicated with informally and the child excluded till free; no actual notification of diphtheria, however, is made. During the first year 758 cultures were examined, Klebs-Loeffler bacilli being detected in 58 (7.3 per cent.), and pseudo-bacilli in 27.3 per cent. cases of children actually in school. During the past year, 890 cultures have been examined, and Klebs-Loeffler bacilli found in 60 cases, and the pseudo-bacilli in the same proportion as before. So that since the laboratory was started there have actually been 118 children thus detected in school, "carriers" of diphtheria. This work can only be done in urgent cases where school infection is feared. When a telegram has been sent to the school to have these children excluded, our work is finished, but it would be to the benefit of the public health that these cases should be followed up by the Sanitary Authorities. In some parts of London this is done very badly, or not at all. There are London Boroughs where the Sanitary Authority makes no arrangement for bacteriological testing of such cases by the Medical Officer of Health. The very unequal way in which sanitary work, in this respect, is being done in London points to the need of one Sanitary Authority for the whole metropolitan area. As shewing the amount of work which it is possible to do, 634 schools sent in notifications. In 22 cases the schools were examined by swabbing 890 children of affected classes, and 60 of these were diphtheria "carriers." Date. School. Number of Cultures. Diphtheria. PseudoDiphtheria. 1904—April Wilton-road (I.) 29 1 9 May Eardley-road (I.) 40 2 11 „ „ „ 53 3 21 „ Atley-road (G.) 44 5 7 „ Eleanor road (I.) 30 3 13 June Hawley-crescent (I.) 34 — 6 „ St. Leonard's-road (G.) 10 1 2 „ Wilton-road (G.) 23 — 1 July Chisenhale-road (I.) 37 5 10 Sept. Bromley Hall-road (I.) 61 2 20 Oct. Immanuel, Streatham (G.) 43 8 18 „ „ „ „ 34 3 9 „ St. George's, Hanover-square (I.) 42 3 15 „ „ „ „ 14 — 3 „ Woolmore-street (G.) 58 — 16 Nov. Chisenhale-road (I.) 32 4 8 „ Queen's-road (I.) 10 1 5 „ Chisenhale-road (I.) 40 4 12 Dec. Merton-road (I.) 23 2 3 1905—Jan. Plumstead Central (I. & G.) 42 1 7 „ „ „ (I.) 28 2 6 „ Plum-lane (I.) 8 — 5 Feb. York-road (I.) 16 1 1 „ Eglinton-road (I.) 30 2 9 March Gainsboro'-road (I.) 9 — 4 „ Church Manor Way (I.) 35 5 12 „ Mitcham-lane (I.) 44 1 11 „ Eglinton-road (G.) 21 1 5 Totals 890 60 249 The results of the work carried on thus have been, on the whole, eminently satisfactory. The necessity for school closure for diphtheria has become very rare in London. It would only be 26 resorted to now as a confession of failure, either from want of time or want of staff, as the measures detailed are efficacious in immediately arresting the spread of the disease in 95 per centof the outbreaks. Through the immense amount of work of other kinds thrown upon the staff, the ideal state of things in which a department should be visited as soon as any suspicion of school influence has arisen has not been attained. It will be some time yet before the effect of the work shows on the incidence of diphtheria. The average notifications weekly for the past three years are, however, encouraging, in the relative rate decrease in cases in Provided Schools. Average Weekly Notifications of Diphtheria, At all Ages. All Children at School Age. Children in the Provided Schools.  1902—3 193 134 51 1903-4 135 94 37 1904-5 137 94 31 Details of Outbreaks.—Dr. Thomas gives the following notes on these outbreaks:— Atley-road School.—During April and May, 1904, there had been 20 cases of diphtheria or exclusions in the Girls' Department. Amongst 44 children swabbed 4 were found to have diphtheria, one had a sore throat at the time of examination; the other 3 were sisters who had been away from school as shown by the class registers ; the reason given by the Mistress was that they had no boots, on examination they betrayed clear signs of recent illness, and all three gave diphtheria bacilli on culture. With the exclusion of these children no further cases occurred. Eleanor-road School—In May, 1904, 20 cases of diphtheria or exclusions occurred, they had been connected with the class aged 6-7 and the baby room. These two classes were swabbed, and 3 cases of diphtheria were discovered amongst the former and none amongst the babies. On exclusion of these 3 children the outbreak ceased. Eardley-road School.—On May 2nd, 1904, an examination was made of the children of Class D (aged 6) on account of several cases of diphtheria, most of which had occurred in connection with this class. Out of 40 children swabbed 3 were found to be carrying diphtheria bacilli. After the visit of May 2nd, no further cases occurred in connection with Class D, but some more cases occurred in Class B (aged 5). The Medical Officer of Health (Dr. Caldwell Smith) thereupon asked that the department should be closed, and this was done, not, however, before Class B was swabbed, amounting to 45 children, on May 12th; amongst these two cases of "carriers" were found. In one case (H. S.) the child had been sent home on suspicion by the teacher, but she returned; a swab was taken by me, and she was found to swarm with Klebs-Loeffler bacilli. The mother then took her to a medical man, who, upon ocular inspection, said that there was nothing the matter, and the next that was heard of the case wa3 that the mother had tried to get the child admitted to the Infants' Department of a neighbouring voluntary school. The second of these cases was a boy with old-standing ear discharge, in which Klebs-Loeffler bacilli were found. A case of ear discharge should always be looked upon with great suspicion in a class where cases of diphtheria have been failing. At this school many children came from an extra-metropolitan area, and notifications of the occurrence of diphtheria were not received from the Sanitary Authority. Since that time steps have been taken to ensure the notification of disease to the schools from all districts in which children come to school from outside the London area. Chisenhale Road School (Infants).—In June, 4 cases of diphtheria had occurred, and 6 cases of exclusion on account of infection at home. They were connected with the classes aged 5 and 6. Fifteen children were selected for swabbing on account of clinical symptoms, and 34 for other reasons; five children showed diphtheria bacilli on culture, and these were entirely amongst those presenting clinical symptoms, such as rhinorrhœa, cervical adenitis, and anæmia. Bromley Hall Road School.—Sixty-one children were swabbed on September 1st in the Infants' Department. Amongst these two were found harbouring diphtheria bacilli: the two children were brother and sister. Upon their exclusion a threatening outbreak subsided. 27 Immanuel School.—On October 6th, attention was drawn to the Immanuel School, Streatham. A number of cases of diphtheria had occurred here before notice was received, many of the children came from outside the Metropolitan area, and the occurrence of diphtheria in their homes was not notified to the school (compare Eardley Road School); in fact the head mistress had been for 15 years ignorant of the name or address of the Medical Officer of Health of the district from which a large proportion of her children came. On October 6th, out of 43 children from whom cultures were taken, 8 showed the presence of diphtheria bacilli. These children had mostly suffered from "sick headache" or sore throat during the previous fortnight; they were all in Standard II. (aged 8). As the outbreak was notified late, and the number of "carriers" excessive, it was determined to close the school, but before doing so, a visit was made on October 11th, and further 34 children examined bacteriologically. Three further cases were discovered, all of whom had symptoms of illness (headache or nasal discharge). St. George's School.—On October 14th another outbreak in a Non-provided School came under notice; at St. George's, Hanover Square, again owing to the fact that the arrangements for taking over the Voluntary schools were incomplete, knowledge of the conditions was delayed. Seven cases of diphtheria had occurred in one class (aged 6) in quick succession, from September 29th to October 10th. The whole of the class was examined, 42 cultures being taken; amongst these 3 "carriers" were found and excluded. One or two cases occurred within the incubation period after the visit, but no further cases, and the outbreak was arrested. A second visit was made on October 19th, but no case found amongst the cultures taken. Mtrton-road School.—In one class in the Infants' Department (age of children 5—6), 4 cases of diphtheria were notified between November 4th and 22nd. A visit was made, and all the children presenting suspicious appearances were swabbed; amongst these 2 children were found harbouring Klebs-Loeffier bacilli, and when they were excluded no further cases occurred. Plumslead Central School.—During the Christmas holiday a communication was received from Dr. Davies, Medical Officer of Health for Woolwich, pointing out that many cases in that borough had been connected with these schools before and during the vacation, and asking that an investigation should be made. Accordingly, on January 11th, a visit was paid on the re-opening, and all the children examined; the majority of the cases had occurred in the upper classes of the Infants' Department. Forty-two cultures were taken, and one or two "carriers" were detected and excluded. Further cases, nevertheless, occurred, and a second visit was paid on January 23rd; one baby (F. R.) was ailing in school and was found to be suffering from diphtheria. The cause of the continued occurrence of cases was, however, found in a little girl, D. G. (age 7), who had recently returned from hospital for scarlet fever. Amongst half-a-dozen children who had been to hospital for this complaint it was noticed that D. G. had a slight nasal discharge. All these scarlatinal returns were swabbed, but D. G. alone showed one or two Klebs-Lœffler bacilli in the nasal discharge; she was excluded and the outbreak at school ceased entirely. To prove that she was the source of the trouble, some days after her exclusion a brother took the complaint from her and was removed to hospital. Uglinton-road School.—During January, Dr. Davies pointed out that a number of cases had occurred in connection with the Infants' Department at this school. On February 3rd the whole of the children were examined, and 30 cultures taken; 2 "carriers" were found amongst these, and excluded, whereupon the outbreak ceased as regards this department, though later on in March and April further cases occurred in a class in the Girls' Department. Church Manor Way School.—On March 6th a visit was made, and 35 infants swabbed after the examination of the whole department. Four "carriers" were excluded, 3 of whom presented symptoms, and the remaining one came from a diphtheria house. Mitcham-lane School.—On March 15th, in consequence of a communication from Dr. Caldwell Smith, the Infants' Department of Mitcham-lane was inspected, and 44 cultures taken. Amongst them a boy (P. H.), aged 6, was found to be a "carrier," and excluded; 2 other children with suspicious growths were also excluded. Eighteen children had been excluded from this department during the 12 weeks previous to the visit made, no further exclusion took place during the 8 weeks subsequent (up to date). 28 The children found spreading diphtheria in schools may be divided into four classes which occur in the following proportions:— 1. Actual mild cases in attendance 80 p.c 2. Cases coming from infected homes, but presenting no symptoms 12 „ 3. Cases of recrudescence after absence for notified diphtheria (return cases) 6 „ 4. "Carriers" without symptoms or demonstrable contact 2 „ The actual mild cases in attendance are by far the most serious cause of spread, amounting to 80 per cent. This makes the detection and control of diphtheria easier than it otherwise would be, as it is a simple matter, on rapid inspection, to single out those presenting clinical symptoms. Another point of extreme importance is that in London an overwhelming majority of these cases occur within certain age limits. It is rare to find a class whose average age is under 5 or over 8 spreading diphtheria. In not one single instance has a babies' class been found with diphtheria spreading in it, nor has a class over 10 been found to do so. Average Age of Class. Percentage of Total Outbreaks. 3—4 — 4—5 2.7 5—6 13.5 6—7 43.2 7—8 19. 8—9 5.7 9—10 8.1 10—11 8.1 Over 11 — This very remarkable fact which our investigations have brought out requires explanation. In order to give a tentative explanation, other facts connected with diphtheria, as it is at present occurring in London, must be taken note of. Briefly recapitulated they are these:— 1. When a school becomes a source of infection, it is generally found that the cases are connected with a class or classes in which the average age of the children is between 5 and 8. Rarely do classes below 5 or above 8 become sources of infection, and never has it happened in our investigations that a class whose average age is less than 4 or above 10 has been found to be acting as a disseminating centre. 2. These classes become sources of infection because the children at these ages appear to have the power of partial resistance to the onslaught of diphtheria bacilli, and a large proportion of them are capable of attending school while suffering from slight attacks. Many instances have occurred in which the majority of the members of a class during this age period (5—8) have suffered from slight attacks of diphtheria, to which attention is only drawn by the fact that younger children in the family suffer from severe diphtheria and one or two members of the class are more severely affected and are notified as diphtheria; thus, at Single-street School, in December, 1903, it was found that a mild epidemic of sore throat had been slowly working its way through Standard I. (aged 7) for six weeks, although there had been only 3 cases of notified diphtheria. It was found that 29 out of 54 children had suffered from the illness of which the characteristic symptoms were vomiting and sore throat, but in no case except those notified had the complaint been severe enough to keep the child from school more than one day. It was very easy to tell on inspection of the class which children had suffered, their pallor and listlessness contrasting with the ruddiness and liveliness of those who were well. On bacteriological examination 2 children showed diphtheria bacilli still, and on their exclusion the outbreak ceased. 3. Frequently it occurs that a new child admitted to such a class from another neighbourhood, or a child who has been out of school for a long period on account of illness or residence in another part of the country, suffers from diphtheria severely, while the others are having slight sore throats and nasal discharge. Thus at Church Manor Way School, in January, 1905, in one week two little girls suffered from diphtheria; one had been out of school for the whole of the autumn and winter, and she within three days of her return fell ill with diphtheria and died. The other case was her particular 29 playmate, who suffered from a slight attack. On investigation it was found that several children in the clas3 had had slight illnesses—sore throats, nasal discharges, glandular enlargements, and even "croup"; on swabbing the class, 5 of the children were found to have at the time diphtheria bacilli in their throats or nasal discharges. As the Medical Officer of Health pointed out, it was extraordinary that with so large a number of "carriers," only 2 cases of diphtheria had been notified. 4. The diphtheria notifications in London, per 1,000 living at each age, are as follows:— Age Period. Per 1,000. Under 1 year 1.96 1—2 6.07 2—3 7.39 3—4 9.61 4—5 9.67 5—6 9.18 6—7 7.85 7—8 6.00 8— 9 4.66 9—10 3.93 10—15 2.90 Putting the 1903 notifications taken from Sir Shirley Murphy's report in diagrammatic form we obtain the following curve:— From this it is seen that the ages of chief diphtheria incidence are from 3 to 5, reaching the maximum at 4; from 5 to 8 there is a very rapid fall in the incidence of diphtheria, which thereafter becomes relatively level. A possible explanation which seems to fit the above facts is the following. At the present time diphtheria bacilli are so widely spread in the community that a proportion of older people have acquired an active immunity, either through slight attacks or through subminimal dosage. At birth many infants have a transient passive immunity obtained from the maternal blood; this gradually wears off, and so an increasingly heavy incidence of diphtheria occurs up to the age of 4; from this stage onwards an active acquired immunity makes itself apparent, and between 5 to 8 there is a rapid diminution of the incidence rate, while after eight years protection becomes sufficiently general to prevent diphtheria spreading to any great degree. It is to be noticed that the years of the rapid lessening of incidence—the downward slope of the curve—are precisely those during which classes at school become foci of infection, due to the fact that if diphtheria is introduced a large number of the children are capable of suffering from slight attacks which do not prevent their attendance at school, and a large proportion become "carriers." In the rare event of a "carrier" appearing in a babies' class, the proportion of children capable of suffering from slight attacks is so small that any who suffer go down with severe attacks, and the class itself does not become a dangerous focus. While over the age of 8 or 10 slight attacks of diphtheria are uncommon, and classes at this age do not present spreading outbreaks. Whether any particular theory attempting to explain the age incidence of diphtheria be accepted or not, it is not to be disputed that the modes of prevention of diphtheria need revision. At the time when the present methods generally used for dealing with diphtheria were organised, not only was little known of the natural history of the disease, but the disease itself differed in 30 character. The provision of isolation hospitals depended upon the belief that all cases of diphtheria partook of the nature of a dangerous illness, and if only the cases were isolated the spread would be controlled. It is now quite certain that the chief agents of spread are individuals suffering so slightly that they may go about their daily avocations, and while in themselves suffering only from slight malaise, may be sources of danger to more susceptible persons; also, though more rarely than the foregoing, those who have been in contact with cases of diphtheria without themselves appearing to suffer in the slightest degree may yet afford, in their buccal cavities, a suitable hiding for the growth of the micro-organism, and these individuals become the "carriers" of infection to others. In view of the number of such cases probably preponderating over the actual cases of severe diphtheria, isolation hospitals must be looked upon as much less important in the prevention of the disease than has hitherto been assumed, they receive mainly the severe cases, which, by the nature of things, must be limited in their power of spreading diphtheria, inasmuch as they are so ill as to be confined to the sick-room, while the slight cases, which are much more dangerous to the community, remain undetected and roam at large. Moreover, it often happens that a child who returns from a fever hospital remains still infectious, and sets up return cases. As Newsholme has pointed out, there are such things as chronic diphtheria and chronic scarlet fever. Much more important than isolation hospitals, therefore, are facilities for bacteriological examination. There is no doubt that these are quite insufficient in the metropolis, and it is a question worthy of the attention of the Council whether a central, well-equipped laboratory, freely available for all suspected cases, is not needed to cope with this widespread danger. Unfortunately, too, these facts in the natural history of the disease are as yet unknown to practitioners, who are generally unaware that diphtheria may be a mild complaint which cannot be clinically recognised, or that healthy contacts may be "carriers" of the complaint. The very slightest catarrh occurring in a member of a household where a case of diphtheria has occurred should be at once isolated, and treated very circumspectly until bacteriological examination has been made; and if we are to hope to have the disease stamped out, no member of a diphtheria household should be allowed to go about his daily employment without first having been tested bacteriologically, and no sufferer should be allowed to mix again in the general community until a succession of testings ha3 given a uniformly negative result. MEASLES. Measles is the most fatal disease of childhood, and the one which plays the greatest havoc with school attendance. Two months after my appointment, the late School Board approved of a scheme for a thorough inquiry in a limited area, to extend over about five years. The area selected was Woolwich, and the Medical Officer of Health has co-operated, so that the measles history of each child is kept on a card from the day of its entering the infant school. In one half of this district it has been attempted to suppress every appearance of measles by rigorous class closure; in the other half individual exclusion is followed, and the schools are not closed if this can be avoided. The inquiry began in the autumn of 1902. It was soon found that 50 per cent. of children had already had measles before coming to the Infants' Department, and 84 per cent. had it before passing out of the infant school. These figures will, of course, vary considerably according to whether the disease has been recently prevalent or not. The cards show at any time the susceptible material present in each class. During the following year each outbreak was followed as well as possible, and the conclusion arrived at that the only successful cases of closure depended on closure on the appearance of the first case in a susceptible class, and experience showed that closure for measles, which hitherto had only been resorted to as a panic measure when the disease becomes prevalent is, under such circumstances, of no avail. The necessity for the prompt notification of every case of measles became apparent, and the fact that where the head mistresses had special knowledge they prevented the spread of the disease in their schools, which suffered much less than the other schools. Now, during the past year increasing duties have made it more difficult for Dr. Thomas to follow up this work, but he has had the aid of a sanitary inspector, and each school has had the 31 measles cards duly filled in. The individual outbreaks have been analysed, and as Dr. Thomas has spent much time on the study of these outbreaks and the effects of school closure, his detailed report is so much worth careful study that it is printed in extenso as an appendix. The generation we began with has not yet been followed through the infant school, but already much valuable information has been gathered. The inclusion of all the Non-provided schools will help to remove an unknown factor in the districts under examination from the results yet to be obtained. The teachers have now become educated to the value of the inquiry, and during the past year the card records are believed to have been fairly reliable. In the first outbreak detailed in 1904, that at Purrett-road, it is shown that 77 per cent, of the 57 per cent, unprotected were affected. It also shows the necessity of closure on the occurrence of the first case; closure at the appearance of the first "crop" being ineffective. Closure during the holidays at Easter did not prevent the dissemination of the disease out of school at Eglinton-road; at the same time closure as usually applied would have appeared to have stopped the disease here, when in reality it would not possibly at the best have prevented 7 out of the 57 cases. Without any closure one or two cases appeared in every class at Burrage-grove. without further extension, and at Maryon Park, where the cases were carefully gone into, 36 out of 115 could be definitely decided as infected out of school, one little maid of 5 being responsible for eleven out of school cases. Union-street, Mulgrave-place, and Conway-road give good examples of how an intelligent head mistress, with hygienic instincts and training, protected even babies' classes. One very unsatisfactory case, from our point of view, was a child of five from a Guardian's Home, where, through mismanagement or ignorance, cases of measles appeared to have been treated whilst others attended the schools. This child, in spite of prompt and energetic measures, may be said to have caused at least 207 known cases in four schools, necessitating 14 separate closures of rooms, or exclusions of non-protected children. The almost explosive outbreaks at Deansfield-road and Timbercroft-road illustrate the evils of ill-ventilated and insanitary temporary buildings, and the necessity for increased floor allowance in these as compared with permanent buildings. The balance of evidence preponderating in favour of closing is yet doubtful, even when the closure is applied at the earliest opportunity; later it is quite futile. Early closure involves closure on false alarms; then, again, the more successful it is the oftener it has to be repeated, and this interferes materially with educational progress. Dr. Thomas states from the Woolwich experience that in towns measles will spread in classes where one-third are unprotected, and will recur until the unprotected are reduced to one-fifth. School closure for measles can never take the place of teachers especially trained in school hygiene, imbued with the ideals that constitute a "sanitary conscience," and working in good hygienic surroundings. Probably exclusion of non-protected individuals will be the ultimate solution of the attendance problem in face of a measles outbreak, and it is very doubtful whether exclusion of children, themselves unaffected but coming from affected households, is required in any except the Infant Departments. VISION. The condition of the special senses is of much importance for education. In 1900 a Committee of the late School Board ordered a general testing of the visual acuity for distance and reading. This was carried out by the teachers, and children found defective were afterwards taken in great numbers, and almost simultaneously, to hospitals, disorganising their work. Oculists' Reports.—Early in 1902 eight ophthalmic surgeons were appointed under the term Oculists. They tested the children as regards visual acuity, and filled in a card for each child, giving its name, age, sex, standard, school and visual acuity, right and left eyes alone, and also both together. Near vision testing was omitted as practically valueless in this work. 32 Vision of 20,000 Children, giving Details of Amount of Defect (p. 14, First Report L.S.B.). vision. Good. Fair. Bad. Acuity. 6/6 6/9 6/12 6/18 6/24 6/36 6/60, or worse. 6 B. 9 15 2 1 ... ... ... G. 23 12 4 1 ... ... ... 7 B. 172 84 23 10 4 1 ... G. 155 90 26 15 4 4 3 8 B. 633 210 55 38 11 8 4 G. 566 199 55 56 21 4 6 9 B. 1,046 220 65 50 16 12 6 G. 887 224 93 59 21 13 12 10 B. 1,328 219 81 63 21 12 4 G. 1,268 245 93 77 26 16 21 11 B. 1,433 169 75 58 21 10 9 G. 1,356 232 124 81 23 11 23 12 B. 1,546 173 79 68 32 15 18 G. 1,439 219 96 93 40 19 20 13 B. 1,482 180 89 60 21 17 21 G. 1,243 203 101 92 39 15 27 14 B. 389 35 12 18 6 6 4 and over. G. 364 51 25 18 9 3 10 Total B. 8,038 1,305 481 366 132 81 66 G. 7,301 1,475 617 492 183 85 122 From a larger number of returns the following analysis was made. First Report to L.S.B. (p.15):- Acuity of Vision. Examination of Boys. AGES LAST BIRTHDAY (AS NOTED ON CARD). STANDARD. VISION. SIX. SEVEN. EIGHT. NINE. TEN. eleven. TWELVE. THIRTEEN 4 OVER. TOTAL. g. F. B. G. F. B. G F. B. g. F. B. G. F. B. g. F. B. g. F. B. g. F. B. G. f. B. I. Good 26 ••• ••• 188 •••... ••• 285 ••• ••• 129 •••. •••. 50 ••• ••• 17 ... ••• 6 ••• ••• 3 ••• ••• 704 ••• ••• Fair ••• 39 ••• ••• 148 ••• ••• 171 ••• ••• 57 ••• •••... 28 ••• • •• 7 ••• ••• 2 ••• ••• 3 ••• ••• 455 ••• Bad ••• ••• ••• ••• ••• 40 ••• ••• 50 ••• ••• 24 ••• ••• 14 ••• ••• 3 ••• ••• 7 ••• ••• ••• ... ••• 141 II. Good ••• ••• ••• 137 ••• ••• 506 ... ••• 468 ••• ••• 205 ••• ••• 84 ••• ••• 32 ••• ••• 21 ••• ••• 1453 ••• ••• Fair ••• ••• ••• • •• 64 ••• ••• 201 ••• ••• 173 ••• ••• 80 ••• ••• 37 ••• ••• 24 ••• ••• 18 ••• ••• 597 ••• Bad ••• ••• ••• ••• ••• 21 ••• ••• 80 ••• ••• 69 ••• ••• 36 ••• ••• 20 ••• ••• 12 ••• ••• 6 ••• ••• 244 III. Good ••• ••• ••• 25 ••• ••• 525 ... ••• 1722 ••• ••• 1634 ••• ••• 874 ••• ••• 516 ••• ••• 267 ••• ••• 5563 ••• ••• Fair ••• ••• ••• ••• 11 ••• ••• 147 ••• ••• 409 ••• ••• 398 ••• ••• 245 ••• ••• 127 ••• ••• 104 ••• ••• 1441 ••• Bad ••• ••• ••• • •• ••• 1 ••• • •• 46 ••• ••• 165 ••• ••• 157 ••• ••• 111 ••• •••. 75 •••. •••. 42 ••• ••• 597 IV. Good ••• ••• ••• 4 ••• ••• 73 ••• ••• 611 ••• ••• 1695 ••• ••• 1460 ••• ••• 918 ••• ••• 554 ••• ••• 5315 ••• ••• Fair ••• ••• ••• ••• ••• ••• ••• 9 ••• ••• 123 ••• ••• 284 ••• ••• 277 ••• ••• 228 •••. ••• 131 •••... ••• 1052 ••• Bad ••• ••• ••• ••• ••• 1 ••• ••• 3 ••• ••• 44 ••• ••• 148 •••. •••. 135 ••• ... 116 ••• ••• 62 •••. ••• 509 v. Good ••• ••• ••• ••• ••• • •• 6 ••• ••• 81 ••• ••• 641 ••• ••• 1479 ••• ••• 1484 ••• ••• 1014 ••• ••• 4705 ••• ••• Fair ••• ••• ••• ••• ••• •••... ••• 2 ••• • •• 18 ••• ••• 97 ••• • •• 235 ••• ••• 280 ••• •••. 226 •••. ••• 858 ••• Bad ••• ••• ••• • •• ••• •••... ••• ••• ••• ••• ••• 2 ••• ••• 49 ••• •••.. 136 ••• ••• 148 ••• ••• 128 ••• ••• 463 VI. Good ••• ••• ••• ••• ••• ••• 1 ••• • •• 6 • •• •••... 134 ••• ••• 652 ••• ••• 1418 •••... ••• 1540 ••• ••• 3751 ••• ••• Fair ••• ••• ••• ••• ••• ••• •••. ••• ••• ••• 2 ••• ••• 26 ••• ••• 76 •••... ••• 192 .••• •••... 251 •••... • •• 547 ••• Bad ••• ••• ••• • •• ••• •••... ... • •• ••• ••• ••• 3 ••• ••• 11 ••• ••• 70 ••• ••• 129 ••• ••• 171 •••... ••• 384 VII Good ••• ••• ••• • •• ••• ••• • •• • •• • •• ••• ••• ... 19 ••• ••• 130 ... ••• 578 ••• ••• 1881 ••• •••... 2608 ••• ••• and Fair ••• ••• ••• • •• ••• • •• •••... •••... • •• ••• ••• ••• ••• 2 •••. •••.. 12 •••.. ••• 91 .••• • •• 256 ••• .••• 361 ••• Ex-VII. Bad ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ... ... ••• ... 15 ... 49 ••• ••• 201 ••• ••• 265 Totals ••• 26 39 3 354 223 63 1396 530 179 3017 782 307 4378 915 415 4696 889 490 4952 944 536 5280 989 610 24099 5311 2603 32013 Each age group is divided into—Good Vision (=6/6), Fair (=6/9 or 6/12), and Bad (=6/18,or worse). Acuity of Vision. Examination of Girls. AGES LAST BIRTHDAY (AS NOTED ON CARD). I. Good 54 ... ... 153 ... ...... 192 ... ... 103 ... ... 33 ... ... 13 ... ... 5 ... ... 1 ... ... 554 ... ... Fair ... 47 ... ... 139 ... ... 182 ... ... 60 ... ... 30 ... ... 8 ... .... ... ... ... 3 ... ... 469 ... Bad ... ... 11 ...... ... 40 ... ... 55 ... ... 23 ... ... 17 ... ... 3 ... ... ... ... ... 1 ... ... 150 II. Good 1 ... ...'.. 112 ... ... 441 ... ... 373 ... ... 178 ... ... 79 ... ... 43 ... ... 20 ... ... 1247 ... ... Fair ... ... ... ... 74 ... ... 233 ... ... 187 ... ... 99 ... ... 54 ... ... 36 ... ... 18 ... ... 701 ... Bad ... ... ... ... ... 20 ... ... 74 ... ... 104 ... ... 46 ... ... 35 ... ... 13 ... ... 7 ... ... 299 III. Good ... ... ... 28 ... ...... 536 ... ... 1602 ... ... 1447 ... .... 790 ... ... 404 ... ... 182 ... ... 4989 ... ... Fair ... ... ... .... 5 ...... ... 130 ... ... 489 ... ... 498 ... ... 287 ... ... 161 ... ... 70 ... ... 1640 ... Bad ... ... ... .... ... 2 ... ... 56 ... ... 187 ... 216 ... ... 136 ... ... 84 ... ... 53 ... ... 734 IV. Good ... ... ... ... .... ... 31 ... 498 ... ... 1311 ... ... 1313 ... ... 821 ... ... 430 ... ... 4404 ... ... Fair ... ... ... ... ... ... ... 8 ... ... 105 ... ... 355 ... 428 ... ... 255 ... ... 178 ... ... 1329 ... Bad ... ... ... ... ... ... ... ... 3 ... ... 47 ... ... 182 ... ... 216 ... ... 146 ... ... 118 ... ... 712 V. Good ... ... ... ... ... ... ... ... ... 38 ... ... 497 ... ... 1245 ... ... 1306 ... ... 914 ... ... 4001 ... ... Fair ... ... ... ...... ..... ... ... ... ... ... 8 ... ... 92 ... ... 303 ... ... 326 ... ... 248 ... ... 977 ... Bad ... ... ... ... ... ... ... ... ... ... ... 11 ... ... ... ... ... 143 ... ... 196 ... ... 151 ... ... 544 VI. Good ... ... ... ... ... ... ... ... ... 2 ... ... 76 ... ... 439 ... 1051 ... ... 1276 ... ... 2844 ... ... Fair ... ... ... ... ... ... ... ... ... ••• 1 ... ... 16 ... ... 85 ... ... 241 ... ... 323 ... ... 666 ... Bad ... ... ... ... ... ... ... ... ... ... ... ... ... ... 11 ... ... ... ... ... 134 ... ... 177 ... ... 377 VII. Good ... ... ... ... ... ... ... ... ... ... ... ... 3 ... ... 83 ... ... 495 ... ... 1785 ... ... 2366 ... ... and Fair ... ... ... ... ... ... ... ... ... ... ... ... ... 3 ... 10 ... ... 81 ... ... 267 ... ... 361 ... Ex-VII. Bad ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 11 ... ... 60 ... ... 229 ... ... 300 Totals ... 55 47 11 293 218 62 1200 553 188 2616 850 372 3545 1093 515 3962 1175 599 4125 1100 633 4608 1107 736 20404 6143 3116 29663 34 The preponderance of very bad vision (6/60 or worse) among the girls is marked. It is generally almost entirely due to spasm of the accommodation in these cases. It was also shown that there is an association between defective visual acuity and retarded position in the school, the group of children who are older than the average age of their standard presenting a considerable excess of visual defect when compared with the younger group. The general conclusions regarding visual acuity were summed as follows:— 1. The percentage with normal vision increases with every year of age and standard, from the First reaching 80 per cent. in Standard VII. 2. A constant number of about 10 per cent. have bad vision (V. 6/18 or worse.). This remains about a constant proportion through school life. 3. The greater part of the defective vision is due to slight defect, which gives imperfect but fair vision, due probably to both mental and ocular conditions, and of the greatest importance educationally in the first half of school life. 4. Very bad visual acuity (6/36 or worse) due to accident, disease, and probably also to spasm and myopia, is met in a small proportion, increasing regularly from 1.5 per cent. in Standard I. to 3.5 per cent. in Standard Ex-VII. After the experience of the first year the method of vision testing was altered. The teachers test the children, both eyes being used simultaneously, and now a column in the attendance register has the visual acuity of each child as determined by the teacher entered up. A list of all children showing any defect in vision should be hung up in each classroom, and a list is sent in to the office of all children having vision of 6/18 or worse, above Standard V. 6/12 or worse. The oculists examine these children and give cards of advice to be taken home. Standard I. Standard II. Standard III. Standard IV. Boys. Girls. Mixed. Boys. Girls. Mixed. Boys. Girls. Mixed. Boys. Girls. Mixed. No. on register 13,493 14,552 4,759 22,085 22,403 7,566 23,235 22,646 5,523 21,269 21,620 4,848 No. returned de- 1,241 1,423 455 1,711 2,296 646 1,688 2,302 348 1,486 1,984 389 fective by teacher No. returned de- 888 1,030 313 1,326 1,674 478 1,338 1,736 274 1,154 1,545 299 factive by oculist Cards given ... 839 958 270 1,256 1,618 444 1,305 1,582 273 1,099 1,412 266 Standard V. Standard VI. Standard VII. and Over. Boys. Girls. Mixed. Boys. Girls. Mixed. Boys. Girls. Mixed. Totals. No. on register 18,186 17,657 3,600 13,341 12,748 2,845 10,347 10,225 2,878 275,826 No. returned de- 2,232 2,880 486 1,459 1,970 338 1,096 1,196 307 27,933 fective by teacher No. returned de- 1,474 2,069 338 1,073 1,308 234 651 750 215 20,167 fective by oculist Gards given 1,437 1,884 269 923 1,189 174 561 619 158 18,536 Taking the children in the standards, an average of 10 per cent, have vision which is bad (V. 6/18 or less) when tested under the ordinary conditions of life. When it is attempted to follow up this 10 per cent., one finds that a minority receive any further treatment, but unless carefully distributed through the year this minority cause great trouble at the hospitals. Children going to hospitals by themselves are rightly refused treatment. Parents refuse to lose work, a half a day or more, for a hospital visit, and each case requires two or even three visits. A considerable proportion of the hospital work is thrown away by the parents refusing to spend the money necessary for glasses. No child's eyes can be said to be satisfactorily examined unless the refraction is determined whilst the eye is under the influence of a mydriatic. This is work which we have considered to fall 35 under treatment, and except in the case of some of the children in residential schools it has not been done. Glasses.—Although there should be no deviation from a proper scientific examination of the eye, yet in the application of the results to practical life certain considerations are of great weight in the case of elementary school children. For young children, where the elasticity of the lens is unimpaired and accommodative power great, single spheres will generally improve vision and relieve strain so much that nothing more is wanted; the correction of a diopter of astigmatism in children under 10 is scarcely ever called for, and, except in neurotic children who happen to be astigmatic, ocular headaches are practically unknown at these ages. A considerable number of children who suffer from corneal and conjunctival troubles of a chronic nature are seen on account of defective vision being given as their reason for nonattendance at school, and in very many of these cases there is a long history of attendance at eye hospitals, and co-existing conditions of the nasopharynx (adenoids), and often actual rhinitis, associated with the conjunctival conditions, which have existed untreated. In such cases treatment directed to the eyes gives no permanent benefit till relief to the nasal and pharyngeal conditions is obtained. Possibly more damage is done to vision by phlyctenulae depending on general conditions than from any other cause common in school children. Apart from hospitals, there is a want of provision for the treatment of defective vision. The field has been much exploited by quacks, "qualified opticians," and others, but the need of a means of obtaining such help at a lower fee than the ophthalmic surgeon's two guineas is shown by the fact that of the class from which candidates are drawn for employment, under the Council (Teachers, Clerks, &c.), who were referred back for defective visual acuity, 80 per cent. went to hospitals for advice. Since January, 1904, the Oculists have reported on many general school matters. They have repeatedly called attention to the prevalence of near eye-working distance in school. This is the worst of school habits, and lies at the base of educational hygiene; it will be referred to in considering school work. It is commonly supposed that almost every child with defective visual acuity requires glasses, but there could be no greater mistake ; some can get no improvement from glasses, some will do better without glasses, a very small number are found with defective visual acuity and no refractive error, and in the course of one or two years ultimately attain normal vision. Viewed from a wide public health point of view, it ought not to be necessary for a considerable percentage of children to wear glasses. The rational treatment of most of these children should rather be an educational modification which avoids the necessity of glasses. There is a considerable number of children with permanently damaged or diseased conditions who are not blind, and not ever likely to benefit by the training as given at blind schools, who yet may be actually harmed by the ordinary school education. Children with diminished visual acuity—seen in cases with considerable corneal opacities, with chronically recurring phlyctenulae, with interstitial keratitis, old choroiditis, high myopia, congenital cataract, congenital absence of iris, some albinos, children with nystagmus. This group is probably as large a group in totality as that of the blind, and, from the results to be obtained, much more worth educating. Some are in blind sohools, some in ordinary schools, and others sometimes away for weeks or months under medical certificates; sometimes a short time in school. Special school classes, with modified tasks, are required for these children. The literary element being as far as possible eliminated from their work, and special attention given to fit them for tasks in which vision is not chiefly involved, but yet of subsidiary use. In 1902 a special inquiry was made as to the vision of children in the Infants' schools. 2,782 infants were carefully tested, every precaution possible being taken to get only the visual acuity. With the smaller letters it was found that the children would not make the effort to recognise them, although they knew them perfectly. Sweets were used as an inducement, and the letter E given to hold in their hands pointing it the same way as the test letter shown, up, down, or reversed. The child has apparently a great difficulty in making the effort to recognise varied letters, unless, as it were, a certain intensity is attained, by stimulation of a considerable retinal area. Using all the 36 means above described, and control tests by Miss Sayer, Dr. Critchley, and myself, the numbers who ultimately attained normal or fair (6/9-6/12) vision were very much greater than had ever before been suspected. Children in Infant Departments— Age Age Age Age Age 1,469 Boys; 1,313 Girls. 6-6½. 6½—7. 7—7½. 7½—8. 8-8½. Vision Fair (6/9—6/12):— Percentages Boys 16.4 17.1 13.1 18.4 16.6 Girls 13.1 13.2 17.8 13.0 20.0 Total 14.8 15.2 15.1 15.3 18.0 Vision Bad (6/18 or less):— Percentages Boys 3.3 6.3 6.1 6.5 8.2 Girls 3.6 4.6 5.2 6.3 7.5 Total 3.5 5.5 5.5 6.4 7.8 The Contagious Eye Diseases.—Numerous cases are turned out of school for "blight" about two-thirds of all cases are simple blepharitis, others chiefly granular lids due to strumous conditions, and are not of any importance as contagious diseases. Conjunctivitis.—Acute contagious conjunctivitis "pink eye" is occasionally seen as a limited outbreak; the disease has been somewhat prevalent in several schools in the East End during this spring. The Koch-Weekes bacillus was the cause bacteriologically determined. Fortunately, although it often spreads through a whole household, exclusion of affected cases generally stays its progress in school, or it may die out rapidly. So far it has caused but little trouble. Mr. Bishop Harman has paid considerable attention to the bearings of cleanliness and social conditions on external eye disease. His observations have enabled him to write an important and original work on "The Conjunctiva in Health and Disease." Blepharitis is most common in children on entering the infant school, and later again on passing to the senior schools. In reporting on the condition of the eyelids of over a thousand children at school, Mr. Harman has made a note of the visible lymph follicles at different ages in boys and girls, and also noted the prevalence of nits in the girls' heads. He points out that at the age when girls begin to be left to themselves in the matter of cleanliness there is an aggravation in the condition of the eyelids, due probably to neglect, as there is also aggravation in numbers of nits noticed in the hair (diagram X). In children with such conditions, conjunctivitis is not rare, but its results are passing, and are commonly termed "blight" by the teachers. Probably it is best for themselves that such children should be excluded for a time. Trachoma, which is said to be so exceedingly common in New York that a large staff of inspectors, numbering more than double our whole staff, is kept at work for its detection, is one of the rarest diseases in England. During several years' charge of a large eye clinic in the North of England, I could have counted the cases seen on my fingers. Mr. Harman, searching for trachoma, has only found five cases in 70,000 native children. In the Whitechapel district, trachoma is not such a rarity. It is imported, as practically every case seen is foreign born. Mr. Hanson has recently given much time and trouble, apart from his service to the Council, in following up and tracing out trachoma cases in the East End, and the following account of the disease and its distribution in London is taken from his reports, but is not final, as he is still studying its dissemination:— Definition.—Trachoma -may be defined as a disease primarily of the eyelids, characterised by inflammatory thickening and drooping of the lid, velvety or "granular" condition of the delicat 37 inner lining membrane of the lids, and discharge variable in amount, finally leading to scarring and atrophy of lid structures, the eyeball itself being liable to serious implication as the disease progresses, ending often in great impairment of vision, sometimes blindness. History.—Trachoma has been known to literature from early days, as early, in fact, as the sixteenth century b.c., often mentioned in the Ebers papyrus as existing in North Africa. Later, in a.d. 1679, in the time of William of Orange, the troops before Breslau were seriously affected with this disease, then termed Maubeeren-Augenlid (mulberry eyelid). Again, in the Napoleonic invasion of Egypt, the French troops were badly affected with trachoma, and on their return to Europe spread the disease far and wide over the European continent. During this period the disease became endemic in Europe, occurring mainly in over-crowded, dirty homes, and in the insanitary barracks of continental armies. The increased facilities for the immigration of impoverished foreigners has, during the last years of the nineteenth century, resulted in the subjection of this country to further inroads. For years endemic in East London, there is some risk of the overflow from the overcrowded Ghetto region distributing the disease slowly over hitherto unaffected London areas. Improved sanitary conditions and by-laws prevent the alarming spread of older days, yet the distribution of alien immigrants over wide areas renders the disease endemic in districts other than the Ghetto. Occurrence in London.—An alien Jewess, A. O., suffering from trachoma was found to be attending a Council school (A) in the electoral division of Stepney, and on inquiry it was found that, some months previously, she had come from a Non-provided school (B) in the same neighbourhood. On visiting the child's home, the following conditions were noted:— "Three-storied tenement house, let in flats, two homes on each floor, consisting of two rooms and small kitchen. Second floor tenement, dirty, overcrowded, constantly inhabited by eight people. Several wage-earners in family. Father works horse and van. One son at home, after stay in hospital. He has bilateral trachoma. Two brothers and one sister go to school B. This family came from Poland, via Paris, and the disease was introduced from abroad." Permission was obtained to inspect school B. Here were found the other 3 members of the family, 2 affected with trachoma. The whole school was then passed in review. In all, some 3,000 children were examined. Of this number 9 boys and 4 girls were found to have trachoma, and most of these were having or had had surgical treatment. All these affected ones were foreign-born, or the brothers and sisters of aliens. There was no indication of spread of the disease from a member of an affected family to any other child outside his or her own family. In other words, spread of the disease occurred certainly in the child's own overcrowded and insanitary home, never in the comparatively clean school buildings. Mr. Hanson paid domiciliary visits in each of the 14 cases, and invariably found one or more of the other members of the family affected. In some instances a parent was blind in one or both eyes as a result of long-standing and bilateral trachoma. A second series of investigations was carried out in another Council school (C) full of Jewish children. Here 2 trachoma cases were discovered among 1,200 children; both children were foreign-born. A third series was then made in another school with Jewish native children; here 1 trachoma case was detected. A visit to her home revealed "an airy house, S.W. aspect, family occupy ground floor"; 2 other members of her family (not of school age) have trachoma; the father has long-standing bilateral disease still active; both eyeballs are grievously affected with the serious secondary results of the disease. From a public health point of view this man's occupation is of interest: he is a retailer of milk —hardly a desirable occupation for a sufferer from trachoma. Most schools in East London contain no cases of trachoma; amongst 5,000 children included in the above inquiry there were 16 cases of trachoma, all in alien children. As far as possible during these inquiries Mr. Hanson investigated the locale of the actual infection to the cases upon his list—Russia, Poland, Holland, Galicia, France, German Poland, Austro-Hungary, The Levant, Syria, and Egypt all contributed one or more cases. Conclusions:— 1.—Alien children, or members of their immediate family circle, are alone affected. 38 2.—The disease is usually contracted abroad. Before any foreign-born child is admitted to a school in this country the head of the family should produce a family bill of health, which should be countersigned by the school doctor. 3.—If contracted in this country trachoma is not spread during attendance at primary London schools, but in dirty homes by carelessness. Trachoma is uncommon, even in such "favourable" schools as those in the Ghetto area, and it occurs unevenly in that area, apparently varying according to the proportion of the population of foreign extraction, and especially incident in those areas which contain most foreign-born. Overcrowding, in spite of by-laws and regulations, is still rife, and menaces public health. HEARING. The examination of the hearing of young children presents great difficulties from the psychological aspect, the child failing to react when often it hears quite well. No testing of this sense has been made on any sufficient scale among London school children. It was estimated in my first Report to the late School Board that probably deafness alone interferes to a considerable extent with the educational progress of at least 5 per cent., and to some extent with at least 10 per cent. more. The catarrhal conditions common in children and associated with debilitated conditions, want of exercise, deficient development of respiratory capacity, and backwardness in school should be well known to every teacher. The presence of "adenoids" is exceedingly common in the damp climate of London. The child with open mouth, frequently nasal discharges, and generally unintelligent appearance is often wonderfully altered by operative treatment. Cases have been deemed mentally defective or so deaf as to require special education by lip reading, but have in a few weeks after operation been able to return to the ordinary school. Operation is indicated wherever a child is a mouth-breather and snores at night. We have some reason to think that such children, apart from the condition of debility which is present unfitting them for education, are also more liable to contract scarlatina or diphtheria. They also suffer liability to suppurative diseases of the ears to about five or six times the extent which children breathing normally do. The importance of such treatment may be strangely overlooked. It is generally passed unnoticed in the children who visit ophthalmic hospitals; and a child has been seen who had spent nine months of the last three or four years in a general hospital, but has been a mouth-breather probably all the time, and within the last three months has lost the hearing through double otitis, the sequela of neglected adenoids. The teachers who notice the symptoms of mouth breathing and snoring, and persuade parents to seek relief for their children, are not only assisting the children to become better pupils, but are conferring a lifelong benefit on them. In this matter, too, the influence of the intelligent and conscientious teacher is very evident. SPECIAL SCHOOLS. Examinations.—Between 1 and 2 per cent. of the children are so defective in some respect that they may be classed as unfit to properly benefit by instruction in the ordinary school. When such a child becomes known, the head teacher, or divisional superintendent if the child is not in school, gives particulars of the case on a form provided for the purpose. This form is then forwarded to the Medical Officer, and medical examinations are arranged at various centres, at each of which not more than twenty cases are presented. The Medical Officer makes a report on each case so examined, and the children are educated in accordance with this report. During the past year the number of examinations required has very considerably increased. Altogether 339 examinations were held, and 5,048 children presented, with the following results:— 39 1904—1905. Number of Eliminations Number Examined. Passed for Mentally Defective. Physically Defective. Blind. Deaf. Elementary School. Imbecile. In valid and Epileptics. April 18 218 69 32 7 4 58 6 42 May 24 336 138 49 6 1 82 20 40 June 32 457 165 58 5 7 114 11 97 July 17 233 73 50 1 4 38 4 63 August 7 108 33 24 2 2 22 1 24 September 31 482 199 73 3 7 117 15 68 October 35 570 274 71 5 10 115 16 79 November 43 726 258 99 6 2 188 18 155 December 30 465 162 79 7 8 104 14 91 January 24 355 87 74 4 4 82 16 88 February 35 460 131 75 7 6 105 13 123 March 43 638 172 92 8 5 191 14 156 Total 339 5,048 1,761 776 61 60 1,216 148 1,026 1903-4 170 2,531 1,046 372 30 32 702 119 230 1904-5 339 5,048 1,761 776 61 60 1,216 148 1,026 Increase 169 2,517 715 404 31 28 514 29 796 Certain cases in which illness or incapacity are alleged as reasons for non-attendance are now sent up to the head office for more detailed examination, and during the six months in which this practice has been followed (excluding children in special schools submitted with a view to transfer to residential schools), 304 cases, almost all complicated by other circumstances, have been reported on, with the following results, so far as it is possible to classify such divergent items:— Deaf. Blind. Mentally Defective and Imbecile and Blind. Elementary School. Invalid and Epileptics Mentally Defective Imbecile. Physically Defective High Myopia. Industrial Schools. Deaf. Blind. Boys 12 11 8 3 1 37 14 13 1 2 4 5 Girls 9 14 9 10 3 71 35 13 5 3 12 8 Total 21 25 17 13 4 108 49 26 6 5 16 13 Special legislation is provided by the Elementary Education (Blind and Deaf) Act, 1893, for the education of these two classes. The powers given are wide. The definition of a blind or deaf child is one which is too blind or too deaf to properly benefit by instruction in the ordinary elementary school. Blind.—There are nine schools for the instruction of children classed as Blind. Of these seven are ordinary day classes and two are Residential institutions: Linden Lodge, for elder boys: Elm Court, for elder girls; and Stormont House, for boys who are blind and mentally defective. During my first year of work under the late School Board each blind child was examined individually, and a note of its condition recorded. Fifty per cent. of the totally blind were estimated to be due to infection and neglect of the eyes during the first week of life. More exact records have shown that 40 per cent. are actually due to this; but the proportion is greater, as many are passed over as doubtful cases. Since then it has been impossible for me to personally continue this work, and Mr. Bishop Harman has undertaken it. We have thus an annual report made after a detailed examination of each child under instruction as blind. This has been a matter of great benefit, many children have been brought under hospital treatment, and what vision persists has often been improved by glasses or operation. A few cases of trachoma have been detected and removed, and each year in almost every class several children have been so improved that they have been able to be transferred to the ordinary school. No child is now allowed to remain long out of school on account of visual troubles without being thoroughly examined. Till recently children with a temporary eye trouble remained out of school sometimes for years if defect of vision persisted, and of the many children reported as unfit for school owing to blindness and examined at the office during the past six months, 25 were returned as "educationally blind," whilst 32 were returned as invalid, 16 had high myopia, and 34 with small scars on the cornea interfering with vision were returned to the ordinary elementary 40 school; but there is undoubtedly need for special schools being established under the Blind and Deaf Act not only for those who will go through life with some vision, but for those who suffer from chronic eye conditions which extend over a large part of school life, and who at the same time should be educated under conditions which eliminate writing with pens or pencils, drawing maps, sewing, or doing any kind of fine work with the head bent much forward. This has already been referred to on p 16. It would be advisable, too, that in the Blind schools some attention should be paid to the appearance of the eyes and to the habits of the children. All attending these schools should wear dark blue glasses (dark smoked domes). This would prevent many bad habits—picking the eyes and so on. In the case of dirty sockets, it would also protect from irritation. Children who have partial vision and wear glasses should either always wear their spectacles or these dark protective domes. I have seen a girl in a residential school sent there out of the ordinary school to relieve her of eye work owing to progressive high myopia, but employed at the Blind school in sewing without glasses and with the work held close up to the eyes. Children who have had an eye removed grow up to have an unpleasant appearance, and when the lids turn inwards sometimes suffer a good deal from want of support to the tissues and lids during growth. To prevent the contraction which will otherwise occur, they should be encouraged to wear some artificial support in the orbit. Deaf.—There are ten Day schools and three Besidential schools for the deaf. The Residential schools are Anerley for elder boys, Oak Lodge for elder girls, and the school at Homerton is chiefly for children, boys and girls, who present other defects combined with deafness. Training is carried on in the last named both orally and by signs. The careful examination of the vision of the deaf in residential schools is also undertaken by Mr. Harman, as the fullest possible acuity is necessary for these children, particularly if they depend on lip reading. Deafness is not absolute in all cases. Many present various degrees of acquired deafness, and some are capable of improvement by operative treatment, particularly in those cases where chronic otitis has followed one of the exanthemata, and the ears present granulations and constant discharge. The seriousness of this being allowed to continue year after year cannot be too strongly insisted on. Cases are seen occasionally where apparently meningitic symptoms have recurred from time to time without effective treatment being followed out. The majority of these cases of chronic suppurative otitis may be regarded as neglected by the hospitals, no thorough or determined efforts being made to effect a cure; and, indeed, they cannot be properly treated except by continuous dressings several times daily, and if this is not effective in a few weeks, then by radical operation. Like the determination of refraction in the eye, the routine treatment of numerous cases of chronic otitis is most uninteresting, and it can scarcely be expected that any man will voluntarily give up hours daily to such work. This is one of the flaws of the voluntary hospital system that a great amount of work not only in this but in ruany other respects which is requisite and necessary in the interests of the public health, is, except here and there in special hospitals, practically neglected. The want of hearing, totally or in part, produces very considerable mental retardation, and the educational capacity of deaf cases varies very greatly. It would be an interesting study to follow up the work, expensive and tedious as it is, of the teachers in the deaf schools, and inquire how many children, trained in the purely oral system, attain such perfection that it is of practical use in after life. Great harm is undoubtedly done by voluntary institutions for the care and help of the deaf, collecting them together, and separating them from their fellows by encouraging the use of sign language, and, what is worse, in many cases leading to the marriage of congenital deaf mutes. A considerable proportion of the deaf do not make progress with oral teaching, most have defects of obscure nature, some of articulation, some of intellect. Most of these are at present classified as "also mentally defective," but they require much closer study than we are able to give them, and to be classified and worked according to their abilities. Some at Homerton are slowly progressing with oral speech. Some are being educated by the use of speaking tubes, and others are using signs. Undoubtedly some of these cases would repay very careful study in the hands of a highly trained teacher or of a medical examiner used to this class of work. 41 Boarded-out Children.—The number of boarded-out children on March 31st, 1905, was as follows:— Blind Deaf. Boys 23 37 Girls 18 19 Total 41 56 and of these 97 children, 30 are extra-Metropolitan. Mentally Defective.—These children are provided for under the Elementary Education (Defective and Epileptic) Act 1899. There are 79 centres, of these 75 are ordinary special schools for day scholars and four classes for older boys. There is also one Residential school. The mentally defective children are defined as those who not being imbecile are yet, by reason of mental (or physical) defect unfit to properly benefit in the elementary school. The Education Acts make no provision for the small class now termed "moral imbeciles." The feeble-minded may be classified as those whose feeble-mindedness is physiological and those in whose case it is pathological. No study of feeble-mindedness is possible except by continuous reference to the normal, and thus these physiological cases are classed as cases of natural variation, and in some respects may be quite normal. In others they are perhaps hopeless. In the second Report to the late School Board this class was illustrated by the cases of "word deaf" and "word blind" children, which we had observed, and it is possible that a similar class exists in the "moral imbeciles." Feeble-mindedness expresses to some extent failure to reach a certain level in the general summation of mental qualities. If by any means we could make a numerical estimate of the mental capacity of each individual, and set it out for a large body of persons who were healthy in all other respects, the distribution of mental qualities would probably be represented by the ordinary "curve of error," the continuous line in the diagram. A few cases at one end would represent geniuses, a few at the other end would be idiots, and one class would gradually pass through the merely clever, through the great mass of mediocrity to the dull and then feeble-minded, but each succeeding class would gradually merge into the other without any sharp break. If now a similar number of persons were taken, but quite unselected, so that those damaged by disease were also included, it would not materially alter the facts, but merely increase the numbers lying on the negative side of the normal, and increase the numbers presenting considerable defect more than it decreased the numbers with mental powers above the average judged by our previous standard (see diagram XI., page 42). Such a curve furnishes us with a good diagrammatic representation of the varying capacities of different individuals. If now an area equal to one-hundredth the whole is cut off one end, this represents the estimate of the Committee on Feeble-minded Children as to the class to be provided for by special education. But there is still a considerable mass of children who from various causes are below the normal, and who, even if they pass through school attaining Standard II. or III. before they leave, receive no such benefit as they would if educated with special regard to their hindrances. These, so far as the imperfect means at command allow, may be estimated as amounting with the feeble-minded to 10 per cent. of all, and this represents the class presently to be referred to who require education by intermediate schools. Similar classes on the other side might be taken as worthy of education beyond the ordinary elementary school, and a smaller class as worthy of secondary training in the highest degree. The effects of loss, partial or wholly, of single senses is known, but when defects are combined the difficulties of education are very greatly increased. The most typical class of combined defects are the victims of inherited disease who are often mentally dull, suffer with eye troubles (interstitial keratitis) during the second half of school life and in some cases also become too deaf to understand speech. There are also many deaf or partially deaf cases presenting mental defect, blind cases with deafness or mental defect, but other cases are merely nervous or debilitated, and it may be said that we have very little knowledge of the mental condition and possibilities of most of the children with combined defects. The importance of a thorough study of these cases, more especially those presenting physiological variations, is not yet realised. They throw much light on the educational processes of 42 normal children, and there is no class of child likely to profit so much individually as this class, with often limited, sometimes quite local, brain defects, which, if misunderstood, may result in the child, who might be made a capable citizen, having to spend his life in an asylum. But even with pathological cases the results of bygone diseases, and especially when combined with such defects as deafness or blindness, partial or complete, the only chance of doing thoroughly good work is by having them properly observed and recorded by skilled examiners, both from the medical and psychological point of view. This work will have to be done in a residential home with full Diagram XI. (see page 41). Diagram to show Variation in Mental Capacity from Physiological Causes. The tendency of pathological effects shewn by dotted lines. opportunities for complete clinical study, and such home must be also regarded as a place for classification and investigation of the physical and mental conditions of the children. In a certain proportion of cases, for want of this preliminary study extending over some weeks, the special school training appears in great measure wasted. On the other hand, all general information obtained by this means is of value in being applicable to, and will react on, the work of the normal children in the ordinary schools. The children submitted with a view to special training numbered 5048. These were presented at 339 examinations, with the following results:— Blind. Deaf. Mentally Deficient. Imbecile. Physically Deficient. Invalid and Epileptic. Ordinary School. 61 60 1,761 149 776 1,026 1,216 43 Imbeciles.—Imbeciles and those of worse degree, idiots, are expressly excluded from the operation of the Elementary Education (D and E) Act of 1899. Any child decided to be imbecile is thereby excluded from school. But the definition of what is an imbecile is very difficult. An individual whose mental powers are, in great measure always have been, and permanently remain beyond the reach of reason may be taken to be an imbecile. At present there is no statutory duty laid on any authority for the care of imbeciles who are not paupers, but the whole matter is now being investigated by a Royal Commission, before whom various representatives of the Council have given evidence. The necessity for such an inquiry was fully shown in my First Report (page 22). There are children referred to occasionally as "morally defective," or in some cases as "moral imbeciles." This class is an exceedingly small one. The children who are word deaf or word blind are such in virtue of defects in the small areas of brain which should store the memories of word sounds or word images. The body of memories stored up, comprising the conventions which regulate our conduct in relation to society, comprise morality, a body of memories probably not more complex than written or spoken speech. These memories are a very late evolution, but earlier than speech. We cannot locate them, but if this idea of morality is correct one should expect localisation, which may, however, be in the silent area of the brain, and is screened from observation by the action of the lower centres. Want of development of these regions will give rise to exactly the type of individual that is found with word blindness or word deafness. Incapable of appreciating one class of memory, incapable of education or improvement in that respect and normal in all other ways, and a normal individual who is wanting in all moral behaviour except such as his lower emotions or appetites suggest, will appear in some ways exceedingly clever. Such are the children who occasionally come to notice as moral imbeciles or moral defectives. Most of these have hitherto passed through the schools unnoticed. They really are not provided for by the Education Acts, as they are quite capable of learning moat things in school. Many in later life undoubtedly will become a danger to the community, and where this is associated with other defects which bring them into notice should not be permitted to be in ordinary schools. Residential institutions or a colony or ship where they can be under constant observation will be the best treatment during school life. They should be registered by the finger-print method, so that in later life on once coming into the hands of the police their dangerous qualities will be known. Epileptics.—A scheme is under consideration for dealing with epileptics. As yet epileptics are considered first with respect to their mental qualities. Are they fit for the ordinary school, or feeble-minded? Then they are considered with regard to the epilepsy. Can this child attend school, or are the epileptic attacks too frequent for it to be advisable to attend? If so, the child is excluded as invalid. The absence of provision for this class is the greatest gap in our Educational System. INTERMEDIATE SCHOOLS. Considerable numbers of old children are still recorded in Standards I. and II. In the second Report to the late School Board (p. 33), the special treatment of backward children in intermediate schools was advocated. It was there estimated that 10 per cent. of the school population were in such a condition, from reasons either of a permanent or of a chronic but temporary nature, attending school under such conditions that the work of the ordinary school is almost wasted on them, if not in many cases actually harmful. This is the more required in that large numbers of children who make little progress in school, and who would greatly benefit by manual work, under the present conditions never reach the standards in which manual work becomes part of the ordinary school course. They may pass their whole school life and for want of scholastic attainments never see the inside of a manual training room. The cases of children already referred to not blind but yet unfit for the continuous ocular strain of school work, the children with aural defects, the simply debilitated children, children backward 44 through repeated or prolonged absence from zymotics, tubercular, and parasitic diseases, the children who do not learn to read, and the considerable mass who, although not actually "mentally defective," are yet of such a low grade mentally that they are neither capable nor worth the effort of being raised to the ordinary elementary school standard; for these simpler schools are required in which objective teaching will to a great degree replace the intellectual work of the ordinary school, and its ideals of literary attainment be very considerably lowered. Such intermediate schools are the basis of the Mannheim School system. Quite apart from the medical aspect this system would repay investigation on the spot by a purely educational expert. BUILDINGS AND FURNITURE. A considerable number of the older schools in London are very defective when judged by modern ideals, more especially in the matter of lighting and ventilation, but it is impossible, at any reasonable cost, to bring them up to modern requirements. The school work must remain hampered by the conditions there existing. Whilst our own schools appear more solidly built, and, as regards woodwork, must be very much more expensive than foreign schools, yet many of these, especially the newer ones in Germany, are better decorated, and produce a much more pleasing impression. It is impossible, having regard to sites, cost of material and labour, to make any comparison between English and German schools, but on inquiry recently I was told that loans on the cost of school buildings were usually repaid in twenty years. Heating and Ventilation.—There have been fewer complaints during the past year. The Oculists have drawn attention to the unsatisfactory heating in 28 schools, unsatisfactory ventilation in 52 schools, unsatisfactory window lighting in 104 schools, and unsatisfactory artificial lighting in 77 schools. These matters have been referred to the Architect. Christianstreet, which is mechanically ventilated and was one of the worst ventilated schools in London. has been somewhat improved by new engines, which allow of speeding up the fans. It still remains bad, however, as regards ventilation. No further work, as regards general principles, has been done in addition to that of last year In reporting then, it was stated that with mechanical ventilation, where less than 2,000 cubic feet per hour of air was supplied, complaints of fatigued feelings were common, and the conveyance of heat by the air was deprecated. A double system of combined propulsion and extraction was suggested, because it would allow of the pressure in the classrooms being about normal, and permit free opening of doors and windows. The conveyance of heat by steam or water pipes instead of mainly by the air was advocated. Mr. W. N. Shaw, F.R.S., has pointed out that thermal considerations play a great part in the physiology of ventilation. Numerous attempts to detect the cause of the effects of foul air have been unsuccessful. Dust and particulate poisons are themselves the cause of specific effects. For instance, the dissemination of measles is fostered by the ill-ventilated temporary buildings in a way that is not found in the permanent schools. Apart, however, from these specific results, all attempts to determine a definite chemical cause for the effects of foul air have been unsuccessful. Recent work abroad has emphasised the importance of "heat retention" by the body as the chief factor in the exhaustion felt from foul air. This heat retention is due to the passage of insufficient quantities of cool air over the body surface. It strengthens the idea that whilst air must be moved mechanically to provide sufficient ventilation at all times, yet the chief distribution of heat must be by other means than the air itself. Desks.—Some experiments are now being made in the use of separate seats and continuous desks. The conditions are not, however, entirely favourable, as they are being used in buildings where the rooms had been planned for dual desks, and the dimensions are therefore rather unfavourable. During the year the Oculists have drawn attention to the wrong position of desks in regard to light, &c., in 38 schools, and desks of the wrong size in 43 schools. These matters have been referred to the Furniture Superintendent. 45 SCHOOL HYGIENE. The necessity for a knowledge by the teachers of the conditions under which school life may be conducted in a healthy manner is now being urged on all sides, and some pressure has been brought to bear on the Board of Education to make this knowledge compulsory. A means exists in the course of training and examination in Physical Training for the Physical Exercise Certificate which is required to be passed by each teacher. It is quite possible to remodel this course and examination, to make it much more useful and practical than it is at present, and instead of a knowledge of physiology, as asked for at present, to draw up a syllabus of a course of lectures which, being given on scientific lines, and by using typical examples, would help teachers to gain a knowledge of the matters which are of importance, not only from the sanitary but also from the educational point of view, and by this means lead to a considerable practical improvement in school conditions and school life. JAMES KERR, Education Offices, Medical Officer (Education). 13th November, 1905. 46 APPENDIX. REPORT BY DR. THOMAS ON MEASLES IN THE WOOLWICH DISTRICT. The inquiry into the spread of measles has been continued in the Woolwich district with the co-operation of Dr. Davies. Particular attention has been given to the incidence of cases in school outbreaks amongst the age groups and amongst the protected and unprotected; it has been possible to do this with increasing certainty and facility since the teachers are becoming accustomed to the measles-history cards, and throughout the division practically every child now in an Infants' department has had its measles history entered upon admission to the school. Diagram XII. Purrett-road School.—The first outbreak demanding notice was at this school during April and May, 1904. (Diagram XII.) Here the first intimation of the impending outbreak was the absence of a number of children in Classroom B (aged 4-5) from April 22nd to 26th. On the 27th it was learnt that many of the cases were measles and the class was closed at once, but too late to be of any effect in arresting the course of the outbreak. Notwithstanding all care the first case or cases had been missed, and the outbreak from April 22nd to 26th was the "first crop," and consisted of 18 cases out of a possible 34. After careful inquiry it was subsequently found that a child had attended on April 11th in this class, undoubtedly in an infectious condition, and had then sown the seed. Already the neighbouring classes had been infected, and although prompt closure was enforced the "second crop," which came down in the four junior classes between May 3rd and 15th, was extremely heavy and practically exhausted the material; 35 out of 51 in the Babies' class; 28 out of 34 unprotected in the class B (aged 4-5); 17 out of 19 in class C, and 7 out of 10 in class D. Classes E and F, both containing children over 7 years of age, entirely escaped. In all 87 children suffered, and out of these 80 had been reported as not having had measles, while 7 were said to be second attacks. At this school, therefore, measles appeared and spread when 85 out of 149 children under five were reported not to have had measles—i.e. 57 per cent., and out of those reported unprotected 77 per cent. suffered. 47 Diagram XIV. (see p. 48), shews the effect upon the classes in a school of freedom from measles for two years followed by a severe outbreak (see diagram XII.). Each square represents a child, the plain squares representing the children who have not had measles. In column 1 the condition at the commencement of the enquiry in 1902 is shewn. Class I. represents the seven year olds and Class VI. the babies. The dotted squares represent those whose measles history could not be obtained. In column 2 is seen the gradual accumulation of material, until in the lower classes over 50 p.c. become unprotected. In column 3 the effect of a sharp outbreak of measles is shewn. Those suffering during this attack are shewn by black squares. In Classes I. and II. no cases occurred, shewing the protective influence of a large proportion of children who have already had measles, exerts; this is shewn also in the lower classes in the proportion of children who escape; in a well-conducted school an epidemic of measles never goes so far as to totally clean the slate; the number of unprotected is brought down to about 15 p.c. or 20 p.c., and then the epidemic ceases. Diagram XIII. Eglinton-road School.—The next school to be attacked was Eglinton-road, a school in the nonclosing half of the district. Here, however, the Easter holiday acted as a closure, and so far from arresting the spread, an examination of diagram XIII. shows that with the conditions of urban life, under which the children meet, the opportunities of contracting and spreading the disease may be considerable even when the schools are closed. The first case here, on March 12th in Class D, a well-protected class (aged 6) the unprotected children in this class (13 out of 77) did not contract it, but a child in class B showed signs on March 20th and one in Class A on March 25th. There was in class A (the Babies) a large number of unprotected cases (62 out of 108) and a crop of 6 cases came down entirely in the Easter holiday; in spite of the fact that the children were not attending school a very large number of children contracted the disease during the holidays, and within four days of the return to school the second crop began to fall, numbering altogether 39 cases in classrooms A and B; although it must be noted that there was on the twelfth day after the school recommenced a great increase in the number of cases, doubtless due to school influence. The number of cases which came down subsequently to this third crop was insignificant, and school closure, had it taken place, say, on April 21st, would not have saved so many as half a dozen cases, although it might have appeared to have arrested the outbreak. Out of the 56 cases of measles here 52 had been reported not to have had measles before, while 4 were said to be second attacks. Earl-street School.—Here the Infants' department commenced the year 1904 with the following distribution of protected and unprotected children:— Class. Previously had measles. Not had measles. Unknown. Percentage unprotected. I. Aet 8 59 5 1 9 II. „ 7 56 8 1 14 III. „ 6 42 13 2 26 IV. „ 5½ 52 20 — 28 Va. „ 5 35 26 — 43 Vb. „ 4½ 23 16 — 41 VI. „ 3½-4½ 42 41 5 52 48 49 In Class I. (percentage unprotected 9) no case occurred. In Class II. (percentage unprotected 14) one case occurred during Christmas holidays. In Class III. (percentage unprotected 26) one case occurred during the Christmas holidays. While five cases occurred on June 16th to June 19th, which were part of a general prevalence of measles, no cause could be found in school; the class was closed from June 22nd to July 6th> and during this period one case occurred. There were only thirteen cases in this class who had not previously had measles, and of these five contracted it during the year, while of the forty-two who were reported to have had measles two were said to have a second attack (diagram XV). In Class IV. (percentage unprotected 28) one case just before the Christmas holidays had measles, and three cases occurred during the holidays; no further cases occurred during the year ; the four were amongst those reported not to have had measles. In Class Va. (percentage unprotected 43) one case occurred during the general prevalence in the Christmas holidays; two further cases occurred on June 16th to 18th, and the class being closed from June 19th to July 4th, eight cases came down during the closing period of fourteen days. Unfortunately the case that had occurred on the 18th of June was not known about till afterwards, so that the closure was just too short, and two children came back on the 4th July who had contracted it from the second case. This necessitated closure, recommencing on July 5th and oarried on into the summer holidays; and it was impossible to ascertain the occurrence of further cases on this account. Of the 13 cases known about 10 were among the 26 reported not to have had measles before. In Class Vb. (percentage unprotected 41) a case occurred on June 3rd, and the class was closed from the 10th to the 19th ; no secondary case was discovered to have occurred during the closing period, but between the 20th June and 10th July 9 fresh cases occurred (this beiDg part of the general prevalence). The class was again closed on July 10th, and the closing merged into the summer holidays, so that here also the channel of information was cut off, and the subsequent history is unknown. The case which occurred on June 3rd, and primarily introduced measles, had only been at school three days, and must have contracted it outside. The 10 cases of measles that were known to have occurred were all among the 16 children reported not to have had measles previously. In Class VI. (the Babies) 52 per cent. were unprotected. One case occurred in the Christmas holidays ; four cases occurred from March 1st to 3rd who contracted it from outside source—indeed, one of these four cases had not been near the school for months and was not in attendance. The class was closed from March 4th to 21st, but no further case was discovered during this period. Another case occurred on April 12th, during the Easter holiday, which was secondary to a baby in the house. Another case failed on June 8th, and the class was closed from June 9th to 23rd. No secondary cases occurred, however, during this period, but on 50 July 3rd and 4th three more cases occurred. Seven out of the 9 cases were amongst the "unprotected" group. Vicarage-road, School—Class closure was resorted to a considerable number of times during the earlier part of 1904. Class V. was closed from March 16th until April 11th (including the Easter holiday), on account of the occurrence of a single case on March 12th. This class was again closed from May 27th to June 10th on account of 8 cases occurring between May 13th and May 26th (diagram XVI.). Class IV. was also closed during the latter period on account or a single case occurring on May 20th; this class had been closed in the previous October and December. Class VI. (the Babies' class) was closed from May 16th to 30th on account of 6 cases between April 29th and May 12th. During this latter period 16 cases failed in this class, making 22 in all out of a number of 45 reported not to have had measles ; no further cases occurred on resumption. In this Babies' class, therefore, in which 45 out of 90, or exactly 50 per cent., were unprotected, it must be assumed that a certain number were saved from an attack by closure. In none of the other classes were any cases ascertained to have occurred during the closing period. In Class II. one case occurred on July 1st, aud the class was closed on July 7th ; no further case was ascertained to have occurred, and it was not likely that such should have happened, as only 6 children out of 59 were said not to have had a previous attack; the single case was amongst these 6. Burrage-grove School.—This school is in the non-closing division. In spite of the fact that one or two cases occurred in every class during the year, there were no secondary cases in any instance, although the protection by previous attacks was not great. Class. Age. No. of Children. No. Unprotected. Cases of Measles during year. A 7 70 18 1 B 6 57 19 2 C 5 48 20 2 D 4½ 57 24 1 E 4 66 38 2 F 3 106 ? 1 Cases occurred also in the following schools before the summer holidays of 1904, but owing to pressure of work the details could not be followed out:— Closing Schools.—Church Manor Way, High-street, Ancona-road, Wickham-lane, Bo3tall-lane, Slade, Plumstead-road. Non-closing Schools.—Elizabeth-street, Wood-street, Plum-lane, Mulgrave-place. In none of these schools did any severe outbreak, however, occur. Since August, 1904, it has been found possible to follow up every case of measles reported, and many instructive outbreaks have been studied in detail. 51 Maryon Park School.—One or two cases had appeared in the neighbourhood of this school before the summer holidays, and, in spite of the closing of schools for a month, these continued to smoulder throughout the vacation. Soon after school resumed on August 22nd cases began to fail, the first cases occurring at so early a period that the children must have been infected in the holiday; thus two cases occurred in Class D on August 27th (diagram, XVII.); Class D was the best protected in the department, and upon this occasion did not become infected. On September 1st and 2nd two cases occurred in Class A (the babies' room), and from them nine cases arose : five in Class B and three in Class C, while one secondary case only arose in Class A. This is most remarkable, seeing that Class A was full of combustible material, while Classes B and C were much better protected, and the only explanation that can be given is that the infection took place to and from the school, and not in school; the babies would not walk home together in a body, but would be taken home by older children. This " first crop" occurred between September 12th and 15th; the second crop came down in these two classes between September 21st and 30th, and numbered 44 cases in these two classes ; as usual, this second crop was practically the final one. In the babies' room (Class A) 5 cases came down during these latter dates, and the next crop, from October 3rd to 14th, comprised 22 cases, and practically ended the outbreak. In Class D another independent infection took place on September 16th, a first crop of 7 failed between September 27th and 30th, and the second and final crop between October 3rd and 14th, comprising 13 cases. Out of 311 children at the beginning of the outbreak 161 had not previously had measles— i.e. 52 per cent.; out of these 115 contracted measles, or 72 per cent.; 5 of the 161 were said to be second attacks. Very careful inquiries were made in this outbreak as to the spread of measles in the homes, and out of the 115 cases which occurred it was found that in 36 instances it was definitely contracted out of school (marked by crosses in diagram , the following case being instructive (for diagram XVIII., see page 52):— Nellie I. (set. 5) failed with measles on September 16th; before she was isolated she played with her cousin, Charles B. (æt. 5), and her bosom friend, Gertie W. (æt. 5). These two children contracted measles from her, Charles B. imparting it to the rest of his family (3 in number) through his sister, Annie B., and also giving it to his next-door neighbour and chum, Chris. C. (failed 11.10.04.). Gertie W. (failed 30.9.04) imparted it to her brother, Dick W. (failed 10.10.04). Nellie I.'s mother was expecting an addition to the family, so since Nellie's attack was only slight she was allowed to get out of doors rather early, after a week's isolation. Nellie repaired, thereupon (on September 24th), to the house of her other bosom friend, Lily S. (æt. 5). and assisted the latter in the task of caring for Sammy S. (æt. 1.8/12); accordingly, Lily and Sammy took measles, and failed on October 7th and 9th respectively. All Nellie's five-year-old companions 52 were now exhausted so on October 1st she had to descend to playing with Ellen R. (æt. 3); Ellen failed with her measles on October 12th. On October 5th Henry George I. was born, and two days afterwards Nellie I. was allowed to see the new arrival, it being now three weeks since she herself had had measles; this interesting experiment proved that even after the lapse of three weeks a convalescent from measles should be shunned, for Henry George began to suffer from his measles on October 19th; he happily recovered This popular young lady, Nellie I., was therefore directly responsible for no less than 11 cases, which could be definitely traced to her. Careful inquiries were made at all the houses known to be infected (92 in number). There were ascertained to be in all 341 children of school age; of these 198 had not suffered before, 130 had had previous attacks, and 13 were uncertain; of the 198 who had not previously had measles, 182 suffered while 16 escaped; of the 130 who were said to have had previous attacks, 125 escaped while 5 suffered second attacks. Amongst the 16 said to be unprotected who escaped, 4 were aged 12, 1 was a baby who died of pneumonia, and 3 were isolated. Union-street School.—That the long summer vacation does not stamp out measles is shown by the fact that several cases occurred during the summer holidays also in this district. Fourteen days before the school had opened a certain child had measles; her sister, who was aged 51/2, and had previously had an attack, attended school on the re-opening on August 22nd and on the subsequent 2 days; during this period she was noticed to have a bad cold, she ceased attending, and a doctor saw her and diagnosed phthisis. He saw no rash, and the mother states that there was no rash. When I saw her a fortnight later she was recovering from apical pneumonia, and there was no doubt that she had conveyed the infection into the school; it is possible she had a second attack of measles without a rash (there was a very definite history of a previous attack of measles). Within a fortnight from her attendance with running eyes and nose a number of cases—in all 16—began to fall, 12 of these, however, being in the very fairly protected class (II.) in which she attended. The head mistress at this school has been a lecturer on hygiene and is very keen and observant as soon as her suspicions were aroused she took energetic measures in the way 53 of inspecting and excluding children at the earliest moment, with the result that although 13 cases out of 27 unprotected failed in the first outbreak in the Class II. in which it was introduced, yet 14 cases only out of 47 unprotected occurred in the babies' class, a result which compares favourably with those obtained by school closure (diagram XIX). A fresh importation of measles took place at the end of October, but, in face of the knowledge and energy displayed by the head mistress, failed to get a foothold. The Slade School.—At the end of September an outbreak began at this school, which spread throughout the neighbourhood. The initial case was in a child of 5 who came from a Guardians Home. She had only been admitted to the Home and to the school a few days ; she was noticed ailing in school on September 26th. Through carelessness or mismanagement at the Home the school authorities were not apprised of the nature of her complaint, and thus an outbreak commenced which affected four schools, produced 207 cases that came to light, and occasioned 14 separate acts of closure of classes or exclusion of non-protected children. Thus a single case which was not immediately known of, in spite of most vigorous action quite early in the outbreak—immediately upon the occurrence of the next two or three cases, in fact—produced an amount of illness and death which was appalling. This serves to show what kind of an enemy measles is to fight, and how little can be done if it gets the first advantage and forces us to act upon the defensive. The first crop that arose from the seed thus sown came down in the form of 8 cases, distributed in the Classrooms III. and IV. (diagram XX.), and mainly amongst children from the Home (who attended in those two classes almost entirely, and who through negligence had been allowed to continue to attend). Both these classes were closed from the 16th to the 24th of October ; it was hoped that this would catch the second crop, but, unfortunately, the later cases, on October 10th, of the first crop had not been heard of, and the second crop had not quite finished coming down when the classes re-opened, and the two classes had to be again closed ; although, as a matter of fact, as is usually the case, the second crop had exhausted the material in these classes, and during the lengthened second closure only one case in each class failed. In Class III., this was the only case which remained to have it, for 23 out of 24 possible had already contracted the disease during the first and second crops. During the second crop period a solitary case occurred in Class II., on October 21st, and this class was closed as soon as this was known (from October 27th to November 8th), again, however a case failed (on November 9th) after resumption, and a second closing period 54 became necessary. On November 9th, unfortunately, the boys of Classes II. and I. had a lesson together, with the result that on November 21st and 22nd 2 secondary cases came down in Class I. Here, as only a very few children were unprotected, the plan of excluding only those reported not to have had measles was tried, and this worked well, for amongst the dozen children excluded 3 failed at the appropriate period, while the 54 allowed to continue in attendance, and who were reported to have already had measles, remained well. By dint of exercising great care in making the babies assemble at a separate entrance door and go out to play at separate times, it was actually kept out of this, by far the most susceptible class, for six weeks. About November 8th the babies, however, began to fail, not through school infection but because the whole district was now thoroughly infected, as may be seen from a glance at the diagram, in which is shown the incidence at the neighbouring Ancona-road school. Ancona Road School.—The outbreak here followed on the general infection of the neighbourhood from the Slade. It commenced about the same time as the babies' class at the latter school, and the diagram shews the diffused chart which is characteristic of a general infection of a locality in which the school crops are secondary features, although they are still to be made out. The babies' class at the Slade (diagram XX.) also shews the sort of chart which is characteristic of locality infection and not school infection. The Ancona Road diagram shews how the most ill-protected classes, VIa, VIb and V. suffered most severely. The better protected classes, Standard I. (a) and (b) suffered more lightly. Here again only the unprotected children were excluded, and no cases occurred amongst the 95 allowed to remain in attendance, while well protected classes like Standard II. (a) and (b) escaped altogether diagram XXI.). Timbercroft Eoad School—This is a temporary building not far from the Slade and Ancona-road Schools. The Infants' department consisted of two classes only. A case occurred in each on November 18th, but only the case occurring in Class I. was reported at the time, the other being missed. In spite of early closure the first crop here partook of the nature of an explosion and practically every child capable of getting the disease took it at the very first opportunity; 56 out of 65 reported not to have had measles were ascertained to have suffered. Timbercroft Road was no exception to the rule that temporary buildings are invariably illventilated and overcrowded, and the outburst, depicted in diagram XXII., see (page 55), shews how much unhygienic school conditions contribute to the spread of disease amongst children. Plum-lane School.—At this school the small outbreak that took place in November and December was part of the sum total of measles in the neighbourhood set up by the child from the Guardians' Home in the Slade school, and occurred during the same period that the babies at the Slade and the lower classes at Ancona-road were affected. It began in the babies' class, and two successive crops exhausted the material here, which only made up 13 unprotected cases; it spread also to Classes III. and IV., but by care and watchfulness on the part of the head mistress 55 the number of cases remained moderate, and although this was a non-closing school the results compared favourably with the closing schools in the neighbourhood (diagram XXIII.). Mulgrave-place School.—At this school several cases arose during October to December, 1904. In spite of the fact that over 50 per cent, of the children under 5 were unprotected there was no considerable spread (diagram XXIV.), although closure was not applied. Here again the slight degree of spread of measles must be ascribed to conscientiousness and knowledge on the part of the head mistress and good hygienic conditions. Conway-road School.—At this school measles was imported several times both before and after the summer holidays, but owing chiefly to the keenness of the head mistress the cases were detected 56 and reported early, so that not only was closure applied early, but there were few cases in the first crops, and the spread of the disease was in all cases arrested. In the first half of the year three cases failed together on May 16th and 17th in the babies' class; this class was closed from May 19th to 29th, 1 secondary case only took place amongst 40 unprotected. In Classes B and C, however, at the expected time (May 26th to 29th), 3 cases fell amongst 68 unprotected children ; these classes were closed, but no further cases could be traced amongst them; at the right period (June 9th to 13th), however, 2 cases occurred in Class D amongst the 20 unprotected children, and closure was here promptly carried out, although no secondary cases occurred (diagram XXV.). In the second half of 1904 a case again occurred at Conway-road, being a child of 7 who brought the complaint from Swindon. Fortunately she belonged to the best protected class (only 4 out of 74 had not had measles); instead of closing the class, only those who had not had measles were excluded, but as it happened none of these contracted the complaint; but at the looked-for time cases occurred in the two neighbouring classes, E and G. E was closed for a period during which 1 secondary case fell, while in G. only the children reported not to have had measles were excluded, and 2 amongst the 5 excluded took it, the 55 remaining in attendance escaping. By these measures happily what few cases there were remained confined to the upper classes, and no spread to the Infants' Department occurred (diagram XXVI.). During the early part of 1905 a single case appeared, and again no secondary case occurred, although the precaution of excluding 7 children who were unprotected was taken. Here, although closure undoubtedly helped, it is clear from the fact that the secondary cases came down in other classes, and that they were few in number, that the care on the part of the head mistress and teachers played the most important part. Closure can never be efficient in itself unless quick intelligence is given by keen and trained teachers. Bostall Lane School.—At this school a large number of importations of measles took place during the year. There were four class closures before the summer holidays and six afterwards. As will 67 be seen from diagram XXVII. most of these were successful in catching secondary cases; but the experience demonstrates that the more successful one is in closing the more closure must be applied, for two classes were closed no less than three times each durirg six months, and another twice in three months. Deansfielcl Road School.—This is a temporary school, consisting of three classes; a case of measles appeared in Class C on January 18th ; this class was closed from January 26th to February 4th. The first crop, however, came down equally in Classes A and B, and practically exhausted all the material. The second crop was almost negligible. Only three cases in the whole school who were reported not to have previously had measles escaped ! Although the whole school was closed upon the earliest opportunity the closure did not the least good; here again is demonstrated the effect of unhygienic school conditions on the spread of disease, practically every child taking measles at the very first opportunity (diagram XXVIII). The reliability of the histories of measles obtained on admission of children to school is a most important consideration. It has previously been pointed out (in the First Annual Report, 1903) that the similarity in the curves of the various schools, and the regular increase of the proportion of the children who have had measles as we pass from the age of 3 to that of 8 is strong presumptive evidence of the very considerable reliability of the histories. We may now apply a test from the facts gained by experience; this test depends, however, upon the amount of protection given by a previous attack of measles. Most observers agree that one attack protects the individual to a very considerable degree, probably in by far the greater majority of children the protection is absolute; but it is doubtful if a single observer would say this is invariably the case, and most medical men will assert they have seen second attacks. Let us assume, however, the position that the protection given by a first attack is absolute, and any second attack reported proves that the history of the first attack was an error. The distribution of the cases occurring during the past year amongst those reported to have had measles and those reported not to have had measles is given in the following table :— 58 Schools. No. of Children with known Histories. No. reported to have had Measles previously. No. reported not to have had Measles. Percentage of Unprotected. Cases of Measles during year. No. said to be Second Attacks. Percentage of Unprotected Children Attacked. Percentage of Children left without being Attacked. Date of Opening. Closing Schools— p. c. p. c. p. c. Purrett-road 390 267 123 31 88 8 65 8.7 1888 The "Slade" 316 209 107 32 57 4 50 15.5 1885 Ancona-road 559 282 177 32 75 2 41 18 1893 Timbercroft-road 147 82 65 37 57 4 81.5 5.5 Temporary Conway-road 589 437 152 26 23 3 13.2 21 1897 EarlBtr-eet 463 329 134 29 51 7 32.7 18 1875 Vicarager-oad 403 241 162 40 57 3 333 25 1881 Deansfieldr-oad 77 48 29 376 26 ... 90 4 Temporary Non-Closing Schools— Eglinton-road 463 322 141 30 56 4 36.5 18 1886 Mary on Park 301 140 161 53 112 11 626. 16 1896 Plum-lane 206 137 69 33 24 1 333 21 1904 Union-street 200 113 87 43 37 425 25 1884 Mulgrave-place 249 160 89 36 20 ... 22-5 27 1894 Thus out of 627 cases of measles, only 48 had been reported to have had measles before, or 7'6 per cent. If we take the outside view that all the second attacks were children wrongly reported in the first instance, we have the error as 7'6 per cent, at the greatest. The probability is that the error is much less, and this is borne out by the successful cases of individual exclusion, to which reference will be made later. The Question of Second Attacks.—Assuming that all the histories were correct, the second attacks would work out at 7'6 per cent.; they are probably, as has been explained, less than this. In the case of Union Street the child who undoubtedly set up the disease was reported to have had measles before, and had been seen by a doctor, both before and upon this occasion; although there is not the least doubt that she carried the infection into school, yet no rash was seen upon her by the doctor or the mother; she had the coryza simply and got pneumonia because the complaint was treated lightly and she was allowed to go out with inflamed bronchial passages. It is possible, therefore, that a person who has once had an attack may suffer from a slighter attack of true measles in which no rash appears; such a phenomenon is known in scarlatina and in small-pox, and there is no reason why it should not occur in measles; however, the question must remain open at present, but even if it does occur it must be so rare as to be negligible as a factor. Another case of interest in this connection is one which occurred at Conway-road on May 27th, 1904. Lilian L. was absent at the time a crop of measles was expected in the class. I visited her and found she had a temperature, a cough, suffusion of the eyes, and Koplik's spots were present in the mouth, yet no rash appeared; the mother watched carefully, and I visited on several occasions, but no rash was to be seen. She was said to have had measles before. Another child in the same class at the same time, Daisy H, (æt. 6), under precisely similar circumstances, in addition to the same symptoms, had a very fleeting measles rash which might almost have been passed by unnoticed; she also had had measles previously. The Effect of Class Closure.—An examination and comparison of the results in the closing and non-closing halves of "Woolwich, given in the above table, shows that the percentage of unprotected cases attacked varied from 13 2 per cent, to 90 per cent, in schools where closure was resorted to at the earliest opportunity, and from 22.5 per cent, to 62.6 per cent, in schools where no closure was carried out. Amongst the former class, however, Timbercroft-road, with 81.5 per cent., and Deansfield-road, with 90 per cent., are temporary buildings. Excluding these we still have Ancona-road giving 41 per cent., "The Slade" 50 per cent., and Purrett-road 65 per cent, of cases—a range higher than the average of the non-closing schools. In these schools, however, the actual first case was missed, and closure only took place on the occurrence of the "first crop." In Earl-street and Vicarage-road, where earlier knowledge was obtained, they suffered to quite as great a degree during the year as in the average of non-closing schools, while at Conway-road, in which alone any striking difference is met (only 13.2 per cent, suffering), every other condition combined to arrest the spread and the very low proportion of susceptible cases in attendance (26 per cent, of the whole) diminishes 59 the value of the experience as a test of class closure—although here it must be evident that closure of classes helped. In all these schools, however, measles tended to break out again and again, until the proportion of children was reduced to a certain degree (down to 25 per cent.), and this necessitated an amount of class closure, which was ruinous to orderly and continuous education, some classes having to close as many times as thrice in six months, and many closures took place, both at these and other closing schools, owing to false alarms. In the non-closing schools, on the other hand, only at Maryon Park is any untoward amount of measles to be noted, and here it is seen that a very large proportion of the children were unprotected (53 per cent.), which fully accounts for the excessive number of cases, which even here does not reach the percentage which was reached at Purrett-road. It will be seen that this year's experience, therefore, does not show any great preponderance of balance in favour of closing, even when closure is applied at the earliest opportunity. Under present urban conditions measles will appear in a school and spread when the proportion of children unprotected exceeds a third of the whole number, and will not subside until the proportion is reduced to a fifth of the whole number. One thing certain is that closure can never take the place of good hygienic school conditions and its corollary, teachers especially trained in school hygiene with well-developed sanitary consciences. The Spread of Measles as Affected by the Proportion of Children Unprotected.—An examination of the table shows that measles in general may be expected to appear and spread in a department when the number of children unprotected reaches about 33 per cent., and that usually, except where special conditions obtain, it ceases to spread when the proportion is reduced to 18 per cent. The Spread of Measles as Affected by School Conditions.—The enormous value of healthy surroundings in school is shown by the fact that cceteris paribus the lighter, the airier, and the less crowded a school the less is the spread of measles. In the two temporary schools of Timbercroft-road and Deansfield-road, in spite of closure at the very earliest knowledge of a single case of measles having occurred, we have the curious and melancholy parallel of 81.5 per cent, and 90 per cent, of the children unprotected attacked, and only 55. per cent, and 4 per cent, of total children left who have not had measles. These temporary buildings are incapable of even fair ventilation (I have found 30 parts per 10,000 of CO2 in one), of proper warming or hygienic class arrangement, and in view of the experience here gained it would be well to insist upon a higher area of floor space per child than in permanent schools; while there can be no doubt that the minimum of floor space per child in all Infant schools should be at least as great as in the older departments. The Spread of Measles as Effected by the Altitude of the Teachers.—We have seen that unless the very first case of measles in a susceptible class is noted and reported closure of the class fails to arrest the spread of measles, so that even here the attitude of the teacher is of prime importance. It is unfortunate that a penny wise and pound foolish attitude has been forced upon teachers from outside, and when imbued with the ideals of increasing their average attendance by every means in their power, the rough and ready principle of accepting and retaining every child regardless of the condition of its health is prone to prevail in spite of its short-sighted nature. In schools driven on this plan much spread of disease is inevitable. When, however, as fortunately often obtains, the teacher, in spite of opposition, insists upon being governed by the higher ideals which we are learning to designate as the "sanitary conscience," measles is likely to spread to a much less degree, and where this conscientiousness is united with special knowledge and training in school hygiene it is probable that we have the greatest safeguard against the spread of disease it is possible to have, and where this is combined with the best hygienic surroundings it is probable that the conditions would be more effective than school closure in confining outbreaks to their smallest dimensions. The Spread of Measles from Class to Class in School.—A glance at the diagrams is sufficient to establish the fact that more usually than otherwise the secondary attacks arising from a single case fall in more than one class-room,and that the ideas obtained from a static survey 60 of the isolated arrangement of classrooms break down in view of the dynamic methods of infant school organisation, in which sections of classes are combined for various purposes. It is probable, however, that in well-ventilated and organised schools the spread takes place more outside school hours than in the actual schoolrooms where the children are under constant supervision. Thus at Maryon Park (diagram XVII.) the infection spread from babies, not to babies, but from babies to the older children whose duty it was to superintend the comings and goings of the babies. GENERAL CONCLUSIONS. The general conclusions which the inquiry seems as a whole up to the present to justify are:— 1. Measles at present in London only spreads in classes under 5 years of age, except in certain better-class districts. Seventy-five per cent, of children above 5 in Infants' Departments are protected. 2. Measles tends to spread whenever a class accumulates unprotected members to the extent of between 30 per cent, and 40 per cent., and when spread has begun it continues until the proportion is reduced to between 15 per cent, to 20 per cent, unprotected. 3. If children under 5 were excluded from school, closure for measles would not be necessary for some time in London, except in one or two special districts; if, however, this were successful in postponing attacks, the question would again become acute in a few years. 4. To deal efficiently with measles accurate knowledge is required; the measles history should be elicited for each child on admission to school. This should be done universally; if notification to School Authority was made compulsory on every parent whose children attended school, our hands would be greatly strengthened. Unless the amount of susceptible material is fairly accurately known for each school, we shall only be working in the dark as heretofore, and nothing of any value can be expected to accrue from our methods. 5. To effect any useful purpose school closure must take place before the "first crop" falls. The old practice of waiting until the attendance fell to a certain limit was useless in arresting the spread of measles, and did absolutely no good. 6. The means of arresting spread of measles other than school closure are of enormous importance; to name two—sanitary buildings and training of teachers; these two factors probably have the greatest effect of all in determining the extent of spread of an outbreak. 7. Deaths often occur from ignorance on the part of parents. Circulars should be sent out wherever measles has appeared in a class (i.e. on the incidence of the first case) begging mothers to notice colds, and upon the slightest suspicion of such symptoms to keep the child at home for a day or two. In this way measles would probably be checked to a far greater extent than has been effected by any other means. Instances have come to our notice where heartbroken mothers have stated that, had they known, they would have treated colds seriously of which they took no note, and thereby their children's lives would have been saved. I suggest that circulars be thus used during next year in Woolwich. 8. Measles never spreads in the Boys' and Girls' Departments. There is no need to exclude children from infected homes who attend the upper departments. As a result of our inquiries, this has actually been carried out at Brighton, with satisfactory results. 9. There is too great a tendency to look at things from an "attendance" standpoint; this is one of the greatest evils with which we have to contend. The withdrawal by the Board of Education of Article 101* was the greatest piece of official folly ever perpetrated. If a whole department is closed the average attendance is not affected ; but if on the score of health a single class is closed by order of Sanitary Authority, or by the Council's Medical Officer, it is supposed that the attendances are missed, and the effect upon the average attendance and consequent grant is enormous. We thus have great difficulty in carrying out our measures, as much opposition is often encountered to the necessary closure of a single class, while the unnecessary closure of a whole department is gladly borne or even welcomed. 10. This is an economic question which is not one of health at all; and when attendance has fallen to a certain percentage at which the loss of grant is so severely affected, the department should be automatically closed independently of the question of health. This percentage ought to be worked out. Corporation of London. PUBLIC HEALTH DEPARTMENT. REPORT, SANITARY COMMITTEE RE Hairdressers' and Barbers' Establishments. 1904. Ordered to be printed 24th November, 1904. POUND,Mayor, A Common Council holden in the Chamber of the Guildhall of the City of London, on Thursday, the 24th day of November, 1904. THE Sanitary Committee did this day deliver into this Court a Report from the Medical Officer of Health, with Regulations for the conduct of Hairdressers' Saloons, prepared by him in conjunction with the Incorporated Guild of Hairdressers, Wigmakers and Perfumers; and recommending that such Regulations be approved and the necessary steps be taken to give effect thereto in the City, in accordance with the suggestions of the Medical Officer of Health, and a copy of this Report be sent to each Member of the Court. Agreed to, and referred back to the Committee accordingly. BELL. Corporation of London. PUBLIC HEALTH DEPARTMENT. Guildhall, E.C., 22nd November, 1904. To the Worshipful the Sanitary Committee. Gentlemen, It having been referred to me by your Worshipful Committee on the 27th October, 1903, to enquire as to the regulations in force in other countries for regulating the business of barber or hairdresser, I at once instituted enquiries in the matter, and a circular letter asking for the desired information was sent to the official British representative of every civilized state in the world; a similar request was also made to the agents of fourteen British Colonies. Sixty replies have now been received, viz., 46 from foreign countries and fourteen from our Colonies abroad. Those countries from which no information could be obtained were the Republics of Honduras, Costa Rica and San Marino. Speaking generally, it may be said that sanitary regulations, or statutes specially controlling barbers and hairdressers, exist in but few of the civilized countries of the world. There are none in force in any of the British Colonies, but the Board of Health of the Province of Ontario, Canada, have the matter under consideration. So far as can be ascertained Regulations of some kind or another are in operation in the undermentioned countries, viz.:— America (New York State). Bolivia. Germany (Anhalt, Waldeck, Hamburg and Danzic). Japan. Salvador. Servia. Sweden. Switzerland (Lausanne, Yevey and Rolle). Turkey. Uruguay. One would not be surprised to find Japan, Germany, Switzerland and Sweden included in the above, but it will be noted as somewhat remarkable that only one English-speaking country is in the list, and still more strange to 2 observe that Servia, Turkey, and at least three of the often abused South American States are amongst the little band of nations that lead the way in so simple and necessary a measure of hygienic control. However, such are the facts as deduced from the reports of our own and foreign consular agents, to whom I am indebted for the following particulars respecting the regulations in force in the countries referred to. NEW YORK, UNITED STATES OF AMERICA. In the State of New York an Act is in operation to regulate the practice of barbering, to establish a State Board of barber examiners, and to provide for the sanitary inspection of barbers' shops. Lancet, 3rd October, 1903. Under this law every practising barber must register and receive a licence, and must conform to certain rules and regulations. These rules enforce antisepticism in a very pronounced form. Cleanliness of the hands must be secured by washing them in an antiseptic fluid after each "shave"; razors, scissors and clippers must be treated with boiling water; powder puffs must be dispensed with; floors must be kept clean with antiseptic washing; and towels, sheets and chairs must be antiseptically clean. This law has met with little opposition, and upwards of 15,000 barbers are said to have registered in New York State. It is stated that one or two other States are petitioning for similar laws. BOLIVIA. In this country the authorities require all hairdressers and barbers to properly disinfect their premises and articles in use in their businesses. Beyond the fact that these places are supervised I have no further particulars. GERMANY. The British Consul-General at Berlin informs me that, while the control of the business of hairdresser or barber has not hitherto been made the subject of legislation for the whole extent of the German Empire of the Kingdom of Prussia, certain regulations for that purpose have been promulgated, and are in force in the Kingdom of Bavaria, and in several counties in Germany. Among the individual Federal States who have issued such regulations are— The Duchy of Anhalt, The Principality of Waldeck, Danzic, West Prussia, and The Free State of Hamburg. 3 Translations of Regulations in force in the first three of the above are appended. Extract from the Publications of the Imperial Department of Health, 1902, No. 8. Anhalt Police Regulations concerning the exercise of the trade of barber, hairdresser and haircutter, dated the 18th December, 1901 (Anhalt Government Gazette, 1901, No. 303). In virtue of the law of Police Administration of the 1st July, 1864, No. 31 of the Law Book, the following rules are issued:— Clause 1.—In the barbers', hairdressers' and haircutting rooms in all localities in which a number of persons are attended by way of business in the exercise of the barber's, hairdresser's and haircutting trade, the strictest cleanliness must prevail. Barbers', hairdressers', and haircutting rooms must not be used as sleeping places. Dogs and cats must not be allowed to remain in the same. Clause 2.—Persons suffering from a skin or hair or other contagious disease must not exercise the trade of barber, hairdresser or haircutter. Clause 3.—The shaving, hairdressing and haircutting must be carried on with clean hands only. In every barber's, hairdresser's and haircutter's shop there must be ample washing opportunity for the attendants, in such a manner, that they may at any time wash their hands with soap in pure unused water, and dry the same with a clean and dry towel. In the exercise of the barbers', hairdressers' and haircutters' trade, the persons in question must always wear a clean dress. Clause 4.—In every barber's, hairdresser's and haircutter's shop there must be at least one spittoon containing water, which has to be cleaned every day. Clause 5.—All towels, wraps, pads, protective materials and the like, used in barbers', hairdressers' and haircutters' shops must be perfectly dry and clean, and in any case free from visible dirty spots. Chairs serving for supporting the head must be covered previously with a protective material, as for instance a sheet of tissue paper. Protective materials consisting of paper are to be destroyed after having been once used. Clause 6.—Scissors, combs, razors and brushes, and all other barbers', hairdressers' and haircutters' utensils are to be cleaned thoroughly after each use, with the exception of the brushes, by washing with soap suds. The common use of cylindrical brushes for the hair, moustache bands, powder puffs and sponges is prohibited. Pads of wadding and blood-stopping materials are to be destroyed after use. Clause 7.—Persons who can be seen to suffer from a hair or skin disease of the head, vermin or any visible contagious disease, must not be attended to at any barber's, hairdressing or haircutting shop. Linen and utensils which have been used when serving such persons outside the business localities, must be thoroughly washed or boiled in strong soap suds before being used again. 4 Clause 8.—A copy of these regulations must be placed in a prominent position so as to be easily legible in every barber's, hairdresser's and haircutting shop. Clause 9.—Contravention of these Regulations on the part of such persons as carry on the trade of barber, hairdresser and haircutter, or are engaged in such trade, are punishable, in so far as no higher penalties apply, by a fine up to M 30, or in case of inability to pay, by a corresponding term of imprisonment. Clause 10.—These Regulations come into force on the 1st day of April, 1902. Dessau, 18th December, 1901. Government of the Duchy of Anhalt, Department of the Interior, MERTENS. Extract from Publications of the Imperial Department of Health, 1903, No. 2. Waldeck Police Regulations concerning the exercise of the trade of barber, hairdresser and haircutter. Dated 10th November, 1903 (Government Gazette, 1903, page 81). In virtue of the Law of 13th January, 1875 (Government Gazette, page 9), the following rules are hereby issued for the district of the principalities of Waldeck and Prymont:— Clause 1 In the barbers', hairdressers' and haircutting shops, and in the exercise of the trade of barber, hairdresser and haircutter, the proprietor of the business is bound to see to proper cleanliness. Barbers', hairdressers' and haircutting shops must not be used as sleeping places. Clause 2.—Persons suffering from a skin, hair or any other contagious disease, must not exercise the trade of barber, hairdresser and haircutter. Clause 3.—In every barber's hairdresser's and haircutter's shop, ample washing arrangements must be provided for the attendants, in such a manner that such attendants may at anytime wash their hands in clean unused water, and dry the same with a clean and dry towel. Before commencing with the shaving, hairdressing and haircutting of any person, the attendant in question must thoroughly clean his hands by washing them with soap. Clause 4.—In every barber's, hairdresser's or haircutting shop there must be provided at least one spittoon containing water, which is to be cleaned at least once a day. Clause 5.—All towels, wraps, pads, protective materials and the like, which are used in the barbers', hairdressers' and haircutting shops, must be dry and clean. The chairs supporting the heads are previously to be covered with a protective material (cloth, tissue paper or the like), the tissue paper used must be destroyed after having been once used. 5 Clause 6.—Scissors, combs, razors, brushes and all other barbers', hairdressers and haircutters' utensils must be cleaned after each use, with the exception of the brushes, by washing with soap suds. Clause 7.—The common use of sponges, powder puffs and moustache bands is prohibited, pads of wadding and blood-stopping materials are to be destroyed after use. Clause 8.—Persons suffering from a contagious hair or skin disease of the head, and particularly of ring-worm of the beard, must not be served in the barbers', hairdressers' or haircutting shops, and no utensils or linen serving for the use of other customers must be used in their case. Utensils and linen which have been used when attending such persons outside the shop, must be washed and boiled in strong soapsuds before being again used. Clause 9.—Dogs and cats must not be allowed to remain in the barbers', hairdressers' and haircutting shops. Clause 10.—A copy of these Regulations must be affixed, and made easily accessible and legible in every barber's hairdresser's and haircutting shop. Clause 11.—In case of contravention against these rules on the part of such persons as carry on the trade of barber, hairdresser and haircutter, or who are engaged in such trade, are punished, unless other and more severe penalties are imposed, by a fine up to M 30, and in case of inability to pay, by a corresponding term of imprisonment. Clause 12.—These Regulations come into force on the 1st day of January, 1903. Arolsen, 10th( November, 1902. V. SALDERN, President of the Province. Extract from the Official Gazette of the Royal Government in Danzic, 1900, No. 20. 402. Police Regulations concerning the exercise of the trade of hairdresser, barber and haircutter. In virtue of Clauses 6 f, 12 and 15 of the Law on Police Administration of the 11th March, 1850, and of Clauses 137 and 139 of the Law on the General Administration of the Province, of the 30th July, 1883, I hereby order, with the consent of the District Committee for the Government District of Danzic. as follows :— Clause 1.—In the hairdressers,' barbers' and haircutting shops, and in the exercise of the trade of hairdresser, barber and hair cutter generally, the strictest cleanliness must prevail. Hairdressers', barbers' and haircutting rooms must not be used as sleeping places. Dogs and cats must not be permitted to remain in the same. 6 Clause 2.—Persons suffering from a hair or any contagious disease must not exercise the trade of hairdresser, barber or haircutter. Clause 3. Hairdressing, shaving and haircutting must be carried on with clean hands only. In every hairdresser's barber's or haircutter's shop sufficient opportunity to wash must be given to the attendants in such a manner that the same may at any time wash their hands with soap in clean unused water, and dry the same on a perfectly clean and dry towel. Clause 4.—All towels, wraps, pads, protective materials, &c., used in hairdressing, shaving or haircutting must be perfectly dry and clean, and in any case free from visible dirty spots. Protective materials, &c., of paper are to be destroyed after having once been used. Chairs serving to support the head are to be previously covered with a protective material. Clause 5.—Scissors, combs, razors, brushes and all other hairdressers', barbers' and haircutters' utensils are to be thoroughly cleaned immediately after each use by washing with soap suds, with the exception of the brushes. The common use of moustache bands, powder puffs and sponges is prohibited. Pads of wadding and blood-stopping materials are to be destroyed after use. Clause 6.—Persons suffering from a hair or skin disease of the head, from vermin or any contagious disease must not be attended to in the hairdressers', barbers' and haircutting rooms. Towels and utensils which have been used when attending such persons outside the said business localities, must be thoroughly washed or boiled in strong hot soap suds before being again used. Clause 7.—A copy of these Police Regulations of the size of half a sheet Imperial (15 inches by 11 inches) must be affixed in every hairdresser's, barber's and haircutting shop, so that it may be easily read and noticed. Clause 8.—Contravention against these Regulations on the part of such persons as exercise the trade of hairdresser, barber or haircutter, or are engaged in this trade, are punishable, as far as no higher penalties are applicable, by a fine up to M 60, or in case of inability to pay, by a corresponding term of imprisonment. Clause 9.—These Regulations come into force on the 1st day of July, 1900. The Police Regulations concerning the same subject for the town of Pr. Stargard, of the 3rd June, 1891, are cancelled. Danzig, 5th May, 1900. PRESIDENT OF THE GOVERNMENT. 7 JAPAN. From the Acting Consul-General for Japan, I learn that Regulations are in force in that country, which are issued in the interest of the Public Health by the Head of the Police at Tokio to all the Police Authorities throughout the country, concerning the business of hairdresser or barber. These Regulations provide:— That proper care should be taken to disinfect the tools by the hairdresser or barber after each person. That strict attention should be paid to cleanliness by the hairdresser or barber to his person and premises. Also the wearing of a white garment, such as an overall, is enforced by the Police Authorities. SALVADOR. South American Republic. The establishments in which hairdressing and barbering is carried on are required to be provided with disinfecting appliances in public view, where all towels and other cloths, brushes, &c., employed in the service of customers, undergo disinfection with formalin gas. Razors, scissors, &c., are required to be treated antiseptically before being used, and customers are expected to see that it is done. SERVIA. In this country the duty of seeing that hairdressers and barbers take proper measures with regard to cleanliness of instruments, &c., devolves upon the District Medical Officer, and as shown by the following reply received from the Consul-General, this trade is under the control of Guilds as formerly obtained in England. According to an extract of the sanitary collection of laws at present in force in Servia, received from the Servian Minister of the Interior, there are two categories of hairdressers and barbers in Servia, viz.: those who have acquired a right from their Guild as master hairdressers and barbers to cut and dress the hair and shave only; and those who have, in addition to such a right, obtained also a qualification for doing smaller surgical operations, such as bleeding, choosing and applying leeches, extracting teeth, syringing, &c., having previously passed an examination before a Special Commission. The County and District Medical Officers have the authority to use all measures they may deem necessary in the interest of public health, as to the cleanliness of instruments, &e., in hairdressers' and barbers' establishments of their respective departments. i It will be seen, therefore, that Medical Officers in Servia have ample power of control over these businesses, but I am unable to say how far they are exercised. 8 SWEDEN. The British Consulate at Stockholm has favoured me with a copy of Regulations in force in Sweden, of which the following is a translation:— Instructions to prevent Infectious Skin Diseases being transmitted by Shaving. 1. Always use clean towels. 2. Lather without using a brush. 3. Disinfect the razor every time you have used it, by placing it for some minutes in a solution of 5 parts of formalin and 1 part of soda in 100 parts of water, or heating in a boiling soap-solution. 4. Carefully wash your hands before you shave a customer. 5. Use only clean cotton wool for applying powder, styptics, &c. 6. Do not shave people afflicted with diseases in their beards. 7. Assistants whose hands are not perfectly free from pimples, pustules or sores must not be allowed to shave or lather. 8. Keep the shop always clean and tidy. Stockholm, 26th May, 1899. Board of Health. See that the above instructions are strictly complied with. SWITZERLAND. Neither the Federal Government of Switzerland nor the Cantonal Governments have issued Regulations relating to the hairdressing trade, but the three towns of Lausanne, Veves and Rolle, in the Canton of Vand, have, however, prescribed Regulations on the subject, as under:— Lausanne. 1. Employees are enjoined to observe habits of cleanliness. 2. A fresh towel must be used for each customer. The head rest of the chair must be covered for each customer with a fresh towel made either of linen or paper. 3. Hair clippers, scissors, combs, and brushes must be regularly disinfected. Razors must be disinfected before and after stropping. 4. Non-removable rolling brushes, powder puffs, alum crystals, and soap in cakes are forbidden. 5. Special instructions will be issued by the Municipality on the advice of the Commission of Healthy A copy of this Regulation must be exhibited in a conspicuous place in each barber's shop. 6. Contravention of these regulations is punishable by the Municipality. The above came into lorce on the 1st day of October 1902. 9 The following are the instructions issued by the Municipality of Lausanne referred to above:— Instructions for Hairdressers in the Town of Lausanne. Several diseases of the skin, hair, or beard are due to parasites of different kinds. It is known that these affections are readily spread, and that barbers' shops that are not conducted properly often become dangerous sources of spread of diseases. To guard against such ill consequences, the Local Commission of Health has drawn up for barbers the following recommendations:— 1. The use of shelves, fittings, and tables of glass on which to rest the instruments. 2. Each subscriber ought to possess his own instruments (razors, shaving brush, comb, brush, &c.). 3. Before each operation the hairdresser ought to wash his hands with soap and water, and brush himself. 4. Hairdressers are recommended to use as a disinfectant a 2 per cent, solution of Lysol, i.e., a soup ladleful in a litre* of water. Brushes are particularly difficult to disinfect, and it is necessary to restrict their use as much as possible. The best means of sterilizing them consists in the employment of formalin vapour. 5. Face powder should always be applied by means of a pad of cotton wool, which can be destroyed after each operation, or by means of a pulverizer. 6. People afflicted with contagious hair or skin diseases (scald head or scurf) should not be shaved or have their hair cut in a barber's shop, but at their own homes. Hairdressers and their workmen suffering from any of these maladies ought not to be allowed to practice their profession. The Municipality of Lausanne ordered the printing of these instructions, and recommended their adoption on 29th August, 1902. Vevey. The Regulations in force in the Commune of Vevey are similar to the foregoing, but there is one important addition, viz.:— A hairdresser suffering from any hair or skin affection is prohibited from carrying on his calling, and a hairdresser must refuse to serve persons suffering from such disorders. Rolle. The Police Regulations in the Commune of Rolle enjoins that hairdressers must take the strictest precautions by means of cleansing and disinfection of their instruments with the object of preventing contagion. The Municipality makes frequent visits in order to see that these measures are properly carried out. *A litre equals 1¾ pints. 10 TURKEY. In March, 1901, in order to prevent contagion of skin and other diseases in barbers' shops, the Municipality of Constantinople issued the following regulations:— Barbers are to wash their hands well with soap before beginning work, and to cleanse their brushes and combs in water with 5 per cent. of soda in it. Scissors, razors, and clipping machines to be boiled in soapy water for ten minutes. All razors are to have metal handles—pending the procuring of such, razors with bone, ivory, or tortoiseshell handles are to be well rubbed with a cloth moistened with spirit. Towels to be washed every day in boiling water. Hair to be swept up with wet sand or sawdust. Spittoons to be provided in every shop. Cleanliness in every respect to be enforced. No one suffering from contagious disease to be allowed to practice as barber. Infractions of the regulations to be severely punished. URUGUAY. The following is a translation of the regulations in force in Uruguay:— National Council of Health. Ordinance No. 118. Montevideo, 26th February, 1903. The National Council of Health duly authorised thereto has resolved to modify Ordinance No. 1 on antiseptic treatment in the hairdressers' shops in the following manner:— Clause 1.—All hairdressers' instruments which are used for the service of the public, with the exception of those exclusively for private use, shall be subject to the antiseptic measures indicated in the following articles. Clause 2.—The metallic instruments, razors, combs, scissors, and mechanical apparatuses, after having served for any customer, are to be immersed for five minutes in a metallic receptacle containing boiling water, to which has been previously added a piece of soap or carbonate of soda in the proportion of 50 grams per litre of water.* The said utensils and the straps may also be disinfected by subjecting them to the action of formol vapours during 15 minutes in an apparatus controlled by the Institute of Experimental Hygiene. Clause 3.—The metallic instruments may also be disinfected in a stove with heated air by keeping them during 15 minutes in a temperature of from 100 to 110 degrees C. *This solution not only does not alter the edge and tempering of the instrument, but preserves the same from oxidation or rust. Provided that they are completely immersed they may remain for entire hours and days in the said liquid without suffering the least alteration. The disinfection is completed within ten minutes. 11 Clause 4.—Preference is to be given to the use of metallic combs and razors with metallic handles, so as to be able to disinfect the same completely by any of the above processes. Clause 5.—The use of brushes and sponges is prohibited. Clause 6.— The powder puff is replaced by an insufflator, or by cotton wool, for the application of powder to the skin. Clause 7.—No razors are passed over strops which have not been previously disinfected. Clause 8.—The cleaning of the razors when they are in use while attending a customer is made by means of a paper specially kept for this purpose, or by indiarubber blocks which are disinfected by any of the said processes. Clause 9.—The shaving brushes are immersed for a period of ten minutes in a solution o£ formol of 5 per cent. Clause 10.—On the part of the seat supporting the head of the customer is placed a towel, or a metallic or indiarubber plate which, after having served,, must be disinfected either in boiling water in the case of a metallic plate, or by a solution of bi-chloride of 1 per 1,000 in the case of indiarubber. The use of sheets of paper which are changed every time is also permitted. Clause 11.—The hairdresser must wash his hands thoroughly with a brush and soap before attending to any customer. Clause 12.—The hair which may fall on the floor is collected by means of moistened sawdust. Clause 13.—The cloths which come in contact with the skin must be washed and ironed each time after having been used. The washing basins, as well as the room, must be in a perfect state of cleanliness. Clause 14.—The present Ordinance is to be exhibited in a prominent position in all hairdressers' and barbers' shops, and will come into force in the Department of Montevideo within the period of two months, and in the other Departments of the Republic within six months of its issue. Clause 15.—Non-observance of this Ordinance will be punished by a fine of ten pesos. Clause 16.—The Economic Administration Board of the Capital and the Sectional Councils and Commissions of Health of the other Departments are charged to watch over the due fulfilment of this Ordinance, and with the application of the fines, the amount of which latter is to be paid into the coffers of the National Council of Health, with the exception of those recovered in the Capital, which are to be divided between the said Corporation and the Economic Administration Board. E. Fernandez Espiro, President. A. Crovetto, Secretary. 12 The foregoing are the only places where the trade is at present under some description of hygienic supervision, but that the question is engaging the attention of other Governments is shown from the accompanying notes relating to the several countries referred to. Austria.—A barber or hairdresser must show proof of qualification (Befahigungs-Nachweis), and produce certificates of apprenticeship, and as an assistant (Gehilfe). The advisability of subjecting these trades to hygienic control has been under consideration for some time past, but no practical steps have yet been taken in the matter. Canada.—In the Twenty-second Annual Report of the Provincial Board of Health of the Province of Ontario, Canada, for the year 1903, the details are given of some excellent work in connection with the Hygiene of Barbers' Shops that has been carried out in the Colony. The Standing Committee on Epidemics having been instructed to secure a thoroughly satisfactory settlement of the hygiene of barbers' shops, drafted some regulations and submitted them to the Board. These were subsequently forwarded for the consideration of the Barbers' Protective Association of Toronto, who in returning them informed the Board of Health that "from the standpoint of the majority of their members these "regulations should become law instead of recommendations, and asked the "Board to use their influence to that end." The Board of Health, with a view of ascertaining the best mode of disinfecting cutting instruments and tools used in a barber's trade, directed a number of experiments to be carried out, and having considered such criticism of the Toronto Barbers' Association as appeared to be valuable and worthy of adoption, as well as the experiments in disinfection, submitted the following amended regulations to the Board for adoption:— 1. A barber should be clean and neat in his person and dress, should use the bath regularly, and be particular in maintaining a healthful condition of the mouth and hands. 2. No person suffering from any disease of the skin, scalp or hair should act as a barber, nor should anyone suffering from consumption, or any disease commonly known as contagious, serve in this capacity. 3. If diphtheria, scarlet fever, small-pox, measles, or any other contagious disease should occur in the family of a barber, or among his friends or acquaintances, he should not nurse or visit the patients, nor in any way come in contact with them, and if any disease should appear in his own dwelling or boarding-house, he should temporarily change his residence. 4. Persons suffering from any disease of the skin, scalp, or hair, or from consumption, or persons who have recently recovered from diphtheria, small-pox, scarlet fever, or other contagious disease, should not visit any barber's shop or parlour, but should be attended by the barber or hairdresser at their own homes. All instruments used on such patients should be carefully disinfected after such use. 13 5. The floor of a barber's shop should be made of hard wood, or, if not so made, should be covered with sound oilcloth or other impermeable floorcovering. The floor of the shop should be frequently washed with hot water and soap. As a matter of ordinary routine, it should be mopped every morning with a damp woollen cloth. If the floor is to be swept it should first be sprinkled with dampened sawdust or wet leaves, or oiled and then swept, in order that as little dust as possible may be raised. 6. The shop or parlour should be well aired before the day's work is begun, and it should also be ventilated during the day. The shop must never be used as a dormitory. Every barber's shop should be provided with running hot and cold water. 7. The shop should be kept very clean, as should also the chairs, razors, clippers, brushes, towels and all other articles or instruments used in the business. Towels should be carefully washed and boiled, and then rinsed to remove the odour of soap. 8. Customers should be encouraged to use or have used on them their own instruments (razors, soap, brushes, &c.), and in the case of persons suffering from diseases of the skin, scalp, or hair, this practice should be compulsory. For operations on the dead body, a barber should have instruments used only for that purpose. 9. (a) Razors, clippers, and scissors may be disinfected by being boiled for ten minutes in soapy water, or in water containing a little carbonate of potassium. For this purpose the instruments should be laid in an enamelled or galvanized metal dish, and be completely covered by the water. After boiling they should be quickly cooled in cold water and carefully dried. Steel instruments boiled in the carbonate of potassium solution are not liable to rust. (b) Razors may be disinfected by being held in a stream of boiling water for thirty seconds. They should then be put into cold water for a short time and carefully dried. (c) Razors, clippers (disarticulated), and scissors may be disinfected by being exposed in a dish for fifteen minutes to the action of Hebra's spirit of soap, Spiritus Saponatus Kalinus* They should then be rubbed dry (d) Razors, clippers (disarticulated), and scissors may be disinfected by being exposed in a dish to the action of per cent. alcohol for forty-five minutes. They should then be rubbed dry. 10. Hair brushes, shaving brushes, combs, and strops may be disinfected by being first washed in a strong solution of sodium carbonate and soap, and afterwards placed in a small air-tight closet or case, in which is kept a saucer constantly filled with formalin, about one ounce of formalin to each cubic foot of space. It is recommended that all instruments be laid on racks or trays in this closet. This disinfection should be carried on every night. * Two parts of soft soap to one part of 95 per cent. alcohol, perfumed with lavender. 14 11. Shaving brushes may be entirely dispensed with, and a puff of cotton used instead, which cm be destroyed after once using. A shaving brush may be disinfected by being placed in boiling water for ten minutes before using. 12. Before passing from one customer to another, the barber or hairdresser should thoroughly wash his hands. 13. The powder puff should be replaced by the powder blower, fresh ball of absorbent cotton or clean towel. 14. A stick of alum should never be used to stop the flow of blood. A small piece of alum, after being used on a customer, should be thrown away. Astringent pencil may be used if after use it is disinfected in hot water. 15. Sponges should not be used in a barber's work, because they cannot be cleaned as a towel may be. In place of sponges, towels or balls of absorbent cotton should be used. 16. Toilet wax should not be used indiscriminately; each customer should have his own toilet wax, which should be kept in a tube. 17. The hairdresser should remove vaseline from the vessel containing it with a spatula or spoon. Preferably, vaseline put up in collapsible tubes should be used by hairdressers. 18. Only strictly clean linen towels, wrappers, &c., should be used for each customer. If a freshly-laundered wrapper cannot be supplied to each customer, a clean towel should be used in place of the wrapper. Denmark.—It is expected that in the course of some years, similar rules to those in force in German}' may be introduced into this country. Norway.—In Norway, sanitary or other regulations or statute specially affecting hairdressers and barbers do not exist, but the Sanitary Board (Sundheds Kommissioneii) have powers to superintend that no trade in general is carried on in a way which may endanger the public health. The British Consul-General at Christiania states that he is informed that the Sanitary Inspector has under consideration certain proposals to regulate the disinfection of hairdressers' and barbers' instruments. France.—There are no regulations controlling the barbers or hairdressers, but the Conseil d'Hygiene of the Seine has issued the following instructions containing suggestions as to precautions that should be taken, the chief of which are : — All razors, scissors, clipping machines, which can readily be taken to pieces, and combs, should immediately after use be heated for at least ten minutes in a vessel containing boiling soap and water. This neither injures the temper or edge of razors, and preserves steel instruments from rust; provided they are completely immersed in the liquid they can remain there several hours or even days without harm. For this purpose metal combs are recommended, and razors with nickel handles. 15 Brushes, scissors, razors and clipping machines can also be disinfected without injury by keeping them for half an hour in a stove or an oven heated from 100 to 110 degrees C. Directions are also given for disinfecting the above by means of formaldehyde. Shaving brushes should be placed in boiling water for several minutes before use. Dry powder, pulverizers or bellows should be substituted for powder puffs. A hairdresser should always wash his hands and brush his clothes before going from one customer to another. Detailed instructions are also given as to the collection and destruction of cut hair. The most scrupulous cleanliness of all linen, &c., is insisted upon. Hungary.—No regulations are yet in operation in this country. "Some, however, have been drafted by the Municipal Council, but have not been put in force in consequence of objections put forward by the Guild of Barbers, and the matter is therefore still under consideration. Mexico.—The Public Health Department has often advised the practice of hygienical preventions, but no regulations are at present in force. Peru.—The Municipal Medical Officers pay periodical visits of inspection to all the hairdressing establishments, and report whether or not they observe the ordinary rules of cleanliness and sanitation. Portugal.—His Britannic Majesty's Consul at Lisbon, writes:— "Unfortunately no regulations or statutes of any kind exist in "this country controlling in the interests of the public health the "business in question. This is undoubtedly the cause of the spread "of a good deal of infection. As a precaution against this, a great "many people keep their own combs, brushes, razors, scissors, &c., "under lock and key at their barbers." Guatemala and Liberia may be classed together. Guatemala.—The British Minister Resident states that some regulations were drawn up a few years ago for controlling the business of barbers and hairdressers in Guatemala, but that they have never been enforced, and are now a dead letter. He was unable even to obtain a copy of them. Liberia.—The reply received from Monrovia, the capital of the negro republic Liberia, West Africa, shows the characteristic failings of the race. "They have absolutely no sanitary regulations of any kind or "sort in this township, even sanitary precautions of the most " primitive kind are ignored." 16 It will be seen from the foregoing that in ten countries the trade in question is dealt with under legislative powers, and that in several others the question of placing them under control is under consideration. Although at the present time comparatively few governments have given local authorities statutory powers of control, it is evident that, in the interest of the public health, the time has arrived when such supervision should be universal. It is most desirable, therefore, that authorities in this country should also take a step in this direction, and failing statutory authority to enforce regulations, it would be advisable that in the City, at least, instructions should be issued to all barbers and hairdressers practising in it as to the best mode of conducting their businesses upon proper hygienic conditions. There are upwards of 180 hairdressers' saloons, toilet clubs, &c., in the City a large proportion of them being owned by foreigners. It must be apparent to all, that from the health point of view, there is much room for improvement in the manner in which the business is conducted in many of these establishments. The present state of things is discreditable to us as a civilised nation as a whole, and one can readily believe that the citizens only require the facts to be brought to their notice to be assured that they would then only patronise registered establishments where they would be free from any risk of infection. The proprietors of some of the elaborate and well-furnished toilet saloons in common with the owners of 1d. shaving shops, fail to take the simplest precautions that are essential for safeguarding customers from risk of infection. That they do so rather from lack of knowledge than a careless disregard of their obligations to the public is clearly the more charitable view to take, and, when once attention has been directed to the best means of improving the existing unsatisfactory and dangerous procedure, we may confidently look forward to the general employment of newer and safer methods. With this object in view, draft regulations were drawn up and presented to your Worshipful Committee. It was also suggested that they should be printed and mounted for exhibition in the premises of those barbers and hairdressers willing to give a written undertaking to carry them into effect, and on receipt of such assurance, the signatory's name and the address of his establishment would be duly recorded at this office in a "Register of Sanitary Hairdressers and Barbers." 17 Having been authorised by your Worshipful Committee on the 28th June last to place myself in communication with the Barbers' Company and the Incorporated Guild of Hairdressers, a letter was addressed to the Clerk of each of these bodies on the 30th June informing them that the matter was under the consideration of your Worshipful Committee, who, before coming to any definite decision, deemed it advisable that the views of their respective Councils should be ascertained, that I should be glad to confer with them thereon, and further that the Committee would be pleased to avail themselves of any suggestions they might have to offer. In reply, the Clerk to the Incorporated Guild of Hairdressers informed me that he had been instructed by his Court to arrange a meeting at which he himself would be present with two gentlemen appointed to assist him. He also stated that the Guild had had the matter under consideration for some time past, and that they would willingly co-operate with us. The Clerk to the Barbers' Company in replying stated that he was requested to point out that their Court of Assistants had no practical knowledge of the subject in question, and suggested the Guild of Hairdressers should be approached in the matter. At the same time he was instructed to express the appreciation of the Court of the invitation to give their views, which they would have been happy to do had there been anyone among them qualified to give the practical and technical assistance required. The decision of the Barbers' Company is much to be regretted, as I had hoped that the Company would have availed themselves of the active support of the Corporation and the public in bringing about reform in the direction indicated in your Medical Officer's Report, and thus bring themselves into line with the other City Guilds who justify their existence by taking such interest as formerly obtained in the trades controlled by them. Moreover, as the Corporation has at present no statutory power for exercising control over the trade, it would appear desirable that the Barbers' Company ascertain if they still retain powers to make Bye-laws for this purpose. In this connection it is interesting to note that it is stated in Vol. III. of the Report of the London Livery Companies Commission, 1884, that the Bye-laws made in 1708 by the United Barbers and Surgeons' Company were then in force, and although it appears that no special record has been made of the proceedings of the Barbers' Company since their separation from the joint Guild, the Barbers' Company may from time to time have exercised their power over City Barbers, even if only to a limited extent. A Conference subsequently was held, when your Medical Officer of Health fully discussed the matter with the representatives of the Guild of Hairdressers, Mr. H. A. Otto Scherf, the Master, Mr. C. J. Edney (Walter Truefitt), and the Clerk, Mr. W, J. Chamberlain. 18 It was stated at that meeting that the Guild were prepared to make Regulations which would apply to the whole country, and are desirous that their Regulations should conform in every detail with those drafted by the Corporation. With regard to registration, the Guild proposed to keep a separate Register, but your Medical Officer of Health pointed out that so far as the City is concerned the Corporation would certainly require to be furnished with a copy. It was ascertained that the Guild had in their possession evidence that the trade are generally in favour of a high standard, and that the Guild, for their own purpose, propose to add a penal clause to any Regulations they may make, stating that the name of any registered hairdresser failing to comply with the Regulations should be advertised as they may deem fit. It was further agreed that no application to be placed on the Register will be considered until the Guild have received the Certificate of the Medical Officer of Health of the Local Sanitary Authority, or some other competent Authority, that the business premises of the applicant are in a satisfactory sanitary condition. This is to be understood to mean:— (1) That all saloons are adequately ventilated and in a cleanly condition. This specially applies to those in basements. (2) That the drains have been inspected and tested, and found to be in good condition, trapped and ventilated. (All lavatory basins must be separately under-trapped). (3) That the products of combustion and fumes from all gasheated apparatus are conducted to the outer air by means of shafts or chimneys. (4) That the premises are in all other respects suitable for the purpose. Although the representatives of the Guild present at the Conference had power to settle details, they preferred to report the general character of the scheme and obtain further powers at a meeting of the Guild that was held on the 4th October, when both the Members' Warden (Mr. C. Unwin) and the Masters' Warden (Mr. T. Foakes) were added to the other delegates appointed to further confer with your Medical Officer of Health. The Guild are of opinion that after sufficent experience has been gained, the trade should be controlled by legislation, but that such legislation should be initiated by the Guild, and any legislation on behalf of Sanitary Authorities should be opposed by them. The Guild further propose to appoint their own Inspectors to see that their Regulations are complied with, but your Medical Officer made it quite clear that any Regulations applying to the City and approved of by the Corporation must be administered by their own Officers. 19 I append the Regulations, recommendations and terms of enrolment provisionally agreed to, subject to confirmation by your Worshipful Committee, and I recommend:— (i.) That the Incorporated Guild of Hairdressers, &c., be informed that these Regulations and recommendations meet with the approval of your Worshipful Committee. (ii.) That it is advisable that a Register be kept at the Guildhall of such Hairdressers, &c., as are willing to be bound by these Regulations, and to exhibit a copy of the same in their establishments. (iii.) That the certificate of sanitaiy condition required before registration be granted by your Medical Officer of Health to the Guild in respect of all such establishments within the City limits, and that the same be renewed annually. (iv). That the necessary inspection and re-inspection, so far as the City is concerned, remain in the hands of your Officers. I have the honour to be, Gentlemen, &c., &c., Medical Officer of Health for the City of London. 20 The following Regulations and Recommendations for the conduct of Hairdressers' Saloons have been drawn up by the Incorporated Guild of Hairdressers, Wigmakers and Perfumers, in conjunction with the Medical Officer of Health for the City of London. 1. All shelves, fittings and tables on which instruments are placed to be of glass, marble, slate or other similar material. 2. Clean towels, &c., to be used for each customer, and a fresh piece of paper or clean linen to be placed on the back of chair or head-rest. 3. No general powder puffs to be used, and powder pulverisers or cotton wool substituted. No sponges to be used. *4. All hairclippers, razors, scissors, combs, or other tools, after use to be placed in a disinfecting solution. 5. Razors to be wiped on paper. 6. Perfectly clean hairbrushes only must be used. *7. Shaving brushes after use to be placed in a disinfecting solution. 8. Liquid or powrdered soap or shaving cream only to be used. 9. Cut hair falling on the floor to be immediately swept up and removed, and floors to be cleansed daily. 10. No general alum crystals or blocks to be used as a styptic, but a liquid or powder applied on towel or cotton wool or by spray. 11. The most scrupulous cleanliness to be observed in all that pertains to the business. In addition to the foregoing Regulations which have to be observed, the Guild makes the following Recommendations. (a) Regular customers and subscribers should be strongly recommended to provide their own toilet articles, razors, brushes, &c., which would be exclusively reserved for the owner's use. (b) All cut hair and paper to be burned. (c) No customer apparently suffering from any skin or hair affection to be attended to save at his own house or offices, or in a private room. * The following disinfectants to be used, viz.:— Cyllin solution, in the proportion of one teaspoonful of Cyllin in one quart of water, or Izal solution, in the proportion of one teaspoonful of Izal in one pint of water. 21 (d) Charges should, if necessary, be re-modelled to enable Hairdressers,&c.r not only to comply with the letter, but the spirit of the above without loss. (e) The operator to wear a clean white garment without pockets, sleeves fitting close to wrists, and wash his hands before attending to each customer. (f) Metal combs to be used. (g) Machine or rotary brushes should be discarded. Applicants for Registration must subscribe to the following. I, the undersigned, do hereby request the said Guild to enrol my name in their Register of Hairdressers and Barbers observing the foregoing Regulations, and do hereby acknowledge that this List of Regulations has been issued to me by the said Guild, and that I will observe each and every thereof; and further, that in the event of my making or permitting any breach therein, the said Guild are at full liberty and I hereby consent to their removing my name from such Register of Hairdressers observing such Regulations, and to advertise such removal as they may think fit. Dated this day of , 1904. The names and business addresses of proprietors of Hairdressing and Barbers' establishments in the City of London, who are enrolled by the above Guild, will be officially recorded in the Public Health Department, Guildhall, E.C., as "Registered Hairdressers or Barbers." Memorandum. Previous to registration, a Certificate will be required from the Medical Officer of Health, stating that the premises are in good sanitary condition. Charlos Skipper & East, Printers, 49, Great Tower Street, E.C.