43/4 LCC 14 London Counts 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 1905 (Printed hy order of the Council, 17th July, 1906.) PRINTED BY SOUTH WOOD, SMITH & CO., LTD., 93 AND 94, LONG ACRE, W.C 11476 London Counts Council. Report of the Public Health Committee submitting the report of the Medical Officer of Health of the County of London for the year 1905. In submitting the report of the Medical Officer of Health of the County of London for the year 1905 we desire to make the subjoined observations on the valuable and interesting information contained in the report. Death-rate.—We observe with satisfaction the continued fall in the London death-rate, the rate for the year 1905 being the lowest on record since registration of deaths was made compulsory. We point out that the death-rate has fallen from 21.0 to 15.1 per 1,000, or nearly 30 per cent., since the coming into operation of the Public Health (London) Act, 1891, which brought the Council into more direct relation with sanitary administration in London. These percentages, however, do not themselves convey their full meaning to the majority of readers, but an easily comprehended statement is that made by the Medical Officer that in 1905, compared with the decennial period 1891-1900, there was, as the result of the diminished death-rate, an estimated gain to the community of 19,584 lives. The continuance of a high rate of infant mortality, while the mortality at all ages has declined, is discussed in the report, and the Medical Officer shows reason for thinking that this is, at any rate in some important degree, due to a more complete registration of the death of infants which survive their birth but a brief period, for the maintenance of the high rate is largely accounted for by extensive mortality in very young infants, and among this class the high rate appears to be in the main explained by increase in the number of deaths registered as due to premature birth, congenital defects, and some other headings. Important support of this view is afforded by the fact that, while social conditions, measured by the amount of "overcrowding," appear to govern the degree of infant mortality in the several parts of London, this is not observable in the mortality occurring within the first few weeks after birth—a fact probably due in part to the less complete registration of the death of new-born infants which might, perhaps, be expected in the most overcrowded districts, and which would presumably manifest itself by causing fewer returns to be made under the headings above named. Epidemic diseases.—There were only 74 notified cases of smallpox during 1905, the disease being at a comparatively low ebb after the wave of prevalence in 1901-02. The behaviour of measles is being watched with special interest, inasmuch as the order of the Council applying certain provisions of the Public Health (London) Act to measles has now been in force for some years, and, as the result of the Council's action, more endeavours have been made to prevent spread of this malady. It is as yet too soon to speak confidently as to the effect of the order. The Medical Officer analyses the results of the inquiries made in certain parts of London as to the effect of aggregation of children upon the prevalence of measles, and of the experience recorded in London schools (see Appendix II.). No conclusive result can as yet be said to have been reached in connection with the attempt which is being made to test the value of school closure in Woolwich by dividing the district into two parts, in one of which school closure is adopted, while in the other it is not. Further particulars of the variations in the age incidence of measles mortality in London are given in Appendix I., in which are also given the figures relating to some other infectious diseases, including diphtheria. The practicability of taking further steps for limiting the mortality from phthisis is engaging our attention, and we note that in 19 out of the 29 sanitary districts voluntary notification of this disease is in force. We shall be in a better position later to ascertain how far further steps may be desirable to bring to the knowledge of the several borough medical officers of health the existence of cases of phthisis in their districts. We note that the rate of mortality from phthisis during the year 1905 is reduced to one-half that for the decennial period 1861-70. The deaths recorded as being due to cancer, which in London, as in England and Wales generally, underwent such marked increase during the last twenty years of the nineteenth century, probably as the result of improvement in diagnosis, have, it is interesting to observe, remained practically stationary during the last few years. The Medical Officer has examined the death-rates (corrected for age and sex distribution) in groups of sanitary areas with varying degrees of overcrowding, and finds in them confirmation of the conclusion already arrived at, as the result of similar inquiry relating to the period 1901-4, that there is no evidence of relationship between cancer mortality and social condition. In this respect cancer stands in marked contrast to phthisis. Milk supply.—The administration of the authority, conferred on the Council by its General Powers Act of 1904, with regard to tuberculous milk has been continued under our direction, and the Medical Officer in his report affords details of such administration. The quantity of milk produced in London cowsheds, however, is but a mere fraction of that which comes into the county to supply the needs of its inhabitants, and we anxiously await the further authority, which the Council has decided to ask Parliament to confer, with the view of securing that milk supj)lied to the community shall be wholesome. Removal of refuse.—The need for systematic control over the removal of offensive trade refuse has long been evident, and we observe that in the districts of Finsbury, Greenwich, iv. Wandsworth and Woolwich the sanitary authorities have formulated schemes for the regular collection and removal of such refuse. Houses let in lodgings.—We regret that in several instances sanitary authorities appear to be lax in administering their powers of registration of houses let in lodgings. Houses infested with vermin.—We are pleased to remark the substantial use which the Medical Officer reports has been made by the majority of sanitary authorities of the authority conferred upon them by section 20 of the Council's General Powers Act of 1904 with regard to the cleansing of houses infested with vermin. Common lodging houses.—The report contains interesting statistics as to the number of persons housed in common lodging houses and of the persons in London apparently homeless. It also contains a table giving the death-rates of males of various ages living in common lodging houses, from which it appears that the total rates of mortality from all causes are for most age periods more than double those among Londoners (males) generally ; phthisis and bronchitis are the causes of death which especially contribute to this excessive mortality in the common lodging houses. Factories and workshops.—We are gratified to note that, as a result of the efforts of sanitary authorities, workshops are reported to be in a better condition than formerly, but we regret that several matters still require to be remedied. The order of the Secretary of State made in August, 1905, appears to have produced useful results. Inspection of food.—The Medical Officer in his report devotes considerable space to the important question of food inspection, and details the efforts made by sanitary authorities to prevent the consumption of unsound food. He lays stress on the fact that the absence of adequate administration for the purpose of meat inspection affords opportunity for the importation into London of meat which would not be allowed to be consumed in any continental city where meat is brought under inspection. This is a matter to which we have devoted great attention, and we hope that the desired authority may be conferred by the passing of the Public Health (Regulations as to Food) Bill, introduced into Parliament, in the session of 1906, by the President of the Local Government Board. R. M. Beaton, Chairman. County Hall, Spring Gardens, S.W., 13th December, 1906. FOURTEENTH ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH OF THE ADMINISTRATIVE COUNTY OF LONDON. TABLE OF CONTENTS. part I. page Populations 5 Marriages 5 Of minors per cent. of total marriages 5 Births 6 Rates per 1,000 persons living and per 100 married females (aged 15-45) in sanitary areas 6 Rates in registration districts per 1,000 persons living in successive decennia 7 Comparative figures for certain large towns 8 In relation to overcrowding 9 Deaths 9 Rates in large English towns 9 Rates in certain foreign cities 10 Rates in the several London sanitary areas 10 Deaths at ages in London sanitary areas 11 London mortality in 1905 compared with the mortality in the decennium 1891-1900 11 Infant mortality 13 Deaths at "all ages" from certain diseases and groups of diseases 19 Rates from specified causes in London sanitary areas 20 Principal epidemic diseases 20 Smallpox and vaccination 22 London vaccination returns 25 Number of certificates of conscientious objection per cent. of births 26 Measles 26 In relation to overcrowding 28 Scarlet fever 31 Scarlet fever and elementary schools 33 Age and sex distribution 34 Diphtheria 35 Comparative case rates in London sanitary areas 36 Diphtheria and elementary schools 37 Age and sex distribution 38 Whooping cough 39 Typhus 41 Enteric fever 42 Age and sex distribution 43 Diarrhœ 44 Erysipelas 45 Puerperal fever 47 Influenza, bronchitis and pneumonia 48 Phthisis 48 Death rates in London sanitary areas 49 In relation to overcrowding 50 Cancer 51 Death rates in London sanitary areas 51 In relation to overcrowding 53 Cerebro-spinal fever 54 Anthrax 54 Glanders 54 Meteorology 54 Part II.— Dairies, cowsheds and milkshops 55 Tuberculosis of the udder in cows 55 Offensive businesses 57 Nuisances 59 Smoke nuisances 59 Nuisance from stable manure 59 Removal of house refuse 60 Removal of offensive matter 60 Nuisance from sewers 61 Nuisance from rivers and canals 61 Housing of the Working Classes Act, 1890 61 Proceedings under Part I. of the Act 61 Proceedings under Part II. of the Act 62 Scheme undertaken by a district council under Part II. of the Act, the County Council contributing to the cost 62 Proceedings under Part III. of the Act 62 Housing in connection with street improvements 62 Proceedings by district councils under Part III. of the Act 63 Proceedings in respect of houses represented under Part II. of the Act ai unfit for human habitation 63 Death rates among persons resident in County Council dwellings 64 Houses let in lodgings 64 Houses infested with vermin 65 11476 A 2 TABLE OF CONTENTS—Continued. page Common lodging houses 65 Common lodging-house population and vagrancy 67 Vacant accommodation in common lodging-houses on night of 17th February, 1905 67 Death rates among inmates of common lodging-houses 69 Accommodation of aliens newly arriving in or passing through London 70 Seamen's lodging houses Revenue Act, 1903 70 Underground rooms 71 Overcrowding 71 Factory and Workshop Act, 1901 72 Table showing proceedings of London sanitary authorities under the Factory and Workshop Act 74 Inspection of food 76 Sale of ice cream 78 Disinfection 79 Shelters 79 Mortuaries 80 Cleansing of Persons Act, 1897 80 London water supply 84 Water supply to tenement houses 85 Report of the Inter-departmental Committee on Physical Deterioration 86 London Equalisation of Rates Act, 1894 86 Midwives Act, 1902 87 Medical Officers of Health of London sanitary areas 91 Appendices— I.— Variations in the age incidence of certain of the principal epidemic diseases. II.— Report of the Medical Officer (Education) for the year ended 31st March, 1906. III.— Report on fried-fish shops, fish curers' and marine store dealers' premises. IV.— Report on certain recommendations of the Inter-departmental Committee on Physical Deterioration. LIST OF DIAGRAMS. facing page. Diagram I.— Marriages, 1851-1905 5 „ II.— Births, 1851-1905 5 „ III.— Deaths ("all causes")1841-1905 9 „ IV.— Infant mortality, 1858-1905 13 ,, V.— Smallpox (deaths) 1841-1905 22 ,, VI.— Measles (deaths) 1841-1905 27 ,, VII.— Measles und Whooping cough (monthly deaths) 1891-1905 30 „ VIII.— Scarlet fever (deaths') 1859-1905 31 ,, IX.— Scarlet fever (admissions to hospitals of Metropolitan Asylums Board, per cent. of total notified cases in London) 1890-1905 31 ,, X.— Scarlet fever (monthly notified cases and case-mortality) 1891-1905 32 „ XI.— Diphtheria and croup (deaths) 1859-1905 35 ,, XII.— Diphtheria (admission to hospitals of Metropolitan Asylums Board per cent. of total notified cases in London) 1890-1905 35 ,, XIII.—Diphtheria (monthly notified cases and case-mortality) 1891-1905 36 ,, XIV.—Whooping cough (deaths) 1841-1905 39 „ XV.—Typhus (deaths) 1869-1905 41 „ XVI.—Enteric fever (deaths) 1869-1905 42 ,, XVII.—Enteric fever (weekly notified cases, 1905, and mean weekly notified cases, 1890-1905) 42 „ XVIII.—Enteric fever (monthly notified cases and case-mortality) 1891-1905 43 „ XIX.—Diarrhoea, dysentery and cholera (deaths) 1841-1905 44 Diagram I. Marriages. Diagram II. Births. REPORT OF THE MEDICAL OFFICER OF HEALTH. 1905 . PART I. The temperature of the air was, on the whole, slightly above the average during 1905, but excess of temperature was limited to February, March, April, May, June, July, and December. The rainfall was, on the whole, below the average, but there was excess of rainfall in March, April, June, August, September, and November. The marriage rate (16.9) was the same as obtained in the years 1887 and 1888, being the lowest rate on record in London. The birth-rate (27.1), and the death-rate (15.1) were the lowest on record in London since the institution of civil registration. The number of deaths from diseases of the respiratory organs were considerably below the average of the preceding ten years. The deaths from phthisis, diphtheria, diarrhoea, measles and whooping cough were markedly below the average, the death-rates of phthisis and whooping cough (1.42 and 0.32 respectively) being the lowest on record in London. The deaths attributed to cancer were in excess of the ten years average. Population. The populations of the Administrative County of London estimated to the middle of the year 1905 was 4,084,794. The populations 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 1905, are shown in the following table— Sanitary area. Estimated population, middle of 1905. Sanitary area. Estimated population, middle of 1905. Sanitary area. Estimated population, middle of 1905. Paddington 147,935 Stoke Newington 52,828 Bermondsey 129,006 Kensington 180,083 Hackney 228,479 Lambeth 313,045 Hammersmith 119,037 Holborn 56,481 Battersea 177,532 Fulham 157,210 Finsbury 98,207 Wandsworth 265,392 Chelsea 74,496 London, City of 22,425 Camberwell 271,240 Westminster, City of 175,606 Shoreditch 116,565 Deptford 114,495 St. Marylebone 129,453 Bethnal Green 130,401 Greenwich 103,493 Hampstead 88,142 Stepney 305,466 Lewisham 144,420 St. Pancras 236,183 Poplar 170,280 Woolwich 125,372 Islington 342,994 Southwark 208,528 Marriages. The number of marriages in the Administrative County of London in 1905 (52 weeks) was 39,631, giving an annual rate of persons married of 16.9 per 1,000 persons 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 1905 16.9 The accompanying diagram I. shows the marriage rate in each year since 1850, in relation to the mean marriage rate of the period 1851-1905. In the year 1905 among the males 3.6 per cent. married were under 21 years of age, and among the females 13.0 per cent.; the figures for previous years are shown in the following table, the proportions in England and Wales being also given for the purpose of comparison— Marriages of minors per cent. of total marriages. Period. London. England and Wales. Males. Females. Males. Females. 1851-60 2.8 11.9 5.7 18.0 1861-70 3.6 14.6 6.8 20.1 1871-80 4.7 16.9 8.0 22.0 1881-90 5.5 18.9 6.8 20.7 1891-1900 4.7 16.5 5.4 17.5 1901 4.4 15.0 5.0 16.0 1902 4.0 141 4.7 15.4 1903 3.8 13.7 4.6 15.2 1904 3.7 13.9 4.6 15.3 6 BlRTHS. The number of births registered in the Administrative County of London in 1905 (52 weeks) was 126,620, giving a birth-rate of 27.1 per 1,000 persons living per annum. The steady decline in the London birth-rate noted in previous reports has continued, and the birth-rate for 1905 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 1905 27.1 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 1905 27.2 The accompanying diagram (II.) shows the London birth-rate in each year since 1850, in relation to the mean birth-rate of the period 1851-1905. 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 1901-4 and for the year 1905 (52 weeks):— Sanitary area. Births, 1905. Birth-rate per 1,000 persons living. Births per 100 married females aged 15-45. 1901-4. 1905. 1901-4. 1905. Paddington 3,185 22.7 21.6 19.9 18.9 Kensington 3,458 19.8 19.3 19.3 18.8 Hammersmith 3,110 26.8 26.2 21.4 20.9 Fulham 4,760 32.7 30.4 22.9 21.3 Chelsea 1,583 21.5 21.3 20.0 19.8 Westminster, City of 2,940 17.2 16.8 16.4 15.9 †St. Marylebone 3,879 30.2 30.0 27.4 27.3 Hampstead 1,421 17.5 16.2 16.9 15.7 St, Pancras 5,811 26.7 24.7 21.2 19.6 Islington 8,604 26.8 25.2 21.1 19.8 Stoke Newington 1,078 21.6 20.5 18.4 17.4 †Hackney 5,884 28.0 25.8 23.2 21.3 Holborn 1,603 28.2 28.5 24.3 24.5 †Finsbury 3,398 36.8 34.7 28.9 27.2 London, City of 302 13.8 13.5 16.3 16.0 Shoreditch 3,897 33.5 33.5 26.5 26.5 Bethnal Green 4,321 35.2 33.2 28.1 26.5 †Stepney 10,744 37.4 35.3 29.6 27.9 Poplar 5,449 34.0 32.1 27.5 26.0 Southwark 6,250 32.6 30.1 24.5 22.6 Bermondsey 4,289 33.0 33.3 26.7 26.9 †Lambeth 8,838 29.6 28.3 23.5 22.5 Battersea 4,843 28.6 27.4 21.3 20.4 Wandsworth 6,892 26.5 26.0 21.8 21.4 Camberwell 6,937 27.7 25.6 22.8 21.1 Deptford 3,289 29.9 28.8 23.1 22.3 Greenwich 2,676 27.6 25.9 23.3 21.9 Lewisham 3,633 25.8 25.2 21.2 20.8 Woolwich 3,546 30.0 28.4 22.5 21.3 London 126,620 28.5 27.1 23.2 22.1 †Lying-in institutions are situated in these districts. The number of births occurring in these institutions during the year 1905 was as follows:—St. Marylebone, Queen Charlotte's Living-in Hospital, 1580; Hackney, Salvation Army Maternity Hospital, 231; Holborn, British Lying-in Hospital, 484; Finsbury, City of London Lying-in Hospital, 622; Stepney, East-end Mothers' Home, 377; Lambeth, General Lying-in Hospital, 614, and Clapham Maternity Hospital, 403. 7 The decline in the birth-rate which has been manifest since the decennium 1871-80, has not been equally conspicuous in all parts of London. Indeed, during the decennium 1891-1900, the birthrate has been greater in the registration districts of Whitechapel and St. George-in-the-East than in 1871-80, a result probably indirectly due to alien immigration. In all other registration districts the birth-rate has declined, as will be seen from the following table:— London. Birth-rates per 1,000 persons living in successive decennia. Registration District. Birth-rate per 1,000 living. 1851-60 = 100. 1851-60 1861-70 1871-80 1881-90 18911900 1851-60 1861-70 1871-80 1881-90 18911900 Paddington 29.56 30.85 31.35 28.85 26.70 100 104 106 98 90 Kensington Fulham Chelsea 31.95 33.03 33.16 34.42 27.14 100 103 104 108 85 S. George's,Han.-squares 28.51 29.12 27.20 24.13 20.35 100 102 95 85 71 Westminster Strand St. Marylebone 30.63 32.72 32.13 31.78 30.39 100 107 105 104 99 Hampstead 23.58 24.72 23.99 23.34 20.08 100 105 102 99 85 St Pancras 33.53 35.08 35.15 32.16 29.12 100 105 105 96 87 Islington 33.44 36.58 36.09 32.37 29.04 100 109 108 97 87 Hackney 31.37 32.97 33.67 31.55 28.94 100 105 107 101 92 St. Giles 33.22 34.20 34.05 31.61 28.52 100 103 102 95 86 Holborn 36.38 38.09 37.63 36.23 34.93 100 105 103 100 96 City of London 28.33 26.92 23.92 19.41 16.62 100 95 84 69 59 Shoreditch 39.66 40.70 40.69 38.46 35.58 100 103 103 97 90 Bethnal-green 38.64 41.87 41.75 40.07 37.13 100 108 108 104 96 Whitechapel 34.97 34.57 36.42 35.12 39.81 100 99 104 100 114 St. George-in-the-East 37.98 39.39 38.99 40.31 42.46 100 104 103 106 112 Stepney 34.50 34.59 36.97 36.48 33.69 100 100 107 106 98 Mile End 37.42 39.41 40.73 38.29 38.04 100 105 109 102 102 Poplar 39.62 42.37 41.22 38.26 35.26 100 107 104 97 89 St. Saviour, Southwark 36.26 37.27 38.84 36.66 34.70 100 103 107 101 96 St. Olave, Southwark 36.79 38.99 41.12 37.80 35.64 100 106 112 103 97 Lambeth 35.25 37.44 37.49 34.47 31.88 100 106 106 98 90 Wandsworth 30.05 32.94 34.10 33.47 28.72 100 110 113 111 96 Camberwell 31.66 34.66 34.78 33.90 29.73 100 109 110 107 94 Greenwich 32.47 36.87 34.54 32.50 29.58 100 114 106 100 91 Lewisham Woolwich London 33.6 35.4 35.4 33.2 30.3 100 105 105 99 90 It is interesting to note that the decline in the birth-rate is manifest in many of the principal European towns, as will be seen from the following table, in which the birth-rate of the first year shown in the table is taken as 100, and that of subsequent years stated in proportion. The behaviour of the birth-rate in Dublin appears to be exceptional so far as the towns selected are concerned:— 8 Birth-Rates. Comparative figures for certain large towns. 1881-1905. Towns. 1881 1882 1883 1884 1885 1886 1887 1888 1889 1890 1891 1892 1893 1894 1895 1896 1897 1898 1899 1900 1901 1902 1903 1904 1905 London 100 99 99 99 96 96 95 93 92 89 92 89 89 87 88 87 87 86 85 84 84 82 82 80 78 Paris 100 92 94 94 89 89 89 89 90 84 83 82 83 82 79 76 78 77 77 77 70 68 67 64 64 Brussels 100 99 97 92 87 88 85 83 83 78 80 77 75 74 70 73 73 71 68 68 66 66 59 57 55 Amsterdam 100 103 103 103 102 102 100 100 95 94 94 92 91 86 85 82 83 81 81 78 80 78 77 74 72 Copenhagen 100 99 101 100 98 95 93 91 91 86 84 79 78 75 78 78 75 76 75 75 74 67 73 71 72 Stockholm – – 100 106 100 105 100 98 95 93 92 85 84 80 80 78 75 78 75 75 73 73 68 69 71 St. Petersburg – – – – – – – – – – – – 100 101 99 105 107 90 89 84 81 81 93 94 93 Berlin 100 99 94 91 90 88 87 89 83 81 86 77 77 75 69 72 72 71 69 71 71 – 66 66 66 Vienna 100 95 94 90 89 87 86 85 86 83 84 81 84 80 78 77 75 77 75 73 73 75 73 72 69 Home – 100 104 106 107 107 116 108 112 103 102 95 94 91 89 86 85 80 81 80 87 – 88 90 84 Christiania 100 99 86 88 88 90 85 76 67 57 50 61 48 44 34 33 27 – 97 101 94 92 96 83 80 Glasgow 100 103 103 106 102 102 99 98 99 97 94 91 91 88 88 90 90 90 89 87 84 85 85 83 80 Dublin 100 , 100 98 99 99 100 96 97 96 92 98 96 99 98 99 103 101 107 105 102 95 99 99 102 102 Where — is inserted in this table, no information as to the birth-rate was obtained. Diagram III . Deaths (All Causes.) 9 The following table has been prepared with a view to showing the relation of the birth-rate to social conditions of the population. The rates are shown for groups of sanitary areas arranged with regard to the proportion of the population living more than two in a room in tenements of less than 5 rooms as shown by the census figures of 1901. The birth-rates have been calculated upon the number of married females aged 15-45 years in each group of districts, but inasmuch as the addresses of mothers in lying-in institutions have not been ascertained no correction has been made for the births occurring in such institutions. The probable effect of this error would be to increase the birth-rate to some extent in groups II. and V., and to a greater extent in group IV. No. of Group. Proportion of population living more than two in a room in tenements of less than five rooms. Birth-rate in each group per 100 married females, aged 13-45. I. Under 7.5 per cent. 2.03 II. 7.5 to 12.5 „ 2.14 III. 12.5 to 20.0 „ 2.08 IV. 20.0 to 27.5 „ 2.25 V. Over 27.5 „ 2.73 Broadly speaking, and subject to the reservation as to the necessity for distributing the births in lying-in institutions, the figures show that the birth-rate is higher in the more overcrowded groups of districts. Deaths. The number of deaths in the Administrative County of London in 1905 (52 weeks) was 70,442, giving au annual death rate of 151 per 1,000 persons living. The London death-rate in successive periods has been as follows:— All causes—Death-rates per 1,000 persons living. 1841-50 24.8 1901 17.11 1851-60 23.7 1902 17.21 1861-70 24.4 1903 15.2l 1871-80 22.5 1904 16.11 1881-90 20.5 1905 15.11 1891-1900 19.11 The death-rate in each year since 1840 in relation to the mean death-rate of the period 1841-1905 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 1905. Towns. Estimated Populalion middle of 1905. Crude death-rate per 1,000 persons living. Death-rate per 1,000 persons living (corrected for age and sex distribution). 1895-1904. 1905. 1895-1904. 1905. London 4,684,794 18.22 15.62 19.1 16.4 Liverpool 730,143 23.2 19.6 24.8 21.0 Manchester3 631,185 22.6 18.0 25.2 20.1 Birmingham 542,959 20.2 16.2 21.7 17.4 Leeds 456,787 19.1 15.2 20.8 16.6 Sheffield 440,414 19.6 17.0 21.1 18.3 Bristol 358,515 16.9 14.6 17.4 15.0 West Ham 294,997 17.8 14.8 19.0 15.8 Bradford 286,799 17.7 15.2 19.6 16.8 Newcastle 264,511 20.9 16.8 22.5 18.1 Hull 258,127 18.8 16.3 19.3 16.7 Nottingham 251,671 18.4 16.5 19.4 17.4 Salford 231,514 22.6 16.9 25.0 18.7 Leicester 228,132 16.7 13.3 17.8 14.2 London had therefore (comparing the corrected death-rates) both in the decennium 1895-1904 and the year 1905 a lower death-rate than any of these towns excepl Bristol. West Ham 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. 3 As extended in 1904. 11476 B 10 The following table enables comparison to be made of the death-rates of London with the death-rates of several foreign cities1:— All causes—Death-rates per 1,000 persons living. Towns. 1895-1904. 1905. Towns. 1895-1904. 1905. London 18.22 15.62 St. Petersburg 25.9 25.0 Paris 19.2 17.4 Berlin 17.8 17.2 Brussels 16.7 14.5 Vienna 20.4 19.3 Amsterdam 15.9 13.8 Rome 19.1 20.6 Copenhagen 17.3 16.3 New York 20.2 18.3 Stockholm 16.5 15.9 It will be seen that in the decennium 1895-1904 the London death-rate was exceeded by the death-rates of Paris, St. Petersburg, Vienna, Rome and New York, and in 1905 was lower than that of any except Brussels and Amsterdam. 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 1905; the mean death-rates for the period 1901-48 are also shown for the purposes of comparison. Crude and corrected death-rates,4per 1,000 persons living, in the County of London, and the several sanitary districts. Standard deathrate. Factor for correction for age and sex distribution. Crude death-rate. Corrected death-rate. Comparative mortality figure (London, 1,000). 1901-4. 1905. 1901-4. 1905. 1901-4. 1905. England and Wales 18.19 1.0000 – – – – – – London 17.31 1.0511 16.4 15.1 17.2 15.9 1,000 1,000 Paddington 17.04 1.0677 14.0 13.3 14.9 14.2 866 893 Kensington 16.88 1.0778 14.7 14.0 15.8 15.1 919 950 Hammersmith 17.47 1.0414 15.8 13.9 16.5 14.5 959 912 Fulham 17.39 1.0462 15.6 15.1 16.3 15.8 948 994 Chelsea 17.56 1.0361 16.6 14.8 17.2 15.3 1,000 962 Westminster, City of 16.22 1.1217 14.8 13.5 16.6 15.1 965 950 St. Marylebone 17.08 1.0652 16.9 15.5 18.0 16.5 1,047 1,038 Hampstead 16.13 1.1280 10.4 9.3 11.7 10.5 680 660 St. Pancras 17.40 1.0456 17.6 15.8 18.4 16.5 1,070 1,038 Islington 17.51 1.0391 15.5 14.5 16.1 15.1 936 950 Stoke Newington 17.43 1.0438 13.1 12.9 13.7 13.5 797 849 Hackney 17.46 1.0420 14.9 14.0 15.5 14.6 901 918 Holborn 16.90 1.0766 19.6 17.5 211 18.8 1,227 1,182 Finsbury 17.57 1.0355 21.5 19.0 22.3 19.7 1,297 1,239 City of London 16.55 1.0993 18.0 17.4 19.8 19.1 1,151 1,201 Shoreditch 17.34 1.0493 20.6 19.7 21.6 20.7 1,256 1,302 Bethnal.green 18.01 1.0102 19.7 18.6 19.9 18.8 1,157 1,182 Stepney 17.41 1.0450. 19.7 17.7 20.6 18.5 1,198 1,164 Poplar 17.64 1.0314 19.0 17.6 19.6 18.2 1,140 1,145 Southwark 17.41 1.0450 20.3 18.5 21.2 19.3 1,233 1,214 Bermondsey 17.76 1.0244 20.0 18.7 20.5 19.2 1,192 1,208 Lambeth 17.63 1.0320 16.4 14.9 16.9 15.4 983 969 Battersea 16.96 1.0728 15.0 14.5 16.1 15.6 936 981 Wandsworth 17.25 1.0547 13.2 12.6 13.9 13.3 808 836 Camberwell 17.54 1.0373 15.4 13.7 16.0 14.2 930 893 Deptford 17.31 1.0511 16.0 14.3 16.8 15.0 977 943 Greenwich 17.82 1.0210 14.6 13.4 14.9 13.7 866 862 Lewisham 17.46 1.0420 12.4 11.7 12.9 12.2 750 767 Woolwich 17.02 1.0690 14.4 12.8 15.4 13.7 895 862 With regard to the foregoing table, it may be stated that a more accurate method of correcting for diSerences in the age and sex constitution of the populations compared than that adopted, i.e., the calculation of an age and sex factor, is that of applying the death.rates at each age-period to a standard population. The method adopted, however, has the advantage of easier application and involves less arithmetical labour, inasmuch as the factor when calculated may be applied each year during an intercensal period; the method also has the advantage of being applicable where the death-rates at the several age-periods are not obtainable. The difference in the results obtained from the use of the tw o methods in question is, however, so slight as to be negligible for practical purposes where the age and sex distribution of the populations compared are not markedly abnormal, thus the London death-rate 1 All death-rates in this report relating to foreign cities are calculated upon figures publishen by the registrar General. 2 See footnote (2), page 9. 3 Owing to the changes consequent upon the London Government Act, 1899, the death-rates in the 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 9). 11 for 1905, corrected by the factor given in the preceding table (a factor which is based on the age and sex constitution of the mean population of England and Wales in the decennium 1891-1900) works out at 15.85 per 1,000 living, while the application of the London death-rates in 1905 at the several ageperiods to the mean population of England and Wales 1891-1900 (taken as a standard population) gives a death-rate of 15.87 per 1,000 living, a difference of 0.02 or 0.13 per cent. Judging by the amount of deviation from unity of the several "correction factors" shown in the table, it will be seen that the most abnormal population among the sanitary areas from the point of view of its age and sex constitution is that of Hampstead, the "correction factor" for which is 1.1280. I have, therefore, worked out the corrected death-rate for 1905 for this district by the two methods referred to, the results giving death-rates of 10.54 and 10.40 respectively, a difference of 0.14 or 1.3 per cent. This percentage may be taken to represent the maximum amount of error so far as the London boroughs are concerned, introduced by the use of the "factor" method in preference to the more accurate method of applying the death-rates at each age to a standard population. The following table shows the number of deaths1 occurring at several ages in each of the sanitary areas of the Administrative County of London during the year 1905 (365 days)— Age-period. 0- 1- 2- 3- 4- Under 5. 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 & upwards All ages. Paddington 394 112 36 24 15 581 25 20 30 45 90 149 201 264 288 204 72 1,969 Kensington 500 154 59 21 27 761 37 32 39 55 133 181 242 337 337 264 101 2,519 Hammersmith 422 91 30 25 17 585 32 13 24 40 83 108 152 211 211 141 46 1,646 Fulham 695 182 78 35 30 1,020 51 20 38 52 129 169 219 218 220 168 52 2,356 Chelsea 184 29 16 12 6 247 14 10 17 18 68 102 119 175 171 130 32 1,103 Westminster, City of 334 87 41 18 13 493 30 21 23 63 173 221 310 328 342 275 88 2,367 St. Marylebone 342 115 41 15 12 525 31 14 28 45 93 166 257 278 284 225 54 2,000 Hampstead 134 32 6 8 10 190 10 7 16 21 55 75 74 92 128 113 39 820 St. Pancras 783 247 73 46 32 1,181 76 40 46 91 229 302 370 458 479 366 76 3,714 Islington 1,075 340 110 74 44 1,643 86 32 71 115 316 374 535 597 644 398 151 4,962 Stoke Newington 131 42 17 7 2 199 11 7 11 12 36 47 56 89 102 76 31 677 Hackney 760 212 94 45 30 1,141 77 36 65 63 174 207 296 372 400 278 96 3,205 Holborn 147 38 19 11 6 221 14 5 15 17 75 103 138 153 146 80 15 g82 Finsbury 428 149 51 28 18 674 35 22 30 33 82 165 174 208 237 168 31 1,859 London, City of 44 10 – 2 – 56 4 2 6 9 22 31 53 71 67 55 17 393 Shoreditch 651 205 84 51 22 1,013 51 36 26 53 105 170 224 216 224 138 30 2,286 Bethnal-green 648 193 84 43 27 995 52 37 37 43 121 173 238 249 239 182 48 2,414 Stepney 1,508 436 176 92 57 2,269 126 79 74 110 304 439 490 599 490 311 85 5,376 Poplar 832 234 105 63 39 1,273 73 45 51 62 142 207 269 327 296 205 47 2,997 Southwark 928 327 108 72 44 1,479 73 48 67 76 206 360 414 438 387 258 44 3,850 Bermondsey 631 190 78 54 15 968 54 36 45 59 143 175 206 255 268 154 41 2,404 Lambeth 1,015 256 103 61 23 1,458 99 55 49 104 271 366 522 546 621 434 124 4,649 Battersea 638 187 58 42 41 966 58 31 39 54 168 203 242 269 280 215 43 2,568 Wandsworth 816 210 63 56 30 1,175 82 46 54 69 200 239 298 352 413 303 100 3,331 Gamberwell 861 222 88 63 35 1,269 96 41 76 71 201 281 337 418 475 331 106 3,702 Deptford 402 99 28 21 9 559 39 26 36 37 78 116 156 182 199 163 40 1,631 Greenwich 321 62 28 11 11 433 45 21 28 28 79 114 121 160 176 127 54 1,386 Lewisham 338 67 33 14 14 466 33 24 18 46 83 135 149 177 235 228 89 1,683 Woolwich 361 73 36 21 13 504 46 30 36 38 119 142 157 154 202 137 36 1,601 London 16,323 4,601 1,743 1,035 642 24,344 1,460 836 1,095 1,529 3,978 5,520 7,019 8,193 8,561 6,127 1,788 70,450 London mortality in 1905 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 1905. The figures for the year 1905 are fully corrected for institution deaths (see footnote page 9), 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 1905. Difference per cent. Mean deathrate 1891-1900. Death-rate 1905. Difference per cent. 0– 71.97 51.63 –28.3 61.99 43.50 –29.8 5– 4.97 3.19 –35.8 5.17 –38.1 10– 2.46 1.97 –19.9 2.48 189 –23.8 15– 3.47 2.67 –23.1 2.94 2.16 –26.5 20– 4.59 3.65 –20.5 3.46 2.64 –23.7 25– 7.36 5.57 –24.3 5.65 4.08 –27.8 35– 14.22 10.45 –26.5 10.68 7.78 –27.2 45– 23.14 19.20 –17.0 17 .12 13. –18.4 55– 40.68 35.55 –12.6 31.01 –15.1 65– 77.78 71.16 – 8.5 63.44 56.27 –11.3 75– 154.13 138.31 –10.3 134.56 119.99 –10.8 85 and upwards 284.10 315.18 +10.9 265.77 288.99 + 8.7 All aees .. 20.88 16.36 –21.6 17.88 13.85 –22.5 11476 1. See footnote ('), p. 9. b 2 12 It will be seen from this table that the rate of mortality in 1905 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 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 1905 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 1905. 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. roups. Deaths calculated according to mean death-rates of 1891-1900. Deaths occurring in the year 1905. Gain ( + ) or loss ( —) of lives in the year 1905, by fluctuation of mortality. Gain (+) or loss (—) of''life capital" in the year 1905 by fluctuations of mortality. Males. 0– 18,425 13,218 + 5,207 + 261,183 5– 1,131 726 + 405 + 20,205 10– 528 422 + 106 + 4,835 15– 749 575 + 174 + 7,179 20– 1,030 819 + 211 + 7,818 25– 2,823 2,135 + 688 + 21,362 35– 4,122 3,028 + 1,094 + 26,234 45– 4,665 3,870 + 795 + 14,111 55– 4,987 4,358 + 629 + 7,768 65– 4,418 4,042 + 376 + 3,000 75– 2,711 2,433 +'278 + 1,365 85 and upwards 511 567 – 56 – 169 All ages 46,100 36,193 + 9,907 +374,891 Females. 0– 15,856 11,126 + 4,730 + 253,812 5– 1,187 734 + 453 + 24,226 10– 542 414 + 128 + 6,310 15– 707 520 + 187 + 8,404 20– 931 710 + 221 + 8,977 25– 2,554 1,843 + 711 + 24,451 35– 3,423 2,492 + 931 + 25,035 45– 3,859 3,149 + 710 + 14,228 55– 4,514 3,835 + 679 + 9,458 65– 5,095 4,519 + 576 + 5,126 75– 4,143 3,694 + 449 + 2,411 85 and upwards 1,123 1,221 – 98 – 313 All ages 43,934 34,257 + 9,677 + 382,125 Total 90,034 70,450 + 19,584 + 757,016 Diagram IV. Mean Death-Rate 1858-1905 141 per 1000 births. Infant Mortality. (Deaths under one year of age per 1000 births.) Mean Death Rate 1858-1905 156 per 1000 births 13 It will be seen from the preceding table that during the year 1905, compared with the decennium 1891-1900, there has been a saving of 19,584 lives, representing a gain to the community of 757,016 years of life capital. Infant Mortality. The deaths of children under one year of age in the Administrative County of London during 1905 (52 weeks) numbered 16,324, being in the proportion of 129 per 1,000 births. The proportion in successive periods has been as follows:— 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 1901 1481 1851-60 155 1902 1391 1861-70 162 1903 1301 1871-80 158 1904 1441 1881-90 152 1905 1291 1891-1900 1581 The accompanying diagram (IV.) shows the infant mortality in each year since 1857 in relation to the mean infant mortality of the period 1858 to 1905, and also the infant mortality in each year after exclusion of the deaths from premature birth. 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. 1895-1904. 1905. Towns. 1895-1904. 1905. London 1552 1313 West Ham 169 153 Liverpool 186 153 Bradford 165 144 Manchester 187 157 Newcastle 172 135 Birmingham 188 154 Hull 175 152 Leeds 176 151 Nottingham 184 155 Sheffield 185 167 Salford 200 148 Bristol 140 122 Leicester 181 148 London had therefore both in the period 1895-1904 and in 1905 a lower infant mortality than any of these towns except Bristol. The following table shows the deaths under one year of age and the number of these deaths per 1,000 births in each of the sanitary areas of the County of London for the period 1901-1, and for the year 1905:— Sanitary area. Deaths under one year of age, 1905. Deaths under one year of age per 1,000 births. 1901-4. 1905. Paddington 392 131 123 Kensington 499 152 144 Hammersmith 420 151 135 Fulham 692 145 145 Chelsea 185 145 117 Westminster, City of 334 130 114 St. Marylebone 343 101 888 Hampstead 134 98 94 St. Pancras 784 146 135 Islington 1,075 132 125 Stoke Newington 131 116 122 Hackney 759 129 129 Holborn 147 114 928 Finsbury 433 143 127 London, City of 45 135 149 Shoreditch 649 183 167 Bethnal-green 652 152 151 Stepney 1,513 151 141 Poplar 832 157 153 Southwark 922 164 148 Bermondsev 636 164 148 Lambeth 1,016 132 115 Battersea 633 143 131 Wandsworth 819 123 119 Camberwell 860 137 124 Deptford 402 141 122 Greenwich 319 134 119 Lewisham 336 117 92 Woolwich 362 124 102 London 16,324 1401 1291 See footnote page 9. 2 See footnote (2) page 9. The low infantile mortality in St. Marylebone and in Holborn is partly due to the large number of birthts occurring in lying-in Hospitals, many of the deaths among these children being registered in other localities. 14 Shoreditch had, it will be seen, the highest infantile death-rate (183) per 1,000 births and Hampstead the lowest (98), in the period 1901-4; in the year 1905 Shoreditch had again the highest (167), the lowest (88) obtaining in St. Marylebone. The Annual Summary of the Registrar-General for the year 1905 shows that the deaths in 1905 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 1905. Cow-pox 2 Meningitis (not tubercular) 304 Measles (Morbilli) 392 Insanity, Gen. Par. of Insane 1 Scarlet Fever 34 Epilepsy 5 Influenza 28 Convulsions 899 Whooping-cough 631 Paraplegia, Disease of cord 6 Diphtheria 51 Nervous System (other diseases) 37 Cerebro-Spinal Fever 3 Heart and blood-vessel diseases 5 Pyrexia (origin uncertain) 2 Croup (not spasmodic nor membranous) 4 Epidemic Diarrhoea (infective Enteritis) 1,729 Bronchitis 1,206 Diarrhoea, Dysentery 903 Asthma, Emphysema 1 Tetanus 17 Pleurisy 16 Venereal Disease 290 Respiratory Diseases (other) 95 Pneumonia 1,675 Tonsilitis, Quinsy 2 Erysipelas 64 Enteritis (not epidemic) 369 Septicaemia (not puerperal) 11 Gastro-Enteritis 358 Pyaemia (not puerperal) 15 Peritonitis 9 Other infective conditions 28 Cirrhosis of liver 1 Tuberculous Phthisis 55 Liver Diseases (other) 2 " Phthisis" 8 Digestive Diseases (other) 312 Tuberculous Meningitis 278 Nephritis, acute 4 Tuberculous Peritonitis 145 Bright's Disease, Albuminuria 1 Tabes Mesenterica 97 Urinary System (other diseases) 4 Tuberculous Diseases (other) 174 Generative organs (diseases of) 8 Scrofula n Other Diseases 3,220 Rheumatic Fever 4 Suffocation in bed 442 Sarcoma 2 Accident (other) 145 Cancer (undefined) 1 Homicide 21 Premature Birth 2,506 The reports of Medical Officers of Health for the year 1905 contain a table prepared under the instructions of the Local Government Board and giving the number of deaths, from all causes and certain specified causes, of infants dying at diSerent periods in the first year of life. From the information thus supplied, the following table has been compiled, showing the figures for London as a whole. County of London, Infantile mortality during the year 1905. Deaths from stated causes in weeks and months under one year of age. Cause of Death. Under 1 week. 1-2 Weeks. 2-3 Weeks. 3-4 Weeks. Total under 1 Month. 1-2 Months. 2-3 Months. 3-4 Months. 4-5 Months. 5-6 Months. 6-7 Months. 7-8 Months. 8-9 Months. 9-10 Months. 10-11 Months. 11-12 Months. Total Deaths under one year. Common Infectious Diseases— Small-pox — — — — — — — — — — — — — — — — — Chicken-pox — — — — — — — — — — 1 — 1 — 1 — 3 Measles 1 2 — — 3 6 4 3 7 22 26 39 40 75 83 81 389 Scarlet Fever — — — 1 1 1 — 1 — — — 10 3 4 9 5 34 Diphtheria and Croup — — — 1 1 4 2 2 2 1 4 2 12 9 9 4 52 Whooping Cough — 1 3 6 10 51 44 47 42 52 54 54 54 71 70 74 623 Diarrhœal Diseases— Diarrhoea, all forms 2 18 28 31 79 215 281 286 247 270 246 228 205 168 167 98 2,490 Enteritis (not tuberculous) 4 14 19 18 55 88 87 72 70 76 60 44 45 25 31 28 681 Gastritis, Gastrointestinal Catarrh 3 10 16 18 47 32 31 26 38 17 12 10 17 10 7 5 252 Wasting Diseases— Premature Birth 1,683 229 173 117 2,202 147 38 19 10 3 3 — 1 — — — 2,423 Congenital Defects 230 80 32 21 363 56 29 24 20 17 11 9 6 5 4 3 547 Injury at Birth 88 5 2 2 97 1 — 1 — — — — — — — — 99 Want of Breast-milk 7 3 1 4 15 28 18 9 5 5 3 4 2 — — 1 90 Atrophy, Debility, 404 170 131 128 833 365 283 195 128 95 79 56 58 36 37 26 2,191 Marasmus 1 See footnote (2) page 9. 15 Cause of Death. Under 1 Week. 1-2 Weeks. 2-3 Weeks. 3-4 Weeks. Total under 1 Month. 1-2 Months. 2-3 Months. 3-4 Mouths. 4-5 Months. 5-6 Months 6-7 Months. 7-8 Months. 8 9 Months. 9-10 Months. 10-11 Months. 11-12 Months. Total Deaths under One Year. Tuberculous Diseases— Tuberculous Meningitis 2 1 1 2 6 10 14 21 22 23 25 32 24 25 40 31 273 Tuberculous Peritonitis: Tabes Mesenterica 1 1 1 – 3 21 20 25 23 24 18 11 14 15 10 8 192 Other Tuberculous Diseases — 1 2 4 7 21 21 21 29 31 25 28 34 16 23 28 284 Erysipelas — 4 7 6 17 13 9 4 2 4 4 4 2 2 1 2 64 Syphilis 14 14 14 18 60 60 42 39 30 7 8 4 8 5 6 2 271 Rickets — 1 — — 1 4 3 5 6 4 11 5 9 9 11 11 79 Meningitis (not Tuberculous) 3 4 — 2 9 8 16 26 28 28 32 36 24 41 32 20 300 Convulsions 146 97 55 39 337 96 51 47 47 50 41 31 29 31 23 20 803 Bronchitis 18 31 58 62 169 211 162 116 91 93 80 64 75 77 72 66 1,276 Laryngitis — 1 1 — 2 3 — 2 3 1 — 1 2 6 2 3 25 Pneumonia 10 18 28 24 80 134 115 113 93 88 126 125 163 165 140 148 1,490 Suffocation, overlaying 66 22 29 16 133 107 68 55 32 26 14 10 3 5 3 6 462 Other causes 204 81 66 44 395 114 73 52 58 46 49 46 49 46 40 36 1,004 Totals 2,886 808 667 564 4,925 1,796 1,411 1,211 1,033 983 932 853 880 846 821 706 16,397 It will be seen from the table that nearly one-third of the deaths of children under one year of age occur during the first month of life, and that the numbers of deaths in each successive month decrease until the ninth month is reached, when there is an increase due in all probability to the change from natural to artificial food. This fact is well brought out by the following life table, which is based upon the figures shown in the table preceding. It will be seen from this life table that the probability of an infant living one month increases with each month of age until the ninth month is reached when the probability is less than that obtaining for the eighth month of life. The experience of further years is necessary to ascertain whether this is a constant feature of the figures of London infant mortality, but it is interesting to note that a similar life-table published in the last annual report, which was based upon the figures of the year 1902 presented by Dr. Tatham to tha Inter-depatrtmental Committee on Physical Deterioration, manifested a similar fall in the probability of living one month during the ninth month of life. That life-table, however, also showed a fall in the probability of living during the seventh month of life, which is not manifested in the table relating to the year 1905. London, 1905. Life Table for the first 12 months of life (based on the mortality of the year 1905). Age-period. x/12 Registered deaths. Probability of living for one month. p/12 Number living at the beginning of each month of age. lx/12 1902. Number living at the beginning of each month of age in the year 1902. lx/12 0—1 month 4,925 .96115 100,000 100,000 1—2 months 1,796 .98529 96,115 95,817 2—3 1,411 .98831 94,701 94,295 3—4 " 1,211 .98988 93,594 93,135 4—5 „ 1,033 .99130 92,647 92,077 5—6 „ 983 .99167 91,841 91,205 6—7 „ 932 .99207 91,076 90,417 7—8 „ 853 .99268 90,354 89,602 8—9 „ 880 .99240 89,693 88,830 9—10 „ 846 .99265 89,011 88,055 10—11 „ 821 .99281 88,357 87,356 11-12 „ 706 .99379 87,722 86,657 0—1 year 16,397 — 87,177 85,965 For the purpose of enabling comparison to be made of the age-distribution of the deaths under one year of age in the several sanitary areas of London, the following table has been prepared:— 16 Deaths at each interval of age from all causes. Sanitary area. 0-1 Weeks. 1-2 Weeks. 2-3 Weeks. 3-4 Weeks-. Total under 1 Month. 1-2 Months. 2-3 Months. 3-4 Months. 4-5 Months. 5-6 Months. 6-7 Months. 7-8 Months. 8-9 Months. 9-10 Months. 10-11 Months. 11-12 Months. Total under 1 Year. Paddington 66 20 17 13 116 40 36 26 26 15 32 24 14 26 20 16 391 Kensington 84 22 25 21 152 47 38 46 30 24 26 36 21 19 32 27 498 Hammersmith 62 20 20 19 121 57 40 28 24 21 14 22 21 22 26 18 414 Fulham 118 26 23 22 189 86 50 50 45 43 33 46 36 39 48 27 692 Chelsea 43 10 13 4 70 23 9 15 9 13 9 8 8 9 6 5 184 Westminster,City of 66 24 18 23 131 31 33 16 11 11 22 16 14 10 13 21 329 St. Marylebone 76 15 10 8 109 26 37 21 28 17 18 21 19 20 27 15 358 Hampstead 37 6 7 4 54 12 9 9 9 7 7 4 6 7 1 8 133 Pancras 154 34 27 32 247 96 90 50 38 64 41 23 37 36 38 27 787 Islington 185 61 54 36 336 124 91 88 65 43 62 48 54 55 52 56 1,074 Stoke-Newington 26 10 8 5 49 17 6 9 12 9 5 5 6 6 3 6 133 Hackney 144 31 24 24 223 100 71 47 41 40 54 34 73 47 47 46 823 Holborn 21 10 5 1 37 22 11 10 10 13 6 5 7 7 12 5 145 Finsbury 72 17 22 13 124 41 42 32 32 24 24 19 33 19 21 18 429 London, City of 11 1 — 1 13 2 1 8 2 3 5 1 — 2 4 1 42 Shoreditch 65 30 28 14 137 86 63 50 41 42 34 52 37 33 41 36 652 Bethnal Green 140 25 24 14 203 74 53 50 49 31 35 30 32 35 35 24 651 Stepney 227 49 52 46 374 180 127 117 99 97 99 85 92 97 67 80 1,514 Poplar 139 36 28 31 234 80 90 62 56 58 52 49 45 41 34 31 832 Southwark 163 52 27 32 274 86 89 80 68 56 40 39 45 60 50 36 923 Bermondsey 96 36 37 20 189 63 46 54 49 34 36 35 35 34 27 29 631 Lambeth 184 55 35 32 306 118 73 81 81 66 59 51 38 44 53 44 1014 Battersea 117 30 29 27 203 65 52 39 30 38 43 40 37 25 28 33 633 Wandsworth 163 49 44 24 280 80 69 52 59 48 44 46 49 34 33 24 818 Camberwell 171 32 28 41 272 98 53 57 47 67 53 44 38 52 44 40 865 Deptford 75 34 21 6 136 42 45 30 22 21 29 18 21 21 18 8 411 Greenwich 56 18 9 14 97 20 25 25 17 27 18 21 23 13 19 13 318 Lewisham 55 31 19 14 119 34 39 27 16 21 15 14 19 16 16 2 338 Woolwich 70 24 13 23 130 46 23 32 17 30 17 17 20 17 6 10 365 London 2,886 808 667 564 4,925 1,796 1,411 1,211 1,033 983 932 853 880 846 821 706 16,397 With a view to the consideration of the effect of social condition on the rates of infant mortality at different periods during the first year of life, the following table has been prepared, in which the rates of infant mortality obtaining for groups of districts arranged on the basis of the amount of overcrowding 1shown by the census of 1901 can be compared :— Age-period. Proportion of overcrowding in groups of sanitary districts. Under 7.5 per cent. 7.5 to 12.5 per cent. 12.5 to 20.0 per cent. 20.0 to 27.5 per cent. Over 27.5 per cent. Under 1 week 21.2 23.1 23.0 23.6 22.6 1-2 weeks 7.2 6.1 7.1 6.3 5.4 2-3 weeks 5.5 4.6 6.5 3.9 5.6 3-4 weeks 4.2 4.6 5.0 4.2 3.9 Under 1 month 38.1 38.4 41.6 38.0 37.5 1-2 months 11.4 14.5 13.8 13.1 17.0 2-3 8.8 10.1 11.6 12.9 12.7 3-4 7.8 9.0 10.4 9.2 11.1 4-5 6.8 7.6 8.3 8.2 9.9 5-0 6.9 8.0 6.7 8.6 8.7 6-7 5.3 7.6 8.1 6.0 8.6 7-8 5.2 6.8 7.3 5.0 8.3 8-9 6.0 7.1 6.5 6.2 8.7 9-10 4.8 6.5 6.6 7.0 8.2 10-11 3.6 7.1 6.2 7.2 7.3 11-12 3.0 5.7 6.3 4.7 7.1 0-3 months 58.3 63.0 67.0 64.0 67.2 3-6 21.5 24.6 25.4 26.0 29.7 6-9 16.5 21.5 21.9 17.2 25.6 9-12 11.4 19.3 19.1 18.9 22.6 0-12 months 107.7 128.4 133.4 126.1 145.1 The term "over-crowding" is used to apply to that proportion of the population shewn by the census figures of 1901 to be living more than two in a room in tenements of less than five rooms. 17 It should be stated in this connection that the births which occur in lying-in institutions have not been distributed to the districts in which the mothers reside. Especially in group No. IV. the death-rates have a tendency to be lower than they would otherwise be, for in that group of districts are situated the two lying-in hospitals in which many women are confined whose homes, in some proportion of the cases, would be situated outside the districts comprising the group. Allowing, therefore, for some irregularity of the figures on this account, it will be seen that the mortality among children under one year of age increases with the proportion of the population living under overcrowded conditions. When the figures for each of the trimesters are considered the same behaviour of the mortality is observable, but it is deserving of notice that the difference in the mortality between the least and most overcrowded groups is least marked in the first three months of life, more marked in the second, still more marked in the third, and most marked in the fourth three months of life. This will be better appreciated by reference to the following table, in which the mortality of the least overcrowded group of districts is taken as 100:— Number of group of districts in order of overcrowding. Comparative m ortality figure. Children aged 0-3 months. Children aged 3-6 months. Children aged 6-9 months. Children aged 9-12 months. I. 100 100 100 100 II. 108 114 130 169 III. 115 118 133 168 IV. 110 121 104 166 V. 115 138 155 195 When the mortality in the first month of life is considered, it is seen that the mortality of the most overcrowded group is not higher than that of the least overcrowded group, but indeed, so far as the figures for one year show, is somewhat less. In all probability this is in part due to the more complete registration of births and deaths in the better-circumstanced districts. It may be noted, however, that the differences become more accentuated as age progresses and this may be due either to decrease in the difference of the completeness of registration of deaths of infants in the several groups as age increases or to the effect of environment becoming more and more marked as it is afforded a longer time in which to operate. The incidence of mortality upon children aged under one month and the increasing divergence in the rates of mortality in the several groups as the age of the child progresses, in the several groups of districts, do not lend support to the view that ante-natal conditions constitute a predominant factor, if any, in determining infant mortality. Inferences of this character can, however, obviously be more safely drawn when the figures for a series of years are available for this purpose. A subject of much interest and importance is the maintenance of the infantile mortality rate, while the death-rate of older persons has greatly decreased. In a table contained in the report of the Inter-departmental Committee on Physical Deterioration, Dr. Tatham has compared the infantile mortality in two periods of five years, 1873-77 and 1898-1902, both in urban and rural counties. In the latter of these periods the infantile mortality in the urban districts was somewhat higher than in the former, the maintenance of the rate being especially due to deaths from diarrhœal diseases and diseases of the stomach, and from premature birth and congenital defects. Dr. Sykes has in his annual report made an interesting analysis of the infantile mortality in St. Pancras in the years 1877 and 1901, having respectively mortalities of 1524 and 154.7 for 1,000 births. These figures show especially that the mortality rate from premature birth and congenital defects was, in 1901, about double that of the rate of 1877, and that it was almost entirely confined to infants in the first week of life. The mortality rate from diarrhceal diseases and from diseases of the stomach and liver had increased by some 50 per cent. in the second period. He states " that mortality statistics in St. Pancras indicate that infants are dying at a younger and younger age, apparently due to increased immaturity at birth, diminished viability or capacity for survival, and increased artificial feeding." Dr. Sykes also shows the infantile mortality in London in several periods since 1888, when the deaths under one were first given in the Registrar-General's reports in ages 0-3, 3-6, 6-12, months, the table exhibiting the greatest increase of mortality in the first six months of life. Thus :— Period. Infantile Mortality per 1,000 Births. London. Months. 0-3 3-6 0-6 6-12 0-12 1888-1892 69.1 31.6 100.7 50.7 151.4 1893-1897 73.5 33.8 107.4 51.3 158.7 1898-1901 74.5 34.9 109.4 51.6 161.0 11476 C 18 Subject matter such as this may be considered in relation to other hypotheses and I would, therefore, submit that these increases may be merely apparent or be due to natural causes. Better certification of deaths, especially of children who survive their birth but a very brief period, would account for much of the apparent increase of mortality in the beginning of life from premature birth, &c. Diarrhoeal diseases are largely governed by temperature and in comparing different periods consideration has to be had for this factor. In the two periods of Dr. Tatham's tables, 1873-77, and 1898-1902, the mean summer temperature stood in the relation to the mean of antecedent years as follows :— Year. Temperature above or below the mean in deg. F. Tear. Temperature above or below the mean in deg. F. deg. F. deg. F. 1873 + 0.6 1898 + 3.0 1874 + 1.2 1899 + 3.3 1875 + M 1900 + 2.0 1876 + 2.1 1901 + 1.9 1877 —1.2 1902 — 0.2 Again, in the three periods of Dr. Sykes' table the summer temperatures in relation to the mear were as follows :— Year. Temperature above or below mean, deg. F. Infantile mortality, Diarrhoeal diseases. Year. Temperature above or below mean, deg. F. Infantile mortality, Diarrhoeal diseases. Year. Temperature above or below in mean, deg. F. Infantile mortality, Diarrhoeal diseases. deg. F. deg. F. deg. F. 1888 — 2.1 12 1893 + 2.2 20 1898 + 3.0 27 1889 — 0.8 15 1894 — 1.2 10 1899 + 3.3 26 1890 — 0.3 15 1895 + 2.7 21 1900 + 2.0 23 1891 — 0.4 14 1896 + 0.7 20 1901 + 1.9 24 1892 — 0.5 14 1897 + 1.1 25 ' Both in respect of Dr. Tatham's periods and Dr. Sykes' periods, therefore, higher temperatures prevailed in the summer quarter of the later period. The following table enables the infant mortality, inclusive of and exclusive of deaths from diarrhoeal diseases, in Dr. Sykes' periods to be compared :— Period. Infant Mortality. Infant Mortality, less Diarrheal Diseases. Months Months. 0-3 3-6 6-12 0-12 0-3 3-6 6-12 0-12 1888-92 69 32 51 152 65 28 45 138 1893-97 74 34 51 159 69 28 43 140 1898-1901 74 35 52 161 68 27 41 136 Much of the increase of mortality in the later period is attributable to diarrhoeal diseases, which are especially subject to climatic conditions, and as already stated, the temperature in the later period has been favourable to increase of deaths from this cause. If the period 1888-92 be compared with that of 1898-01, and deaths from premature births be deducted from both, the following figures are obtained for the ages 0-3 months :— Period. Infant mortality. Less deaths from Premature Birth. Less deaths from Premature Birth and Diarrhoeal diseases. 1888-92 69 53 49 1898-1901 74 54 48 The difference, therefore, between these two periods may be explained by (a) an increase in the number of deaths from diarrhœal diseases, and (b) an increase in the number of deaths from premature births ; the former is probably due to increased temperature in the summer quarter, the latter is explicable on the hypothesis of more complete registration, leading to registration in greater degree of children who survive their birth but for a brief period. Further, reference to diagram IV. shows the effect which the increasing number of deaths registered as due to premature birth has upon the maintenance of the rate of infant mortality. 19 The high incidence of diarrhoea among hand-fed infants is a fact generally recognised. Instructive figures are contained in a report by Dr. Howarth, of Derby, who has shown the mortality from different causes among 8,343 infants whose history during the first year of life he recorded. The following figures are extracted from a table contained in a paper he read in 1905 before the Derby Medical Society:— Diarrhœa and epidemic enteritis. Nature of feeding. Number of Infants. Deaths per 1,000. Breast-fed 5,278 8.6 First breast-fed and afterwards hand-fed 1,439 21.6 Hand-fed 1,626 51.7 Further, he shows that under each other cause of mortality the rule holds good that the handfed infants die in greater proportion than those who are first breast-fed and afterwards hand-fed, and these again in greater proportion than those who are wholly breast-fed. The annual reports show that throughout London, generally, sanitary authorities are devoting increased attention to the study and prevention of infantile mortality. A conference on the subject, under the presidency of Dr. R. M. Beaton, was held in June, 1905, at the St. Pancras Town Hall, This conference was largely attended and resolutions were adopted which aimed at the bringing of newborn infants under the early supervision of the health authority, with a view to securing the better treatment and feeding of infants. In the majority of districts female inspectors are employed in this connection, and in order to enable sanitary authorities to obtain early knowledge of the birth of infants, the Registrar-General has authorised registrars of births, deaths and marriages to supply them with the addresses of parents the births of whose infants have been registered. The London County Council, moreover, in its administration of the Midwives Act, has arranged to receive from midwives weekly the names and addresses of patients attended by them and this information is communicated to the Medical Officers of Health concerned. The returns received from midwives are at the rate of about 30,000 births per annum, or about a quarter of the total births. In this way new-born infants in the poorest-class of the London population can be brought under supervision shortly after birth. The action taken by sanitary authorities is shown in the majority of the annual reports. The homes of the mothers are visited, and printed and verbal advice is given. In Battersea and Lambeth milk depots have been provided by the sanitary authorities, and in Finsbury by charitable effort, the Medical Officer of Health being the advisor. In Holborn, the Borough Council has made arrangements with a dairy company for the supply of suitable milk at a cost of 4d. per infant, per day, in cases in which the Medical Officer of Health certifies that the supply is necessary. 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 1905 under certain of the more important headings in the list of causes of death, as compared with the annual average deaths of the preceding 10 years, corrected for increase of population. Cause of death. Diminution in 1905. Excess in 1905. Smallpox 163 Measles 772 — Scarlet Fever 48 — Typhus 3 — Influenza 497 — Whooping Cough 429 — Diphtheria 1,160 — Pyrexia (origin uncertain) 4 — Enteric Fever 350 — Diarrhoea 510 — Pneumonia — 631 Phthisis and other Tuberculous Diseases (including Scrofula) 1,934 — Cancer — 319 Premature Birth 189 — Diseases of Nervous system 1,883 – Diseases of Circulatory system – Diseases of Respiratory system 2,483 — Diseases of Urinary system 63 80 Childbirth and Puerperal Septic Di seases — Accident 492 — Homicide 15 — Suicide — 12 All other Causes 2,141 – Net diminution or excess 12,094 — 1 For purposes of comparison deaths from Infective Endocarditis are included under this heading. 11476 c 2 20 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 9). 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 49 and 51 respectively. Death-rates per 100,000 living from all causes, and from various causes, in each of the various sanitary areas, 1905 (365 days). Sanitary area. Measles. Rheumatic Fever. Carcinoma. Sarcoma. Cancer. Tabes Mesenteric*. Tubercular Meningitis. Phthisis. Other Tube rcular and Scrofulous Diseases. Pneumonia. Other Respiratory Diseases. All other Causes. All Causes. Paddington 43 11 68 9 25 3 19 95 16 124 153 764 1,330 Kensington 31 4 49 3 44 12 17 114 11 146 149 819 1,399 Hammersmith 23 4 64 6 32 13 22 115 16 122 124 842 1,383 Fulham 53 10 61 7 18 10 27 121 18 159 133 880 1,497 Chelsea 7 4 62 8 32 8 15 148 13 168 181 835 1,481 Westminster, City of 21 5 65 7 34 7 17 150 15 129 126 772 1,348 St. Marylebone 29 2 63 8 60 9 19 141 27 158 182 844 1,542 Hampstead 9 6 51 6 14 3 14 83 11 87 64 583 931 St. Pancras 33 11 61 6 33 9 16 148 18 163 163 912 1,573 Islington 36 7 40 6 53 13 19 125 17 140 146 845 1,447 Stoke Newington 23 9 47 4 53 6 25 131 21 106 117 740 1,282 Hackney 36 5 46 5 38 11 27 113 19 116 135 851 1,402 Holborn 21 5 53 5 34 12 18 278 30 182 184 915 1,737 Finsbury 42 6 44 7 19 14 42 201 18 176 231 1,093 1,893 London, City of 4 9 94 – 49 4 4 134 31 161 210 1,052 1,752 Shoreditch 54 4 41 6 41 23 45 194 23 163 226 1,141 1,961 Bethnal-green 37 8 36 4 41 21 31 203 18 183 209 1,059 1,850 Stepney 51 6 47 5 21 11 23 172 27 200 179 1,018 1,760 Poplar 47 8 50 6 26 15 21 153 23 157 205 1,049 1,760 Southwark 74 5 77 5 23 12 27 213 24 208 215 963 1,846 Bermondsey 49 7 60 5 19 19 42 178 26 216 176 1,067 1,864 Lambeth . i 30 6 52 9 45 10 20 136 19 146 132 879 1,484 Battersea 72 5 53 5 41 10 19 136 16 123 147 820 1,447 Wandsworth 33 8 37 7 42 9 17 101 9 123 91 779 1,256 Camberwell 30 7 46 5 34 13 26 121 15 111 156 799 1,363 Deptford 14 9 59 3 28 8 20 121 16 109 162 876 1,425 Greenwich 17 6 52 7 36 11 25 124 20 110 112 820 1,340 Lewisham 28 5 54 8 28 8 15 85 11 91 108 724 1,165 Woolwich 10 7 33 6 29 10 18 151 12 111 101 791 1,279 London 36 7 52 6 35 11 22 140 18 145 153 878 1,503 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, typhus, enteric fever, pyrexia (1) and diarrhoea during 1905 (52 weeks) was 7,894, giving an annual death-rate of l.70 per 1,000 persons 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 1901 2.223 1851-60 5.13 1902 2.212 1861-70 5.23 1903 1.753 1871-80 3.86 1904 2.142 1881-90 3.05 1905 1.702 1891-1900 2.682 It will be seen from the following table that London in the decennium 1895-1904 had a lower death rate from these diseases than any of the undermentioned English towns, except Bristol, Bradford and Newcastle-upon-Tyne, and in 1905 a lower death-rate than any except Leeds, Bristol, Bradford, Newcastle-upon-Tyne and Leicester :— 1 Origin uncertain. Originally described as simpls continued fever. 2 See footnote (1) p. 9. 21 Principal epidemic diseases—Death-rates per 1,000 persons living. Towns. 1895-1904. 1905. Towns. 1895-1904. 1905. London 2.45 1.711 West Ham 3.46 2.98 Liverpool 3.40 2.59 Bradford 1.98 1.42 Manchester 3.26 2.25 Newcastle-upon-Tyne 2.11 1.33 Birmingham 3.03 1.90 Hull 3.10 2.37 Leeds 2.64 1.61 Nottingham 2.49 2.27 Sheffield 3.29 3.20 Salford 4.16 2.57 Bristol 1.88 1.50 Leicester 2.75 1.62 The following table shows that the London death-rate from the first six of these principal epidemic diseases, viz , smallpox, measles, scarlet fever, diphtheria (including croup), whooping cough, and fever (including typhus, enteric fever and pyrexia), both in the period 1895-1904 and in the year 1905, exceeded the rates of all the undermentioned foreign towns except St. Petersburg. Six principal epidemic diseases—Death-rates per 1,000 persons living. Towns. 1895-1904. 1905. Towns. 1895-1904. 1905. London 1.611 0.981 St. Petersburg 3.09 3.33 Paris 0.81 0.48 Berlin 1.03 0.84 Brussels 0.68 0.36 Vienna 1.05 0.80 Amsterdam 0.82 0.96 Rome 1.02 0.82 Copenhagen 0.91 0.54 New York 1.38 0.89 Stockholm 0.90 0.91 The following table shows the deaths from the principal epidemic diseases and the death-rates per 1,000 persons living in each of the sanitary areas of the County in 1905, and the period 1901-4:— Sanitary area. Deaths in 1905. Death-rate per 1,000 persons living. 1901-4. 1905. Paddington 205 1.59 1.39 Kensington 250 1.57 1.39 Hammersmith 202 2.24 1.70 Fulham 425 2.67 2.71 Chelsea 76 1.50 1.03 Westminster, City of 140 1.14 0.81 St. Marylebone 143 1.69 1.12 Hampstead.. 47 0.77 0.53 St. Pancras 354 2.21 1.50 Islington 502 1.76 1.47 Stoke Newington 60 1.27 1.14 Hackney 451 2.01 1.98 Holborn 63 2.00 1.12 Finsbury 213 2.70 2.17 London, City of .. 13 0.98 0.57 Shoreditch 344 3.16 2.96 Bethnal-green 294 2.67 2.27 Stepney 787 2.78 2.58 Poplar 451 3.04 2.65 Southwark 500 2.81 2.39 Bermondsey 285 2.88 2.21 Lambeth 465 1.96 1.50 Battersea 351 2.19 1.99 Wandsworth 386 1.64 1.46 Camberwell 354 1.99 1.30 Deptford 135 2.41 1.19 Greenwich 133 1.93 1.30 Lewisham 137 1.45 0.95 Woolwich 128 1.75 1.02 London 7,894 2.092 1.702 It will be seen from the foregoing table that the death-rate from the principal epidemic diseases was, both in the period 1901-4 and the year 1905, highest in Shoreditch (3.16 and 2.96) and lowest in Hampstead (0.17 and 0'53). The death-rates from these diseases during each of the four quarters of the year 1905 were as follows—first quarter, 1.09; second quarter, 1.34; third quarter, 2.98; and fourth quarter 1.33 per 1,000 persons living. 1 See footnote (2) page 9. 2 See footnote (1) page 9. 22 Smallpox and Vaccination. The deaths from smallpox in the Administrative County of London numbered 10 in 1905 (52 weeks), and two deaths were attributed to cowpox and effects of vaccination. The death-rates from smallpox in successive periods have been as follows:— Period. Smallpox death-rate per 1,000 persons living. Period. Smallpox death-rate per 1,000 persons living. 1841-50 0.402 1901 0.0511 1851-60 0.280 1902 0.2821 1861-70 0.276 1903 0.0031 1871-80 0.457 1904 0.0051 1881-90 0.145 1905 0.0021 1891-1900 0.0101 The smallpox death-rate in each year since 1840 in relation to the mean smallpox death-rate of the period 1841-1905 is shown in diagram V. During the complete years in which the notification of infectious diseases has been obligatory, the number of cases of smallpox (uncorrected for errors in diagnosis) notified to the medical officers of health in the various sanitary districts comprised in the administrative county has been as follows— Tear. Cases notified. Case-rate per 1,000 persons 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 1905 74 0.016 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 1895-1904 the London death-rate was higher than that of any except West Ham and Hull, and in the year 1905 was exceeded by the death-rates of Leeds, Bradford, Newcastle-upon-Tyne and Hull. Smallpox death-rates per 1,000 persons living. Towns. 1895-1904. 1905. Towns. 1895-1904. 1905. London 0.04 0002 West Ham 0.06 — Liverpool 0.03 — Bradford 0.01 0.02 Manchester 0.01 — Newcastle-upon-Tyne 0.01 0.01 Birmingham 0.01 o.oo Hull 0.07 0.01 Leeds 0.01 0.01 Nottingham 0.01 0.00 Sheffield o.oo — Salford 0.00 — Bristol o.oo — Leicester 0.01 — In this table 0.00 indicates that the deaths were too few to give a rate of 0.005; where no death occurred — is inserted. The following table shows that the London smallpox death-rate was in the decennium 1895-1904 higher than that of any of the undermentioned foreign towns except St. Petersburg, and in the year 1905 was exceeded only by the death-rates of Paris and St. Petersburg. Smallpox death-rates per 1,000 persons living. Towns. 1895-1904. 1905. Towns. 1895-1904. 1905. London 0.042 0.00 St. Petersburg 0.10 0-05 Paris 0.03 0.04 Berlin o.oo o-oo Brussels 0.03 0.00 Vienna o.oo — Amsterdam o.oo — Rome o.oo o-oo Copenhagen 0.00 — New York 0.03 o-oo Stockholm o.oo — In this table 0 00 indicates that the deaths wore too few to give a rate of 0 005 ; where no death occurred — is inserted. 1 See footnote (1) page 9. 2 See footnote (2) page 9 Diagram V. —Smallpox.— 23 The following table shows the smallpox cases notified, deaths, case-rates, and death-rates in the year 1905, the case-rates in the decennium 1895-1904, and the death-rates in the period 1901-4 in the several sanitary areas of the Administrative County— Sanitary area. Notified Cases, 1905. Case-rate per 1,000 persons living. Deaths, 1905. Death-rate per 1,000 persons living. 1895-1904. 1905. 1901-1904. 1905. Paddington 2 0.1 0.0 — 0.04 — Kensington — 0.l — — 0.02 — Hammersmith — 0.1 — — 0.06 — Fulham – 0.1 — — 0.03 — Chelsea – 0.1 — — 0.03 — Westminster, City of.. 2 0.2 o.o — 0.08 — St. Marylebone — 0.3 — — 0.06 — Hampstead — o.o — — 0.02 — St. Pancras 3 0.3 0.0 — 0.13 — Islington 3 0.1 o.o 1 0.05 o.oo Stoke Newington 1 0.2 o.o — 0.05 — Hackney 4 0.2 o.o 2 0.08 0.01 Holborn 1 0.8 o.o — 0.33 — Finsbury 1 0.3 o.o — 0.11 — London, City of — 0.2 — — 0.09 — Shoreditch 2 0.4 o.o 2 0.17 0.02 Bethnal-green 4 0.7 o.o — 0.14 — Stepney 13 0.7 o.o 1 0.24 o.oo Poplar.. — 0.5 — — 0.16 — Southwark — 0.4 — — 0.11 — Bermondsey — 0.3 — — 0.09 — Lambeth — 0.2 — — 0.05 — Battersea — 0.2 — — 0.04 — Wandsworth 1 0.1 o.o — 0.03 — Camberwell 13 0.2 o.o — 0.07 — Deptford 2 0.2 0.0 — 0.08 — Greenwich 4 0.1 o.o — 0.06 — Lewisham 9 0.1 0.1 4 0.02 0.03 Woolwich 7 0.3 0.1 — 0.08 — Port of London 2 — — — London 74 0.3 0.0 10 0.091 0.001 In this table 0 0 indicates that the cases were too few to give a rate of 005 ; where no cases occurred — is inserted. The following table shows the number of cases of smallpox notified in London in each week of the year 1905— Smallpox—Notified cases, 1905. Week ended. No. of cases notified. Week ended. No. of cases notified. Week ended. No. of cases notified. January 7 1 May 13 2 September 9 „ 14 1 „ 20 2 16 — „ 21 1 „ 27 3 23 — „ 28 1 June 3 1 30 — February 4 — „ 10 2 October 7 — „ 11 1 „ 17 3 14 1 „ 18 3 „ 24 1 21 — „ 25 1 July 1 1 28 — March 4 9 8 2 November 4 — 11 1 „ 15 1 11 — 18 11 „ 22 1 18 — 25 3 „ 29 — 25 — April 1 1 Aug. 5 2 December 2 — 8 5 „ 12 — „ 9 — 15 — „ 19 — 16 — 22 6 „ 26 — 23 — 29 4 Sept. 2 — 30 — May 6 3 The occurrences of actual cases of small-pox in London in 1905 may be thus summarised— In January three oases occurred, two in Woolwich and one in Lewisham. The Woolwich cases were the last of a series of seven cases, five of which had occurred in the preceding year due to infection from a man the nature of whose illness had not at first been recognised; the Lewisham case 1 See footnote (1), page 9. 24 was that of a commercial traveller who died at home and the source of whose infection was unknown. In the four weeks ending the 25th February, four cases occurred in London, two in Islington and two in Camberwell. The Islington cases were those of two Italians; the first was infected before arriving in England and he infected the other; the Camberwell cases were those of two children living in the same house; the source of infection being unknown. In the five weeks ending the 1st April, twenty cases occurred, two in Hackney, ten in Stepney, six in Camberwell and two in Greenwich. The two Hackney cases were those of husband and wife, both of whom died; the source of infection of the wife, who infected the husband, was unknown. Of the ten Stepney cases, nine were associated. The first was that of a printer's joiner who worked in Finsbury. His attack was followed by those of five of his children and of three other persons living in the same house. The tenth case was that of a Russian who was infected before arrival in England. The six Camberwell cases were removed from the same house as that in which cases occurred in the preceding month. The two Greenwich cases were those of a miller's labourer, the source of whose infection was unknown, and of a man who had been infected during a voyage from South America. In the four weeks ending the 29th April, thirteen cases occurred, one in Paddington, one in Westminster, one in Stepney, one in Greenwich, six in Lewisham, two in Woolwich and one in the Port of London. The Paddington case was that of a woman who was infected on board the same vessel as that of the'Greenwich case previously mentioned. The Westminster case was that of a commercial traveller employed in Halifax. The Stepney case was that of a woman living in Peabody-buildings; the source of her infection was unknown. The Greenwich case was that of a woman, the source of whose infection was not known. The six cases in Lewisham were all associated; the first was that of an errand boy whose illness was mistaken for chicken-pox and the source of whose infection was unknown; he infected his father, mother, aunt, sister and brother. The Woolwich cases were those of a father and child; the father worked in the Arsenal, the source of infection was unknown. The case in the Port was that of a man who arrived in a ship from Spain, where he was infected. In the four weeks ending the 27th May, seven cases occurred, one in Hackney, three in Camberwell, one in Deptford, one in Lewisham and one in Woolwich. The Hackney case was that of a woman who kept a stall in the Spitalfields market and the source of whose infection was unknown. The three Camberwell cases were those of a boy, the source of whose infection was unknonw, and those of two other children in the same house whom he infected. The Deptford case was that of an infant who was infected on the voyage from Rangoon. The Lewisham case was that of a disinfector. The Woolwich case was that of a man working in the Arsenal. In the four weeks ending the 1st July, four cases occurred, one in Stoke Newington, one in Shoreditch, two in Bethnal-green and one in Greenwich. The Stoke Newington case was that of an engineer, the source of whose infection was unknown. The Shoreditch case was that of a pork butcher, the source of whose infection was unknown. The Bethnal-green cases were those of sisters, attacked about the same time and the source of whose infection was unknown. In the four weeks ending the 29th July, one case occurred, that of a girl employed as a French polisher in Bethnal-green and the source of whose infection was unknown. This was the last case occurring: in 1905. The actual cases were thus distributed:— Area. 4 weeks ending 28th Jan. 4 weeks ending 25th Feb. 5 weeks ending 1st April. 4 weeks ending 29th April. 4 weeks ending 27th May. 5 weeks ending 1st July. 4 weeks ending 29th July. Total. Paddington – – – 1 – – 1 Westminster, City of — — — 1 — — – 1 Islington — 2 — — — — — 2 Stoke Newgtn. — — — — — 1 — 1 Hackney —• — 2 — 1 — — 3 Shoreditch — — — — — 1 — 1 Bethnal-green — — — — — 2 1 3 Stepney — — 10 1 — — — 11 Camberwell — 2 6 — 3 — — 11 Deptford — — — — 1 — — 1 Greenwich — — 2 1 — 1 — 4 Lewisham 1 — — 6 1 — — 8 Woolwich 2 — — 2 1 — — 5 Port of London — — — 1 — — — 1 Total 3 4 20 13 7 5 1 53 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 the hospitals of the Board during 1905. Fifty-three such persons were received, of whom four were admitted from outside the County, the remaining 49 being received from the County of London. 1 Reference to cases of smallpox occurring among school children in February, 1906, and to a resolution of the County Council prohibiting, without their sanction, the examination of the children in the schools with a view to ascertaining their condition as to vaccination will be found in Appendix II., page 30. 25 The following table has been prepared from the tabular statement referred to:— Admissions. Deaths. A. Vaccinated class— (A1) Half and upwards of one-half square inch total area of cicatrices 22 (A2) One-third but less than half ditto 4 1 (A8) Less than one-third ditto 3 1 (A4) Area not recorded — — Total of vaccinated class 29 2 B. Doubtful class 4 2 C. Unvaccinated class— (C1) Not vaccinated successfully after having been infected with smallpox 15 4 (C2) Successfully vaccinated after having been infected with smallpox 5 — Total of unvaccinated class 20 4 Grand totals 53 8 Of the above persons one, aged 43, stated that he had been successfully re-vaccinated both 37 and 30 years ago; there was good evidence of one successful re-vaccination only. He suffered from discrete smallpox. The number of cases admitted into hospital at several ages classified according to the ondition as to vaccination is as follows :— Age period. Vaccinated. Doubtful. Unvaccinated. Cases. Deaths. Cases. Deaths. Casts. Deaths. 0—5 – – – – 4 – 5—10 1 – — — 5 — 10—15 — – — — 5 1 15—25 6 – — 4 1 25 and upwards 22 2 4 2 2 2 Total 29 2 4 2 20 4 London vaccination returns. The following table shows the proportion of children born in each year who were not finally accounted for in respect of vaccination. It will be observed that this number has, since 1898, been gradually decreasing:— Teat Children not Anally accounted for (including ca>es post* poned) per cent, of total births. Year. C hildren 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 1903 20.7 11476 D 26 The proportion of children born who were exempted by "conscientious objection" certificates since and including 1898, has been as follows:—1898, 1.4; 1899, 1.0; 1900, 1.0; 1901, 1.1; 1902, 0.8; 1903,10. During these years, the proportion of children exempted by certificate of oon3cientious objection, together with the proportion of children not finally accounted for in the several unions has been as follows:— Number of certificates of conscientious objection and number of children not finally accounted for "per cent of births. Metropolitan Union. 1893. 1899. 1900. 1901. 1902. 1903. Bethnal-green 67.0 48.2 49.2 52.2 44.1 44.9 Camberwell 41.2 29.7 23.0 20.0 21.4 21.8 Chelsea 17.3 14.9 16.0 13.4 14.9 13.9 Fulham 15.4 12.6 13.7 12.0 11.8 12.7 St. George, Hanover-square .. 11.1 9.0 7.1 5.8 7.5 5.1 St. George-in-the-East 34.6 35.0 33.5 30.6 29.7 27.7 St. Giles and St. George 32.5 33.0 33.6 30.7 27.1 24.9 Greenwich 17.2 14.2 13.8 12.6 11.1 11.1 Hackney 49.0 38.6 40.4 38.5 26.1 25.5 Hammersmith 13.8 11.7 9.1 8.3 9.4 7.2 Hampstead 15.4 10.3 11.0 10.0 9.2 9.5 Holborn 43.8 31.8 28.5 27.6 23.2 20.7 Islington 31.1 29.2 26.2 21.6 17.7 17.0 Kensington 13.5 10.2 9.2 9.0 7.2 6.6 Lambeth 30.6 25.2 20.6 22.2 20.4 21.0 Lewisham 27.8 22.6 20.7 15.7 13.5 15.4 London, City of 25.4 18.3 14.2 11.3 11.3 11.8 Marylebone 18.0 20.9 17.7 14.6 12.5 10.8 Mile End Old Town 68.9 69.9 68.0 66.1 58.8 59.8 St. Olave (Bermondsey) 32.5 23.6 21.8 18.0 17.5 16.3 Paddington 14.7 14.6 13.5 11.0 10.1 11.7 St. Pancras 36.7 36.1 32.9 32.8 26.2 25.3 Poplar 63.6 50.1 49.0 49.1 44.2 46.9 Shoreditch 68.8 52.4 53.0 44.7 36.4 36.6 Southwark 32.6 30.3 27.6 26.8 25.4 24.9 Stepney 48.6 46.9 44.4 44.3 37.2 35.8 Strand 25.2 19.7 19.2 16.1 19.0 18.6 Wandsworth and Clapham .. 32.2 25.1 23.0 20.5 19.2 17.2 Westminster 17.4 14.8 12.2 13.3 13.4 12.1 Whitechapel 11.8 14.5 13.1 10.5 9.5 10.1 Woolwich 10.2 8.3 7.5 9.8 9.7 7.1 Measles. The deaths from measles in the Administrative County of London during 1905 (52 weeks) numbered 1,709, as compared with 2,256 in 1904. The death rates from this disease per 1,000 persons living in 1905 and preceding periods have been as follows:— 1841-50 0.62 1901 0.431 1851-60 0.53 1902 0.511 1861-70 0.58 1903 0.441 1871-80 0.51 1904 0.49l 1881-90 0.64 1905 0.371 1891-1900 0.581 Inasmuch as the birth-rate has not been constant during these periods and the proportion of population in the early years of life has diminished, the death-rate of children under five years of asre deserves to be stated. The following table shows the death-rate from measles of children at this age in successive periods:— Period. Death-rate per 1,000 persons living at ages 0—5. Period. Death-rate per 1,000 persons living at ages 0—5. 1851-60 3.89 1901 3.701 1861-70 4.18 1902 4.421 1871-80 3.65 1903 3.901 1881-90 4.74 1904 4.301 1891-1900 4.82 1905 3.191 1 See footnote (1), page 9. Diagram VI. —Measles.— 27 The death-rate in each year since 1840 in relation to the mean death-rate of the period 1841-1905, calculated on the population at all ages, is shown on diagram VI. The following table shows the deaths and death-rates from measles in 1905 (52 weeks) in each of the sanitary areas of the County:— Sanitary area. Deaths 1905. Death-rate per 1,000 persons living. 1901-4. 1905. Paddington 62 0.29 0.42 Kensington 56 0.38 0.31 Hammersmith 28 0.56 0.24 Fulham 84 0.57 0.54 Chelsea 5 0.39 0.07 Westminster, City of.. 38 0.24 0.22 St. Marylebone 38 0.36 0.29 Hampstead 8 0.12 0.09 St. Pancras 77 0.53 0.33 Islington 123 0.43 0.36 Stoke Newington 12 0.21 0.23 Hackney 83 0.41 0.36 Holborn 11 0.49 0.20 Finsbury 41 0.64 0.42 London, City of 1 0.14 0.04 Shoreditch 63 0.73 0.54 Bethnal-green 47 0.62 0.36 Stepney 157 0.57 0.52 Poplar 79 0.61 0.47 Southwark 154 0.72 0.74 Bermondsey 62 0.81 0.48 Lambeth 96 0.41 0.31 Battersea 125 0.58 0.71 Wandsworth 89 0.38 0.34 Camberwell 82 0.44 0.30 Deptford 16 0.59 0.14 Greenwich 18 0.41 0.17 Lewisham 41 0.22 0.28 Woolwich 13 0.24 0.10 London 1,709 0.471 0.371 In the distribution of measles mortality throughout the year 1905, the highest death-rate obtained in Southwark (0.74) and the lowest in the City of London (0.04). For the period 1901-4, Bermondsey had the highest measles death-rate (0.81) and Hampstead the lowest (0'12). The death-rates from this disease in the four quarters of 1905 were as follows :—First quarter, 030; second quarter, 0.47; third quarter, 0.22, and fourth quarter, 0.47 per 1,000 persons living. The following table shows the measles death-rate at age 0-5 obtaining in the several sanitary areas of the County of London during the year 1905. It will be observed that Southwark (5.93) and the City of London (0.78) had, as at " all ages," the highest and lowest death-rates respectively :— Sanitary area. Death-rate per 1,000 persons living aged 0-5. Sanitary area. Death-rate per 1,000 persons living aged 0-5. Sanitary area. Death-rate per 1,000 persons living aged 0-5. Paddington 4.57 Stoke Newington 2.06 Bermondsey 3.63 Kensington 3.88 Hackney 3.13 Lambeth 2.65 Hammersmith 2.10 Holborn 2.63 Battersea 5.66 Fulham 3.97 Finsbury 3.29 Wandsworth .. 2.89 Chelsea 0.79 London, City of 0.78 Camberwell 2.53 Westminster, City of 2.85 Shoreditch 4.31 Deptford 1.01 St. Marylebone 3.36 Bethnal Green 2.59 Greenwich 1.42 Hampstead 1.01 Stepney 3.66 Lewisham 2.35 St. Pancras 3.06 Poplar 3.55 Woolwich 0.81 Islington 3.17 Southwark 5.93 London 3.191 The mortality from measles in the several districts is in a large degree determined by the social condition of the population. If London districts be grouped in relation to overcrowding, it is found that the groups having the largest proportion of their population "overcrowded"2 have the highest death-rates from measles. The following table shows the measles mortality under five years of age in five groups of districts, arranged in order according to the proportion of their population living more than two in a room in tenements of less than five rooms :— 1 See footnote (1), page 9. 11476 2 See footnote (1), page 16. D 2 28 Measles and overcrowding, 1901-5. Proportion of overcrowding in groups of sanitary areas. Measles death-rate at ages 0—5 years 1901-5, per 1,000 living. Under 7.5 per cent. 2.351 7.5 to 12.5 „ „ 3.731 12.5 to 20.0 „ „ 4.071 20 0 to 27.5 „ „ 4.961 Over 27.5 „ „ 4.381 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 1895-1904, the London death-rate exceeded that of any of these towns except Manchester, West Ham, Hull and Salford, and in 1905 was exceeded by the doathrates of Birmingham, Sheffield, Bristol and Nottingham. Measles—Death-rates 'per 1,000 persons living. Towns. 1895-1904. 1905. Towns. 1895-1901. 1905. London 0.532 0.372 West Ham 0.61 0.35 Liverpool 0.50 0.32 Bradford 0.33 0.04 Manchester 0.79 0.37 Newcastle-upon-Tyne 0.45 0.13 Birmingham 0.43 0.44 Hull 0.53 0.09 Leeds 0.47 0.24 Nottingham 0.33 0.92 Sheffield 0.51 0.94 Salford 0.91 0.32 Bristol 0.42 0.50 Leicester 0.32 0.23 The following table shows that in the decennium 1895-1904 the London measles death-rate was higher than that of any of the undermentioned foreign towns except St. Petersburg, and in 1905 exceeded all except Amsterdam and St. Petersburg. Measles—Death-rates per 1,000 persons living. Towns. 1895-1904. 1905. Towns. 1895-1904. 1905. Londoa 0.532 0.372 St. Petersburg 0.57 0.83 Paris 0.28 0.15 Berlin 0.20 0.21 Brussels 0.21 0.09 Vienna 0.46 0.31 Amsterdam 0.32 0.43 Rome 0.32 0.30 Copenhagen 0.18 0.15 New York 0.21 0.13 Stockholm 0.15 0.08 The following table shows the number of deaths from measles at several age-period3 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 9). Measles (365 days). Age -period. 0— 1— 2— 3— 4— Under 5. 5— 10— 15 and upwards. All ages. Paddington 17 26 8 5 4 60 3 – – 63 Kensington 13 28 6 4 5 56 — – – 56 Hammersmith 12 8 5 1 1 27 — – – 27 Fulham 24 32 14 5 6 81 3 – – 84 Chelsea 1 1 1 2 5 — – – 5 Westminster, City of 10 17 5 2 1 35 1 1 – 37 St. Marylebone 11 15 5 3 2 36 2 – – 38 Hampstead 1 2 2 2 — 7 1 – – 8 St. Pancras 24 28 9 8 5 74 2 – 1 77 Islington 27 50 22 12 6 117 5 – – 122 Stoke Newington — 6 3 1 — 10 2 – – 12 Hackney 19 33 19 6 2 79 4 – – 83 Holborn 3 5 2 1 1 12 — – – 12 Finsbury 10 17 7 5 — 39 2 – – 41 London, City of 1 1 — – – 1 Shoreditch 18 27 11 5 2 63 — – – 63 Bethnal Green 11 17 11 4 3 46 2 – – 48 Stepney 41 65 25 14 4 149 6 – – 155 1. See footnote (J), page 9. 2. See footnote (2), page 9. 29 Age-poriod. 0— 1— 2 3— 4— Under 5. o— 10— 15 and upwards. All ages. Poplar 20 35 14 4 4 77 3 – – 80 Southwark 32 71 27 11 11 152 3 — – 155 Bermondsey 12 28 10 7 3 60 2 — 1 63 Lambeth 18 40 20 7 4 89 6 — – 95 Battersea 33 55 18 4 11 121 6 — – 127 Wandsworth 14 42 11 8 6 81 6 87 Camberwell 9 42 14 9 4 78 3 — – 81 Deptford 5 6 3 — — 14 2 — – 16 Greenwich 4 9 3 — 1 17 1 — – 18 Lewisham 8 14 6 5 3 36 3 2 41 Woolwich 7 3 — 2 — 12 1 — – 13 London 405 722 281 135 91 1,634 69 1 4 1,708 In the absence of the requirement of notification of cases of measles, the only knowledge as to the number of cases of this disease occurring, is based upon the information which medical officers of health receive from teachers in the elementary schools, supplemented by such further information as they obtain as the result of inquiries at houses to which their attention is directed, either by the teachers or by the death returns. In the majority of the annual reports the number of cases thus brought to knowledge is stated, and this number amounts to 5 per 1,000 of the population. The mean case rate based on 20 years notifications of measles in Aberdeen was approximately 16 per 1,000. The fact, therefore, that the London figure of 1905 is nearly one-third of the mean figure obtained by notification in Aberdeen is matter for satisfaction. With annual variations of prevalence and fatality such as occur in measles these figures must, of course, not be thought of as being more than suggestive. The annual reports of medical officers of health give but little information as to the age of attack of cases coming under their cognisance, but the following figures are supplied by the reports of Dr. Reginald Dudfield, of Paddington, and of Dr. Newman, of Finsbury :— Age-period. 0— 1— 2 3— 4— Paddington 102 215 198 243 312 Finsbury 47 75 73 106 103 Total 149 290 271 349 415 Dr. Reginald Dudfield groups the Paddington cases at the older age, thus— 5—13 years. 13—15 years. 15 and above. 602 10 32 Dr. Newman sub-divides the 47 Finsbury cases under one year of age as follows :— 0—3 months. 3—6 months. 6—9 months. 9—12 months. — 7 19 21 and classifies the cases over 4 years of age thus— 5—10 years. 10—15 years. 156 1 Figures showing the age distribution and fatality of measles in Aberdeen, during 20 years in which notification has been compulsory, have recently been published by Dr. George N. Wilson,1 from which the following have been extracted:— M easles—A berdeen. Age. Number of cases. Attack-rate per 1,000 population at each age. Number of deaths. Fatality. Per cent. Age. Number of cases. Attack-rate per 1,000 population at each age. Number of deaths. Fatality. Per cent. 0— 3,034 43.7 426 13.9 9— 672 11.3 4 .6 1— 5,222 85.6 526 10.0 10— 406 6.7 1 .2 2— 5,195 85.6 178 3.4 11— 259 4.5 — — 3— 5,053 79.3 82 1.6 12— 241 4.1 — — 4— 4,836 75.4 43 .9 13— 169 2.9 2 1.2 5— 5,352 86.3 35 .7 14— 150 2.6 — — 6— 4,628 75.2 21 .5 15-25 762 1.4 7 .9 7— 2,818 47.3 14 .5 25-60 312 .33 2 .6 8— 1,258 21.0 5 .4 60+ 7 .03 – – The fatality of measles at "all ages" in Aberdeen during this period was 3.33 per cent., which if applied to the 1,709 deaths which occurred in London in 1905, would represent about 11 cases per 1,000 of population. 1 Measles: Its Prevention and Mortality in Aberdeen. Public LLealth, Vol. XVIII. 30 The greatest number of deaths in London and Aberdeen occurred in the first two years of life when, as the Aberdeen figures showed, the fatality is greatest. Children at this age are not directly exposed to infection at school, but the question needs to be considered what proportion of children at this age owe their infection to older children who are themselves infected in school. Dr. Newman, writing of Finsbury cases and deaths in 1905, states " In 1905 there were 75 cases and 14 deaths in the second year of age. Of the total of 89 we have positive findings in 77 with regard to the source of infection. It appears from these investigations that 55 of the 77 (or 71.4 per cent.) contracted their infection at home from elder children in the same families (10 from children in their third year, 18 from children in their fourth year and 27 from children in their fifth year). Most of these infecting children attended infant school." The annual report of Dr. William Butler, Medical Officer of Health of Willesden, gives information of much value as to the source of infection of 1,636 cases of measles occurring in that urban district and which became known to him during the year 1905. Notification of cases of measles is not obligatory in Willesden, but information as to the occurrence of this disease in school-attending children is obtained from teachers in the schools, and inquiries are made in the homes by lady health visitors. Of these 1,636 cases, 919 were primary attacks in families, the children attending the infant school, where they had been exposed to infection. These 919 cases gave rise to 308 other cases, of which 36 were under one year of age and 219 were from one to five years of age. Again, 66 primary cases in families occurred among children attending the boys', girls', or mixed departments, where they had been exposed to infection, and these gave rise to 14 secondary cases, of which two were under one year of age and nine were from one to five years of age. There were, in addition, 87 primary cases attending school, but not known to have been infected in school (from which 29 secondary cases arose, of which one was under one year of age and 19 from one to five years of age), and 175 primary cases in which the infected person was not attending any school. The 175 cases gave rise to 38 secondary cases, 12 of which were under one year and 21 of which were from one to five years of age. Thus 985 children infected in school, in their turn infected 322 in the homes, 38 of whom were under one year of age and 228 of whom were from one to five years of age. The age distribution of the known Willesden cases is different from that of Aberdeen and, therefore, probably different from that which would have been obtained by a system of obligatory notification, for in Willesden only 46 per cent. of the cases are under five years of age while 58 per cent. of the Aberdeen cases are of this age, and again, only 4.4 per cent. of the Willesden cases are under one year of age, while 7.5 per cent. of the Aberdeen cases are of this age. The Willesden cases, however, suffice to show the total primary and secondary cases which were known to be associated with attendance at elementary schools in that district. In the main, measles manifests increase of mortality in London in alternate years. The intervals between successive prevalences correspond more closely to 18 months, or less, than to two years, and these prevalences are, no doubt, associated with the accumulation of susceptible children in the intervals, the incidence of mortality from measles being much greater on children in the second year of life than on children of any other year of age. As will be seen on reference to diagram VII., there is a tendency for the occurrence of the maxima to alternate between the winter and the summer and thus two maxima are produced when a composite seasonal curve is prepared which is based upon the measles mortality of a series of years. It is interesting to observe that if composite seasonal curves are prepared showing measles mortality in successive groups of years, the summer maximum is in the later groups becoming greater and is occurring earlier in the year. The intervals between successive prevalences is thus becoming shorter and notwithstanding decline of measles mortality in 1891-1900 and 1901-5 as compared with 1881-90, and the continued fall in the birth-rate, deaths of children in the first two years of_ life constitute in the last two periods a greater proportion of the total deaths from measles than in 1881-90. Indeed, the following table shows, with the exception of the period 1881-90, when the fall in the birth-rate began, with its inevitable effect on the number of children in the early years of life, the relative proportion of children dying from measles in the first and second year of life has increased since 1851-60. Measles—Deaths all ages 1,000. Years. 0— 1— 2— 3- 4 — 5— 10- 1 15— 20 + 1851-60 162 366 219 116 62 63 5 2 5 1861-70 183 386 216 107 53 46 4 1 4 1871-80 213 393 184 97 50 55 3 1 4 1881-90 197 383 187 104 59 63 3 1 3 1891-1900 212 409 172 98 55 48 2 1 3 1901-1905 226 423 170 86 50 41 2 0 2 This shifting of measles mortality on to the first two years of life is, no doubt, the result of increased aggregation of population in London and increased opportunity of infection, the result of aggregation of children in schools ; for measles, in greater degree than scarlet-fever or diphtheria, spreads in the home to the children of pre-school age if the disease be introducsd into the home by a school-attending child. Hence, it is not matter for surprise that examination of diagram VII. shows that measles mortality frequently declined after the Christmas holiday. Variations in the age-incidence of measles mortality in London is further discussed in Appendix I. Diagram VII. —Measles & Whooping Cough(Deaths 1891-1905.)— Diagram VIE. Scarlet Fever. 31 The Order of the London County Council applying certain provisions of the Public Health (London) Act to measles appears to have been beneficial in impressing upon parents the importance of taking precautions to prevent infectious children associating with others. The more complete returns made by school teachers to medical officers of health, informing them of children absent from school on account of attacks of measles have been operative in the same direction, and sanitary authorities have, by the distribution of cards or leaflets containing information as to the measures necessary, both in the care of children who are attacked, and to prevent extension of disease, done much to supply the knowledge which must be the basis of all efforts to limit measles mortality. Dr. Sidney Davies is of opinion that the lower measles mortality in Woolwich is attributable to the information thus imparted to parents. The London County Council has revised the conditions upon which children are excluded from schools on account of measles. The Code now provides that children suffering from measles must be excluded for at least one month; that all children coming from homes in which measles exists must, if they have not had measles, be excluded; children coming from infected homes, who have had measles and are not attending infants' schools, need not be excluded. Children excluded from other than infants' schools must remain away until the Monday following the expiration of fourteen days from the occurrence of the first case. Children excluded from infants' schools must remain away until the Monday following the expiration of 14 days from the occurrence of the last case. Account of the behaviour of measles among school-attending children will be found in an appendix (see Appendix II.). Dr. Kerr finds in the experience of the year 1905, support for the view previously expressed that the disease tends to spread in a class where the number of susceptible children reaches 30 or 40 per cent., and continues until the proportion of unprotected children has been reduced to 15 or 20 per cent. It is, of course, impossible to say what is the proportion of children who are protected by previous attack which has not been recognised, or who are naturally insusceptible. The early closing of infant classes on the occurrence of the first cases of measles has been practised during the year and infant classes have been closed in 90 instances, while in 28 instances infant'3 departments, in 1 instance boys', in 1 instance girls', and in 1 instance a mixed department have been closed during the year. (See Appendix II., p.27.) The value of closing of schools on account of the occurrence of measles among the pupils has continued to be tested in Woolwich by the division of the district into two parts, in one of which schools are, on such occurrence, closed, and in the other case are not closed. The results are as yet inconclusive. Disinfection after measles is carried out in most districts, and in the annual reports relating to the following districts it is stated that this course is adopted:— Paddington, Kensington, Westminster, St. Marylebone, Islington, Finsbury, Shoreditch, Bethnal-green, Poplar, Battersea, Deptford, Wandsworth, Hammersmith, Fulham and Lambeth. The medical officer of health of Paddington includes in his annual report an interesting table showing the number of houses in which multiple attacks of measles occurred. Dr. Reginald Dudfield thus states that the cases in 1905 occurred as follows:— Paddington—Measles. Houses having 1 case. 2 cases. 3 cases. 4 cases. 5 cases. 6 cases. 7 cases. 8 cases. 242 141 60 30 10 3 3 2 One of the objections which have been made to disinfection alter measles is that nouses invaded by measles may require repetition of disinfection after a brief interval, and Dr. Dudfield mentions that in 1905 the total number of disinfections was 1,078 and that in 36 instances a house was twice, and in one instance three times, disinfected. Scarlet Fever. The cases of scarlet fever notified in the Administrative County of London during 1905 (52 weeks) numbered 19,461, compared with 13,439 in 1904. The number of deaths registered from this cause was 549 in the vear 1905. compared with 365 in the year 1904. The London rates for 1905 and preceding periods are shown in the following table:— Period. Death-rate per 1,000 persons living. Case-rate per l,000 persons living. Case mortality per cent. 1861-70 1.13 1 1 1871-80 0.60 1 1 1881-90 0.33 1 —1 1891-1900 0.192 4.8 3.9 1901 0.132 4.1 3.2 1902 0.122 3.9 3.1 1903 0.082 2.7 2.9 1904 0.082 2.9 2.7 1905 0.122 4.2 2.8 The death-rate in each year since 1858 in relation to the mean death-rate of the period 18591905 will be seen on reference to diagram VIII. The monthly case-rate and case-mortality in each of the years 1891-1905 in relation to the mean of the whole period is shown in diagram X. 1 The Infectious Disease (Notification) Act came into force in 1889. 2 See footnote (1) p. 9. 32 It will be seen from the following table that in the decennium 1895-1904 the London scarlet fever death-rate was lower than the death-rates of all the undermentioned English towns, except Bristol, and West Ham, and in 1905 was «xceoded by the death-rates of Liverpool, Manchester, Sheffield, Bradford, Salford and Leicester:— Scarlet fever—Death-rates per 1,000 persons living. Towns. 1895-1004. 1905. Towns. 1895 -1904. 1905. London 0-131 0-121 West Ham 0.13 0.12 Liverpool 0.27 0.41 Bradford 0.16 0.16 Manchester 0.21 0.13 Neweastle-on-Tyne 0.14 0.05 Birmingham 0.23 0.10 Hull 0.14 0.09 Leeds 0.18 0.09 Nottingham 0.15 0.07 Sheffield 0.19 0.22 Salford 0.34 0.29 Bristol 0.12 0.11 Leicester 0.14 0.15 The following table shows that the London scarlet fever death-rate was, in the decennium 18951904, exceeded by the death-rates of St. Petersburg, Berlin, Vienna and New York, and in 1905 was exceeded by the death rates of Stockholm, St. Petersburg and Berlin:— Scarlet fever—Death-rates per 1,000 persons living. Towns. 1895-1904. 1905. Towns. 1895-1904. 1905. London 0.13' 0.121 St. Petersburg 0.54 0.51 Paris 0.05 0.02 Berlin 0.24 0.21 Brussels 0.04 0.03 Vienna 0.16 0.09 Amsterdam 0.02 0.03 Rome 0.01 0.01 Copenhagen 0.12 0.07 New York 0.22 0.12 Stockholm 0.13 0.31 The following table shows the scarlet fever case3, deaths, case-rates, and death-rates for the year 1905, the case-rates for the decennium 1895-1904, and the death-rates for the period 1901-4 in the several sanitary districts of the County:— Sanitary area. Cases, 1905. Case-rate per 1,000 persons living. Deaths, 1905. Death-rate per 1,000 persons living. 1895-1904. 1905. 1901-1904. 1905. Paddington 278 3.4 1.9 7 0.07 0.05 Kensington 335 2.9 1.9 21 0.08 0.12 Hammersmith 360 3.5 3.0 11 0.08 0.09 Fulham 780 4.3 5.0 22 0.09 0.14 Chelsea 228 3.4 3.1 9 0.07 0.12 Westminster, City of 370 2.8 2.1 15 0.06 0.09 St. Marylebone 278 3.1 2.2 15 0.11 0.12 Hampstead 180 3.0 2.0 6 0.05 0.07 St. Pancras 986 4.0 4.2 27 0.14 0.11 Islington 1,198 4.3 3.5 38 0.10 0.11 Stoke Newington 178 3.9 3.4 3 0.06 0.06 Hackney 1,066 4.7 4.7 19 0.09 0.08 Holborn 156 3.5 2.8 4 0.07 0.07 Finsbury 478 4.6 4.9 21 0.15 0.21 London, City of 76 3.3 3.4 1 0.07 0.04 Shoreditch 792 3.8 6.8 28 0.10 0.24 Bethnal Green 794 5.1 6.1 26 0.18 0.20 Stepney 1,844 4.6 6.1 58 0.11 0.19 Poplar 991 4.1 5.8 29 0.11 0.17 Southwark 776 4.3 3.7 28 0.15 0.13 Bermondsey 752 4.8 5.8 17 0.20 0.13 Lambeth 1,025 3.7 3.3 31 0.10 0.10 Battersea 848 4.8 4.8 24 0.08 0.14 Wandsworth 1,490 3.7 5.6 28 0.07 0.11 Camberwell 1,220 4.3 4.5 31 0.11 0.11 Deptford 609 5.0 5.3 10 0.14 0.09 Greenwich 283 3.9 2.7 5 0.06 0.05 Lewisham 572 3.5 4.0 5 0.09 0.03 Woolwich 515 4.6 4.1 10 0.07 0.08 Port of London 3 — — — London 19,461 4.0 4.2 549 0.102 0.122 1. See footnote (2) page 9. 2. See footnote (1) page 9. Diagram X. Scarlet Fever. 33 It will be seen from the foregoing table that the scarlet fever death-rate was in the period 1901—4 highest in Bermondsey (0.20) and lowest in Hampstead (005), and in the year 1905 was highest in Shoreditch (0.24) and lowest in Lewisham (0.03). The scarlet fever death-rates obtaining in London during the four quarters of the year 1905 were as follows:— first quarter, 0.11; second quarter, 0.10; third quarter, 0.11; and fourth quarter, 0.15 per 1,000 persons living. Scarlet fever appears to have manifested greater infectivity during the year, but the fatality still remained low, both the number of cases and of deaths having been some 50 per cent. greater than in the preceding year of 1904. Only one outbreak of scarlet fever was attributed to the distribution of an infected milk supply. This outbreak occurred in Wandsworth, mainly in the early part of the month of April, and involved the attack of 20 persons. A child of one of the men employed in distributing the milk was among the sufferers and Dr. Caldwell Smith found no other cause to which he could attribute the outbreak. The annual reports give account of local prevalences due to communication of infection from one person to another, the mildness of the disease giving opportunity for Cases of scarlet fever to remain undetected. In these circumstances it is not matter for surprise that much difficulty was experienced in finding the source of infection of many cases. In Finsbury, Dr. Newman was able to discover the source of infection in 265 of 456 cases brought to his knowledge; in Battersea, Dr. McCleary was able to find the source of infection of 144 out of 801 cases, and in Bermondsey, Dr. Brown in 120 cases out of 768. In Battersea, in 144 cases there was history of exposure to infection from a previous case, in 55 cases there was good reason for suspecting school infection, and 23 were "return cases." The sources of infection of the Bermondsey cases were attributed in 47 cases to previous cases in the house or family, in eight cases to friends (visiting), in four cases to infection in hospital where they were sent for other reasons, in thirty-five cases to infection in school, and twenty-six were " return cases." Dr. Reginald Dudfield shows the number of cases occurring in Paddington and Dr. Bond the number of cases occurring in Holborn to be distributed as follows:— Houses with One case each. Two cases each. Three cases each. Four cases each. Paddington 185 31 6 3 Bermondsey 133 8 1 1 In a number of the annual reports "return cases" are discussed. This subject was reported upon in 1904 by Dr. A. G. R. Cameron, and is still being investigated by Dr. F. M. Turner on behalf of the Metropolitan Asylums Board. The results are not finally conclusive and it is interesting to note that the observations of Dr. Cameron cast suspicion especially, as sources of infection, upon children who developed rhinorrhoea, while Dr. Turner has not found evidence of infectivity above the average in such cases after ten weeks detention in hospital. A notice as to the precautions to be observed on the return home of a child discharged from hospital is now communicated to parents whose children have suffered from scarlet fever in the hospitals of the Board. Scarlet fever and elementary schools. The summer holiday of the London County Council schools began in 1905 on Thursday, the 27th July, i.e., the latter part of the 30th week, and the schools re-opened on Monday, the 28th August, i.e., at the beginning uf the 35th week. If the number of cases notified in the four weeks, which would be most subject to holiday influence, be compared with the number of cases notified in the four preceding and four subsequent weeks, the results shown in the following table are obtained:— Scarlet fever—Notified cases, 1905. Period. Notified cases—Ages. Increase ( + ) or decrease ( —) per cent. 0.3 3.13 13 and upwards. 0.3 3.13 13 and upwards. Four weeks preceding weeks of holiday influence (28th to 31 st) 186 1,093 186 — — — Four weeks of holiday influence (32nd to 35th) 208 1,160 189 + 11.8 + 61 + 1.6 Four weeks following weeks of holiday influence (36th to 39th) 219 1,647 263 +5.3 +42.0 +39.2 It is interesting to note that the year 1905 is the first year since the question has been considered that the number of cases of scarlet fever among children at school age has in the summer holiday month exceeded that of the preceding month. This increase has been due in the main to exceptional prevalence in St. Pancras, where an outbreak occurred during the month of August, involving in that and the subsequent period the attack of some 140 persons, and to exceptional prevalence in Stepney in the neighbourhood of Montague-street and Wentworth-street, apparently due to infection from a boy, the nature of whose illness had not been recognised and whom Dr. Thomas found to be suffering from desquamation of the skin. Dr. Kerr (see Appendix II.), states that in only three instances were school departments (infants.) closed during the year ended March, 1906, on account of the occurrence of scarlet fever among the scholars, while in nine instances classes were closed on this account, seven of the classes being in infants. departments. 11476 E 34 In connection with the usually observed decrease of scarlet fever during the August holiday month the question has in previous reports been considered to what extent this decrease has been due to decrease in the London population, owing to the customary exodus from London of persons who take their holiday in the country at that time of the year. The Local Government Board supplies to medical officers of health a weekly return of notified cases of infectious disease in London and a number of other communities, and it is interesting to note that in 1905 there was a decrease of notified cases of scarlet fever during the holiday month in places to which it is usual for many persons to resort at that time. The return referred to does not include all the principal places of holiday resort in England and Wales, but the total number of cases of scarlet fever notified in 44 of these localities1 selected as especially likely to have influx of population during the holiday will be seen by the following figures to have decreased during that month. (See also Appendix II., page 30). The number of notified cases in London is also shown:— Period. London. Holiday resorts. Cases. "All ages." Increase (+) or decrease (.) per cent. Cases. ''All ages." Increase ( +) or decrease(.) per cent. Four weeks preceding weeks of holiday influence 1,465 — 317 — Four weeks oj holiday influence 1,557 + 6.3 205 — 35.3 Four weeks following weeks of holiday influence 2,129 + 36.7 267 + 30.2 The variations in the age.incidence of scarlet fever mortality and their relation to school attendance during the period 1861.1905 are discussed in an appendix to this report (see Appendix I.). Proportion of cases of scarlet fever removed to hospital. It will be seen from diagram IX. that the proportion of cases of scarlet fever admitted to the hospitals of the Metropolitan Asylums Board was greater in 1905 than in any preceding year. Scarlet fever—Age and sex distribution. The following table shows the notified cases, deaths, case.rates, death.rates and fatality of scarlet fever at the several ages and for each sex in London during the year 1905. It will be seen that the death.rate and fatality was higher among males at "all ages" than among females, though the case.rate was higher among the latter. In the age groups adopted for the purposes of this table, the greatest incidence of attack was made upon both males and females of four years of age. The greatest incidence of death was upon both male3 and females of two years of age. The fatality, it will be observed, was highest among males of one and among females under one year of age. Scarlet fever2, 1905. Age.period. Males. Females. Notified Cases. Deaths. Case mortality per cent. Bates per 100,000 living. Notified Cases. Deaths. Case mortality per cent. Bates per 100,000 living. Cases. Deaths. Cases. Deaths. All ages 9,131 287 3.1 413 13 10,330 265 2.6 418 11 0— 142 18 12.7 250 32 122 16 13.1 216 28 1— 359 49 13.6 714 97 379 38 10.0 753 76 2- 668 61 9.1 1,314 120 694 48 6.9 1,370 95 3— 980 48 4.9 1,979 97 927 37 4.0 1,849 74 4— 1,090 28 2.6 2,249 58 1,081 32 3.0 2,241 66 5— 3,828 63 1.6 1,683 28 4,404 67 1.5 1,918 29 10— 1,196 9 0.8 557 4 1,615 11 0.7 738 5 15— 401 4 1.0 186 2 432 3 0.7 180 1 20— 228 2 0.9 102 1 296 5 1.7 110 2 25— 179 3 1.7 47 1 310 6 1.9 69 1 35— 47 2 4.3 16 1 47 2 4.3 15 1 45— 9 — — 4 — 14 — — 6 — 55 and upwards 4 — — 2 - 9 - — 3 - 1 Tunbridge Wells, Broadstairs and St. Peter's, Dover, Folkestone, Hythe, Eastbourne, Seaford, Brighton, Hove, Worthing, Bognor, Portsmouth, Gosport and Alverstone, East Cowes, Newport (Isle of Wight), Ryde, St. Helen's (Isle of Wight), Ventnor, Bournemouth, Southampton, Southend, Clacton, Walton, Lowestoft, Weymouth, Exeter, Dawlish, Teignmouth, Torquay, Dartmouth, Plymouth, Devonport, Ilfracombe, Penzance, Weston.super. Mare, Bath, LeamingtoD, Seaforth, Southport, Blackpool, Scarborough, Whitby, Aberystwyth, Bangor. 2 In the preparaion of this table the rates and 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. Diagram XIII Diphtheria. Diagram, XI. Diphtheria. 35 Diphtheria. The cases of diphtheria (including membranous croup) notified in the administrative county of London in 1905 (52 weeks) numbered 6,482, compared with 7,219 in 1904. The number of deaths registered from this cause in 1905 was 546, compared with 723 in 1904. The diphtheria case.rates, death.rates, and case mortality in 1905, 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 1881-90 0.26 2 2 1891-1900 0.491 2.6 19.0 1901 0.291 2.7 10.9 1902 0.251 23 10.8 1903 0.161 1.7 9.6 1904 0.161 1.6 10.0 1905 0.121 1.4 8.4 The death-rate in each year since 1858 in relation to the mean death-rate of the period 1859. 1905 is shown for diphtheria and also for diphtheria and croup combined in diagram XI. The monthly case-rate and case-mortality in each of the years 1891-1905 in relation to the mean of the period is shown in diagram XIII. 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 1895.1904 the London rate exceeded the rates of all these towns, except Sheffield, West Ham, and Leicester, while in 1905 it was lower than the rate of any except Leeds and Leicester. Diphtheria—Death.rates per 1,000 persons living. Towns. 1895-1904. 1905. Towns. 1895-1904. 1905. London 0.373 0.123 West Ham 0.56 0.26 Liverpool 0.25 0.21 Bradford 0.17 0.28 Manchester 0.18 0.20 Newcastle-upon-Tyne 0.17 0.19 Birmingham 0.28 0.17 Hull 0.19 0.30 Leeds 0.33 0.10 Nottingham 0.13 0.19 Sheffield 0.43 0.13 Salford 0.34 0.36 Bristol 0.26 0.16 Leicester 0.49 0.05 The following table shows that the London diphtheria death-rate was in the decennium 1895.1904 higher than that of any of the undermentioned foreign towns, except Stockholm, St. Petersburg, and New York, and in 1905 was exceeded by the rates of Stockholm, St. Petersburg, Berlin, Vienna, and New York :— Diphtheria—Death.rates per 1,000 persons living. Towns. 1895-1904. 1905. Towns. 1895-1904. 1905. London 0.373 0.123 St. Petersburg 0.84 0.50 Paris 0.16 0.07 Berlin 0.27 0.15 Brussels 0.12 0.08 Vienna 0.29 0.24 Amsterdam 0.14 0.10 Rome 0.09 0.09 Copenhagen 0.16 0.07 New York 0.58 0.38 Stockholm 0.38 0.26 The following table shows the diphtheria cases, deaths, case-rates, and death-rates for the year 1905, the case-rates for the decennium 1895-1904, and the death-rates for the period 1901-4, in the several sanitary districts:— ' See footnote ('), page 9. 2 The Infectious Desease (Notification) Act came into force in 1889. 3 See footnote (2), page 9. 11476 E2 36 Sanitary area. Notified Oases, 1905. Case-rate per 1,000 persons living. Deaths, 1905. Death-rate per 1,000 persons living. 1895-1904. 1905. 1901-4. 1905. Paddington 97 1.8 0.7 3 0.19 0.02 Kensington 130 1.6 0.7 9 0.14 0.05 Hammersmith 242 1.8 2.0 21 0.22 0.18 Fulham 286 3.4 1.8 24 0.25 0.15 Chelsea 52 2.4 0.7 5 0.10 0.07 Westminster, City of 118 1.4 0.7 5 0.10 0.03 St. Marylebone 131 1.6 1.0 5 0.19 0.04 Hampstead 66 1.5 0.8 3 0.13 0.03 St. Pancras 287 2.4 1.2 26 0.31 0.11 Islington 351 2.1 1.0 34 0.23 0.10 Stoke Newington 80 1.9 1.5 5 0.17 0.09 Hackney 385 3.2 1.7 26 0.29 0.11 Holbom 46 2.0 0.8 4 0.16 0.07 Finsbury 141 2.9 1.4 12 0.25 0.12 London, City of 16 2.1 0.7 2 0.21 0.09 Shoreditch 182 2.4 1.6 18 0.20 0.15 Bethnal Green 305 3.2 2.3 31 0.33 0.24 Stepney 639 3.2 2.1 61 0.26 0.20 Poplar 491 3.6 2.9 41 0.42 0.24 Southwark 304 3.1 1.5 44 0.20 0.21 Bermondsey 167 2.8 1.3 18 0.19 0.14 Lambeth 451 2.2 1.4 37 0.14 0.12 Battersea 192 2.5 1.1 12 0.12 0.07 Wandsworth 350 2.2 1.3 30 0.20 0.11 Camberwell 247 3.3 0.9 19 0.24 0.07 Deptford 148 3.3 1.3 9 0.27 0.08 Greenwich 147 2.6 1.4 16 0.19 0.16 Lewisham 157 2.5 1.1 8 0.19 0.06 Woolwich 274 2.2 2.2 18 0.18 0.14 Port of London — 1 - - - London 6,482 2.5 1.4 546 0.221 0.121 It will be seen from the foregoing table that in the period 1901.4 the diphtheria death-rate was highest in Poplar (0.42), and lowest in Chelsea (0.10), and the City of Westminster (0.10); in the year 1905 Bethnal Green (0.24) and Poplar (0'24) had the highest death-rates, and Paddington (0.02) the lowest. The diphtheria death-rate in each of the four quarters of the year 1905 were as follows: first quarter, 0.14; second quarter, 0.10; third quarter, 0.09; and fourth quarter, 0.14 per 1,000 persons living. To enable the variations in diphtheria prevalence in the several sanitary areas to be more clearly appreciated, the following table has been prepared. This table shows the comparative case-rates of each area in each of the years 1891.1905 inclusive, i.e., the case-rates of each area 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. 1905. Paddington 104 77 73 117 74 66 91 98 68 44 89 65 59 63 50 Kensington 78 60 68 63 86 70 67 49 51 74 52 43 59 63 50 Hammersmith 195 164 87 72 77 67 49 58 58 85 74 70 82 106 143 Fulham 61 58 78 126 139 99 109 145 135 178 174 126 118 125 129 Chelsea 138 110 83 107 143 184 107 79 61 74 56 78 76 50 50 Westminster, City of 58 91 57 53 61 53 59 67 50 59 52 70 59 50 50 St. Marylebone 70 81 88 78 64 66 53 64 47 59 74 78 100 56 71 Hampstead 105 96 73 53 61 84 47 65 48 74 70 52 59 44 57 St. Pancras 89 95 103 83 90 64 76 78 79 93 148 152 129 94 86 Islington 152 119 86 103 70 106 73 60 68 70 100 113 82 63 71 Stoke Newington 83 113 97 77 70 70 52 59 34 111 104 83 47 75 107 Hackney 131 147 135 108 93 89 122 152 106 107 167 139 141 156 121 Holborn 52 89 79 61 66 61 104 102 46 70 104 87 53 50 57 1. See footnote (l) page 9. 37 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. 1905. Finsbury 118 82 130 81 86 112 170 163 93 74 107 100 76 94 100 City of London 59 130 60 49 51 74 71 60 68 89 96 161 65 106 50 Shoreditch 124 89 131 95 80 97 103 80 103 111 104 83 76 100 114 Bethnal Green 154 230 181 168 143 114 144 100 89 115 133 104 112 206 164 Stepney 106 132 112 123 157 150 128 93 89 107 104 113 106 169 150 Poplar 191 148 214 159 179 133 141 105 83 141 137 117 147 250 207 Southwark 71 72 116 113 86 106 102 151 207 141 100 113 100 87 107 Bermondsey 68 60 84 126 80 99 97 90 177 133 93 91 76 94 93 Lambeth 88 97 91 83 88 74 83 103 121 104 63 70 65 69 100 Battersea 144 123 132 122 97 81 125 178 116 70 59 74 106 81 79 Wandsworth 74 83 84 79 60 51 100 114 99 74 74 135 124 100 93 Camberwell 69 65 67 112 140 180 154 102 156 130 122 113 82 63 64 Deptford 72 68 86 153 225 113 141 132 121 111 144 104 241 106 93 Greenwich 60 43 84 85 137 189 82 105 122 89 74 78 124 94 100 Lewisham 48 74 82 70 57 122 85 127 170 126 85 130 118 56 79 Woolwich 32 68 66 66 81 96 91 86 100 115 67 91 88 81 157 London 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 Diphtheria showed decline in 1905 both in respect of prevalence and fatality. Of the 29 districts in the county in only five was there excess of diphtheria mortality in 1905 over that of 1904, in almost all the other districts there was decline. In the eastern districts the death-rates were highest, but showed an improvement on the rates of the preceding year. Dr. Kerr states (see Appendix II., page 27), that eight departments were closed (four infants'), and one girls' class during the year ended March, 1906, on account of the occurrence of diphtheria among the scholars. Increased prevalence due to spread of disease through school attendance is mentioned in some of the reports of medical officers of health. Thus in Poplar it became necessary to close the infant and girls' departments of the Monteith-road school in the month of July. Prevalence of diphtheria among the children attending the Mitcham-lane school, Wandsworth; a school in the neighbourhood of Charlton, Greenwich; and the Church Manorway, Eglinton-road, and Union-street schools, Woolwich, are referred to. The practice of bacteriological examination of material from children exposed to infection, and the exclusion of children found to harbour the Klets-Loeffler bacillus was carried out, but in the case of the Eglinton-road school it became necessary finally to close the school. Dr. Davies states that this brought the outbreak to an end. Dr. Brown reports that the plan instituted in Bermondsey of examining all diphtheria contacts among children before permitting them to return to school has been continued unaltered. Children found to be harbouring the diphtheria bacillus are excluded from school and the parents are advised to secure the treatment of the throats of the children. The County Council has recently recognised the principle that children harbouring the Klebs-Loeffler bacillus should be excluded from school as possibly infective, and has authorised the Education Committee to refuse during the presence of diphtheria in any district re-admission to school of children excluded on account of diphtheria or sore throat until such children shall have obtained a medical certificate of freedom from infection based on a bacteriological examination. In connection with the more systematic examination of the throats of children attending school, Dr. Sidney Davies points out that this has added to the number of notified cases of diphtheria occurring in Woolwich, cases of so mild a character that they would otherwise have escaped detection, with the result that the notified cases were numerous, although the deaths few. It is necessary to bear in mind the effect which this procedure necessarily has upon the fatality rate, which is calculated on the cases notified and deaths resulting from diphtheria. In many of the reports the number of instances is stated in which there was examination at the public expense of material fro m the throats of persons suspected to be suffering from diphtheria. The following show these numbers with the results obtained:—Paddington 36, 8 positive; Fulham 191, 42 positive; Westminster 102, 24 positive; St. Marylebone 42, 14 positive; St. Pancras 91, 24 positive; Islington 147, 61 positive; Stoke Newington 47, 21 pssitive; Hackney, 93, 42 positive; Holborn, 13, 11 positive; Finsbury 61, 12 positive; Shoreditch 32, 5 positive; Poplar 293,64 positive; Bermondsey, 108, 20 positive; Lambeth 1,644, 111 positive; Battersea 165, 50 positive; Wandsworth 174, 51 positive; Deptford 71, 30 positive; Greenwich 119, 31 positive; Lewisham 106, 34 negative; Woolwich 712, 102 positive. In these districts, therefore, there were 4,247 examinations, and of these 757 or 17.8 per cent, gave positive results. These examinations do not include those that were made in the laboratory of the County Council in the Education offices. 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 27th July, i.e., the latter part of the 30th week, and the schools re-opened on Monday, the 28th August, i.e., the beginning of the 35th week. If the number of cases in the four weeks preceding and 38 four weeks subsequent to the weeks most subject to holiday influence be compared, the following results are obtained for the age periods of 0—3, 3—13, and 13 years and upwards. It will be observed that the decrease in the number of cases notified during the period of holiday influence is 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 (28th to 31st) 67 329 82 — — — Four weeks of holiday influence (32nd to 35th) 89 212 84 + 32.8 -35.6 + 2.4 Four weeks following weeks of holiday influence (36th to 39 th) 90 334 87 + 1.1 + 57.5 + 3.6 On p. ,54 it is shown that there was decline during the holiday month in the number of cases of scarlet fever notified in places to which people resort at this time. The same fact is observable when the number of cases of diphtheria is considered. Reference to the subject will also be found on page 30 of Appendix II. The following figures relate to the same places as those mentioned in connection with scarlet fever:— Period. London. Holiday resorts. Cases. "All Ages." Increase or decrease per cent. Cases. "All Age*." Increase or decrease per cent. Four weeks preceding weeks of holiday influence 478 - 121 -. Four weeks of holiday influence 385 — 19.5 106 — 12.4 Four weeks following weeks of holiday influence 511 + 32.7 163 +[53.8 Diphtheria—Age and sex distribution. The following table shows the notified cases, deaths, case-rates, death-rates, and fatality of diphtheria at the several ages and for each sex in London during the year 1905. 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 at "all ages," 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 both males and females of under one year of age. Diphtheria, 1905. Age.period. Males. Females. Notified Cases. Deaths. Case mortality per cent. Rates per 100,000 living. Notified Cases. Deaths. Case mortality per cent. Rates per 100,000 living. Cases. Deaths. Cases. Deaths. All ages 3,023 276 9.1 137 12 3,459 285 8.2 140 12 0— 106 28 26.4 186 49 73 25 34.2 129 44 l— 252 54 21.4 501 107 205 54 26.3 407 107 2— 341 45 13.2 671 88 300 53 17.7 592 105 3— 388 42 10.8 783 85 347 49 1.41 692 98 4— 377 37 9.8 778 76 360 31 8.6 746 64 5— 907 57 6.3 390 25 1,160 60 5.2 505 26 10— 289 7 2.4 135 3 393 7 1.8 180 3 15— 114 1 0.9 53 0 170 1 0.6 71 0 20— 106 2 1.9 47 1 140 — — 52 — 25— 96 2 2.1 25 1 205 1 0.5 45 0 35— 33 1 3.0 11 0 71 3 4.2 22 1 45— 11 — — 5 25 1 4.0 11 0 55 and upwards 3 — — 2 — 10 - — 4 — 1 See footnote (2) page 35. Diagram XTV. Whooping Cough. ' ' 39 The variations in the age-incidence of diphtheria mortality in London and their relation to school attendance during the period 1861-1905 are discussed in an appendix to this report (see Appendix I.). Proportion of cases of diphtheria removed to hospital. It will be seen from diagram XII. that the proportion of cases of diphtheria removed to the hospitals of the Metropolitan Asylums Board was about the same as that in the preceding year. Whooping-cough. The deaths from whooping-cough in the Administrative County of London in the year 1905 (52 weeks) numbered 1,487, as compared with 1,495 in 1904. The death-rates from this disease in 1905 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 1901 0.351 1851-60 0.88 1902 0.401 1861-70 0.88 1903 0.351 1871-80 0.81 1904 0.321 1881-90 0.69 1905 0.321 1891-1900 0.501 In view of the fall of the birth-rate it is desirable that the whooping-cough death-rate of children under five years of age should be stated. The following are the death-rates of children under five years of age. The steady fall of the death-rate during these periods is conspicuous:— Period. Death-rate. Period. Death-rate. 1851-60 6.56 1901 3.132 1861-70 6.53 1902 3.562 1871-80 6.02 1903 3.162 1881-90 5.34 1904 2.912 1891-190 4.212 1905 2.882 The death-rate in each year since 1840 in relation to the mean of the period 1841.1905 is shown in diagram XIV., while the deaths in each month since 1890 in relation to the mean monthly deaths of the period 1891.1900, are shown in diagram VII., page 30. It will be seen from the following table that the London whooping-cough death-rate was in the decennium 1895.1904 exceeded by the death-rates of Liverpool, Manchester, Birmingham, West Ham, Newcastle-upon-Tyne and Salford, and in 1905 exceeded the death-rates of all the undermentioned large English towns except Bristol, West Ham, Bradford, Newcastle-upon-Tyne, and Hull Whooping-cough—Death-rates per 1,000 persons living. Towns. 1895-1904. 1905. Towns. 1895-1904. 1905. London 0.412 0.322 West Ham 0.47 0.56 Liverpool 0.52 0.20 Bradford 0.29 0.34 Manchester 0.49 0.31 Newcastle-upon-Tyne 043 0.33 Birmingham 0.49 0.29 Hull 0.34 0.50 Leeds 0.38 0.26 Nottingham 0.33 0.24 Sheffield 0.39 0.29 Salford 0.60 0.20 Bristol 0.33 0.34 Leicester 0.31 0.22 The following table shows that the London whooping-cough death-rate was both in the decennium 1895.1904 and the year 1905 higher than that of any of the undermentioned foreign towns. Whooping-cough—Death-rates per 1,000 persons living. Towns. 1895-1904. 1905. Towns. 1895-1904. 1905. London 0.412 0.323 St. Petersburg 0.22 0.27 Paris 0.13 0.11 Berlin 0.28 0.22 Brussels 0.12 0.07 Vienna 0.09 0.12 Amsterdam 0.26 0.28 Rome 0.06 0.06 Copenhagen 0.35 0.22 New York 0.15 0.10 Stockholm 0.19 0.22 1 See footnote (l) page 9. 2 See footnote (2) page 9. 40 The following table shows the whooping-cough deaths and death-rates for the year 1905 and the death-rates for the period 1901-4 in the several metropolitan sanitary districts:— Sanitary area. Deaths, 1905. Death rate per 1,000 persons living. 1901-4. 1905. Paddington 50 | 0.25 0.34 Kensington 60 0.27 0.33 Hammersmith 57 0.38 0.48 Fulham 83 0.43 0.53 Chelsea 22 0.33 0.30 Westminster, City of 28 0.19 0.16 St. Marylebone 24 0.25 0.19 Hampstead 17 0.17 0.19 St. Pancras 82 0.40 0.35 Islington 112 0.36 0.33 Stoke Newington 10 0.25 0.19 Hackney 65 0.30 0.29 Holborn 17 0.27 0.30 Finsbury 32 0.48 0.33 London, City of 2 0.17 0.09 Shoreditch 88 0.52 0.76 Bethnal Green 54 0.42 0.42 Stepney 137 0.44 0.45 Poplar 80 0.50 0.47 Southwark 80 0.48 0.38 Bermondsey 37 0.45 0.29 Lambeth 80 0.38 0.26 Battersea 51 0.41 0.29 Wandsworth 76 0.27 0.29 Camberwell 68 0.34 0.25 Deptford 19 0.41 0.17 Greenwich 14 0.38 0.14 Lewisham 26 0.25 0.18 Woolwich 16 0.32 0.13 London 1,487 0.36 0.32 It will be seen from the foregoing table that in the period 1901-4, the whooping-cough death-rate was highest in Shoreditch (0.52), and lowest in Hampstead (0.17), and the City of London (0.17); in the year 1905, the highest rate was again in Shoreditch (0.76), and lowest in the City of London (0.09). The whooping-cough death-rate in each of the four quarters of the year 1905 were as follows: first quarter, 0.37; second quarter, 0.45; third quarter, 0.22; and fourth quarter, 0.24 per 1,000 persons living. As in the case of other infectious diseases medical officers of health receive information from the teachers in elementary schools of the absence of children from school on account of attack of whooping-cough; the number of cases thus heard of is, however, only exceptionally stated in the annual reports. Figures, therefore, which have been obtained during ten years notification of cases of this disease in Aberdeen (1891-1900) are of value in giving indication of the account of prevalence of this disease in an urban community. The following figures are extracted from a paper by the late Dr. J.S. Laing and Professor Matthew Hay.* W hooping-cough—Aberdeen, 1891-1900. Ages. No. of cases. Attack rate per 1,000 of population at each year of age. No. of deaths. Fatality per cent. Ages. No. of cases. Attack rate per 1,000 of population at each year, of age. No. of deaths. Fatality per cent 0— 2,492 69.2 313 12.5 10- 56 1.8 - - 1— 2,327 73.5 235 10.1 ll— 43 1.4 — — 2— 2,297 7.31 76 3.3 12— 21 .6 1 4.7 3— 2,129 64.5 48 2.2 13— 21 .7 - - 4— 1,808 54.3 30 1.6 14— 7 .2 — - 5— 1,676 52.2 9 .5 15—25 42 .1 - - 6— 1,163 36.4 8 .7 25—60 45 .1 — — 7— 584 18.9 l .1 60 & upwards 2 .02 — 8— 266 8.5 1 .3 9— 114 3.8 — — All ages 15,093 722 4.7 * Whooping-cough, Its Prevalence and Mortality in Aberdeen," by James S. Laing, M.D., D.P.H. Revised and extended by Professor Matthew Hay, M.D. Public Health, 1902. 1 See footnote ('), page 9. Diagram XV. Typhus 41 If the fatality of the Aberdeen case during this period be applied to the 1,487 deaths from whoopingcough which occurred in London in 1905, this would give a case rate of about 7 per 1,000 of population. As in the case of measles, Dr. Reginald Dudfield shows the number of cases occurring in houses in Paddington invaded by whooping-cough and coming to his knowledge. The results were as follows:— Paddington—Whooping-cough, number of cases per house, 1905. Houses with 1 case each, 2 cases each, 3 cases each, 4 cases each. 5 cases each. 6 cases each, 7 cases each. 148 93 44 13 3 — 1 For the limitation of whooping-cough, school children attacked by the disease are excluded from school for as long as the cough continues, and for not less than five weeks from the commencement of the whooping. Children coming from houses in which whooping-cough exists, although not suffering from the disease, are dealt with much in the same way as in the case of measles (see page 31 ante). In one instance during the year ended March, 1906, an infants' department was closed on account of whooping-cough among the scholars (see Appendix II., page 27). In some districts disinfection after whooping-cough is carried out. The medical officer of health of Wandsworth expresses the opinion that the provisions of the Public Health Act, which in 1903 were extended to measles, should in like manner now be extended to whooping-cough. The variations in the age-incidence of whooping-cough mortality in London during the period 1861-1905 are discussed in an appendix to this report (see Appendix I.). Typhus. No deaths from typhus were registered in the Administrative County of London during the year 1905, but as will be seen later, one death, although not registered as due to this cause, must be attributed to this disease. The deatn-rates trom this disease in successive periods have been as follows:— Period. Death-rate per 1,000 persons living. 1871-80 .055 1881-90 . 008 1891-1900 .0011 1901 .001 1902 .0001 1903 .001 1904 -1 1905 -1 In this table .000 indicates that the deaths were too few to give a rate of .0005; where — is inserted no death occurred. The death-rate in each period since 1868 in relation to the mean death-rate of the period 1869-1905 is shown in diagram XV. During the year 1905, nine persons were certified to be suffering from typhus, one resident in St. Pancras, one in Hackney, and seven in Stepney. After removal to hospital the St. Pancras case and two of the Stepney cases were found not to be cases of typhus. Dr. Thomas supplies information concerning the five remaining cases notified and also concerning that of a medical man whose death had been attributed to influenza and toxoemia. The Hackney case was that of a nurse who attended the Stepney cases admitted to the Eastern Hospital in Hackney. The details of the Stepney cases were as follows:— Millie G., aged 12 years, Branbridge-street, Whitechapel, who attended the London Hospital as an out-patient on the 14th January and was subsequently attended at home by Dr. C., of Burdett-road. She was finally removed to the Eastern Hospital on a certificate that she was suffering from enteric fever but on admision was found to have typhus fever; later her brother Abraham was admitted to the London Hospital where his illness was certified to be typhoid fever, but he was subsequently recognised to have typhus and was removed to the Eastern Hospital. On the 14th February, Kate, aged nine, Woolf, aged ten. sister and brother of the above-mentioned cases, were removed to the Eastern Hospital, both suffering from typhus. Millie had been attended at home by Dr. C., from the 17th to the 24th January, and he was removed to the London Hospital on the 5th February, where he died on the 14th February. His illness was characterised by marked mental symptoms, and the cause of his death was certified to be influenza and toxaemia. There is no reason for doubting the accuracy of Dr. Thomas' conclusions that Dr. C. died from typhus contracted from Millie G. The only other case of typhus known to have occurred during the year was that of a girl aged 19, a cap maker, living in Fashion-street, Stepney, who was certified to be suffering from typhoid fever but whose illness was recognised in the Eastern Hospital to be typhus. Dr. Thomas reports, with reference to the family G., that it consisted of father, mother and six children, and that they occupied four rooms in a house occupied also by a man and his wife and six children. The rooms occupied by the G. family were clean but slightly overcrowded. The father G. was a tailor's presser; he had been living in Reading for some months. He returned home for the Christmas holidays and was sufficiently unwell on the 25th December to seek medical aid. The medical man who saw him thought he was suffering from mild pleurisy; on the 3rd January he returned to Reading where he was also medically attended. He was too unwell to work and on the 9th January returned to London. If his malady were typhus it must have been contracted in Reading. 1 See footnote (1), page 9. 11476 F 42 Enteric Fever. The number of cases of enteric fever notified in the Administrative County of London during 1905 (52 weeks) was 1,552, compared with 1,896 in 1904. The deaths from this disease numbered 234 in 1905, compared with 286 in 1904. The case-rate and death-rates per 1,000 persons and the case-mortality per cent. in 1905 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 -1 -1 1881-90 0.19 1 1 1891-1900 0.142 0.8 18.2 1901 0.1l2 0.7 15.6 1902 0.122 0.7 15.8 1903 0.082 0.5 15.7 1904 0.062 0.4 15.1 1905 0.052 0.3 15.1 The death-rate in each year since 1868 in relation to the mean death-rate of the period 1869-1904 is shown on diagram XVI. The notified cases in each week of 1905 may be compared with the average weekly notifications of the period 1890-1905 on reference to diagram XVII. 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 XVIII. The following table shows the enteric fever cases, deaths, case-rates, and death-rates for the year 1905, the case-rates for the decennium 1895-1904, and the death-rates for the period 1901-4 in the several sanitary districts— Sanitary area. Notified Cases, 1905. Case-rate per 1,000 persons living. Deaths, 1905. Death-rate per 1,000 persons living. 1895-1904. 1905. 1901-4. 1905. Paddington 46 0.5 0.3 5 0.08 0.03 Kensington 53 0.5 0.3 13 0.06 0.07 Hammersmith 41 0.6 0.3 5 0.09 0.04 Fulham 56 0.6 0.4 10 0.09 0.06 Chelsea 16 0.5 0.2 4 0.06 0.05 Westminster, City of 41 0.6 0.2 4 0.09 0.02 St. Marylebone 46 0.7 0.4 6 0.07 0.05 Hampstead 18 0.6 0.2 2 0.08 0.02 St. Pancras 72 0.9 0.3 7 0.11 0.03 Islington 100 0.7 0.3 16 0.10 0.05 Stoke Newington 10 0.6 0.2 — 0.09 — Hackney 165 1.0 0.7 27 0.13 0.12 Holborn 21 0.8 0.4 4 0.12 0.07 Finsbury 46 0.8 0.5 9 0.10 0.09 London, City of 3 1.0 0.1 — 0.08 — Shoreditch 36 0.9 0.3 3 0.11 0.03 Bethnal Green 61 0.9 0.5 8 0.10 0.06 Stepney 127 0.9 0.4 21 0.10 0.07 Poplar 71 1.1 0.4 11 0.12 0.06 Southwark 74 0.8 0.4 11 0.10 0.05 Bermondsey 41 0.9 0.3 8 0.12 0.06 Lambeth 75 0.6 0.2 10 0.08 0.03 Battersea 33 0.7 0.2 6 0.09 0.03 Wandsworth 99 0.5 0.4 11 0.08 0.04 Camberwell 62 0.6 0.2 9 0.09 0.03 Deptford 34 0.7 0.3 6 0.07 0.05 Greenwich 27 0.7 0.3 5 0.07 0.05 Lewisham 38 0.4 0.3 6 0.06 0.04 Woolwich 26 0.6 0.2 7 0.08 0.06 Port of London 14 — — — London 1,552 0.7 0.3 234 0.092 0.052 It will be seen from the foregoing table that among the several sanitary districts the enteric fever death-rate was, in the period 1901-4, highest in Hackney (0.13) and lowest in Kensington (0.06), Chelsea (0.06) and Lewisham (0.06); in 1905, Hackney (0.12) had again the highest; Stoke Newington and 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 1905 were as follows:— first quarter, 0.04; second quarter, 0.04; third quarter, 0.06; and fourth quarter, 0.05 per 1,000 persons living. 1 The Infectious Disease (Notification) Act came into force in 1889. 2 See footnote (1), page 9. Diagram XVII. Enteric Fever. Diagram XVI. Enteric Fever. 43 Enteric fever.— Age and Sex Distribution. The following table shows the notified cases, deaths, case-rates, death-rates, and fatality of enteric fever at the several ages and for each sex in London during the year 1905. The case-rate at " all ages " was greater among males than among females ; the death-rate was equal in both sexes, but the fatality was much higher among females at " all ages." In the age-groups adopted for the purposes of this table the greatest incidence of attack was upon males aged 10-15, and upon females aged 5-10. The greatest incidence of death was upon males aged 35-45, and upon females aged 20-25 and aged 35-45. The fatality was greatest both among males and females aged 55 and upwards. Enteric fever 1905. Age-period. Males. Females. Notified Oases. Deaths. Case mortality per cent. Bates per 100,000 living. Notified Cases. Deaths. Case mortality per cent. Eates per 100,000 living. Cases. Deaths. Cases. Deaths. All ages 848 121 143 38 5 704 126 17.9 28 5 0— 1 — 1 1— 6 . 4 . 2— 3 _ 2.4 16 0 5 2 18.2 13 2 3— 14 — 7 2 4— 17 1 16 2 5— 116 9 7.8 51 4 95 7 7.4 41 3 10— 113 6 5.3 53 3 86 11 12.8 39 5 15— 113 10 8.8 52 5 94 14 14.9 39 6 20— 113 18 15.9 50 8 107 18 16.8 40 7 25— 176 31 17.6 46 8 152 29 19.1 34 6 35— 113 28 24.8 39 10 86 24 27.9 27 7 45— 52 13 25.0 26 6 34 10 29.4 15 4 55 and upwards 11 5 45.5 6 3 17 7 41.2 7 3 The decline in the enteric fever case.rate and death-rate, which has been manifested for a number of years, has been maintained in 1905. With this decline the proportion of cases in London due to infection received in other parts of the country or on the Continent becomes more conspicuous. Cases which occurred in London during 1905 were frequently attributed as in previous years to infection derived from an antecedent case or to some article of food which is commonly thought of as being responsible for the conveyance of infection. In no instance, however, were any of the cases attributed to infected milk supply. Instances in which infection was believed to have been received from an antecedent case are mentioned in the reports relating to the following districts. Paddington—A girl contracted enteric fever in Teignmouth, probably from eating shell-fish. This girl's illness was followed by that of another child in the house, the girl's nurse, her aunt, her mother, and subsequently six other persons in the same house. Hackney—Ten groups of cases occurred in which a primary case in a house gave rise to others. The primary case was followed by one case in three instances, by two cases in four instances, by three cases in one instance, by four cases in one instance, and by eight cases in one instance. Shoreditch—Infection from an antecedent case is said to have occurred in a few instances. Southwark—The illness of a man was followed by that of his wife and four children ; one of these children visited two other families in the street, among each of which a case subsequently occurred. In nine cases in this district the infection was probably due to an antecedent case. A similar source of infection was found in six cases in Battersea, and in thirteen cases in Wandsworth. One group of seven cases occurred in Wandsworth, the first of which was a boy whose own illness was thought to be probably due to eating shell-fish, inasmuch as he was the companion of costermongers who sold mussels and winkles; the disease subsequently spread to the others. In a number of reports shell-fish or fish is stated to have been eaten within a period before the attack which suggested that it might have been the source of infection. Thus, in Paddington, of 46 cases oysters had been eaten in four, periwinkles in two, and mussels in one case. In Kensington, of 49 cases shell-fish came under suspicion in a few cases, oysters having been eaten in two cases. In Westminster, of 37 cases, it is stated than seven persons may have received infection through articles of food; in one instance cockles had been eaten shortly before the attack. In Hampstead, of 17 cases, in one case cockles had been eaten. In Finsbury, of 42 cases, in six the illness was thought by the friends of the patients to have been caused by eating shell-fish. In Shoreditch, where 36 cases occurred, shellfish and fried fish were stated to have been eaten in a few cases. In Bethnal Green, where 61 cases occurred, 22 of the patients were stated to have been in the habit of eating fried fish, and six had recently eaten shell-fish. In Poplar, of 70 cases, 10 were attributed to the eating of shell-fish. In Southwark, of 74 cases, mussels had been eaten in nine and cockles in four cases. In Bermondsey, of 42 cases, in 1. See footnote (2) page 34. 11476 F 2 44 three cases the patients had been in the habit of eating mussels and in two cases cockles and whelks. In Lambeth, of 72 cases, in 28 there was a history of the patient having eaten shell-fish from one to three weeks before attack. In Battersea, of 27 cases, in five, it is thought, there was probability that the eating of shell-fish was responsible for the illness. In Wandsworth, where 82 cases occurred, in 12 the suggested cause was the consumption of shell-fish, viz., oysters in two cases, mussels in three, winkles in three, cockles in one, whelks in one and shrimps in two cases. In Greenwich, of 28 cases, six may have been due to eating fried fish or oysters. In Woolwich, of 2? cases, in one case oysters from Emsworth had been eaten, in one case cockles from Southend, in one periwinkles, and in one case lobster, which it is suggested may have been contaminated after boiling. Watercress, as a possible cause of the cases of enteric fever which occurred, is mentioned in four reports. In Bethnal Green, watercress had been eaten in seven cases, in Wandsworth in five, and in Woolwich in one case. In Bethnal Green, the seven persons attacked were reported to be in the habit of eating watercress. Dr. Caldwell Smith states in reference to the five cases occurring in Wandsworth: " In all the five cases where watercress was suspected it was purchased from itinerant vendors and further enquiry showed that it had, in two cases, been grown at watercress beds just outside the borough. The water from this bed had been examined by the officials of the London County Council and unfavourably reported on." Of other suggested causes it may be mentioned that ice cream in connection with the cases which occurred is less frequently referred to than formerly. In the case of a boy who was attacked in Greenwich, bathing in the Thames is mentioned as a possible cause. The Widal test for the diagnosis of enteric fever was employed at the cost of sanitary authorities in a number of districts, the results being shown in annual reports, as follows :— No. of examinations. No. of positive results. No. of examinations. No. of positive results. Fulham 49 32 Lambeth 33 6 Westminster 22 12 Battersea 31 7 Islington 56 34 Deptford 17 6 Stoke Newington 4 — Greenwich 29 6 Hackney 30 16 Lewisham 6 2 Holborn 18 8 Woolwich 20 9 Shoreditch 10 1 Diarrhœa. The deaths in the administrative county of London attributed to epidemic diarrhcea and infective enteritis numbered 2,125 in 1905 (52 weeks), while 1,285 deaths were attributed to diarrhoea and dysentery. The age constitution 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. ipidemic diarrhoea (infective enteritis) 1,729 345 11 6 8 23 3 2,125 Diarrhoea and dysentery 903 168 10 19 50 106 29 1,285 Total 2,632 513 21 25 58 129 32 3,410l No accurate comparison of the deaths from epidemic diarrhoea for a long series of years in London can be made; diagram XIX., however, shows the death-rate from cholera, dysentery, and diarrhoea combined, in relation to the mean death-rate of the period 1841-1905 in each year since 1840. The following table shows that the London diarrhoea death-rate was in the decennium 1895-1904, lower than the death-rate of any of the undermentioned large English towns except Bristol and Newcastleupon-Tyne, and in the year 1905 was lower than that of any except Bristol, Bradford and Newcastleupon-Tyne. Diarrhea—Death rates per 1,000 persons living. Towns. 1895-1904. 1905. Towns. 1835-1964. 1905. London 0 84l 0 731 West Ham 1.39 1.59 Liverpool 1.57 1.35 Bradford 0.85 0.50 Manchester 1.41 115 Newcastle.upon-Tyne 0.78 0.58 Birmingham 1.39 0.83 Hull 1.62 1.28 Leeds 1.09 0.79 Nottingham 1.26 0.76 Sheffield 1.50 1.52 Salford 1.65 1.21 Bristol 0.64 0.36 Leicester 1.35 0.93 1. See footnote (2) page 9. 45 The deaths and death-rates from diarrhoea for the year 1905, and the death-rates for the period 1901—4 in each of the sanitary areas in London, are shown in the following table :— Sanitary area. Deaths, 1905. Death-rate per 1,000 persons living. 1901-4. 1905. Paddington 78 0.67 0.53 Kensington 91 0.62 0.51 Hammersmith 80 0.85 0.67 Fulham 202 1.21 1.29 Chelsea 31 0.52 042 Westminster, City of 50 0.37 0.29 St. Marylebone 54 0.64 0.42 Hampstead 11 0.20 013 St Pancras 135 0.59 0.57 Islington 178 0.49 0.52 Stoke Newington 30 0.43 0.57 Hackney 229 0.71 1.01 Holborn 23 0.56 0.41 Finsbury 98 0.97 1.00 London, City of 7 0.22 0.31 Shoreditch 142 1.33 1.22 Bethnal Green 127 0.87 0.98 Stepney 351 1.05 115 Poplar 211 112 1.24 South wark 183 1.05 0.88 Bermondsey 143 1.01 111 Lambeth 211 0.80 0.68 Battersea 133 0.87 0.75 Wandsworth 152 0.61 0.57 Camberwell 145 0.70 0.54 Deptford 75 0.84 0.66 Greenwich 75 0.76 0.73 Lewisham 47 0.62 0.33 Woolwich 64 0.78 051 London 3.3561 0.76l 0.721 It will be seen from the foregoing table that the diarrhoea death-rate was in the period 1901-4 highest in Shoreditch (1.33) and lowest in Hampstead (0.20); in the year 1905, Fulham (1.29) had the highest death-rate, the lowest obtaining again in Hampstead (0.13). The diarrhoea death-rates in London in each of the four quarters of the year 1905, were as follows:—first quarter, 0.13 ; second quarter, 0.18 ; third quarter, 2.28 ; and fourth quarter, 0.28 per 1,000 persons living. The death-rate from diarrhœal diseases was in 1905 below the average of the preceding four years. The temperature in the month of July was 4.5 deg. above the average of 50 years and that in the months of August and September slightly below this average. In some of the annual reports it is suggested that the efforts now being made to ensure the better feeding of infants is probably responsible for some of the decrease in diarrhœal mortality. There is no doubt that, if as the result of these efforts a larger proportion of mothers were induced to feed their babies at the breast the rate of mortality should be affected by this circumstance alone. An interesting effort is being made in Woolwich to obtain knowledge of diarrhœal diseases by the institution of a system of voluntary notification of zymotic enteritis occurring during the months of July, August and September. Dr. Davies states that 212 cases were notified during this period in 1905 and that 38 of this number died, giving a fatality rate of 18 per cent. Half the cases notified were between 3 and 12 months of age, the largest number in any three months being between 3 and 8 months, and he states " From inquiries made I have no doubt that the disease affects persons at all ages,but is much more serious under the age of two and again in extreme old age." He found of 212 tenements in which the affected persons lived that 39 were dirty, and that in 45 the number of persons to a room was between 1½ and 2 persons. The action taken upon the notification was that the houses were visited, usually by the lady inspector, and a leaflet left and explained, in which advice is given as to cleanliness, feeding of infants, disinfection, etc., mothers being especially cautioned to wash their hands before preparing the baby's food. Any insanitary condition found in the house was remedied. Dr. Davies states that the probable source of infection was discovered in 41 cases, in most of which the disease was prob ably contracted from relatives who were suffering from the disease- Flies were complained of in two instances. Erysipelas. The deaths from erysipelas in the Administrative County of London registered during 1905 (52 weeks) numbered 226. 1 See footnote (l) page 9. 46 The age distribution of these deaths was as follows— Under 1 Tear. 1-5. 5-20. 20-40. 40-60. 00-80. 80 and upwards. All a gen. 64 3 3 23 65 56 12 2261 The number of cases notified and the number of deaths registered from this disease since 1890 have been as follows— Erysipelas. Year. Notified Cases. Case-rate per 1,000 persons living. Deaths. 1 -rate1 per 1,0(i0 persons living. 1891 4,764 1.13 214 .05 1892 6,934 1.63 292 .07 1893 9,700 2.26 424 .10 1894 6,080 1.40 221 .05 1895 5,660 1.30 179 .04 1896 6,436 1.43 207 .05 1897 5,794 1.31 184 .04 1898 5,169 1.16 165 .04 1899 5,606 1.25 213 .05 1900 4,762 1.06 182 .04 1901 4,604 1.02 171 .04 1902 5,536 1.19 183 .04 1903 4,372 0.95 183 .04 1904 4,943 1.08 232 .05 1905 4 972 1.06 226 .05 The number of cases of erysipelas notified and the case-rate for the year 1905, together with the case-rate in the decennium 1895-1904, in the several sanitary areas are shown in the following table— Sanitary area. Cases 1905. Case-rate per 1,000 persons living. 1895-1904.  Paddington 137 l.0 0.9 Kensington 158 1.1 0.9 Hammersmith 122 1.0 1.0 Fulham 145 1.0 0.9 Chelsea 78 0.8 1.0 Westminster, City of 124 0.8 0.7 St. Marylebone 162 1.5 1.3 Hampstead 44 0.6 0.5 St. Pancras 227 1.3 1.0 Islington 252 1.0 0.7 Stoke Newington 28 0.9 0.5 Hackney 290 1.3 1.3 Holborn 36 1.7 0.6 Finsbury 115 1.5 1.2 London, City of 25 0.8 1.1 Shoreditch 139 1.6 1.2 Bethnal Green 202 2.2 1.6 Stepney 519 1.5 1.7 Poplar 208 1.4 1.2 Southwark 295 1.4 1.4 Bermondsey 160 1.4 1.2 Lambeth 293 1.0 0.9 Battersea 176 1.2 1.0 Wandsworth 254 1.1 1.0 Camberwell 344 1.1 1.3 Deptford 153 1.3 1.3 Greenwich 92 1.1 0.9 Lewisham 108 0.7 0.7 Woolwich 83 0.8 0.7 Port of London 3 London 4,972 1.2 1.1 1 See footnote (2) page 9. 47 The following table shows the age and sex distribution of the notified cases of erysipelas in 1905— Age. All ages. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75 and upwards. Males 2,175 200 77 88 108 120 289 399 402 285 143 64 Females 2,797 220 104 138 161 182 366 470 475 353 227 101 Persons 4,972 420 181 226 269 302 655 869 877 638 370 165 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 females attacked exceeds the number of males attacked. Puerperal Fever. The deaths in the Administrative County of London during the year 1905 (52 weeks) attributed to puerperal fever1 numbered 183. Ihe number ol cases notified and the number ol 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 1905 292 183 If these cases and deaths are considered in relation to the total population and total births the following rates are obtained— Year. Case-rate per 1,000 living. Case-rate per 1,000 births. Death-rate' per 1,000 living. -rate2 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 .07 234 .04 1.51 1903 .05 1.78 .04 1.30 1904 .06 211 .04 1.53 1905 .06 2.31 .04 1.45 If the death-rates from the disease per 1,000 births be shown in three quinquennial periods, viz. 1891-5, 1896-1900, and 1901-5, it will be seen that the death-rate has, during this period, declined. Period. rate per 1,000 births. 1891-5 1.96 1896-1900 1.51 1901-5 1.44 The subject of puerperal fever occurring in the practice of midwives will be found in the reference to the administration of the Midwives Act, 1902, which is made later, see pages 88 and 89. 1. Including deaths from puerperal septicaemia and puerperal pyaemia. 2. See footnote (2), page 9. 48 Influenza, Bronchitis and Pneumonia. The deaths attributed to influenza in 1905 numbered 689, compared with 709 in the year 1904. The deaths from bronchitis in 1905 numbered 6,049, compared with 6,373 in 1904. In 1905 there were 6,965 deaths from pneumonia, an increase of 356 oyer the number occurring' from the same cause in the year 1904. The deaths from these diseases since 1889 have been as follows:— Year. Deaths1 from Influenza. Deaths' from Bronchitis. Deaths' from Pneumonia. 1890 652 12,448 fi,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 1905 689 6,049 6,965 The distribution of deaths from influenza throughout the year for each of the years 1890 to 1905 is shown in the following table c— Influenza—Deaths registered in London in four-weekly periods, 1890-1905. Number of weeks. 1890. 1891. 1892. 1893. 1894. 1895. 1896. 1897. 1898. 1899. 1900. 1901. 1902. 1903. 1904. 1905. 1—4 303 9 1,308 52 272 59 37 40 244 66 1,016 57 77 141 67 94 5—8 167 7 637 96 96 164 58 55 368 259 298 75 224 103 62 119 9—12 75 8 119 162 69 1,343 61 94 193 430 130 134 298 89 74 119 13—16 39 29 42 180 56 257 50 121 140 302 172 102 89 54 62 75 17—20 13 770 33 125 32 106 50 96 61 121 105 81 58 46 40 56 21—24 5 1,044 22 72 27 35 33 54 51 82 57 30 35 37 21 38 25—28 6 242 15 49 19 28 17 26 25 42 16 21 20 25 17 16 29—32 6 51 7 23 17 14 15 18 27 27 12 18 7 18 5 4 33—36 3 32 9 23 20 17 10 13 10 11 11 11 16 6 9 11 37—40 6 13 6 18 14 15 12 19 17 19 15 12 13 17 24 22 41—44 5 15 20 28 29 22 27 29 46 55 17 23 35 13 92 39 45—48 13 35 18 152 41 47 56 35 49 61 55 44 65 44 98 44 49—52= 6 81 28 546 58 49 56 71 52 342 46 56 99 51 138 52 The deaths occurring in the 53rd -week of the years 1890, 1896 and 1902 aro excluded from these figures. Phthisis. The deaths from phthisis in the Administrative County of London during 1905 (52 weeks) numbered 6,622, as compared with 7,526 in the year 1904. The death-rates from this disease in successive periods have been as follows :— Period. Death rate per 1,000 persons living. Period. Death rate per 1,000 persons living. 1851-60 2.86 1901 1.662 1861-70 2.84 1902 1.60 1871-80 2.51 1903 1.55 1881-90 2.09 1904 1.62 1891-1900 1.84 1905 1.42 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 1. See footnote (2). page 9. 2. See footnote (1), page 9. 49 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.1 Factor for correction fur age and sex distritribution. Crude death-rate. Corrected death-rate. Comparative mortality figure. (London 1,000.) 1901-4. 1905. 1901-4. 1905. 1901-4. 1905. London 1.74 1.00000 l*612 1.42 1.612 1.422 1,000 1,000 Paddington 1.80 0.96659 1.10 0.96 1.06 0.93 658 655 Kensington 1.78 0.97419 1.34 114 1.31 1.11 814 782 Hammersmith 1.74 0.99600 1.43 116 1.42 1.16 882 817 Fulham 1.69 1.02786 1.39 1.22 1.43 1.25 888 880 Chelsea 1.83 0.95018 1.63 1.51 1.55 1.43 963 1,007 Westminster, City of 1.95 0.89205 1.72 1.51 1.53 1.35 950 951 St. Marylebone 1.85 0.93836 1.83 1.46 1.72 1.37 1,068 965 Hampstead 175 0.98862 0.83 083 0.82 0.82 509 577 St. Pancras 1.80 0.96551 1.86 1.52 1.80 1.47 1,118 1,035 Islington 1.75 0.99145 1.49 1.26 1.48 1.25 919 880 Stoke Newington 1.77 0.97914 1.39 1.33 1.36 1.30 845 915 Hackney 1.68 1.02969 1.41 115 1.45 1.18 901 831 Holborn 1.97 0.87894 2.96 2.84 2.60 2.50 1,615 1,761 Finsbury 1.72 1.01050 2.29 2.02 2.31 2.04 1,435 1,437 City of London 1.89 0.91946 1.79 1.34 1.65 1.23 1,025 866 Shoreditch 1.66 1.04206 2.14 1.96 2.23 2.04 1,385 1,437 Bethnal Green 1.59 1.08984 2.10 2.04 2.29 2.22 1,422 1,563 Stepney 1.65 1.05281 205 1.72 2.16 1.81 1,342 1,275 Poplar 1.66 1.04772 1.74 1.53 1.82 1.60 1,130 1,127 Southwark 1.74 0.99829 2.47 2.13 2.47 2.13 1,534 1,500 Bermondsey 1.65 1.05026 1.88 1.79 1.97 1.88 1,224 1,324 Lambeth 1.75 0.99258 1.55 1.38 1.54 1.37 957 965 Battersea 1.69 1.02483 1.37 1.34 1.40 1.37 870 965 Wandsworth 1.72 1.01050 1.03 1.02 1.04 1.03 646 725 Camberwell 1.68 1.03522 1.40 1.21 1.45 1.25 901 880 Deptford 1.68 1.02969 1.27 1.22 1.31 1.26 814 887 Greenwich 1.67 104143 1.20 1.26 1.25 1.31 776 923 Lewisham 1.69 1.02543 0.93 0.85 0.95 0.87 590 613 Woolwich 1.70 1.01881 1.59 1.52 1.62 1.55 1,006 1,092 It will be seen from the foregoing table that among the several sanitary areas, both in the period 1901.4 and the year 1905 (comparing the corrected death.rates), Holborn (2.60 and 2.50 respectively) had the highest phthisis death-rate, and Hampstead (0'82 and 082 respectively) the lowest. The following table shows the number of deaths from phthisis at several age-periods in each of the sanitary areas. Phthisis (365 days). Age-period. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85anc upwards All ages. Paddington 2 2 1 7 12 23 32 30 22 9 1 141 Kensington 4 — 5 8 17 45 57 38 21 10 1 206 Hammersmith 4 3 1 2 16 27 30 23 21 8 2 — 137 Fulham 6 3 1 10 18 39 43 35 26 7 2 190 Chelsea 1 — 3 3 5 24 26 22 22 3 1 110 Westminster, City of 4 1 2 3 11 54 62 59 34 25 7 1 263 St. Marylebone 4 1 — 9 12 29 43 42 32 8 3 — 183 Hampstead 1 — — 5 8 20 25 5 5 2 2 — 73 St. Pancras 16 5 4 9 26 80 82 69 45 11 2 1 350 Islington 12 5 3 20 38 120 95 83 39 11 1 — 427 Stoke Newington 1 — 3 3 7 19 15 13 8 - — — 69 Hackney 7 5 5 16 18 75 59 40 21 12 1 — 259 Holborn 2 2 1 3 7 28 35 31 30 16 2 — 157 Finsbury 9 2 3 10 11 24 52 51 28 7 — — 197 London, City of — — — — 3 6 7 5 7 1 1 — 30 Shoreditch 13 1 6 9 18 33 67 48 21 9 1 — 226 Bethnal Green 11 5 4 14 18 50 68 64 24 6 1 — 265 Stepney 10 5 6 22 40 120 126 118 53 18 5 1 524 Poplar 18 6 4 9 34 50 70 39 30 1 — — 261 Southwark 21 5 3 18 36 86 116 90 56 13 — — 444 Bermondsey 13 8 1 12 23 45 52 40 28 6 1 — 229 Lambeth 12 8 3 18 40 103 97 90 34 16 4 — 425 Battersea 14 2 3 11 22 66 58 35 26 3 1 — 241 Wandsworth 10 3 5 18 28 71 59 41 21 10 1 — 267 Camberwell 9 5 4 24 22 75 82 55 36 16 1 — 329 Deptford 4 3 2 13 8 27 31 33 10 6 1 — 138 Greenwich 4 4 2 9 11 33 29 18 12 4 1 1 128 Lewisham 2 2 4 6 14 25 24 30 9 6 1 — 123 Woolwich 2 6 5 11 15 44 31 41 20 13 1 — 189 London 216 92 84 302 538 1441 1573 1288 741 257 44 5 65812 The standard death rate used in the calculation of the " factors for correction " have been calculated to more than the two places of decimals shown in the table. 2. See footnote (M page 9. 11476 G 50 The steps taken in London for the limitation of phthisis are in the main based upon the view of the communicability of the disease from the sick to the healthy by means of the sputum. The practice of voluntary notification of cases of phthisis is now adopted in the majority of London districts, and during the year 1905 there was notification in 19 of the 29 sanitary areas of London. Thus there was voluntary notification in— Kensington St. Pancras Southwark Hammersmith Islington Bermondsey Fulham Stoke Newington Lambeth Chelsea Holborn Wandsworth < Westminster, City of Finsbury Greenwich St. Marylebone London, City of Woolwich Hampstead The districts in which a system of voluntary notification of cases of phthisis had not been adopted were— Paddingtoti Stepney Deptford Hackney Poplar Lewisham Shoreditch Battersea Bethnal Green Camberwell The number of cases notified was small, ranging from 297 in Southwark to 24 in Chelsea. In cases brought to the knowledge of the medical officers of health, advice was given as to the precautionary measures which should be adopted in dealing with the sputum, as to the maintenance of cleanliness in the home and as to ventilation of the rooms occupied by the patient. In cases in which death occurred or in which there had been removal of the patient, the sanitary authority undertook the disinfection of the room which he had occupied, whenever consent was given for the purpose. It would appear that the public is, more than before, recognising the desirableness of following the directions which are generally deemed to be necessary in cases of this disease. Thus Dr. Newman states, with respect to 178 cases of phthisis in Finsbury brought to his knowledge by means of voluntary notification, that he found precautions were already being taken in 62 cases, and Dr. Reginald Dudfield states that as the result of inquiry in 112 cases in which death had taken place, in only 26 did it appear that nothing had been done in the way of precautionary measures. In some reports the number of cases is stated in which there had been exposure to antecedent phthisis in the home. Dr. Davies states, that of 145 cases notified in Woolwich in 1905, 44 were probably infected by relatives; Dr. Newman writes that 47 or 32*1 per cent, of the total deaths in Finsbury occurred in homes already infected. A history of previous phthisis in the family was obtained by Dr. Reginald Dudfield in 35 of 112 cases in Paddington. London, 1901-5. Phthisis death-rates in relation to " overcrowding" (1901 census). Percentage of overcrowding in each group of sanitary areas. 1901-5 crude phthisis deathrate per 1,000 persons living. Standard deathrate. Factor for age and sex correction. Corrected deathrate per 1,000 persons living. Corrected deathrate (London, 1,000). Under 7.5 per cent. 1.109 1-718 1.00991 1.120 717 7.5 to 12.5 per cent. 1.376 1.705 1.01761 1.400 896 12.5 to 20 per cent. 1.495 1.771 .97969 1.465 937 20.0 to 27.5 per cent. 2.075 1.805 .96124 1.995 1,276 Over 27.5 per cent. 2.068 1.651 1.05090 2173 1,390 London 1.563 1.735 1.00000 1.563 1,000 1 See footnote (1) page 16. The conditions under which persons suffering from phthisis were housed are shown by the following figures extracted from annual reports:— Paddington. No. of instances. Kensington. Finsbury. Homes of one room .. 32 110 25 Homes of two rooms ... 25 69 74 Homes of three rooms 27 37 21 Homes of four or more rooms 28 33 22 and Dr. Keginald Dudneld writes that In one.room homes separate sleeping accommodation, except where the home is occupied by one person only (there were 13 such homes) is impossible. In other homes of all classes 11 of the deceased had separate bedrooms, and 26 others separate beds but not separate bedrooms." It is obvious that if administration is to be based upon the view that phthisis is communicable from one person to another, the home conditions of persons attacked by phthisis should be considered in the selection of cases for removal to hospital, and hence the necessity for bringing the administration of sanitary authorities into relation with that of those authorities concerned with hospital provision. Dr. Louis Parkes includes in his report a table showing the death.rate from phthisis in 1893-6, 1897-1900 and 1901-4, in the Metropolitan Borough of Chelsea in industrial dwellings and in 11 poorclass streets, and shows that the death-rate in Chelsea, as a whole, has decreased in the second and thiid periods, and in industrial dwellings had diminished slightly in the third period ; whereas that of the population of the poor streets had remained undiminished. The following table shows the mortality from phthisis in groups of London sanitary districts arranged in respect to the proportion of their population living more than two in a room in tenements nf less than five rnnms 51 During 1905, the Public Health Committee of the County Council communicated to London sanitary authorities a memorandum by their medical officer on the subject of voluntary notification of phthisis, which contained suggestions for obtaining information as to the cases of phthisis attending the out-patient departments of hospitals, with a view to the addresses of these patients being forwarded to the medical officers of health concerned. In April, 1905, the Metropolitan Asylums Board received a deputation urging the Board to take action with a view to the provision of accommodation for the isolation and treatment of consumptive patients. The annual report of the Board states that the Local Government Board have informed the Managers " that the information at present before them does not appear to afford sufficient justification for the veiy heavy outlay which would be involved in the proposals." Cancer. The deaths from cancer in the Administrative County of London during 1905 (365 days) numbered 4.345. The death-rates from this disease in successive periods have been as follows:— Period. Kate per 1,000 persons living:. Period. Kate per 1,000 persons living. 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 1905 0.931 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 deathrate. Factor for correction for age and sex distribution. Crude death-rate. Corrected death-rate. Comparative mortality figure (London 1,000). 1901-4 1905. 1901-4. 1905. 1901-4. 1905. London 087 1.00000 0 921 0 931 0 921 0-931 1 000 1,000 Paddington 0.98 0.89478 1.05 1.02 0.94 0.91 1,022 978 Kensington 1.02 0.85622 1.02 0.96 0.87 0.82 946 882 Hammersmith 0.90 0.96811 0.89 1.02 0.86 0.99 935 1,065 Fulham 0.77 1.13828 0.82 0.86 0.93 0.98 1,011 1,054 Chelsea 1.03 0.84874 111 1.02 0.94 0.87 1,022 935 Westminster, City of 0.96 0.91348 0.99 1.06 0.90 0.97 978 1,043 Marylebone 0.99 0.88571 1.14 1.31 1.01 1.16 1,098 1,247 Hampstead 092 0.94816 1.08 0.71 102 0.67 1,109 720 St. Pancras 0.92 0.95229 0.99 1.00 0.94 0.95 1,022 1,022 Islington 0.90 0.96704 0.99 099 0.96 0.96 1,043 1,032 Stoke Newington 0.98 0.89387 0.97 1.04 0.87 0.93 946 1,000 Hackney 0.88 0.99341 0.85 0.89 0.84 0.88 913 946 Holborn 0.95 0.91924 1.01 0.92 0 93 0.85 1,011 914 Finsbury 0.84 1.04071 0.83 0.70 0.86 0.73 935 I 785 London, City of 1.06 0.82316 1.32 1.43 1.09 1.18 1,185 1,269 Shoreditch 0.79 1.10518 0.87 0.88 0.96 0.97 1,043 1,043 Bethnal Green 0.78 1.12077 0.85 0.81 0.95 0.91 1,033 978 Stepney 0.74 1.17976 0.74 0.73 0.87 0.86 946 925 Poplar 0.81 1.08327 0.78 0.82 0.84 0.89 913 957 Southwark 0.82 1.06350 0.88 105 0.94 112 1,022 1,204 Bermondsey 0.81 1.08462 080 0.84 0.87 0.91 946 978 Lambeth 0.92 0.95333 1.01 1.06 0.96 101 1,043 1,086 Battersea 0.79 1.10798 0.87 0.99 0.96 1.10 1,043 1,183 Wandsworth 0.88 0.99116 0.96 086 0.95 0.85 1,033 914 Camberwell 0.87 1.00483 0.91 0.85 0.91 0.85 989 914 Deptford 0.81 1.07396 0.91 0.90 0.98 0.97 1,065 1,043 Greenwich 0.87 1.01064 0.79 0.95 0.80 0.96 870 1,032 Lewisham 0.92 0.95333 0.91 0.90 0.87 0.86 946 925 Woolwich 0.78 1.11933 0.79 0.68 0.88 0.76 957 817 11476 1 See footnote (1) page 9. G 2 52 It will be seen from the foregoing table that in the period 1901-4 (comparing the corrected deathrates) the City of London (1.09) had the highest cancer death-rate and Greenwich (0'80) the lowest; in the year 1905 the City of London (1.18) had again the highest death-rate, while Finsbury (0.73) had the lowest. 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. (a) Deaths1 from Sarcoma. Age-period. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 and upwards All ages. Paddington - 1 2 2 2 2 3 1 1 14 Kensington - — — — — 1 1 3 1 — — 6 Hammersmith - — — — 1 1 1 4 7 Fulham 2 — 1 2 1 3 2 11 Chelsea 1 — 1 1 2 1 6 Westminster, City of — — — 1 1 3 2 2 2 1 1 13 St. Marylebone — — 1 — 1 1 — 2 5 - 1 — 11 Hampstead — — — — — — 1 1 2 - 1 — 5 St. Pancras — — — 2 — 1 2 4 1 2 1 13 Islington 2 — 1 — 2 6 1 4 1 — 21 Stoke Newington — — — — — — 1 — 1 — — — 2 Hackney 1 — — 1 1 ] 3 4 1 — — — 12 Holborn 1 2 3 Finsbury 1 1 1 1 — 1 1 1 7 London, City of - - - - - - - - - - - - - Shoreditch — — 1 1 2 3 7 Bethnal Green 1 1 — — 1 1 1 — 5 Stepney.. 1 — 1 — — 2 — 4 2 4 — 1 15 Poplar — — — 1 1 — 1 3 2 1 1 — 10 Southwark 1 — — — 3 1 4 1 10 Bermondsey — — — 2 1 — 2 — 1 — — — 6 Lambeth — — — 1 2 4 4 9 5 4 — 29 Battersea 1 — 1 2 1 2 2 ___ 9 Wandsworth — — — 3 1 3 2 3 6 18 Camberwell — 1 — — — 2 5 1 1 2 2 14 Deptford — — — 1 1 — — 1 — — — — 3 Greenwich 1 1 1 1 — — 1 — 1 1 — — 7 Lewisham — — — — 1 3 2 4 1 1 12 Woolwich — — 1 — 1 2 — 1 1 1 — — 7 London 13 4 8 18 18 33 32 59 53 31 13 I 283 (b) Deaths1 from Carcinoma. Age-period. 0- 5- | 10- | 15- 20- 25- 35— 45- 55- 65- 75- 85 and upwards ges. Paddington — — — 5 5 18 35 25 12 100 Kensington — — — — - — 6 20 30 21 9 2 88 Hammersmith — — — — - 3 9 13 21 19 9 2 76 Fulham — — — — - 2 20 20 23 19 10 2 96 Chelsea — — — — - 1 5 7 23 8 2 46 Westminster, City of — — — — - 2 16 26 33 29 8 114 St. Marylebone — — — — 1 1 12 16 24 20 5 3 82 Hampstead — — — — - 1 2 10 9 16 7 45 St. Pancras — — — 1 1 5 11 34 38 34 18 1 143 Islington — — — — 1 3 12 32 49 30 10 1 138 Stoke, Newington — — — — - — 3 4 6 9 3 — 25 Hackney — — — — - 2 13 17 30 28 14 1 105 Holborn — — — — - 3 6 10 3 6 1 1 30 Finsbury — — — — - — 3 8 16 12 4 43 London, City of — — — — - 1 3 5 6 4 2 21 Shoreditch - — — - 2 7 12 11 9 7 48 Bethnal Green - — — — - 2 6 9 17 9 4 47 Stepney - — — — - 8 17 32 42 26 17 1 143 Poplar - — — — - 2 5 19 34 18 7 — 85 Southwark - — — — - 2 27 37 45 33 17 — 161 Bermondsey - — — — - 1 7 19 24 25 1 1 78 Lambeth - — — — - 8 10 40 42 41 18 3 162 Battersea - — — — - 6 9 28 32 15 4 94 Wandsworth 1 — — — - 2 13 24 26 20 12 1 99 Camberwell 1 — — — - 5 12 34 34 29 8 3 126 Deptford - — 1 — - — 8 18 21 15 5 — 68 Greenwich - — — — - — 6 16 16 9 4 3 54 Lewisham - 1 — — - 1 9 16 19 23 6 3 78 Woolwich - — — — - 1 7 11 7 13 1 1 41 London 2 1 1 3 69 269 555 716 565 225 29 2436 1 See footnote (1) page 9. 53 (c) Deaths1 from Cancer (otherwise undistinguished). Age-period. 0- 0- 10- 15- •20- 25- 35- 45- 55- 65- 75- 85 and upwards ges. Paddington - - - - - 6 7 10 10 4 - 37 Kensington - — — - — 3 5 14 32 15 9 1 79 Hammersmith - - - - - 1 1 9 12 11 3 1 38 Fulham - - - - - 2 2 8 7 10 — - 29 Chelsea - — — — — — 1 7 7 6 2 1 24 Westminster, City of - - - - - - 3 11 19 18 5 3 59 St. Marylebone - — — — — 1 7 25 21 15 9 — 78 Hampstead - — — — — — — 1 3 5 2 1 12 Pancras - — — 1 1 1 5 14 29 18 8 2 79 Islington - — — — — 4 8 44 50 60 13 2 181 Stoke Newington - - - - - 1 1 4 11 7 3 1 28 Hackney - — — — 1 1 7 24 25 25 2 1 86 Holborn - — — — — — — 5 10 2 1 1 19 Finsbury - — — — — 1 3 — 9 2 4 — 19 London, City of - - - - - - - — 3 6 2 — 11 Shoreditch - — 1 — — 2 7 10 13 10 4 1 48 Bethnal Green - — — — — — 4 12 14 20 4 — 54 ! Stepney 1 - - - - - 11 14 20 15 4 — 65 Poplar 1 - - - - - 2 11 15 12 4 — 45 Southwark - — — — 1 1 8 10 16 9 3 — 48 Bermondsey - — — — 1 1 2 9 5 6 1 — 25 Lambeth - - - - - 5 13 28 42 37 13 2 140 Battersea - — — — 1 1 9 18 16 17 8 3 73 Wandsworth - — — — — 4 12 23 33 27 12 — 111 Camberwell - — — — — 1 6 20 28 25 9 3 92 Deptford - — — — — — 2 7 13 8 2 — 32 Greenwich - - - - - 1 6 8 11 7 3 1 37 Lewisham - - - - - 1 3 6 10 11 9 1 41 Woolwich - - - - - - 6 8 9 10 3 36 London 2 — 1 1 5 32 140 357 493 424 146 25 1626 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- «. 55- 65- 75- 85 and upwards. Sarcoma 1,000 332 113 208 187 110 46 4 Carcinoma 1,000 32 110 228 294 232 92 12 Cancer 1,000 25 86 220 303 261 90 15 Total 1,000 49 102 223 290 235 88 13 In the report for the year 1904, a table was included showing the cancer death-rates in the period 1901-4 in areas presenting different degrees of overcrowding,2 the object being to compare the death-rates of population differently circumstanced in respect of social condition. The following table shows the corresponding death-rates for the period 1901-5:— London, 1901-5. Cancer death-rates in relation to overcrowding1 (1901 census). Percentage of overcrowding in each group of sanitary areas. 1001-5'crude cancer deathrate per 1,000 persons living. Standard deathrate. Factor for age and sex correction. Corrected death-rate per 1,000 persons living. Corrected death rate (London, 1,000). Under 7.5 per cent. 0.913 0.883 .99003 0.904 980 7.5 to 12.5 per cent. 0.916 0.864 1.01180 0.927 1,005 12.5 to 20 per cent. 0.959 0.921 .94919 0.910 987 20.0 to 27.5 per cent. 1.005 0.904 .96704 0.972 1,054 Over 27'5 per cent. 0.793 0.774 1.12946 0.896 972 London 0.922 0.874 1.00000 0.922 1,000 As was the case when the period 1901-4 was investigated there is no evidence from the figures when treated in this manner that there is either direct or inverse relationship between cancer mortality and social condition of the population. Further analysis of the figures for a longer period would be necessary in order to establish this absence of relationship as a fact, but the figures available show no indication of relationship between cancer mortality and social condition. 1 See footnote (l) page 9. 2 See footnote (') page 16. 54 Cerebro-Spinal Fever. The occurrence in Northamptonshire in 1905, of groups of cases of cerebro-spinal fever, among which four cases terminated fatally, led the Local Government Board to communicate to medical officers of health copies of a memorandum on this disease, prepared by the Board's medical officer, Mr. W. H. Power, C.B., F.R.S. Deaths attributed to this disease are from time to time registered in London: thus in 1902, four such deaths were registered ; in 1903, six ; in 1904, six ; and in 1905, five. Of the five cases in 1905, three were of children under one year of age and two of children from one to five years of age. These cases occurred in the months of January, February, May, July and November. In some districts, copies of the Board's memorandum were distributed to medical practitioners, and medical officers of health were called to suspected cases. In Battersea, a boy aged 14 years died two days after an illness in which the symptoms pointed to cerebro-spinal meningitis, but neither the diplococcus intracellularis nor the tubercle bacillus were found. Other cases to which attention was directed by medical practitioners were not deemed to be cases of this disease. Anthrax. Three deaths were attributed to anthrax. The first occurred in April and was that of a dock labourer, aged 42, employed in Stepney. The second was that of a skin sorter, aged 47, living at Walthamstow but employed by a firm in the City. He died in the London Hospital. The third, who was 39 years old, was that of the wife of a waterside labourer. She had been handling wet and damaged China hides at St. Olave's Wharf, and was infected in the cheek. Three other cases, none of which was fatal, are mentioned in the annual reports. The first of these was that of a market clerk employed by a firm in the City, who had been engaged in inspecting hides on a wharf on the south side of the Thames. The second was that of a Bermondsey labourer, who had been employed in carrying hides and who was infected in the neck. The third, also a Bermondsey resident, worked on piles of dry foreign hides. Glanders. Six deaths were attributed to glanders during the year 1905, viz.:— An ostler, aged 33, died during March. He was employed by a firm of carmen in Limehouse. There was no clinical evidence that the horses with which he was in contact were affected with the disease. A horsekeeper, aged 52 years, died in Fulham. He was employed in stables belonging to an omnibus company in Fulham. Three horses with which he had been associated were found to be suffering from glanders. A carman's wife, aged 44 years, died in June. Her husband was employed ty a milk company in Westminster. She was in the habit of feeding horses subsequently found to be suffering from glanders. A horsekeeper, aged 45 years, died in August. He was employed by an omnibus company in Westminster. There was no clinical evidence that the horses with which he was associated were at the time affected, but horses in the stables had recently suffered from glanders. A carman, aged 33, died in Lambeth in August. The cause of death was notified to be " chronic glanders three years." A carman, aged 21 years, died 'in August in Stepney. He was employed by a firm of carmen in Wapping. There was no clinical evidence that the horses with which he was associated were suffering from glanders. 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 1905 was 49.9 deg. Fahrenheit, or 0.8 deg. Fahrenheit above the average of the preceding 50 years. The rainfall during the year amounted to 23.03 inches, a decrease of 1.50 inches on the average of the preceding 50 years. The temperature and rainfall in each month of the year 1905 are shown in the following table:— Month. Temperature of the air. Departure of mean monthly temperature from average of 50 vears, 1855-1904. Bain. Absolute maximum. Absolute minimum. Mean for month. Number of days it fell. Amount collected. deg. F. deg. F. deg. F. deg. F. Inches: January 54.0 19.5 38.0 —0.5 8 1.00 February 53.5 31.2 42.3 +2.8 13 0.72 March 61.4 27.1 45.4 +3.7 22 3.56 April 64.9 311 47.3 +0.1 17 1.70 May 82.3 34.3 53.9 +0.8 8 1.33 June 80.1 46.1 60*2 +0.8 18 4.32 July 87.2 48.2 66.9 +4.5 8 0.92 August 76.9 44.6 61.5 —o.i 13 2.54 September 75.1 41.4 56.6 —0.6 13 2.31 October 59.6 26.1 45.3 —4.7 15 0.91 November 54.9 23.1 41.2 —2.0 18 3.12 December 57.3 25.4 40.1 +0.4 8 0.60 55 PART II. Dairies, Cowsheds and Milkshops. The County Council received during the year 257 applications for cowhouse licences, of which 255 were granted. The number of applications for licences received during the last twelve 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 1905 257 255 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 sanitary authorities. Tables showing these proceedings included in this report 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. The following table relating to cowsheds has been thus prepared :— Cowsheds. Sanitary area. Number of cowshed premises. Number of Inspections 1905. Number of notices 1905. Number of prosecutions 1905. On register at end of 1904. Added in 1905. Removed in 1905. On register at end of 1905. Paddington 1 - 1 4 - - Kensington 1 - — 1 26 — — Fulham 3 - — 3 12 — Chelsea 4 - — 4 58 - Westminster, City of 3 - 2 34 St. Marylebone 6 — — 6 St. Pancras 10 - — 10 189 — - Islington 10 - i 9 116 — Stoke Newington 2 - — 2 Hackney 23 - — 23 309 — Ilolborn 1 - 1 — - Finsbury 6 - — 6 69 4 - Shoreditch 7 - 7 42 — - Bethnal Green 15 - 15 84 3 - Stepney 40 - — 40 76 4 Poplar 16 - — 16 80 Southwark 5 - — 5 79 Bermondsey 7 - — 7 103 4 - Lambeth 17 - 2 15 Battersea 3 - 3 — - Wandsworth 15 - 1 14 56 4 - Camberwell 20 - 20 307 — - Deptford .. 6 - — 6 37 6 Greenwich 4 - — 4 12 13 - Lewisham 16 - 1 15 122 5 1 Woolwich 18 - — 18 72 11 1 In two instances the borough councils took proceedings against cowkeepers for keeping cows in unlicensed sheds, and fines were imposed. The Council's inspectors attended the hearing of the cases to give evidence in support of the prosecutions. Tuberculosis of the udder in cows. London County Council (General Powers) Adt, 1904 (Part V.). 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 (а) 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. 56 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. 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 the detection of cows suffering from tubercular disease of the udder. Thus, during 1905, there were four periodical inspections of all the cows in the London cowsheds. The number of cows found by Mr. Shaw to be affected in one or another way is shown in the following table :— Examination of cows for tubercular disease of the udder—Summary of Mr. Shaw's reports for the year 1905. Details of Examination. 1st period, 20th Dec. (1904)—10th April (1905). 2nd period, 11th April— 5th July, (1905). 3rd period, 6th July— 7th October (1905). 4th period, 8th October— 14th Dec. (1905). Total number of cows examined 3,482 2,704 3,838 4,030 Affected with disease or defects of the udder 164 215 349 282 Clinically affected with tubercular disease of the udder 2 — 3 — Suspected cases of tubercular disease of the udder .. 5 4 2 — Subjects of acute mastitis 18 27 34 24 Affected with chronic induration of the udder 5 5 9 5 Atrophy of one or more quarters 88 82 209 176 Injuries, abscesses, simple eruptions, strictures and obliterations of milk ducts 34 32 24 29 Hypertrophied udders without induration 2 3 6 3 Giving milk of poor quality, dried-off cows 10 47 58 38 Presenting symptoms of tuberculosis 3 — — — Suffering from chronic diarrhoea - — — - Mr. Shaw's reports also show the action taken for the elimination of tuberculous cow? from the London cowsheds, thus— First period.—Samples of milk were taken by Mr. Shaw from seven cows suspected to be affected with tubercular disease of the udder, and submitted for bacteriological examination. Two of them proved to be tuberculous. Of the two cows from which the positive samples were taken, one was slaughtered by the owner before the result of the bacteriological examination of the milk had become known, whilst the other animal was seized and slaughtered, the owner being compensated under the provisions of the London County Council (General Powers) Act, 1904. In the latter case the cow was apparently in good condition when slaughtered, but on a post-mortem examination being made of the carcase, the internal organs were discovered to be so badly affected with tuberculosis that the carcase was condemned as unfit for human food, and destroyed. Three cows affected with general tuberculosis, as well as a cow suffeiing with septicemia from udder infection, were sent by the owners to the knacker's yaid. Eighteen cows were affected with acute mastitis and five cows had chronic induration of the udder—the result, Mr. Shaw thinks, of previous attacks of mastitis; these cows were kept under observation. Second period.—Four cows were suspected to be affected with tubercular disease of the udder. Samples of milk were taken from three of them and submitted to bacteriological examination. No tubercle bacilli, however, were found to be present. In the fourth case the cow was slaughtered by order of the owner and removed to the knacker's yard, as the animal had developed symptoms of septicaemia. Twenty-seven cows which were affected with mastitis were kept under observation until the affected quarters of their udders either recovered or became atrophied, except that in a few instances the cows were removed from the sheds and slaughtered by the owners. There was an increase of 37 in the number of dried-off cows or cows giving milk of poor quality, but this increase is due to the smaller demand for fat beasts during the hot weather. Third period.—Three cows were suspected to be affected with tubercular disease of the udder, and two were at once removed for slaughter under the provisions of the London County Council (General Powers) Act, 1904. Mr. Shaw's suspicions proved to be well founded, and compensation was paid to the respective owners as provided by the Act. From the third suspected animal a sample of milk was taken for bacteriological examination, with the result that the cow was proved to be suffering from tuberculosis of the udder. In the meantime, the owner had caused the animal to be killed and its carcase to be removed to the knackers. The large number of dried-off cows (58), and of cows having atrophy of one or more quarters of the udder (209), or affected with chronic mastitis (34), was due to the cheapness of country milk and to the inability of the owners to obtain during July and August a reasonable price for fatted beasts. 57 Fourth period.—One cow was found to be affected with tuberculosis of the lungs, and was ordered by the owner to be slaughtered; the carcase being condemned and destroyed. The number of cases of mastitis (24), atrophy of one or more quarters of the udder (176), is slightly less than that reported during the previous period of inspection. In summary, it may be stated that during the year 11 samples of milk were taken by Mr. Shaw from cows suspected to be affected with tubercular disease of the udder and submitted for bacteriological examination. In the case of three cows, the samples taken proved to be tuberculous, negative results being obtained in respect of eight cows. In connection with efforts to prevent contamination of milk, the attention of sanitary authorities has continued to be directed to the need of keeping milk vessels covered. In Holborn, a letter on this subject was addressed to all milk vendors. Dr. Newman states that almost all milk-dealers in Finsbury now cover their milk pans and take increased precautions as to storage, but he adds: "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." Again, Dr. Davies, writing of cows and cow sheds in Woolwich, states that " some attempt at grooming the cow is now made and the hands of the milkers are said to be washed ; in these respects, however, there is much room for improvement, but until the sanitary authority has power to do something more than advise, there is not likely to be much advance." With a view to inducing cow keepers in England to adopt better measures for preventing contamination of milk, the Board of Agriculture issued in 1905 a memorandum giving advice on this subject. The conditions under which milk is often produced and the need for a material alteration of the practices of dairy farmers are well known, but there is at the present time absence of adequate administration for insisting on dairy farmers taking the precautions which are necessary. Dr. Collingridge classified 22 samples of milk which were examined in 1905 by Dr. Klein, for the City Corporation, as follows : clean and pure, fifteen ; unclean, five ; tubercular, two. In St. Pancras, a churn of milk was seized at Euston Station as unfit for human food. The churn was labelled " warranted pure new milk with all its cream and free from preservative." Di. Sykes writes that " There was seen on the surface of this milk a quantity of floating foreign matter, straws, little lumps of brownish matter like cow dung, hairs, and numerous black particles, giving all the appearances of an impure and very dirty milk, unfit for human food." Samples of the milk were taken from the top and bottom of the churn and submitted to bacteriological examination. " This examination showed in the top samples the presence of pus cells, granular debris, and various kinds of micro-organisms ; the deposit consisted principally of faecal material, granular debris, epithelial cells, and pus ; and subsequently a guinea pig, inoculated with the material, developed tuberculosis." As the result of prosecution by the Borough Council, the defendant was fined £25 and £5 5s. costs. Only exceptionally can proceedings, as in this case, be instituted under section 47 of the Public Health (London) Act, and powers are needed for the sampling and for the examination of milk with a view to the determination whether the milk is fit for human consumption. In 1905, Dr. Houston, under the instructions of the County Council, examined milk taken from premises (a) where known precautions were taken to preserve the milk from contamination ; (b) from milk vendors who made claim to take precautions ; and (c) from vendors who sold milk in the ordinary way. While conditions of temperature and time were found largely to govern the number of bacilli in the samples, the total weight of deposit was found to be in inverse proportion to the precautions taken. Dr. Houston's report was presented to the Council and was printed and put on sale. The Council has decided to apply to Parliament for powers which would subject to penalty vendors of milk which is found, after examination, to be so contaminated as to be dangerous to health. Offensive Businesses. In the year 1905 the County Council received 322 applications for licences for slaughter-houses and granted 318. 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. Tear. 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 1893 442 429 1905 322 318 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 :— 11476 h 58 Sanitary area. Number of Slaughter-houses. No. of Inspections 1905. No. of notices 1905. On Register at end of 1904. Removed in 1905. On Register at end of 1905. Paddington 8 — 8 620 l Kensington 12 — 12 92 Hammersmith 12 12 286 29 Fulham 5 1 4 22 - Chelsea 6 — 0 84 - Westminster, City of 1 — 1 11 St. Marylebone 10 — 10 70 - Hampstead 5 — 5 146 - St. Pancras 21 — 21 555 Islington 40 1 39 2,227 - Stoke Newington 8 — 8 — Hackney 27 2 25 366 2 Holborn 2 1 1 26 — Finsbury 4 1 3 104 — London, City of 1 8 — 8 Shoreditch 13 1 12 67 — Eethnal Green 6 — 6 26 5 Stepney 10 — 10 19 1 Poplar 20 1 19 96 2 Southwark 6 — 6 77 Bermondsey 2 — 2 76 2 Lambeth 30 3 27 Battersea 7 1 6 Wandsworth 22 — 22 318 1 Camberwell 10 1 15 163 — Deptford 0 — 6 50 7 Greenwich 7 2 5 30 1 Lewisham 10 — 16 140 — Woolwich 11 — 11 66 3 The only change in the number of offensive trade premises, other than slaughter-houses, in London is a reduction in the number of fat melters and gut scrapers' premises, one of each of these businesses being abanded in Wandsworth and Woolwich resnpctivelv. 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 24 Tripe boilers 23 Glue and size manufacturer. 5 Knackers 5 Fellmongers 6 Bone boilers 6 Manure manufacturers 3 Soap boilers 13 Tallow melters 10 Gut manufacturers 4 Gut scrapers 1 Animal charcoal manufacturers 1 101 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. Sanitary area. No. on Register at end of 1905. No. of Inspections, 1905. Sanitary area. No. on Register at end of 1905. No. of Inspections, 1905. Kensington 1 41 Poplar 10 45 Hammersmith 4 104 Southwark 7 101 St. Marylebone 2 3 Bermondsey 12 225 St. Pancras 2 35 Lambeth 4 Islington 7 155 Battersea 2 Hackney 2 22 Wandsworth 7 125 Holborn 1 Camberwell 4 Finsbury 1 Deptford 5 103 Shoreditch 1 Greenwich 2 4 Bethnal Green 2 Woolwich 1 Stepney 7 56 1 The eight slaughter-houses in the City of London are not licensed by the London County Council. 59 In three instances, proceedings were instituted by the borough councils in respect of breaches of the bye-laws regulating offensive trades, viz., two in Deptford, the proceedings being instituted against a firm of bone boilers and two in Wandsworth against the same firm as in Deptford in respect of effluvium nuisance from their premises in that district. Convictions were obtained in each instance. Proceedings were unsuccessfully instituted in Bermondsey against a firm of fat melters, for enlargement of their premises without the consent of the London County Council. In each of these cases the County Council's inspectors attended the hearing to give evidence in support of the prosecution. Other effluvium nuisances mentioned in the annual reports are—occasional nuisance in Kensington from gas works in Kensal-green; nuisance in Westminster from benzine and ammonium sulphide arising from motor tyre works, from benzine in connection with cork-hat making, from a fried fish business leading to impregnation of uniforms, made on the upper floor, with the smell of the fried fish. In this case a judge's order was made requiring the nuisance to be abated and the business was discontinued. Other nuisances were: nuisance from brick burning in Hammersmith; nuisance in Chelsea from deposit of unconsumed cinder ash from the works of an electricity supply company and from the chimneys of the workhouse and laundry; nuisance in Lambeth from the making of bookbinder's glue and builder's size ; " in both processes glue is first soaked in tanks or tubs and then melted in cylinders, mixed with sugar, alum, etc." ; also in Lambeth, nuisance from a provision merchants, a laundry, a dust destructor, and a pickle factory. The subject of nuisance from fried-fish shops, fish-curers' and marine store dealers' premises and suggestions for the regulation of these businesses are discussed in a report which is appended. (See Appendix III.) Nuisances. Smoke Nuisance. The annual reports show efforts by London sanitary authorities to deal with smoke nuisances. These efforts are supplemented by those of the Public Control Department which, during the year ending 31st March, 1906, forwarded 554 reports of smoke nuisance to the metropolitan borough councils, with the result that 315 statutory notices were served and legal proceedings were instituted in 49 cases and conviction obtained in 47 cases, nenalties including costs being obtained amounting to £219 16s. to £219 16s. The following table shows the action taken by sanitary authorities for the abatement of smoke nuisance, so far as reference to this subject is made in the annual reports of medical officers of health. Sanitary Area. Observations and inspections. Nuisances and complaints. Notices. nses. Paddington 131 Kensington (25 premises) Hammersmith (50 premises) 21 Fulliam 13 Chelsea 3 1 Westminster, City of 2,715 52 147 11 St. Marylebone (358 inspections) (298 observations) 49 1 Hampstead 13 13 5 1 St. Pancras (661 inspections) (221 premises) 29 78 2 Islington 533 28 Stoke Newington Hackney 1,660 43 Holbom 258 26 Finsbury 202 35 11 London, City of 554 21 1 Shoreditch (14 premises) 19 3 Bethnal Green (737 premises) 31 Stepney 70 2 Poplar 127 126 6 South w&rk 642 85 44 5 Bermondsey 395 100 3 Lambeth 600 54 Battersea 45 54 4 Wandsworth 133 6 Camberwell 92 Deptford 106 43 43 2 Greenwich 423 q o Lewisham 254 25 Woolwich 184 24 24 Nuisance from stable manure. The increasing use of motor vehicles is having effect in leading to decrease in the number of horses in London. Dr. McCleary states that one large stable in Battersea, where some hundreds of horses were kept, is now used as a garage for motor omnibuses, and Dr. Caldwell Smith states that a large number of horses in Wandsworth have been disposed of and that one of the largest stables has been converted into a car shed. The result is that less manure is produced than formerly, and in one direction the problem 11476 H 2 60 of dealing with London manure is being simplified. Difficulty has been felt with regard to the proposal that as in the case of house refuse, the ownership of manure should be vested in the sanitary authorities and should be collected and disposed of by them, for the reason that value attaches to manure when produced on any premises in large quantities. With the substitution of motor for horse vehicles, large stables in which much manure is produced are disappearing, and there will evidently eventually remain only the small stables in which the quantity of manure produced is not sufficient to pay the cost of removal, and for this the intervention of the sanitary authority is especially needed, as the owners have much difficulty in disposing of it. Frequency of removal is being insisted upon by London sanitary authorities, as complaints of nuisances from stables are frequently made, especially in hot weather. In Paddington and Holborn, manure is required to be removed every 48 hours, in Finsbury, seven firms are under the obligation to remove their manure daily, and in Battersea this obligation is on all owners of manure. The Public Health Committee of Westminster has asked the Highways Committee to consider a scheme for the systematic removal of manure by the City Council, and pending settlement of the scheme arrangements have been made for the assistant engineer to remove, at the cost of the owners, any small quantities of manure the removal of which the owners have a difficulty in securing. Comment is made in several of the annual reports on the nuisance caused by the use of peat moss litter. This nuisance is experienced when the manure is disturbed at the time of removal and the remedy pointed out is to require the manure, when taken from the stable, to be deposited directly into the vehicle in which it is removed from the premises, thus obviating the subsequent disturbance which must otherwise occur. Removal of House Refuse. The weekly removal of house refuse from all premises in London which was required by the by-law of the County Council made in 1893, has led to systematic scavenging in replacement of the old system in which the dustman perambulated the streets and removed the refuse on the application of the occupiers of houses. As a result, the number of complaints as to non-removal has greatly decreased, Dr. Harris stating that in Islington the annual number of complaints has fallen from upwards of 10,000 in 1901 to 312 in 1905, and Dr. Warry stating that in Hackney the "requests" were as few as 108. Difficulty is still being experienced owing to the unwillingness of house occupiers to permit collection, the number of refusals amounting in Hackney to some five or six thousand weekly. In this matter the sanitary authority has the remedy in its own hands, inasmuch as refusal constitutes obstruction, for which a penalty can be enforced. Weekly removal, however, must obviously give place to more frequent removal. The need for this is especially obvious, as the medical officer of health of Paddington points out, in flats and in houses and tenements where gas fires only are used, and where, therefore, there is no opportunity for the occupiers to burn vegetable and animal refuse; a bi-weekly removal is therefore effected in some areas. Thus in Holborn the contractors are now required to remove house refuse twice a week in the period April to October inclusive, and once a week during the rest of the year, and in Finsbury in a few streets the collection is daily, and from model buildings is bi-weekly. In parts of some other districts a daily removal is effected. A by-law of the London County Council provides that where a sanitary authority arrange for the daily removal of house refuse, the occupiers may be required to deposit the dust receptacle at such hour as the sanitary authority may fix on the kerbstone or in a conveniently accessible position on the premises. In 1905, the Wandsworth Borough Council desired to institute a system of daily collection in a part of their district and made the requirement that the householders should deposit their receptacles on the kerbstone or edge of the footpath in front of their premises, no option being given them of depositing the receptacle in a conveniently accessible position on the premises. This requirement was held by the magistrate to be beyond the by-law and this opinion was upheld in the High Court. The bylaw, however, gives considerable facilities to sanitary authorities prepared to collect house refuse daily and it is much to be hoped that this practice will in course of time be more largely adopted. Removal of offensive matter. The removal of offensive trade refuse by the sanitary authority is being continued in Woolwich and evidently with good results. In Finsbury, refuse from fishmongers' premises is collected by the sanitary authority in a van especially constructed for the purpose, at a charge from one to two shillings per week. In Wandsworth, where for a time such matter was collected by the sanitary authority ths d fficulties of disposal have led the borough council to enter into an arrangement with a contractor for this purpose, and Dr. Caldwell Smith says that this arrangement has proved satisfactory. In Greenwich, like arrangements have been made and the following extract from the annual report of Dr. Annis gives a useful account of the details— During the year material alterations and considerable improvements have been effected in the method adopted for the collection of this material. From time to time the question has been under the consideration of the Public Health Committee, and the suggestion has been made and seriously considered as to whether or not this Council ought go undertake the collection of this material themselves in order to have it dealt with in as satisfactory a manner as possible. Up to the present the supporters of the view that the municipality should not undertake this work, but should require the private firms to carry out this work more satisfactorily have, I am pleased to say, prevailed, and with the object of having more intimate control over the collection, but without entering upon the business themselves, a contract has been entered into by the Council with Messrs. Hempleman and Sons, of West Ham, for the collection and removal of this material in a perfectly inoffensive and entirely satisfactory manner at a fixed charge, the payment being made by the offal producers themselves direct to Messrs. Hempleman. The method adopted is that one or more metal drums with lids are left at the premises of each person entering into the scheme, in which they are to place their offensive material, Messrs. Hempleman's van then calls at frequent, regular, and stated times for these drums, the lid is securely fastened down upon a rubber seating by means of a strong spring lever, the whole tin and its contents are lifted bodily into the van and conveyed away unopened ; a clean drum is left at the premises in exchange for each one removed. Since the adoption of this scheme there have been no complaints whatever as to nuisance occasioned by the collection of this material, while complaints were of very frequent occurrence previously. Having placed this model method of collection at the disposal of all makers of offensive refuse in the borough, the Council were then in a position 61 to bring pressure to bear upon all other persons making, storing, or collecting and removing this material in an improper manner ; this pressure has had the very satisfactory result of causing competing firms to discard their old method, and adopt this newer and more satisfactory form. Nuisance from sewers. Nuisance from sewer ventilators is discussed in several of the annual reports and particularly in respect of a proposal which has been made that the intercepting trap of house drains should be abolished and that the sewers should be ventilated through the house drains. In the annual reports for Paddington, Kensington and Fulham, the flooding of basements is mentioned, a condition which works undertaken in connection with sewers should eventually remedy- Nuisance from rivers and canals. Nuisance from the River Lea is still subject of serious complaint and the medical officer of health of Hackney thus refers to the condition of this river in that borough: " The river as it passes through the borough remains in its usual filthy condition, causing a nuisance during the hot summer months of the year to persons frequenting the large open space adjoining it, as also to persons living in its vicinity." The medical officer of health of Poplar states that with the object of preventing nuisance from the dead bodies of dogs and cats, of which 1,102 were taken from the river between Hackney-marshes and the Thames, notices were published stating that the dead bodies of such animals could be given to the dust collectors at their calls at houses, with a view to their destruction in the dust destructor. The Regents and Grand Junction Canals were kept under observation, as in previous years, by the officers of the London County Council and the sanitary authorities concerned and samples of the water were analysed at the instance of the London County Council and the St. Pancras Borough Council. Housing of the Working Classes Act. The following is a summary of the principal proceedings in 1905 of the London County Council and of the Metropolitan Borough Councils under the Housing of the Working Classes Act. Ptoreedings under Part I. of the Act. Webber-row, King's Bench-walk and Wellington-place scheme, Southwarlc.—On the 4th April, 1905, the Council resolved to make application to the Local Government Board for a provisional order authorising the Council to provide accommodation in connection with this scheme for 2,186 persons instead of 903, which the scheme originally required, and in June the Council accepted an estimate of £51,500 for the erection on this estate of five blocks of buildings for 1,130 persons in 120 tenements of three rooms, 96 of two rooms, and 4 of one room, and 18 cubicles, the block of building fronting Waterloo-road to contain ten shops with store rooms. Garden-row scheme, St. Luke.—On the 1st August the Council sanctioned expenditure not exceeding £40,135 for the erection on this site of Chadworth-buildings for 728 persons in 58 tenements of two rooms, 67 of three rooms, 9 of four rooms, and 2 cottages of 3 and 4 rooms respectively. With these buildings were to be provided 19 shops. Aylesbury-place, Clerkenwell, and Union-buildings, Holborn scheme.—On the 19th December the Council sanctioned expenditure not exceeding £80,050 for the accommodation, on the Union-buildings area comprised in this scheme, of 1,250 persons. Bow-road (Brewery-yard and Gandy-court) areas, Poplar and Cusack-place, Gareth-place and Porlockplace area, Bermondsey.—In March, 1905, the Council resolved that certain areas represented respectively by the medical officers of health of Poplar and Bermondsey were not of general importance to the County of London and should be dealt with under Part II. of the Act. The areas are thus described in reports presented to the Council by the Housing of the Working Classes Committee. Bow-road (Brewery-yard and Gandy-court) areas, Poplar. On 1st July, 1904, the medical officer of health of the Metropolitan Borough of Poplar, Dr. F. W. Alexander, made an official representation under Part I. of the Housing of the Working Classes Act, 1890, in respect of two areas situated on the south side of Bow-road, and known as the Brewery-yard and Gandy-court areas. The Brewery-yard area comprises 12 dwelling-houses in Brewery-yard and Baker's-alley and 12 tenements in Kinnears-dwellings, while the Gandy-court area contains 10 houses in Gandy-court and 4 houses in Bow-road. The total population of both areas on the date of the representation was 196, of whom 82 were children under 12 years of age. We have visited the areas and find that most of the houses are approached from Bow-road through narrow covered passage-ways, those in Bakers-alley being also approached from High-street, Poplar. The houses in Breweryyard are two-storey cottages, some of which are of timber construction, while most of them, being situated in close proximity to the rear of houses in Bow-road, are ill ventilated. The houses in Bakers-alley and Gandy-court appear to be very old and worn, and some of them are undoubtedly in very bad condition. As a result of our inspection, however, we are of opinion that many of the evils existing in the areas can be remedied by the application of the provisions of Part II. of the Act relating to closing and demolition orders, and by the enforcement by the borough council of its powers under the Public Health (London) Act, 1891. In fact, closing orders have quite recently been obtained in respect of six houses comprised in the Brewery-yard area. The Housing Act of 1890 describes the areas which should be dealt with under Part I. thereof as those containing houses, courts, or alleys, the evils connected with which. cannot be effectively remedied otherwise than by an improvement scheme for the re-arrangement of the streets and houses within such areas, or of some of such streets or houses. We are unable to describe the areas in question as requiring the preparation of so large a scheme as is contemplated under Part I. of the Act. It appears to us that their extent and general disposition are not such as to justify their being considered as of importance to the county of London as a whole, and that, if they should be dealt with by way of scheme, it should be prepared by the local authority under Part II. of the Act. Under the circumstances the procedure which we think the Council should adopt is that prescribed by section 73 (1) (6) of the Act of 1890, as amended by the Order in Council, made in accordance with the provisions of section 2 of the Act of 1903, transferring the powers and duties of the Home Office under the Housing Acts to the Local Government Board. Under this section the Council may resolve that an area officially represented under Part I. of the Act is not of general importance to the county of London, and should be dealt with under Part II. of the Act, and such resolution may be submitted to the Local Government Board. The Board may then institute an enquiry if they deem such a course necessary, and may, under section 73 (2), make an order pointing out the way in which the areas should be dealt with, 62 Cusack-place, Gareth-place and Porloctc-place area, Bermondsey. The medical officer of health of the Metropolitan Borough of Bermondsey, Dr. R. K. Brown, has made an official representation, dated 11th November, 1904, under Part I. of the Housing of the Working Classes Act, 1890, in respect of an area comprising Cusack-placc, Gareth-place, and a part of Porlock-place within the borough. The area comprises about 44 houses situated at the rear of premises on the eastern side of Crosby-row, between Snow's-fields and Long-lane, Bermondsey. The houses are surrounded by high buildings on every side and have insufficient space at the front and rear, some of them having no back yards at all. We are of opinion that the area is too small to be dealt with as an unhealthy area under Part I. of the Housing of the Working Classes Act, 1890, and it appears to us that if the evils complained of cannot be satisfactorily remedied by the exercise of the powers vested in the borough council under the provisions of Part II. of the Act relating to closing and demolition orders and the Public Health (London) Act, 1891, such scheme of reconstruction as may be deemed necessary should be undertaken by the borough council in the manner provided by section 39 (1) (b) of the Housing Act. That section provides that where it appears to the local authority that the closeness, narrowness and bad arrangement or bad condition of any buildings, or the want of light, air, ventilation or proper conveniences, or any other sanitary defect in any buildings is prejudicial to the health of the said or neighbouring buildings, and that the demolition or reconstruction and re-arrangement of the said buildings or of some of them is necessary to remedy the evils, and that the area comprising the buildings is too small to be dealt with under Part I. of the Act, the local authority shall pass a resolution to that effect and direct a scheme to be prepared for the improvement of the area. As the size of the area does not justify its being considered as of importance to the county of London as a whole, we think that the Council should adopt the procedure prescribed by section 73 (1) (6) of the Act of 1890, as amended by the Order in Council, made in accordance with the provisions of section 2 of the Act of 1903, transferring the powers and duties of the Home Office under the Housing Acts to the Local Government Board. Under this section the Council may resolve that an area officially represented under Part I. of the Act is not of general importance to the county of London and should be dealt with under Part II. of the Act, and such resolution may be submitted to the Local Government Board. The Board may then institute an inquiry if they deem such a course necessary, and may, under section 73 (2), make an order pointing out the way in which the area should be dealt with. Brady-street area and Digby-street area, Bethnal-green.—These areas were represented by the medical officer of health of Bethnal-green under Part I. of the Housing of the Working Classes Act and on the consideration of these representations by the Housing of the Working Classes Committee of the London County Council the Committee was of opinion that in the case of the Brady-street area, having regard to the prospect of the area being redeveloped by private enterprise, they did not see their way to recommend the Council to deal with the area under Part I. of the Act. In the case of the Digbystreet area, the Committee received a deputation on the subject, and the borough council subsequently decided to deal with the area under Part II. of the Act. Dr. Bate now reports that no advance has been made towards the clearing of these two areas. In November, 1905, he represented four houses in Little Collingwood-street in the Brady-street area, under Part II. of the Act", repairs, however, were effected and no order for demolition was made. Proceedings under Part II. of the Act. Chapel-grove and Eastnor-place schemes, St. Pancras.—In August, the Local Government Board issued an Order confirming these schemes which are being carried out by the St. Pancras Metropolitan Borough Council. The estimated net cost of the Chapel-grove scheme is £32,970 13s. 9d. and accommodation is to be provided for 400 persons in lieu of 501 to be displaced. The estimated net cost of the Eastnor-place scheme is £9,224 4s. 8d. and dwellings are to be provided for 100 persons in lieu of 189 to be displaced. The County Council contributes one-third of the net cost of these schemes. Scheme undertaken by a district council under Part II. of the Act, the County Council contributing to the cost. Prospect-terrace and Brantome- place scheme, St. Pancras.—Dr. Sykes reports with respect to the Prospect-terrace area included in this scheme, that negotiations have still been proceeding for the acquisition of the roadway from the Rectors of St. George-the-Martyr and St. George, Bloomsbury, and arbitration as to purchase has been withdrawn. Proceedings under Part III. of the Act. Norbury estate.—In February, the Council accepted a tender for the erection of fifty-two cottages on a part of section A of this estate for the sum of £13,176 and for the erection of three other blocks containing forty-two cottages at the schedule of prices contained in the tender. Brixton.—In April, the Council approved an estimate of £29,000 for the erection of Briscoebuildings on Brixton-hill, to accommodate 718 persons in three five storey-blocks of buildings containing 10 tenements of two rooms, 73 of three rooms, and 30 of four rooms. White Hart-lane Estate. — In June, the Council sanctioned expenditure of £13,919 for the erection of 60 cottages on section G of this estate, viz-: 28 with five rooms, 8 with four rooms, and 24 with three rooms, and in December, sanctioned expenditure of £30,430 for the erection of 122 cottages on the first part of the Tower-gardens section, viz., 32 with five rooms, 44 with four rooms and 46 with three rooms. Wedmore-street, Holloway.—In July, the Housing of the Working Classes Committee reported the completion of the third block of Wessex-buildings for 340 persons in 40 tenements of two rooms and 30 of three rooms, making, altogether on the Wedmore-street site, accommodation for 1,050 persons in 5 tenements of one room, 140 of two rooms and 80 of three rooms. Housing in connection with street improvements. Fulham Palace-road and High-street, Fulliam.—In August the Council authorised expenditure of £10,475 for the erection of Bearcroft-buildings in connection with this improvement. Rotherhithe Tunnel.—In February, the Housing of the AV orking Classes Committee reported the completion of dwellings erected in Swan-lane on the south side of the Thames in connection with displacements in the construction of this Tunnel, and in August the Council accepted a tender of £14,105 63 3s. 3d., for the erection of the first section of Bekesbourne-buildings in London-street, Ratcliff, in connection with displacements on the north side of the Thames. Proceedings by district councils under Part 111. of the Act. The following is a summary of proceedings by district councils under Part III. of the Act as shown in the Annual Reports of the Medical Officers of Health:— Kensington.—Dr. T. Orme Dudfield states in reference to the purchase of houses in Kenley-street, Notting Dale, by the Borough Council and their adaptation for occupation by persons of the poorer classes, that the houses on the north side of the street are now in occupation, and that those on the south side have been demolished and will be replaced by six blocks of flats—constituting an important public health improvement. It is intended to erect single room tenements on a site in Hesketh-place and Thomas-place in the Potteries. Chelsea.— Dr. Parkes states in reference to Sir Thomas More-buildings that Winchester and Dacre Houses were opened in 1905, Kingsley, Burleigh, and Cadogan Houses having been opened in 1904, the total number of persons accommodated being 798. Onslow-dwellings which had been erected in 1860 and which in 1903 came into possession of the Borough Council by purchase, were altered and improved. Six houses in Pond-place, included in the leasehold of Onslow-dwellings and purchased by the Borough Council were demolished and the Council resolved to erect dwellings in a building of five storeys similar to the St. Thomas More-buildings, providing 8 two-room and 24 three-room tenements. Hampstead.—The buildings being erected by the Borough Council at the corner of Lower Crossroad and Upper Park-road will soon be ready for occupation Batter sea.—The Borough Council has erected eighteen houses on land at the rear of the Town Hall, fourteen of which contain two tenements of three rooms and four of which contain two tenements of two rooms. These houses closely resemble those erected by the Borough Council on the Latchmere estate. Woolivich.—Of twenty-five houses belonging to the Borough Council in North Woolwich, 21 were occupied on the 1st April, the number of inmates being about five to a house. Proceedings in respect of houses represented under Part II. of the Act as unfit for human habitation. The following tabular statement shows the proceedings of district authorities concerning houses represented in 1905 as unfit for human habitation, and in respect of which the County Council has received copies of representations:— Sanitary areas. Total number of bouses concerning which the Council has received information that representations have been made from the 1/1/05 to the 31/12/05. Number of houses dealt with by owners, closing crders not obtained. Number of houses for which closing orders were granted. Number of houses for whioh closing orders were refused. Number of houses represented but subsequently dealt with under Public Health (London) Act, 1891. Still closed. Demolished. Improved, or being improved. Total. Still closed. Demolished. Improved. Total. Battersea — — — — — — — — — — — Bermondsey 5 — — — — 5* — — 0 — — Bethnal Green 4 — — — — — — 4 4 — — Camberwell — — — — — — — — — — — Chelsea — — — — — — — — — — — Deptford — — — — — — — — — — — Finsbury — — — — — — — — — — — Fulham 10 — — — — — 4 6 10 — — Greenwich — — — — — — — — — — — Hackney 23 — 1 22 23 — — — — — — Hammersmith — — — — — — — — — — — Hampstead — — — — — — — — — — — Holborn 15† — — — — — — — — — — Islington — — — — — — — — — — — Kensington — — — — — — — — — — — Lambeth 2 — — 2 2 — — — — — — Lewisham 4 — — 4 4 — — — — — — Paddington — — — — — — — — — — — Poplar — — — — — — — — — — — St. Marylebone — — — — — — — — — — — St. Pancras — — — — — — — — — — — Shoreditch — — — — — — — — — — — Southwark — — — — — — — — — — — Stepney — — — — — — — — — — — Stoke Newington — — — — — — — — — — — Wandsworth — — — — — — — — — — — Westminster City of — — — — — — — — — — — Woolwich 10 — — 5 5 5 — — 5 — — Total 73 — 1 33 34 10 4 10 24 — — † Dealt with under Warner-street scheme. * Closing orders applied for during 1906. 64 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 1905. The population thus dealt with comprised 19,035 persons, and the death-rate at "all ages" after correction for age and sex distribution was 11.7 per 1,000 living compared with 15.1 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 :— Death-rates of persons resident in the County Council's dwellings. Cause of death. Death rate per 1000 living. Council's dwellings. London. All causes all ages 11.7 15.1 ,, „ age 0—5 35.8 47.6 „ „ 5-20 3.3 2.5 ,, ,, ,, 20 and upwards 8.9 15.1 Diarrhœa 1.2 0.7 Principal Epidemic Diseases (excluding Diarrhœa) 1.3 1.0 Phthisis 1.1 1.4 Tubercular diseases other than Phthisis 0.5 0.5 Bronchitis 1.0 1.3 Pneumonia 1.2 1.5 Houses let in lodgings. The following table shows the number of houses let in lodgings on the registers of the several sanitary authorities, and for most districts the number of inspections of such houses. The total number of houses on the register at the end of 1905 in London was 22,284. Sanitary area. Number of places. No. of Inspections, 1905. Notices, 1905. Prosecutions, 1905. † On register at end of 1904. Added in 1905. Removed in 1905. On register at end of 1905. (a) For overcrowding. (b) For other conditions. Total. Paddington 1,031 140 21 1,150 7,758 36 3,019 3,055 37 Kensington 2,070 37 — 2,107 7,757 50 1,105 1,155 1 Hammersmith 2,229 348 311 2,266 242 Fulham 329 — — 329 693 43 176 219 — Chelsea 602 — — 602 161 — — — — Westminster, City of 1,659 12 30 1,641 1,578 St. Marylebone — — 758 1,345 Hampstead 908* 199 — 199 — — — — — St. Pancras 2,000 205 13 2,192 5,637 Islington 749 143 1 891 11,906 41 780 821 3 Stoke Newington 219 103 63 259 — Hackney 463 — 75 388 122 10 112 122 Holborn 767 7 15 759 1,465 20 167 187 — Finsbury 1,131 45 7 1,169 7,973 59 2,710 2,769 12 London, City of 360 343 465 Shoreditch 257 26 — 283 356 110 1 Bethnal Green 445 27 17 455 1,088 Stepney 2,661 187 176 2,672 3,611 335 1,057 1,392 35 Poplar 768 114 877 2,558 27 556 583 4 Southward 1,142 120 21 1,241 Bermondsey 218 4 1 221 596 10 194 204 — Lambeth 372 — — 372 Battersea 121 — — 121 — 54 54 — Wandsworth 217 7 6 218 400 10 254 264 2 Camberwell 228 17 28 217 184 84 177 261 1 Deptford 189 80 — 269 — — — — — Greenwich — 3 — 3 3 — — — — Lewisham 17 6 6 17 241 6 58 64 — Woolwich 235 41 11 265 594 49 271 320 1 * The registration of these houses was held to be invalid. † Of these prosecutions, it is stated that 9 in Stepney and in Camberwell wore on account of overcrowding. 65 As stated in the last report the amendment of the by-laws as to houses let in lodgings had been rendered necessary by certain decisions in the courts. The annual reports show that in Kensington new by-laws came into operation in August, 1905. New by-laws relating to Fulham were confirmed in March, 1906. In Hampstead by-laws amending those of the year 1895 were confiimed in June, 1905, and the borough council was advised that the decision which had declared the by-laws of 1895 to be invalid, also invalidated the registration of all the houses already on the register, consequently it became necessary to proceed with the work of re-registration- Amending by-laws for Shoreditch were confirmed in August, 1905. New by-laws for Southwark were confirmed in January, 1906, for Battersea in December, 1905, and for Wandsworth in October, 1905. The medical officer of health of Woolwich states that certain ratepayers having petitioned the Local Government Board not to confirm the by-laws, the Board held a local enquiry and subsequently proposed certain alterations, and with most of these the borough council had no difficulty in agreeing. The Local Government Board proposed, however, to exempt from the application of the by-laws, houses where the sub-letting was to one family only, and to a limited number of persons, and to this the council were unable to agree. The matter remained in this position at the date of the medical officer's report. It is probable that the small number of houses registered in some districts is due to the fact that pending confirmation of amended by-laws, the administration of Section 94 of the Public Health Act relating to houses let in lodgings was in abeyance. This, however, does not appear to be always the explanation where but few houses are registered. Thus concerning Lambeth, where there were 372 houses on the register and none was added during the year, the medical officer of health writes: " the custom in Lambeth borough is to depend upon dealing with contraventions of the sections of the Public Health (London) Act (i.e., nuisances) as they may arise, rather than with contravention of such by-laws"; and concerning Greenwich, where but three houses have been registered, the medical officer of health writes: "as indicated in the last annual report, no special work has been carried out under these by-laws during the year, on account of the inadequacy of the present staff." Houses infested with Vermin. Section 20 of the London County Council (General Powers) Act, 1904, provides that when on the certificate of the medical officer of health, it appears to the sanitary authority that any house or part thereof in any distiict is infested with vermin, the sanitary authority shall give notice in writing to that 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. The same section 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 summaiily 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 enquire 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. A substantial beginning of the use of this Act has been made by the majority of sanitary authorities in 1905, the annual reports for that year showing the numbers of premises and rooms cleansed to be as follows:— Premises. Booms. Premises. Rooms Paddington 99 Stepney 162 Kensington 199 Poplar 27 Fulham 25 Bermondsey 4 Chelsea 67 Wandsworth 7 Westminster, City of 9 22 Camberwell 14 8t. Pancras 22 Deptford 7 Islington 15 Greenwich 4 Finsbury 29 Woolwich 53 Shoreditch 22 The nature of the notices served in this connection in Paddington may be understood from the following which is extracted from the annual report of the medical officer of health. " The notices require all wall papers to be stripped off, defective plaster to be cut away, vermin to be destroyed, where accessible by blow-pipe and by sulphur fumigation (2 lbs. to each 1,000 c.f.), after which plaster to be made good, walls repapered, paint-work washed, etc." In the annual reports of the Medical Officers of Health of Islington and Southwark, the need for providing temporary accommodation for persons whose rooms are thus being cleansed is dwelt upon, and further reference to this subject will be found under the heading " Shelters," page 79. Common Lodging Houses. The administration of the Common Lodging Houses Acts devolved upon the Council in 1894. New by-laws governing common lodging houses came into force on the 1st October, 1903. In the following table will be seen the number of houses registered, the authorised number of lodgers, and the number of convictions, with the penalties inflicted, and other particulars during each year since 1894:— 11476 I 66 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 30 112 16 0 65 71 1897 581 28,718 26,121 — 31 30 92 11 0 59 48 1898 560 28,332 27,658 — 29 29 167 3 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 13 102 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 1905 413 27,571½ 28,158 1,565 21 16 77 3 0 53 14 † The number of deaths stated in the above table includes only those deaths brought to the knowledge of the inspectors as actually occurring in the houses, and not those occurring in infirmaries and other institutions to which the lodgers were removed when attacked with fatal illness. 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 1905 proceedings before the magistrates were instituted in 21 instances, resulting in 16 convictions, the penalties amounting to £54, with costs amounting to £23 3s. In addition to the number of inspections mentioned in the table there were 883 day and 104 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 were as follows c—Erysipelas, 7 ; Scarlet fever, 5; Diphtheria, 1; Enteric fever, 1; Total 14. It will be seen from reference to the above table that the number of cas.es of infectious disease in common lodging houses for the year 1905 was the lowest recorded since the administration of the Common Lodging Houses Act devolved upon the Council. In the annual reports for the years 1902 and 1903 reference is made 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 years 1904 and 1905 the work of inspecting these houses, and reporting upon the adequacy of means of escape in case of fire, made considerable progress, and at the end of the year every house had been dealt with and lists of requirements served upon the respective keeDers. 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 areas of London, other than that of the City, on 31st December, 1905. Sanitary area. No. of houses. Authorised accommodation. Men. Women. Couples. Total. Battersea 8 157 78 23 281 Bermondsey 5 885 — — 885 Bethnal Green 15 717 — — 717 Camberwell 6 538 — — 538 Chelsea 9 331 52 — 383 Deptford 7 445 — — 445 Finsbury 7 505 — — 505 Fulham 2 60 — — 60 Greenwich 4 157 — — 157 Hackney 6 401 — — 401 Hammersmith 9 457 9 4 474 Hampstead — — — — — Holborn 32 1,830 213 — 2,043 Islington 42 1,178 217 18 1,431 Kensington 24 439 272 — 711 Lambeth 8 726 — — 726 Lewisham 1 30 — — 30 Paddington 7 195 40 — 235 Poplar 11 1,344 — — 1,344 St. Marylebone 18 1,370 7 — 1,377 St. Pancras 14 880 144 — 1,024 Shoreditch 11 731 — — 731 Southwark 47 3,226 497 4 3,731 StepDey 67 5,514 683 228 6,653 Stoke Newington 1 37 — — 37 Wandsworth 9 176 5½* 20 221 ½* Westminster, City of 19 1,759 75 — 1,834 Woolwich 24 527 48 11 597 London—excluding the City of London 413 24,615 2,340½* 308 27,571½* * ½ — one child. 67 The common lodging-house population and vagrancy. In giving evidence before the Departmental Committee on Vagrancy on behalf of the County Council, I included in a statement submitted for the consideration of that Committee, the following paragraphs relating to the result of two attempts to ascertain the number of persons without settled homes who passed the night in the streets, instead of sleeping either in common lodging houses or casual wards c— "On the night of the 29th of January, 1904, effort was made by the County Council to enumerate the number of people in London who, on that night, were walking the streets, or sleeping on staircases, in doorways, or under arches, with a result that the Council's inspectors counted 1,463 men, 116 women, 46 boys, and 4 girls, who appeared to be under 16 years of age, walking the streets, 100 males and 68 females asleep on staircases, in doorways, or under arches, making a total of 1,797. The figures suggest that an estimate that one person in every 2,000 was homeless would probably approximate to the truth." "On that night 23,442 persons slept in common lodging houses and shelters, viz., 21,058 single men, 1,517 single women, 390 married couples, and 54 boys and 33 girls below 16 years of age. The number of men in Rowton Houses was 3,530. The same night there was vacant accommodation in the common lodging honses and shelters for 5,365 men, 603 women and 53 married couples. In the casual wards there were 1,034 men, 175 women, and 9 children, the available accommodation being for 1,243 men, 410 women, and 114 women and children. "Returns from the keepers of common lodging houses and shelters showed that 832 men, 118 women, and 7 children were, the same night, turned away from these places mainly on account of inability to pay for a night's lodging." "In connection with the number of people turned away from common lodging-houses through inability to pay for their bed, an experience of certain keepers of common lodging-houses is interesting. It was a general practice to allow frequenters of common lodging -houses to occupy the kitchens during the day, and indeed until closing time, which is usually at midnight or 1 a.m. The keepers did not know until that time which of these people would pay for a bed and which would not, with the result that a large number of ' turn outs ' as they were called, resulted." "Early last year, however, a number of keepers resolved to alter this practice, and refused to allow anyone to occupy the kitchen without payment, and as a result there were not only no 'turn outs' from these houses, but men who before used to be 'turn outs' found work and paid for their night's lodging. I understand, however, that this new practice has not been maintained." "On the night of the 17th February, 1905, effort was again made to count the number of persons in London apparently homeless, the Council's officers and the officers of several Sanitary Authorities engaging in the enquiry. The results were as follows:—1,869 men and 312 women were found in the streets or on staircases or under arches, or 2,181 in all; of these 827 men and 39 women were in Wych Street, Strand, where food was being given away by the Salvation Army, and 161 men and 60 women in Whitechapel Road, where food was also being given away by the Salvation Army. In a tent of the Church Army in Clare Market, Strand, 300 men were or had been chopping wood, they were given two meals during the night, and were given tickets for beds in common lodging houses which, however, would not be used until the following night; these should be added to the total. There were also 64 men in premises of the Salvation Army in Wych street, who subsequently were admitted into the Salvation Army shelter in Millbank Street. These are not therefore regarded as homeless." "In the common lodging houses and shelters that night were 23,381 persons, viz., 21,055 single men, 1,578 single women, 357 married couples and 34 children under ten years of age. All these people were lodgers, and to these might be added 140 men and 110 women in the Providence Row night shelter, as yet unlicensed, and 59 in an unlicensed shelter in Paradise Street, Rotherhithe, both of which are free shelters. Among the inmates of the common lodging houses were 1,600 men who had been given tickets for their lodging by the Church Army. The number of men in Rowton Houses was 3,589, or an increase of 59, while in Carrington House at Deptford, belonging to the County Council, were 461 men." "The same night there was vacant accommodation in the common lodging houses for 4,610 men, 856 women, and 62 married couples." Vacant accommodation in common lodging houses on night of 17th February, 1905. Sanitary Area. Vacant Accommodation for Men. Women. Married Couples. Total Persons. Battersea 42 52 3 100 Bermondsey 246 — — 246 Bethnal Green 154 — — 154 Camberwell 132 — — 132 Chelsea 65 15 — 80 City of London 7 — — 7 Deptford 180 — — 180 Finsbury 70 — — 70 Fulham 8 — — 8 Greenwich 48 — — 48 11476 I 2 68 Sanitary District. Vacant Accommodation for Men. Women. Married Couples. Total persons. Hackney 96 — — 96 Hammersmith 103 4 1 109 Hampstead — — — — Holborn 183 122 — 305 Islington 280 105 5 395 Kensington 103 105 19 246 Lambeth 183 — — 183 Lewisham 8 — — 8 Paddington 35 11 9 64 Poplar 342 — — 342 St. Marylebone 212 1 — 213 St. Paneras 61 54 — 115 Shoreditch 110 — — 110 Southwark 721 190 2 915 Stepney 820 163 1 985 Stoke Newington 1 — — 1 Wandsworth 38 — 9 56 Westminster, City of 345 24 — 369 Woolwich 17 10 13 53 Total 4,610 856 62 5,590 Several censuses have been taken at various times with the obiect of showing how far the authorised accommodation is made use of. authorised accommodation is made use of. The results of these censuses, are shown in the following table:— Date of Census. Authorised Accommodation. Number of Persons occupying Beds. Men. Women Married Couples. Total Persons. Men. Women Married Couples. Children Total Persons. 21st June, 1897 28,929 19,083 1,770 — 139 20,992 23rd June, 1897 — — — 28,929 18,735 1,693 — 105 20,533 Average for week ending 28th June, 1902 25,5011 1,862 539 28,441½ 20,922 1,635 473 — 23,503 Average for week ending 26th October, 1902 25,751 1,843 556 23,706 22,031 1,844 463 — 24,801 14th November, 1903 25,718 2,281 447 28,893 22,596 1,655 428 — 25,107 29th January, 1904 25,718 2,281 447 28,893 21,058 1,517 390 87 23,442 17 February, 1905* 25,671 2,450 422 28,965 21,055 1,578 357 34 23,381 * Including 69 beds for men in houses in the City of London, of which 62 beds were occupied. These figures show an average of between five and six thousand vacant beds each night in London common lodging houses. "The number (2,481) of homeless persons found on the night of the 17th February, 1905, is greater by 684 than the number found in the beginning of 1904, and, indeed, the fact that the Church Army gave away 1,600 tickets, and the Salvation Army gave free beds to 64 persons, suggests that this difference might be as large as 2,348. In the districts not included in the first census 196 persons were found. It is, of course, impossible to say how many of the persons receiving food, and who were reckoned as homeless, may subsequently have found their way to their own homes; how many who were given free beds would otherwise have provided for themselves, and how many may have been attracted to London by the expectation of receiving assistance. One of the Council's inspectors enquired of 318 persons receiving food whether they were Londoners, and in 277 cases the reply was in the affirmative, 39 persons admitting coming from the provinces, while 2 were foreigners. The Chief Inspector put a similar question to 100 men in the Church Army tent in the Strand, and 30 stated that they had come to London so recently as from one day to one month previously. Again the Council's inspectors found, among the persons receiving food, many who were known to them as frequenters of common lodging houses. It is noteworthy that, notwithstanding the fact that the Church Army issued tickets for beds in common lodging houses to 1,600 men, the actual number of persons who slept in common lodging houses and shelters that night was some 60 less than on the night of the first census in January of last year." 69 Death-rates among inmates of common lodging houses. 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 shown for comparative purposes. Table I. Common lodging houses. Death-rates per 1,000 males living at five age periods from certain causes in London (1904) and in licensed common lodging houses 1904 and 1905. Cause of Death. Age 26 to 35. Age 36 to 45. Age 45 to 55. Age 55 to 65. Age C5 and upwards. London, 1904. C.L.H 1904. C.L.H. 1905. London, 1904. C.L.H. 1904. C.L.H. 1905. London, 1904. C.L. H 1904. C. L. H 1906. London, 1904. C.L.H. 1904. C.L.H 1905. London, 1904. C.L.H. 1904. C.L.H. 1905. Phthisis 2.47 6.86 6.72 4.12 15.13 10.02 5.04 21.16 18.84 4.20 16.51 19.83 2.13 11.50 21.16 Other tubercular diseases 0.15 0.21 0.42 0.18 0.18 0.55 0.17 0.67 0.45 0.13 — — 0.13 — — Alcoholism (including cirrhosis of the liver) 0.13 0.62 0.21 0.47 1.98 0.55 0.94 1.80 1.12 1.31 3.07 1.14 1.02 5.75 2.23 Urinary diseases 0.23 0.83 0.42 0.56 1.62 0.91 1.33 1.12 1.12 2.99 3.46 3.05 7.88 13.79 13.36 Violence 0.59 — 0.42 0.84 1.26 — 1.33 0.67 0.90 1.76 0.77 1.53 2.61 1.15 3.34 Cancer 0.13 — 0.63 0.54 0.18 0.18 2.30 1.57 2.24 4.99 4.99 8.39 8.72 17.24 17.82 Circulatory diseases 0.60 1.87 1.89 1.55 3.96 3.28 3.47 5.62 5.38 8.47 9.60 8.39 22.07 36.78 26.73 Nervous diseases 0.15 0.42 — 0.46 1.08 — 0.70 112 0.45 1.49 3.43 1.91 4.56 8.05 6.68 Bronchitis 0.10 0.42 0.84 0.38 2.52 1.28 1.06 3.82 4.25 3.84 11.90 9.53 16.36 48.28 50.12 Pneumonia 0.45 1.04 0.42 1.01 2.34 1.28 1.69 4.27 2.92 2.77 61.4 6.48 5.18 13.79 1.2.25 Other causes 0.93 0.21 0.42 1.46 1.08 0.91 2.48 2.70 1.35 4.68 3.46 4.20 23.85 36.78 35.64 Total (all causes) 5.93 12.48 12.39 11.57 31.33 18.96 20.51 44.50 39.02 36.63 63.35 64.45 94.51 193.10 189.33 Table n. 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 (1904) and licensed common lodging houses 1904 and 1905. Cause of death. Age 25 to 35. Age 35 to 45. Age 45 to 55. Age 55 to 65. Age 65 and upwards. London, 1904. C.L.H. 1904. C.L.H. 1905. London, 1904. C.L.H. 1904. C.L.H. 1905. London, 1904. C.L.H. 1904. C.L.H. 1905; London, 1904; C.L.H. 1904. C.L.H. 1906. London, 1904. C.L.H. 1904. C.L.H. 1905. Phthisis 417 550 543 356 483 529 246 475 483 115 261 308 23 60 112 Other tubercular 25 17 34 16 6 29 8 15 11 4 — — 1 — — Alcoholism (including cirrhosis of the liver) 22 50 17 41 63 29 46 41 29 36 48 18 11 30 12 Urinary diseases 39 67 34 48 52 48 65 25 29 82 54 47 83 71 70 Violence 99 — 34 73 40 — 65 15 23 48 12 24 28 6 18 Cancer 21 — 51 46 ???6 10 112 35 58 136 79 130 92 89 94 Circulatory diseases 101 150 152 134 126 173 169 126 138 231 152 130 234 190 141 Nervous diseases 26 33 — 39 34 — 34 25 11 40 55 30 48 42 35 Bronchitis 17 1 33 67 33 81 67 52 86 109 105 188 148 173 250 265 Pneumonia 76 83 34 87 75 67 82 96 75 75 97 100 55 71 65 All other causes 157 17 34 127 34 48 121 61 34 128 54 65 252 191 188 Total (all causes) 1,030 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 70 A decision has been given in the Court of Appeal, in a case in which the Council was not a party, which it is claimed has the effect of exempting from the Common Lodging House Acts all institutions in which no charge is made to the lodgers. The matter is continuing to receive the consideration of the County Council. The accommodation of aliens newly arriving in or passing through London. In dealing with the question of the accommodation of aliens newly arriving in London, much difficulty has been caused owing to the fact that these people are often received in houses not suitable for the purpose, and occupy such houses, it may be, under overcrowded or otherwise objectionable and insanitary conditions. I have reported upon such cases from time to time, and prosecutions have been instituted for contravention of the Common Lodging Houses Acts. The Aliens Act of 1905, which came into force on the 1st January, 1906, while excluding transmigrants from the definition of "immigrants" [section 8 (1) a] provides that in the case of such transmigrants, i.e., of passengers holding prepaid through tickets to some destination out of the United Kingdom, the master or owner of the ship in which they are brought shall give security to the satisfaction of a Secretary of State that they will be properly maintained and controlled during their transit [section 8 (1) b]. In connection with this provision the Council has addressed a letter to the Home Secretary pointing out the difficulties experienced in dealing with transmigrants, and suggesting that they should be accommodated in houses approved and licensed by the Council as common lodging houses. 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. 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 and 1905 houses were added to and removed from the register, and on 31st December, 1905, the total number of seamen's lodging houses under supervision was 77, situated in the following metropolitan boroughs :— Metropolitan Borough. Houses. Lodgers. Poplar 18 360 Stepney 58 1,123 Woolwich 1 26 Total 77 1,509 During the year 1,509 visits were made to these houses by the Council's inspectors, and in eight instances notices were served for the remedying of dirty or defective conditions. Proceedings before the magistrate were instituted in five instances, the fines amounting to £5 5s. 6d., with costs amounting to £4 8s. Only one case of notifiable infectious disease was reported in seamen's lodging houses during the year, viz., one case of scarlet fever. Revenue Act. The annual reports show the large amount of work which devolves upon many medical officers of health under the Revenue Act. All premises concerning which application is made for exemption from inhabited house duty are inspected and in a great number of instances alterations are required to be made and work to be done before the certificate is granted, while in some others the certificate is refused. A point deserving of note is mentioned by Dr. Reginald Dudfield, medical officer of health of Paddington. He writes c " In the course of the inspection a number of bed rooms were found to have no open fireplaces, warming being provided for by gas stoves. The flue pipes from the stoves are connected to one vertical shaft of small dimensions, the chimney being thus common to all the floors. The top of the flue has a small iron grating—not a chimney pot. There is no provision for the ventilation of the rooms except the doors and windows. When a stove is lighted in one of the lower rooms, the fumes escape into the upper—usually the room on the top floor—and complaints of the nuisance have been received. The issue of the certificate has been suspended until satisfactory steps have been taken to provide for the escape of the fumes, and the attention of the County Council (Architect's Department) has been directed to the case. The present Building Acts do not provide the necessary powers to prohibit this defective construction." The following table, showing the number of applications for certificates and other particulars, is compiled from information contained in the reports of medical officers of health. The reports for Holborn, Shoreditch and Poplar show that no applications were received in 1905. The reports for the other districts not shown in the table do not eupply information on this point— 71 Applications under the Revenue Act. Sanitary area. No. of houses for which applications were received during 1905. No. of tenements comprised therein. No. of Tenements for which certificates were Granted. Refused. Deferred. Paddington 124 1,074 1,027 37 10 Kensington 6 17 17 — — Hammersmith 116 530 507 15 8 Fulham 118 409 257 54 98 Chelsea 7 23 7 16 — Westminster, City of 19 141 134 — 7 St. Marylebone 20 82 46 35 1 Hampstead 181 215 39 (houses) — 142 (houses) Islington 28 360 336 — 28 Hackney 7 397 397 — - Finsbury 5 101 101 — - Bethnal Green 4 59 39 14 6 Stepney 12 84 72 12 - Bermondsey 3 42 40 — 2 Lambeth 64 458 267 12 179 Battersea 63 67 61 6 — Wandsworth 614 885 875 10 - Camberwell 2 5 — — 5 Deptford 1 15 15 — - Greenwich 7 25 25 — - Lewisham 45 91 81 10 - Underground Rooms. In a number of districts underground rooms were found to be illegally occupied. In a number of districts underground rooms were found to be illegally occupied. The following table is compiled from information contained in the annual reports of medical officers of health — Sanitary area. No. of cases in which illegal occupation was dealt with. No. of rooms closed. Sanitary area. No. of cases in which illegal occupation was dealt with. No. of rooms closed. Kensington 22 22 Shoreditch 5 Fulham 2 2 Bethnal Green 3 3 Chelsea 1 1 Stepney 79 32 St. Marylebone 7 Lambeth 14 Islington 40 40 Battersea 7 7 Hackney 1 1 Greenwich 5 5 Holborn 11 11 Woolwich 3 2 Finsbury 24 — < Overcrowding. In the following table will be found the number of instances in which overcrowding was found and dealt with. The table shows the need for unceasing watchfulness over the conditions under which poor persons are dwelling. In many instances poverty makes the payment of money for sufficient accommodation a matter of great difficulty, and in his annual report to the Bermondsey Borough Council, Dr. Brown gives interesting details of the wage earnings of 13 families found to be living in overcrowded condition. There is, whatever the cause, need of administrative control of overcrowding and it may be expected that as the facilities for cheap travelling are increasingly provided, those who work in the central districts of London will be able to live further from their place of employment and rents will be proportionately diminished. The need for such control is especially manifest in the borough of Stepney, where the instances of overcrowding found were very numerous and where, it should be recollected, there is a considerable alien population. 72 Overcrowding. Sanitary area. No. of dwellingrooms overcrowded. No. of cases remodied. No. of prosecutions. Paddington 102 91 - Kensington 95 95 — Fulham 113 113 1 Chelsea 15 15 Westminster, City of 120 Marylebone 133 133 — Hampstead 11 11 — Pancras 132 Islington 178 178 — Stoke Newington 12 12 Hackney 54 54 — Holborn 60 60 — Finsbury 118 118 — Shoreditch 102 102 — Bethnal Green 101 101 3 Stepney 1,048 1,048 15 Poplar 47 47 — Southwark 562 2 Bermondsey 38 38 — Lambeth 57 Battersea 39 39 - Wandsworth 92 92 - Camberwell 137 137 - Deptford 30 30 - Greenwich 15 15 - Lewisham 38 38 - Woolwich 154 154 Factory and Workshop Act. 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. The table has, however, not sufficed to ensure the uniformity of statement which is needed and the amount of information as to the administration of this Act which is contained in the annual reports varies considerably. From the tables contained therein or supplied subsequently and from other information, the summary table on pages 74 and 75 has been prepared. A similar table was included in the report of the preceding year and comparison on certain points therefore may be made between the figures relating to 1904 and 1905— Including— 1904. 1905. Number of workshops on register 34,488 35,187 Number of inspections 84,600 85,263 Total number of defects found 18,922 19,023 Want of cleanliness 5,752 6,522 Want of ventilation 799 828 Overcrowding 413 347 Sanitary accommodation* Insufficient 403 284 Unsuitable or defective 8,645 8,411 Not separate for sexes 808 239 The figures, therefore, show some increase in the number of workshops on the register in 1905, about the same number of inspections as in 1904, and a slight reduction in the number of defects found. In several of the reports the statement is made that as the result of the work done workshops are in better condition than formerly. Eeference is made to the use of basement rooms as workrooms, and on this point Dr. Parkes, who says there are in Chelsea 19 such workrooms occupied by milliners and dressmakers with accommodation for 167 workers, states that these rooms are by no means * Exclusive of sanitary accommodation in Woolwich (one in 1904 and ten in 1905), insufficiently classified for the purposes of the above table. 73 satisfactory in respect of lighting, warming, ventilation and, in some cases, aerial disconnection from water closets. Dr. Parkes expresses the opinion that regulations should be made by the Secretary of State prohibiting the use of underground rooms unless they complied with certain conditions, and he indicates the conditions which should be required. Such regulations would undoubtedly serve a useful purpose. Among improvements being effected in London is the abolition of gas stoves having no flue for the removal of the products of combustion. "Unventilated gas stoves" according to Dr. Reginald Dudfield, "are gradually being banished from workshops of all classes" in Paddington. Laundries are also stated to be in better condition in London than formerly, but Dr. Harris, in writing of laundries in Islington, compares the requirements for factory laundries with other laundries and says "At present the owner of a factory laundry must provide a fan or its equivalent to regulate the temperature of the ironing room and to carry off steam in the wash house, and he must keep all stoves for heating irons away from the ironing rooms. Regulations cannot be enforced in hand laundries. The workers in the ironing room often work in a temperature which has been greatly raised by the presence of unscreened stoves for heating irons." This-, he points out, calls for remedy. In August, 1905, an Order was made by the Secretary of State which had the effect of extending the requirement of section 107 (relating to lists of outworkers), of section 108 (relating to employment in unwholesome premises) and of section 110 (relating to the prohibition of homework in places where there is infectious disease) to the following trades— The making of covers for, and the covering, finishing, altering or repairing of, umbrellas, sunshades, parasols, and articles of a similar character, and any work incidental thereto; The making of paper bags and of paper boxes ; Brush making; and The making of stuffed toys. In addition to the object for which this Order is made, Dr. Newman states that this Order has been found in Finsbury to have had an effect beyond that for which it was designed, inasmuch as it has been the means of the discovery of a considerable number of small workshops and workplaces which would otherwise have escaped detection. The number of outworkers was 34,579 in 1904; and 38,798 in 1905 inasmuch as the figures shown in the table are the total of the two half-yearly lists required to be sent by the Act, these figures will require to be divided by two to show approximately the actual number of outworkers notified to the sanitary authorities. The annual reports show that difficulty is still experienced in obtaining the necessary lists from employers, but Dr. Collingridge states that satisfactory results have followed in the City from the sending to employers, shortly before the lists are due, a letter reminding them of their obligations. Further difficulty also results from inaccuracy in the lists of information as to addresses of outworkers, leading to waste of time of the officers who visit the outworkers' homes. The co-operation of employers is evidently much needed in this matter. 11476 K 74 TABLE SHOWING PROCEEDINGS OF LONDON SANITARY Premises, Particulars, Class, &c Paddington. Kensington. Hammersmith. Fulham Chelsea. City of Westminster. St. Marylebone. Hampstead. St. Pancras. Islington. Stoke Newington. Inspection. Factories (including factory laundries) 345 81 601 115 2 — 52 122 112 365 16 Workshops (including workshop laundries) 1,323 2,843 1,787 572 471 1,866 1,676 1,229 981 4,976 162 Workplaces 13 446 110 305 154 1,530 723 1,366 124 536 10 Home workers' premises 308 249 75 226 41 510 844 22 183 1,229 170 Total (Inspections) 1,989 3,619 2,573 1,218 668 3,906 3,295 2,739 1,400 7,106 358 Defects, &c., Found. Nuisances under the Public Health Acts. Want of cleanliness 82 223 152 75 19 185 82 82 123 558 32 Want of ventilation 3 47 - 2 — 51 16 18 10 7 — Overcrowding 9 36 3 9 5 29 5 11 2 14 2 Want of drainage of floors 2 6 7 3 1 4 1 3 5 4 5 Other nuisances 23 109 50 65 4 120 53 274 27 334 19 Sanitary accommodation insufficient — 4 2 14 — 19 — 18 5 25 2 unsuitable or defective 10 71 51 4 2 378 31 76 25 115 21 not separate for sexes 4 5 4 1 — 33 3 4 12 3 — Offences under the Factory and Workshop Act. Illegal occupation of underground bakehouse (S. 101) - - - - - - - - - - - Breach of special sanitary requirements for bakehouses (SS. 97-100) — 3 98 9 — 7 — — 50 — Failure as regards lists of outworkers (S. 107) — 51 — 6 — 30 — — — 47 — Giving out work to be done in premises which are. unwholesome - - - - - - - - - - - (S.108) infected (S. 110) - 5 - - - - - - - - - Allowing wearing apparel to be made in premises infected by scarlet fever or smallpox (S. 109). - - - - - 1 - - - - - Other offences 19 - - - - - - - 5 - - Total (defects) 152 560 367 188 31 57 191 486 264 1,107 81 Other Matters. Matters notified to H.M. Inspectors of Factories. Failure to affix abstract of the Factory and Workshop Act (S. 133) 15 34 — 29 25 110 30 52 18 105 2 Action taken in matters referred by H.M. Inspector as remediable under P. H. Acts but not under the Factory Act (S. 5). Notified by H.M. Inspector 22 25 18 5 6 97 50 1 6 13 3 Reports (of action taken) sent to H.M. Inspector 22 19 18 5 6 97 39 — 6 13 3 Other 1 5 — — 4 — — 1 — 6 Underground Bakehouses (S. 101). Certificates granted in 1905 1 1 - - — — — 28 — — In use at the end of 1905 61 75 38 50 34 79 75 22 133 109 20 Homework. Number of lists received 84 44 85 34 58 312 111 105 49 221 15 Number of outworkers 421 403 189 96 517 2,052 1,277 331 303 1,793 143 Addresses of cutworkers Forwarded to other authorities 246 299 50 46 380 642 410 273 176 947 78 Received from other authorities 183 197 139 125 57 283 509 31 550 1,903 476 Notices prohibiting homework in unwholesome premises (S. 108) — — — — — — — — - - - Cases of infectious disease notified in hemeworkers' premises 1 5 — — 1 — — 3 1 11 1 Orders prohibiting homework in infected premises (S. 110) — — — — - - - - - - Workshops on the Register at the end of 1905 (S. 131). Bakehouses 79 94 58 69 43 98 84 35 178 260 28 Laundries 171 227 324 88 34 30 2,570 6 88 161 342 Other Workshops 1,182 1,289 521 280 434 2,357 646 1,093 1,872 Total (Workshops) 1,432 1,610 903 437 511 2,485 2,654 687 1,359 2,293 370 75 AUTHORITIES UNDER THE FACTORY AND WORKSHOP ACT. Hackney. Holborn. Finabury. City of London Shoreditch. Bethnal-green. Stepney. Poplar. Southwark. Bermondsey. Lambeth. Battersea. Wandsworth. Caraberwel). Deptford; Greenwich. Lewisham. Woolwich. 29 103 708 656 31 51 2 292 98 159 6 829 493 521 33 52 79 10 2,158 950 2,011 2,025 2,932 3,760 2,458 921 1,286 251 230 1,583 2,628 2,253 432 378 1,519 304 3 1,752 1,719 854 827 531 21 1,114 1,419 461 648 1,571 425 258 121 322 1,365 172 467 21 743 3,797 32 1,770 387 754 303 134 241 958 279 169 212 308 3,555 2,977 4,905 3,556 4,536 8,139 2,513 4,097 3,190 1,625 539 3,194 4,933 4,157 1,002 720 2,132 622 310 57 118 852 501 389 514 364 581 141 135 135 228 52 258 76 182 16 18 5 16 471 3 6 67 1 43 6 2 8 7 1 4 2 3 11 18 9 11 34 5 5 63 5 8 — 14 3 13 11 - 2 18 3 6 — 1 — — — — — 47 3 - 5 3 7 - - 7 1 469 14 380 1,258 109 362 79 275 753 115 51 241 263 58 108 20 100 12 2 1 22 24 7 13 27 3 25 10 1 12 23 7 11 2 5 163 23 423 1,220 38 105 1 17 23 29 197 91 79 93 3 16 106 8 6 12 11 66 4 3 32 9 8 1 7 8 1 — — — 2 2 - - - - - - - - - - - - - - - 1 1 - — 1 — 3 — 1 — — — — 73 6 — — 14 — — 358 81 86 376 17 20 — — — 15 — 17 — — 3 — — — - - - 1 - - - - - - - - - - - - - - - - - 1 - - - - - - - - - - - - - - - - - - - - - - - - - - - - 2 - - - — - 106 - - - - - - - - 1 - - - 1 - - 1,350 203 1,174 4,306 684 904 783 674 1,488 320 407 594 623 229 389 134 424 53 70 38 58 51 - 53 36 63 31 - 63 54 67 25 9 17 50 - 60 13 25 32 84 18 184 6 5 2 22 2 3 9 2 5 10 3 8 13 25 32 13 18 184 11 5 2 22 2 3 6 2 5 10 2 1 48 1 — — — — 12 — - 1 3 1 12 18 — - - - - - - - - - - - - - - - 1 - 0 49 27 40 27 45 28 62 36 41 33 72 32 48 66 28 19 23 24 447 125 215 576 31 75 1,345 79 141 42 2 76 33 565 92 98 242 76 3,366 848 4,688 8,127 629 1,095 5,507 1,604 1,147 531 11 469 365 1,294 497 349 449 308 1,619 134 4,402 7,891 494 467 643 552 748 234 5 64 231 803 267 95 144 31 2,138 208 488 236 1,305 1,427 4,134 891 794 660 140 240 146 1,272 404 125 174 97 - - - 1 - - - - - - - - - - - — 8 — 1 75 12 8 56 7 5 6 4 5 12 3 — - - - - - 12 - - 12 - - - - - - — 113 33 61 35 75 91 169 114 109 105 207 86 162 169 76 73 94 62 114 19 32 1,947 32 32 2,081 44 69 527 1,225 50 125 90 11 20 85 15 886 825 1,827 1,186 1,390 364 1,514 425 1,414 983 182 154 814 130 1,113 877 1,920 1,982 1,293 1,513 2,250 522 1,692 632 1,432 561 1,701 1,242 269 247 993 207 11476 K 2 76 The table on pages 74 and 75 shows that the proportion of inspections to premises differs considerably in the several districts. In some districts the inspections number several times the number of premises, in others less. Dr. Brown, the medical officer of health of Bermondsey, again calls attention to the need for the appointment of a female inspector in this district for the purposes of this Act. The Inspection of Food. A report by Dr. G. S. Buchanan to the Local Government Board on administration in London with regard to meat of pigs affected by tuberculosis, shows the need of comprehensive rearrangement of the work of inspection for the purpose of safeguarding consumers against such risks as attach to the consumption of tuberculous meat. After discussing the administration of foreign countries from which the meat of pigs is exported to this country, the examination of the carcases of animals in the Central Market,in the Islington Market and in private slaughterhouses and in butcher's shops, Dr. Buchanan says that the earlier parts of his report, in which these administrations are described, " indicate, as regards London, incompleteness and lack of uniformity in measures adopted by public authorities to control or prevent the importation, sale, or use for manufacture, of meat of tuberculous pigs." He is of opinion that there would be "many advantages in extending the system adopted in Dutch and Danish slaughterhouses of attesting the fact that a given carcase, together with its viscera, has passed official inspection. The official labels which at present are attached to these carcases might usefully be supplemented by stamping or branding the carcase in several places with an appropriate mark," and he adds " Similar marking and labelling could, I imagine, be easily undertaken in the case of pigs slaughtered under official inspection at Islington when new slaughterhouse arrangements are made." He adds, " I do not think there is any reason to apprehend that marking the carcase (an every day practice on the Continent) will in any way prejudice its sale to the public, and it seems probable that retail butchers and other buyers will appreciate the security afforded by the mark. This has certainly been the case with the labels attached to the officially inspected carcases imported from Holland. The danger appears to me to be rather the other way, that unequal treatment may be accorded to the home producer who cannot profitably send his pigs alive to Islington and is obliged to slaughter in private slaughterhouses. In the absence of care or knowledge on the part of men who slaughter or dress the carcase—and many of them are altogether ignorant of the significance of tuberculous lesions —and being without the advantage of official inspection, he may send carcases of tuberculous animals to London with the result that (under the system of marking), they are specially looked over and tuberculosis is discovered. In such cases he would not only lose the value of the carcases, but would be at a disadvantage, when compared with the foreign importer, in consequence of the risk of prosecution which he would incur." The view that buyers will learn to value the security of inspection which the stamp indicates is, I believe, well founded, and there is every expectation that the purchaser will become accustomed to look for the stamp, and that English produce which cannot thus claim to have been inspected will be regarded and, provided the foreign inspection is efficient, deservedly regarded as less free from risk to the consumer than that which has been inspected abroad.* It is, therefore, not matter for surprise that the Danish Government has made an order which will provide for the marking of bacon of Danish manufacture, as will be seen from the following statement I have just received from the Commissioner to that Government— A Danish law, of 30th March, 1906, which cainc into forcc on the 3rd October, provides for the marking of bacon of Banish manufacture intended for export from Denmark. A royal decree of 30th August orders, in section 3, that all Danish lightly salted bacon exported from Denmark shall bear a mark like this [Mark here indicated.] The mark shall be applied to each half carcase on no more than three places according to directions to be issued by the Minister of Agriculture. A Ministerial Order of 1st September directs every exporter of bacon of Danish origin to apply to the Minister of Agriculture, who will cause the veterinary inspectors appointed under the law of 24th April, 1903, and Ministerial Order of 18th February, 1905, to be supplied with the necessary stamp for applying the mark ordered by the Royal decree. The inspector is responsible for the use of the stamp, which must not be delivered or lent to others, and which must only be applied to carcases which the inspector has passed for export according to the instructions given him. Another Ministerial Order of 22nd September cancels section 3 of Ministerial Order of 18th February, 1905, concerning export of meat, as far as this refers to bacon. Bales of Danish bacon will not in future need to have a label attached, signed by the veterinary inspector and sealed by a lead seal. By instructions of 26th September to the veterinary inspectors, amending instructions of 18th February, 1905, * The following Order dated January, 1905, has been issued by the Danish Minister of Agriculture :— " Supplement to Instruction by the Minister of Agriculture of 15th August, 1903, to the veterinary inspectors appointed to control the export of meat. " As it has been brought to the notice of the Minister that carcases of pigs which have suffered from tuberculosis even in a very minute degree, are condemned by English officers of health as unfit for human food, it shall, under reference to Section 4 of the Instruction issued on August the 15th, 1903, from now henceforth be the duty of the veterinary inspectors authorised to inspect meat for export to retain from export to Great Britain the carcase of any pig examined according to the Order of August the 15th, 1903, in which, or in the organs of which, is found the smallest deposit of a tuberculous nature. " As the removal of any part of the serous membranes in several markets in England causes a suspicion that the animal in question has suffered from tuberculosis, the veterinary inspector shall not pass for export to Great Britain any carcase of an ox or pig examined according to the same Order from which any part of the pleura or peritoneum has been removed. 77 all cases of pigs intended for export in lightly salted condition (bacon) will have to be stamped, while freshly killed., with the prescribed mark which has to be applied on three places, fore end, middle and gammon, as indicated : [Method of stamping indicated.] The mark is to be applied by the inspector himself or in his presence, and on his responsibility. The mark is to be put on in colour (red ink). The inspector has to see that the mark is plainly and boldly put on. It will be noted that this Order only applies to lightly salted bacon, but there can be little doubt that the system will eventually be extended to all Danish meat intended for export. Dr. Buchanan's conclusion that, under a system of marking, the butcher who slaughters in a private slaughterhouse is at a disadvantage compared with the butcher, who is able to slaughter under conditions where the meat is subjected to systematic inspection, is undoubtedly true. In this connection, he points to a report which was before the County Council in 1898, in which was advocated the slaughter of animals in public slaughterhouses and the stamping of the meat therein, as well as that which would be brought to inspection stations, and says " establishment of such inspection stations, together with marking of meat there inspected, would go far to remove the disadvantage to the home producer to which I have referred, and to enable carcases of tuberculous pigs to be dealt with on uniform lines throughout the metropolis." In the meantime, it is interesting to observe that the proportion of home grown meat, as compared with foreign grown meat, which finds its way into the Central Meat Market has continually decreased. Dr. Collingridge states that " the returns furnished by the superintendent of the market continue to show an increasing ratio of imported to home grown supplies. In 1896 the proportions were nearly equal, but last year the amount of foreign produce was about three times as large as that of British," and he adds that "this will probably continue so long as the present low prices can be profitably accepted for meat grazed on the Australian downs, the South American pampas, and the Canadian prairies. These advantages are at present driving the home producer altogether out of the race, while the excellent quality of this imported meat shows that the growers oversea can not only undersell the English farmer in his own market, but can also produce an equally good article." There is now probability thatby the extension of the system of slaughtering under conditions which provide for inspection and of the stamping of meat which has passed this inspection, some foreign countries will offer to the consumer in this country inducements to purchase meat which has been inspected abroad instead of home produced meat of which the greater proportion is supplied to the consumer without any systematic inspection and indeed, often without any inspection at all. The annual reports of medical officers of health show the amount of food diseased or unsound seized in the several distiicts. In the City, where are situated the Central Markets, 2,128 tons, 9 cwts. and 2 qrs. of meat were seized of which 167 tons, 14 cwts., and 3 qrs. were diseased, and in the Billingsgate Market 674 tons, 3 cwts. and 2 qrs. of fish were condemned. In respect of seizures of diseased meat there were 12 convictions, the average fines and expenses amounting to £30, one of the defendants who had been previously convicted being sentenced to imprisonment for three months. In Finsbury, where the "outside market" is situated, 94 tons of meat were confiscated, of which 30 tons were diseased, and there were nine convictions- Among the defendants was a sausage maker who was found using the flesh of pigs from some of which the glands had been removed before delivery, as well as the flesh of one or more pigs, proved to be tuberculous. Other articles of food were seized including rabbits, eggs, fruit, vegetables, etc. In Islington more than 1½ tons of meat were seized, of which 14 cwts. were found in the slaughterhouses; other articles of food seized included fish, fowls, fruit, vegetables, etc. Large quantities of unsound food, largely tinned food, was seized in Stepney in which river wharves are situated, the total seizures and surrenders amounting to over 232 tons. In Poplar, it is stated that, over 4,000 tins of preserved food were surrendered, in Bermondsey nearly 4½ tons of various tinned foods brought to the wharves were destroyed, and in Southwark there were destroyed nearly 30 tons of food stuffs—mostly arriving at the wharves. In both of the latter districts effort was made to secure the destruction of a large amount of coffee which had been submerged in the Thames owing to the sinking of a ship of which it formed the cargo. In the City upwards of 173 tons of food stuffs removed from the wharves were destroyed. In Westminster the food destroyed included upwards of 3,000 tins of preserved food, besides large quantities of vegetables and fruit, and two heads and one carcase of tuberculous pigs. In Poplar, about 40,000 lbs. of fruit pulp was seized from a factory and an associated store and condemned. It was intended to convert the pulp into jam, but after the conviction of the defendant the factory was closed. In this district also several pigs' heads were destroyed. In Hackney, over 2 tons of unsound food was seized, of which more than half consisted of meat including a number of heads of tuberculous pigs. Rabbits were condemned in Bethnal-green, Shoreditch, Finsbury, Wandsworth, Camberwell, Deptford and Chelsea, mostly in large quantities. Dr. Parkes states that the rabbits destroyed in Chelsea were purchased in the Smitfiheld Market in October, by a costermonger, and found to be in a "spotted condition." They were part of a consignment which arrived in London from Australia in May and had been kept in cold storage since that time. The appearances found were probably due to post-mortem changes, and as Dr. Parkes points out" further information is required as to what is the effect of these long periods of cold storage on such articles of food as rabbits, poultry and fish." In this connection it may be pointed out that Dr. Hamer, as the result of his inspection of cold stores in 1904 (see Appendix I. to the Annual Report for the year 1904), came to the conclusion that there is need of extension of knowledge with regard to the effect of cold storage on perishable foodstuffs. Seizures and surrenders of various articles of food were made in most, if not all, other 78 districts, including the flesh of tuberculous pigs in St. Pancras and nearly 1,000 lbs. of tuberculous pork in Paddington. It is interesting to note the result of examination of glands, other than those presenting naked eye appearances of disease, which yielded positive results in an instance recorded by Dr. Allan who thus writes of tuberculous pork seized in Westminster. "In certain cases where only the head was found and only one gland was visibly affected, it was thought desirable to have a bacteriological examination of the other glands which presented a sound appearance to the naked eye. This was done by Professor R. Tanner Hewlett, of King's College, who reported that as the result of his examination he had no doubt that these glands were also tuberculous. This supports the view taken by the Royal Commission in their report (1898) and disposes of a contention which is not infrequently urged before the magistrate that the affection is slight and of no serious import." Dr. Reginald Dudfield gives account of the number of carcases in 1905, from which the glands had been removed and which he inspected in Paddington. Thus of 1,100 Dutch pigs 57 had been stripped, of 900 English pigs 48 had been stripped, and of 400 from other countries 16 had been stripped. None of these carcases were condemned and he says c " That there is good reason to believe that the majority of, if not all, the - stripped - carcases were tubercular, is evidenced by the facts that the parts removed were frequently abnormal, and that morbid changes—the nature of which was not recognisable by the naked eye as tubercular—were found in other parts of the bodies. It is commonly found that the spaces left after removing the glands are considerably larger than they would be after removal of healthy glands. The tonsils arc the glands most frequently removed. In many cases the other glands, such as the inguinal, iliac, parotid, etc, are. also cut into, sometimes minced up so that the naked eye can hardly recognise the gland structure. Such glands have been found enlarged, discoloured and unhealthy in carcases from which the enlarged tonsils had previously been removed. It has also been found that, where the tonsils have been removed, leaving large, wet vacuities, and no other glands have been cut into, the latter, when examined, have proved to be tubercular. On one or two occasions fragments of tubercular disease have been left after removal of the tonsils. : ; : ; ; The fact that the vacuities are found moist indicates that the ' stripping' has been but a short time before the examination. It is not done in the borough, as the carcases have been frequently examined as delivered from the carrier's cart. Whatever may be the result of further knowledge as to the need for following the recommendations of the Royal Commission of 1898, that the flesh of swine should be dealt with on lines different from those thought sufficient for the flesh of other animals, there is no doubt that if the meat of pigs having tubercular glands is to be allowed to be sold for human food it is especially necessary that the operations of the butcher in the excision of diseased parts should be subject to the supervision of responsible authorities, who should ensure that the removal of tuberculous tissue is complete. There is now no administration which provides this assurance. The absence of any adequate administration for the purpose of inspection of meat gives opportunity to persons in all parts of the country to send to London meat which would not be allowed to be consumed in any Continental city where meat is brought under inspection. With a view to checking, as far as is practicable under existing conditions, the introduction of diseased meat from the country, the Stepney Borough Council in January, 1905, addressed a letter to other London Sanitary Authorities inviting them to join in representation to the Local Government Board on the need for amendment of the law so as to enable sanitary authorities to proceed against the original vendor of unsound meat to which the attention of the sanitary authority is directed by the local butcher receiving it. The circumstances which are held to make this amendment necessary are stated as follows— " The medical officer of health has pointed out to them that at the present time if a person in the country sells to a butcher in town carcases of diseased animals, and the butcher, acting in a straightforward manner, and before he tries to sell the meat, requests the sanitary authority to examine it, and such meat is condemned, the sanitary authority cannot successfully institute legal proceedings against the original vendor of the meat, because at the time of its surrender the meat is not ' exposed for sale or deposited in any place for the purpose of sale or of preparation for sale.' Proceedings cannot be successfully taken if the meat be seized in transit, as it is not then exposed or deposited for sale as human food, and therefore the original vendor cannot be proceeded against. Again, after delivery to the consignee has actually taken place, it is sometimes ascertained that the latter is a cat's meat purveyor who is used by the original vendor as a medium for the distribution of the meat for human consumption. Here again, it is impossible to obtain a conviction against the original vendor." The Sale of Ice Cream. In several of the annual reports it is stated that premises in which ice cream is manufactured or sold are in better condition than formerly, and Dr. Harris reports that the vendors of this commodity in Islington, who are mostly Italians, are year by year becoming amenable to rule and more anxious to prepare their goods under satisfactory conditions. In a number of instances, however, the intervention of the sanitary authority was needed to enforce the provisions of the London County Council (General Powers) Act of 1902, the condition needing remedy being mostly dirty premises or the manufacture of ice cream in living or sleeping rooms. No prevalence of disease was attributed during the year to the consumption of ice cream, although cases of infectious disease occurred on the premises of some of the vendors, thus in one instance (in Battersea) a person suffering from scarlet fever was found in the same room as that in which the ice cream was being manufactured. The large majority of the annual reports supply information from which it has been possible to prepare the following table showing the proceedings of sanitary authorities in 1905 in connection with this subject. 79 Ice cream premises. Sanitary area. Number of places. No. of inspections 1905. No. of notices 1905. No. of prosecutions under Act, 1905. On register at end of 1904. Added in 1905. Removed in 1905. On register at end of 1905. Paddington 129 8 - 137 58 - - Kensington 167 — 3 164 334 45 — Hammersmith 172 4 1 175 516 24 - Fulham 117 7 12 112 230 13 - Chelsea 55 - 7 48 53 4 - Westminster, City of 108 3 — Hampstead 69 7 3 73 140 — — Islington 234 — 4 230 235 25 — Stoke Newington 35 34 Hackney 107 23 Holborn 43 38 14 67 245 — 2 Finsbury 100 4 1 103 192 36 1 London, City of 237 249 — Shoreditch 69 10 7 72 172 21 — Bethnal Green 65 23 16 72 176 29 — Stepney 44 3 2 45 63 8 — Poplar 134 77 188 26 — Southwark 83 101 42 — Bermondsey 69 1 1 69 295 36 — Battersea 116 — 6 110 300 15 2 Wandsworth 192 40 9 223 339 40 — Camberwell 221 23 22 222 495 6 4 Deptford 94 12 7 99 189 14 4 Greenwich 116 20 29 107 143 20 — Woolwich 83 5 1 87 212 8 — Disinfection. Dr. T. Orme Dudfield reports that the new disinfecting station for Kensington, situated at Wood-lane, Shepherds-bush, was approaching completion; this station has since been opened. Dr. Reginald Dudfield states that legal difficulties arising from the conditions of purchase led to the abandonment of the intention to provide a disinfecting station for Paddington on land in Kensal-road, in rear of the public baths, and that a communication had been addressed to the Kensington Borough Council enquiring whether the new station in Wood-lane could be used for the purposes of Paddington. The disinfecting station belonging to the City Corporation had been destroyed by fire in 1904 and Dr. Collingridge reports that the rebuilding was nearly completed. In Bermondsey a modern machine was removed from Bull Head Dock to the Neckinger depot and reinstated on the piece of land between the baths and wash-houses and the dust destructor. A new disinfecting station for Wandsworth has been provided in that district. It has been decided to provide a small laundry in connection with the Battersea disinfecting station, and the Local Government Board has been asked to sanction a loan for this purpose; Dr. McCleary states that the cost of disinfection in Battersea in 1905 was £1,091 0s. 3d., whereas the cost, at the charges formerly made by a contractor, would have been £2,267 12s. 6d., showing a saving of £1,176 12s. 6d. through the borough council doing the disinfection itself, and the cost of the provision of the station has already almost been covered. Dr. Jackson also states that the cost of disinfection in Fulham at the Borough Council's station was in 1905 £1,052, including £105 for interest and £216 for repayment of principal. The average cost during the three preceding years when the work was done by a contractor was £1,257 per annum, and at that time there was no disinfection after measles or tuberculosis as in 1905. The use of formic aldehyde or formaline for the purposes of disinfection is increasing and Dr. Harris writes that this has effected a saving of some £500 in a year in Islington. Dr. Alexander reports that the Borough Council of Poplar had under consideration the proposal to manufacture " electrolysed salt water" for disinfection in substitution for disinfectants used in the district. Shelters. The use of shelters for the accommodation of persons during the disinfection of their houses has been much less during the last year owing, on the one hand, to the smaller prevalence of infectious disease in London and especially of small-pox, and on the other, to the adoption of methods of disinfection which have not involved the closing of the rooms during the night time. The last has been the greater factor, leading in some districts to disuse of the shelter. Thus it is stated in the annual reports that in 1905 the shelters were not used in Paddington, Hampstead, Lambeth, Camberwell, Deptford, Greenwich, or Woolwich. In other districts the shelters accom- 80 modated the following number of persons Fulham 3, Chelsea 85, Westminster 6, St. Marylebone 7, St. Pancras 39, Islington 11, Hackney 93, Holborn 3, Finsbury 61, City of London 8, Shoreditch 20, Bethnal-green 21, Stepney 252, Southwark 1,047, Bermondsey 90, Battersea 33, Wandsworth 9 and Lewisham 1. Mortuaries. The sufficiency of the accommodation provided in mortuaries has been under the consideration of some of the sanitary authorities during 1905. A "Chapel of Rest for the Dead" has been erected in Avondale-park, Kensington, at a cost of £1,300, and Dr. T. Orme Dudfield states that 56 bodies were received into it during the year. The Public Health Committee of the Westminster City Council recommended that some of the existing mortuaries should be improved, with a view to giving encouragement to their use. Dr. Collingridge reports that the work of restoration or rebuilding of the mortuary of the City, which had been destroyed by fire, was almost completed. In Poplar the provision of suitable accommodation was under consideration and the County Council agreed with the Borough Council of Poplar in respect of the erection of a mortuary and coroner's court. The Lambeth Borough Council decided to improve and extend the mortuary in High-street, Lambeth and the Borough Council of Wandsworth signed the contract for the purchase of land and issued advertisements for designs for a mortuarv and coroner's court. The extent to which mortuaries were used during 1905 is shown in the following table, in which the number of bodies accommodated is stated— Sanitary Area. Total number of bodies received. Number of infectious bodies received. Sanitary Area. Total number of bodies received. Number of infectious bodies received. Paddington 265 1 Shoreditch 417 3 Kensington 394 11 Bethnal Green 364 7 Hammersmith 201 — Stepney 679 9 Fulham 164 1 Poplar 462 2 Chelsea 118 1 Southwark 555 14 Westminster, City of 370 — Bermondsey 225 4 St. Marylebone 342 5 Lambeth 391 2 Hampstead 97 3 Battersea 253 — St. Pancras 439 6 Wandsworth 188 1 Islington 625 — Camberwell 324 3 Stoke Newington 52 — Deptford 85 — Hackney 433 2 Greenwich 147 2 Holborn 153 3 Lewisham 123 5 Finsbury 335 13 Woolwich 170 1 London, City of 183 — The Cleansing of Persons Act. The Cleansing of Persons Act was passed in 1897. The Act empowers every sanitary authority "when in their discretion they see fit, to permit any person who shall apply to the said authority, on the ground that he is infested with vermin, to have the use, free of charge, of the apparatus (if any) which the authority possess for the cleansing of the person and his clothing from vermin." In the beginning of 1905 Dr, Wauktyn inquired on behalf of the County Council concerning the provisions which London sanitary authorities had made for the cleansing of persons, and the Public Health Committee reported to the Council in March as follows :— 1.—We have had under consideration a report by the medical officer presenting a report by Dr. Wanklyn oa the administration in London of the Cleansing of Persons Act, 1897, The provisions of the Act are as follows— "(1) Any local authority shall have the power, when in their discretion they shall see fit, to permit any person who shall apply to the said authority, on the ground that he is infested with vermin, to have the use, free of charge, of the apparatus (if any) which the authority possess for cleansing the person and his clothing from vermin. The use of such apparatus shall not be considered to be parochial relief or charitable allowance to the person using the same, or to the parent of such person, and no such person or parent shall by reason thereof be deprived of any right or privilege or be subject to any disqualification or disability. "Local authorities may expend any reasonable sum on buildings, appliances and attendants that may be required for the carrying out of this Act, and any expenses for these purposes may be defrayed out of any rate or fund applicable by the authority for general sanitary purposes, or for the relief of the poor. "(2) In this Act, 'local authority' means in England the council of any county borough, the district council of any district, any board of guardians, and in the county of London any sanitary authority as defined in the Public Health (London) Act, 1891." The application of the Act is permissive, and, except in the Metropolitan Boroughs of Hackney, St. Marylebone and St. Pancras the action, if any, taken by Metropolitan Borough Councils has only been such as would enable the shelter provided for the reception of persons during the disinfection of their houses to be utilised for the purpose of the cleansing of persons, or else an arrangement has been made with the Board of Guardians for persons to be cleansed in the baths of the casual wards, their clothes being disinfected in the ovens used for the disinfection of the clothes of the inmates of these wards: In each of the three metropolitan boroughs mentioned above, a separate station has been provided for the cleansing of persons and, as regards disinfection, the arrangement in the Metropolitan boroughs of St. Pancras and Hackney, is that the apparatus used for the disinfection of clothes is utilised for the purposes of the Act, whilst in St. Marylebone the disinfecting chamber for the cleansing of persons is distinct from that used for other purposes. By direction of the St. Marylebone and St. Pancras Borough Councils, handbills or notices, to the effect that 81 persons infested with vermin or parasites will be attended to with consideration on applying at the cleansing station, have been placed in common lodging-houses, Salvation Army shelters, police stations, public libraries, dispensaries, out-patient departments of hospitals, and hospitals for the treatment of skin diseases, and copies of the notices have also been supplied to school teachers. It appears from Dr. Wanklyn's report that, when special accommodation is provided and the arrangements made under the Act become known, a considerable number of persons are willing to avail themselves of the facilities afforded for cleansing their clothing and persons. For instance, in 1898 the St. Marylebone Metropolitan Borough Council began to administer the Act, and between that time and November, 1904, the number of persons cleansed was 32,500, of whom 1,790 were females. Again, in the Metropolitan Borough of St. Pancras, the Act was, prior to 1904, administered by the guardians, and few applications were made for the use of the accommodation, but in May, 1904, the special provision made by the Borough Council came into use, and during the six months ended October, 1904, about 1,400 persons were cleansed, of whom 600 were women and children. In the Metropolitan Borough of Hackney a special and complete cleansing station has been in use since March, 1902, and about 50 persons annually make use of the station. The Metropolitan Borough Councils of Camberwell, Chelsea, Fulham, Greenwich, Hampstead, Lewisham, Poplar, Shoreditch, Southwark, Stepney and Wandsworth make use of the ordinary reception house and the disinfection station, and since the Act came into operation only about 10 persons have made use of the accommodation offered in Chelsea, and about 20 have utilised the accommodation in Southwark, whilst no applications have been received in the nine remaining boroughs. In Islington about 20 persons have been cleansed under the provisions of the Act. The Corporation of the City of London and the Metropolitan Borough Councils of Battersea, Bermondsey, Bethnal-green, Deptford, Finsbury, Hammersmith, Lambeth, Kensington. Paddington and Woolwich have made arrangements with their respective boards of guardians for the cleansing of applicants at the various casual wards, with the result that there have been 20 persons cleansed in the City of London under the provisions of the Act, about five in Kensington, about two in Finsbury, and none in the remaining eight boroughs. In the City of Westminster also, applicants are cleansed at the casual wards or at the disinfecting station, and in the Metropolitan Borough of Holborn, the baths of the casual wards are used for cleansing the persons of applicants, their clothes being disinfected in the disinfector of the metropolitan borough council. The medical officer points out that the locality of the cleansing station probably has an important effect upon the extent to which the accommodation provided under the Act is utilised. Having regard to the fact that the provisions of the Act are effectively made known in two Metropolitan Boroughs only, viz., St. Pancras and St. Marylebone, we think it advisable that the attention of the remaining Metropolitan Borough"Councils should be directed to the report by the medical officer, and that they should be urged to avail themselves more fully of the provisions of the Act and to give full publicity to the arrangements made thereunder. We recommend— That a copy of the report by the medical officer presenting a report by Dr. Wanklyn on the administration in London of the Cleansing of Persons Act, 1897. be sent to each of the metropolitan borough councils, and the attention of those authorities which have not made effective arrangements under the Act be called to the desirableness of their availing themselves more fully of its provisions, and of giving full publicity to the arrangements made thereunder; that a copy of the report be sent to the Departmental Committee on Vagrancy for their information; also that the report be published and placed on sale. This letter was accordingly sent. In some of the annual reports for the year 1905 the subject of provision for persons thus needing cleansing is discussed and information as to that which has been made and the extent of its use is given. The following is extracted from these reports— Kensington.—"Nominal effect was given to the Act soon after it passed, by an arrangement made by the late vestry with the guardians whereby cleansing and disinfecting apparatus at the 'AbieBodied Workhouse,' Mary-place, in the Potteries, was made available on payment of a small fee—an unsatisfactory arrangement which is still in force. Little use has been made of the apparatus owing probably to ignorance of the arrangement on the part of the poor intended to be benefited; and possibly, to some extent, to the locality and ownership of the apparatus." Westminster.—"Under the provisions of this Act seven persons received a free bath and had their verminous clothing disinfected. Since the closing of the Denzell-street premises there has been no accommodation for this work, but provision is to be made at the new central station, and as it will be in the vicinity of most of the common lodging-houses, it is likely that greater use will be made of it. The Guardians have dealt with frequenters of their casual wards at their own establishments." St. Marylebone.—"Special provision has been made in this district and the baths were used in 1905 as follows :—Males from Salvation Army shelter 4,981, males from lodging-houses in the borough 3,000, females from private addresses 20, females working for Church Army 80, females with no addresses 1,331—a total of 9,412. Special baths for school children—boys 107, girls 353, total 460." St. Pancras.—"Special provision has been made in this district, the number of persons cleansed was 2,126 males, 1,174 females, 101 children, total 3,401 persons, and 334 batches of articles in an unwholesome condition were purified." Islington.—"The bath in the shelter house was used by two persons. After consideration of a report by the medical officer of health, the borough council resolved to extend the shelter premises so as to provide the necessary accommodation, and applied to the Local Government for permission to borrow the money, but the Act does not give power for this purpose. The matter was therefore in abeyance, but Dr. Harris has recommended the Borough Council to make the necessary provision out of current expenditure." Stoke Newington.—"Opportunity was given by agreement with the Hackney Borough Council for cleansing at the baths and disinfecting station in the lower part of Millfields-road, Lower Clapton, an unsuitable position for Stoke Newington; only one person was cleansed." Hackney.—"Baths are provided at the disinfecting station in Millfields-road, and 241 persons were cleansed." Holborn.—"Opportunity for cleansing is given at the baths at the casual wards, and 600 men and 13 women were disinfected. On account of alterations it was necessary during the latter part 11476 L 82 of the year to limit the number of persons being cleansed to six persons of each sex per day, resident either in Holborn or Finsbury, the cleansing was then effected at the casual wards, Little Gray's Innlane." Finsbury.—" Arrangements have been made with the Guardians of the Holborn Union for persons to be cleansed at the casual wards in Gray's Inn-lane, where the accommodation consists of six baths on the men's side and three on the women's. These arrangements are to come into force early in 1906." Bethnal-green.—"In March a circular letter was received from the London County Council calling attention to this Act and suggesting that more use might be made of its provisions. The letter was referred to the Public Health Committee, but as no application under the Act has ever been received the Committee decided to take no action at present. It would be quite easy to allocate one of the bath rooms at the new disinfecting station to the purposes of the Act, should the necessity arise." Poplar.—"The Committee considered a circular from the London County Council on the administration of the Cleansing of Persons Act and recommended the Council ' that public notices be issued directing attention to the facilities provided at the disinfecting station and shelters for cleansing persons and their clothes from vermin.'. . . Since the posting of the bills 427 persons applied for baths and for their clothes to be disinfected." Southwark.—" The medical officer of health called attention to the objection to using the reception house for verminous persons, and advised the sanitary authority to take a house until a proper building can be put up. The Council decided to fit up a bathroom adjoining the reception house to meet this objection." Bermondsey.—The medical officer of health reported on this Act at the end of March, 1905, and the Borough Council adopted a scheme for providing separate accommodation of two bathrooms adjoining the public baths at the Neckinger depot." Battersea.—" On receipt of the letter of the London County Council, the medical officer of health presented a report suggesting that the tenement of the shelter opening into Sheepcote-lane could be used for the purpose. The Health Committee deferred any further action until the early part of 1906, so that the necessary expenses involved in carrying out the Act might be included in the annual estimates." Wandsworth.—"The borough council agreed to the erection of two bath houses at the disinfecting station, Tooting, for the purpose of carrying out more fully the provisions of the Act and also for dealing with children reported, by the officials of the London County Council, to be in a verminous condition, and in attendance at school." Camberwell.—" It was decided to let the public know there were facilities provided by this authority." Woolwich.—" A bathing station for the purposes of this Act was approaching completion, it adjoins the Plumstead disinfection station, White Hart-lane. Only one bath is to be provided in the first place, but the station has been arranged so that it can be duplicated and a bath allotted to each sex as soon as need arises." In many districts steps were taken to give wider publicity to the provision which had been made for the cleansing of persons and to assist in bringing knowledge of the existence of any provision which had been made to the knowledge of persons likely to make use of it. The County Council communicated with the keepers of common lodging houses and obtained their consent to the exhibition in the kitchens of these houses of bills giving the necessary information. With the object of obtaining more recent information on the subject, I addressed a circular letter on 17th November, 1906, to all the medical officers of health in the administrative county, asking the following questions:— (1) The precise nature of the provision made for the cleansing of verminous persons and their clothing. (2) Whether such provision is separate from or in conjunction with the ordinary disinfection station. (3) Whether any special provision is made for the cleansing of children. (4) Whether the work is carried out by the Borough Council or by arrangement with the Guardians. (5) The extent to which the provision has been made use of in recent years, distinguishing the sex of the persons who have taken advantage of the facilities afforded. From the replies received it would appear that in most cases some provision has been made to give effect to the Act, the only exceptions being Deptford, Fulham, Hammersmith, Hampstead, Lambeth and Lewisham, though in Deptford the matter is now under consideration. In Greenwich, arrangements had been made to carry out this work at the disinfecting station, but I am informed by the medical officer of health that the whole scheme is now in abeyance. In four boroughs, Finsbury, Holborn, Kensington and Paddington, the work is done by the Guardians at the casual ward. Generally, however, baths are provided at the several disinfection stations under the control of the Borough Councils. In very few instances has special provision been made for the cleansing of children, though some attention has been drawn to the matter as the result of a communication from the Council's Medical Officer (Education). The following table shows the substance of the replies to my letter of 17th November 1906:— 83 Cleansing of Persons Act, 1897. Borough. Provision made. If at disinfection station. If any special provision for children. If by Borough Council. Extent to which provision has been utilised. Battersea Waiting, cleansing and bath rooms Separate provision Children received on days set apart for women Yes July to Nov., 1906— 95 males. 4 females. 2 children. Bermondsey One bath for each sex Yes It is proposed that children shall use bath for females Yes No applications. Bethnal Green Special shelter provided. Two baths Yes No Yes A few boys from school and a few men from Salvation Army shelter. Camberwell One bath Yes Cards printed for use of Council's nurses Yes A few men from common lodging houses. Chelsea Bath room Yes Under consideration Yes No applications. Deptford Under consideration — — Guardians — Finsbury Bath. Services of barber Casual ward No Guardians (Holborn Union) In 5 months, 25 males disinfected, but 56 cleansing orders were given. Fulham As in 1904 Yes Small scheme under consideration Yes — Greenwich At present in abeyance and under consideration. — — — — Hackney One bath for each sex Yes No Yes 10 months in 1906— 202 males. 16 females. 76 children. Hammersmith None — — — — Hampstead None — — — — Holborn Baths at Goldsmithstreet and Little Gray's Inn-lane Casual wards No Guardians 1902—22 persons. 1903— 16 „ 1904— 9 ,, 1905—600 males. 13 females. Islington Bath at shelter house. Bed if necessary Yes No Yes 1903—2 males. 1904—3 ,, 1905—2 „ 1906 (6 months)— 9 males, 3 females, all children. Kensington Apparatus at Casual ward Casual ward No Guardians Since April, 1903— 6 males. 3 females. Lambeth No provision — — — — Lewisham None - — - — Paddington As in 1904, but scheme under consideration Casual ward No Guardians Poplar 4 baths Yes No, but existing accommodation ample Yes Since May, 1905— 1,166 male adults. St. Marylebone 4 baths for men, 2 for women, 2 for boys and 3 for girls. Separate w.c. accommodation and disinfecting apparatus Separate provision Yes Yes M ales. 1899—4,341 Females. To 31st Oct. 1900—3,352 28 1901—3,967 135 1902—4,250 278 1903—5,515 655 1904—7,089 1,376 1905—7,981 1,431 Ch. — 107 358 1906—5,905 1,699 Ch. —1,486 2,568 11476 L 2 84 Borough. Provision made. If at disinfection station. If any special provision for children. If by Borough Council. Extent to which provision has been utilised. St. Pancras 2 baths and waiting room for each sex Adjoining disinfection station Yes Yes Males. Females. 1904 952 514 1905 2,126 1,174 l906 1,019 22 Sep. Children. 1904 330 under 10 1905 101 ,, 1906 708 under 15 Sep. Shoreditch Baths at shelter. New scheme under consideration Yes No Yes By males on two or three occasions. Southwark Special premises for bathing and cleansing Separate premises Children are received and, if necessary, sleep in Reception House Yes 1905— 33 males, 43 females. Stepney Free baths and disinfection Yes No, but matter is under consideration Yes 1906— 27 males, 2 females (girls). Stoke Newington As at Hackney Yes No Hackney Borough Council One male in last two years. Wandsworth Two baths Yes No Yes 1906 (7 months)— 7 males, and including 6 nurses for puerperal fever cases, 7 females. Westminster — — — — — Woolwich One bath Yes No Yes Only just opened. It will thus be seen that some progress is being made in providing the necessary accommodation for the cleansing of persons who are in a verminous condition. It is much to be hoped that there will no longer be delay in the exercise of the powers conferred by the Act of 1897 and that every London district will shortly be fully equipped to deal with verminous persons among its population. In the schools the freedom of children from this condition is being insisted upon, and 32 nurses are now being employed by the County Council in the examination of children for this purpose. Moreover, in St. Marylebone a system has been adopted by which the administration of County Council and Borough Council, working in conjunction, are doing much to secure the cleansing of children, and referring to the condition of children attending the County Council Schools in London generally, Dr. Kerr is able to point to a distinct improvement. (See Appendix II.) The provision of baths in continental schools for the use of children attending the schools has been referred to in my annual report for the year 1897, and subsequently. This subject is also discussed by Dr. Kerr in appendix II. London Water Supply. At the end of 1904 the subsidence reservoirs which had been constructed at Staines came into use, and in 1905 the report of the Water Examiner appointed under the Metropolitan Water Act shows that the capacity of the reservoirs for the several districts of the Metropolitan Water Board and of the filters was as follows:— Water area. Capacity of subsidence reservoirs. Number of days' supply. Filter area. Area per million gallons of average daily supply. Monthly rate of filtration. Monthly average. Maximum average. gallons. acres. acres. gallons. gallons. Chelsea 190,000,000 15.5 8 .653 1.649 2.006 Eastern 2,405, OOu, 000 55.5 34 .801 1.072 1.30 Grand Junction 58.500,000 3.4 24¼ 1.408 .870 1.077 Lambeth 468,500,000 14.9 14¾ .48 2.04 2.19 New River 168,100,000 4.8 165/6 .407 2.41 2.68 Southwark and Vauxhall 390,000,000 12.7 23 .746 1.46 2.19 West Middlesex 397,500,000 16.4 221/3 .93 1.202 1.504 Staines reservoirs 3,300,000,000 16.6 — — - - 85 The Water Examiner also reports that the linking up of the different systems of supply has made progress and that in 1905 a connection has been made between the 5 in. main in the Lambeth district and the 6 in. Kent main at Brockley. Commenting upon the intimate connection which exists between the volumes of water passing down the river and the quality of the water distributed from the several district works, Dr. Thorpe points out that during 1905 the Grand Junction supply was not nearly so much affected at flood times as it used to be and he attributes this marked improvement in the quality of the water to the introduction of the Staines storage. The prolonged storage of the Thames water, he writes, causes it to diminish in hardness, the reduction compared with the raw water, being about 20 per cent.; and the nitrates originally present almost disappear. Dr. Thorpe finds, moreover, that the residual organic impurity in the impounded water is very much less easily oxidised by the acid permanganate in the " oxygen consumed " process than is the soluble organic matter in the raw Thames water and the nitrogenous organic matter after storage is more easily broken down in the " albuminoid ammonia " tests. Dr. Thorpe states that in October an excessive proportion of chlorides was found in a sample of water taken in the neighbourhood of the Plumstead Well and this, as was shown by a report of Dr. Houston, was accompanied by a falling off in bacterial purity the result, Dr. Thorpe states, of excessive pumping. An important safeguard to the consumers of the water of the Metropolitan Water Board has been provided by the establishment of a laboratory under Dr. A. C. Houston, Director of Water Examinations whose first report appears in the Water Examiners report for the month of November, 1905. Dr. Houston writes :— "With an average daily supply of over 213 million gallons to an estimated population of over 6,700,000, with eight water works, and a very large number of filter beds, and with numerous deep wells and three sources of raw water supply, it becomes a task of some complexity to so organise the work of water examinations as to be effective at a reasonable cost. No pains have been spared to make the work of water examinations as thorough as possible. Samples are constantly collected from separate filter wells (wherever this is practicable) as well as from general filter wells. All the works are visited on five occasions during each week, and samples collected from the separate filter wells in rotation. It is proposed, as opportunity offers, to supplement the routine sample collection work with special collection work, so as to control any weak spots in the routine method of sampling and, generally, to bring the examination of the London waters, as a whole, to as perfect a pitch as the magnitudo of the task will permit." Water Supply to Tenement Houses. During 1904, the Public Health Committee had under consideration the subject of the adaptation, to use as tenement houses, of houses originally constructed for one family, and in a report by Dr. C. W. F. Young, which was before the Committee, the inadequacy of the provision of water supply in the basement and ground floors to the inhabitants of the upper storeys of such houses was pointed out. The questions of the sufficiency of sections 2 and 48 of the Public Health (London) Act were considered, and later the Woolwich Borough Council instituted proceedings concerning a house thus inadequately supplied. These proceedings were successful and the Public Health Committee thus reported in January, 1905, to the Council upon the subject;— 1.—On 10th May, 1904 (p. 770,; we brought to the notice of the Council the report by the medical office) of health as to the result of an enquiry by Dr. Young respecting the sanitary accommodation in houses originally built for one family, but now let in separate tenements to several families. One of the important facts disclosed in that report was the inadequacy of the arrangements for the supply of water to the tenants of the upper floors in such houses ; there being in many, if not most, of such houses but a single tap, and that in the basement or on the ground floor. The supply of water to inhabited houses is regulated by the provision of sections 2 and 48 of the Public Health (London) Act, 1891. Section 2 provides that, where there is a constant supply of water, absence from premises of water fittings shall be a nuisance liable to be dealt with summarily under the Act, and section 48 1 provides that "an occupied house without a proper and sufficient supply of water shall be a nuisance liable to be dealt with summarily under this Act, and if it is a dwelling-house, shall be deemed unfit for human habitation." . We were doubtful whether these provisions were sufficient to enable sanitary authorities to require a supply of water to the tenants of each floor in tenement houses, and on 14th June, 1904 (pp. 971-2), the Council decided to promote legislation on the subject, but its resolution was subsequently rescinded on 6th December, 1904 (pp. 3012-3), as the Parliamentary Committee reported that they were advised that it was by no means clear that the present law was insufficient to meet the case, and as we were endeavouring to get the matter tested at the instance of one of the metropolitan borough councils. We are now glad to report that on 16th December, 1904, as the result of proceedings by the Woohvich Metropolitan Borough Council respecting the water supply of a tenement house, No. 1, High-street, Woolwich, the magistrate decided that the supply of water from a tap in the yard was not a proper and sufficient supply within the meaning of section 48 of the Public Health (London) Act, 1891, and he made an order to abate the nuisance, and ordered the defendant to pay £5 5s. costs. Dr. Hamer, the Council's assistant medical officer of health, gave evidence supporting that given by the medical officer of the borough council, and the following extracts from the proof of Dr. Hamer's evidence show the conditions which he found on visiting the premises in question on 13th December, 1904— "The house is a three-story house; a single man occupies the ground floor rooms. A woman and her child occupy the first floor front room; the first floor back is separately let. In the top floor front there are a man and wife and two children (one of the children is, however, not always at home), and in the top floor back there is a single man. The only appliance for supplying water for domestic use to the occupiers of these five sets of tenements is that situated in the back yard of the house. All water for cooking, drinking, personal ablution, washing clothes, and scrubbing floors has to be fetched from the yard; there is no washhouse, and the copper in the yard is in a dilapidated conditon. "The tenants of the top floor store water in a pail, which is kept on the landing at the top of the staircase; this staircase is very dark and the pail is uncovered, and water stored in this manner is liable to become polluted. "The conditions as regards cleanliness of the rooms and staircase are unsatisfactory, and this is not surprising, having in view the need of carrying water from the yard all the way upstairs." 86 The case is an important one and we think that the attention of all the metropolitan borough councils should be called to it. We therefore recommend— That a letter be addressed to the metropolitan borough councils calling their attention to the decision of 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 is not a proper and sufficient supply within the meaning of section 48 of the Public Health (London) Act, 1891, and expressing the Council's hope that they will take all possible steps to secure the provision of a proper and sufficient supply of water for the tenants of every floor of a tenement house. Proceedings in respect of similar inadequacy of supply in two houses in Holborn were also instituted, and the magistrate hearing the case made an Order in respect of both. Subsequently the borough council of Paddington instituted like proceedings, but with a different result. The following details of this case are thus given in Dr. Reginald Dudfield's annual report:— In February, 1905, a letter was addressed by the County Council to all the Metropolitan Boroughs, directing attention to case heard at Woolwich in December, 1904, in which the magistrate decided that a tap in the yard of a house of three floors, occupied by five families, was not a proper and sufficient supply of water as required by section 48 of the Public Health (London) Act, 1891. It was suggested in the letter that efforts should be made "to secure the provision of a proper and sufficient supply of water for tenants of every floor of a tenement house." Instructions were given to the medical officer of health to cause enquiries to be made in the borough as to the supply provided in the Clarendon-street area, and a report was submitted in June showing the provision at 30 houses, 10 each in Circencester, Clarendon and Woodchester-streets. The Committee being of opinion that the supply was not a sufficient and proper one, directed a circular letter to be sent to the owners of the houses requesting them to provide a better supply. Certain did so, but others took no action. Subsequently notices under section 4 of the Act were issued, followed later by proceedings at the police-court against the owners of six houses. The owner of one house then gave the additional supply, but the others contested the cases. It was shown in evidence that the houses comprised four floors, were occupied by from five to eight families, and the only supply was from a tap in the basement—in one case under basement. Mr. Plowden decided that section 48 did not apply; it was a fallacy to suppose that the question of whether a supply of water was sufficient turned on the number of taps from which it could be obtained. It depended, in fact, on the source from which the water came. Here there was plenty of water, but there was inconvenience in getting it." He dismissed the summonses. The Council's solicitor advised that the case was -prima facie one of fact, and that, having regard to the wording of the section, the opinion expressed by the magistrate was right. No appeal was therefore taken. The County Council has since resolved to apply to Parliament for powers, requiring a more adequate supply and other conditions in tenement houses. Report of the Inter-Departmental Committee on Physical Deterioration. The report of the Inter-Departmental Committee on Physical Deterioration was referred to in the last annual report. In 1905 the Council referred to several Committees for report various questions which were discussed in the report of the Inter-Departmental Committee and upon some of these questions the medical officer was instructed by the Public Health Committee to report, and accordingly a statement which will be found in the appendix (see appendix IV.), was prepared. 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 fighting, and so far as not required for that purpose those incurred in respect of streets, and where the sanitary district comprises two or more parishes the sum paid must be apportioned among such parishes in proportion to their population, and the amount apportioned to each parish credited to each parish in the reduction of the rate required from such parish towards the above-mentioned expenses. The sanitary authority is required to render annually to the Local Government Board a return showing the amount of the sum to be paid and the total expenses incurred in respect of the three subjects mentioned. If the Local Government Board, under section 101 of the Public Health (London) Act, are satisfied that the sanitary authority have been guilty of such default as in such section mentioned, and have made an order limiting a time for the performance of the duty of the authority, the London County Council shall, if directed by the Local Government Board, withhold the whole or any part of the payment of the sum due to such authority. The Act provides that for the purposes of the distribution of the fund an estimate of population on the 6th April in each year will be made by the Registrar-General upon returns which the Local Government Board will receive from the authority making the poor rate in each parish showing the total number of houses entered in the rate book of the parish. 87 The following table shows the estimated population on the 6th April, 100"), 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, 1906— Sanitary area. Estimated population, 6th April, 1905. Equalisation charge, being excess of contribution over grant. Net grant, being excess of grant over contribution. £ s. d. £. s. d. Paddington 144,315 4,671 19 2 — Kensington 181,064 16,771 15 4 — Hammersmith 115,901 — 7,403 13 6 Fulham 152,635 — 13,232 8 3 Chelsea 71,669 4,733 9 5 — Westminster, City of 173,060 100,519 - 11 — St. Marylebone 128,185 15,138 10 7 — Hampstead 85,718 6,547 - 8 — St. Pancras 232,196 — 6,977 10 5 Islington 336,898 — 26,950 11 1 Stoke Newington 51,823 — 2,904 14 10 Hackney 221,509 - 19,903 16 9 Holborn 55,912 11,693 15 5 — Finsbury 102,441 1,638 4 5 — London, City of 25,390 120,977 14 2 — Shoreditch 116,445 — 6,499 7 3 Bethnal-green 128,227 — 15,467 14 4 Stepney 292,418 — 29,596 9 9 Poplar 169,482 — 17,547 17 5 Southwark 197,393 — 12,559 3 - Bermondsey 129,295 — 5,858 1 8 Lambeth 306,425 — 21,024 9 3 Battersea 171,586 — 12,685 12 6 Wandsworth 285,433 — 19,105 19 6 Camberwell 264,764 — 26,618 11 5 Deptford 111,815 — 9,756 16 4 Greenwich 100,537 — 7,615 7 6 Lewisham 153,216 — 9,720 16 3 Woolwich 135,018 — 12,215 18 2 Inner Temple 127 596 7 2 — Middle Temple 107 357 1 11 - 88 as to cleanliness, the possession of the requisite apparatus and antiseptics, the keeping of case books and registers and the giving the required notices to the Local Supervising Authority. Mies V. E. M. Bennett, M.B., B.S., was appointed as the inspector under the Act, and in addition to her routine inspections and special enquiries, she gave assistance to midwives by explaining the use of appliances, by interpreting the rules and by affording advice on difficulties arising in the course of a midwife's duties. During the year 1,057 routine visits of inspection were made. In 572 cases the midwives were found to be satisfactory, in 330 unsatisfactory and in 155 cases the midwife was out or away from home. Considering that many of the 330 unsatisfactory reports were made after the first visit to midwives and that these women had hitherto been under no supervision, this number does not appear to be excessive. There seems to be good ground for hoping that as the number of those who are unsatisfactory through ignorance and want of training will tend to diminish from year to year, a better standard of efficiency will be attained. In 19 cases there were more or less serious breaches of the rules but these were dealt with by severe caution, and in only one instance was a prima facie case of misconduct established and reported to the Central Midwives Board. The Board, after considering the case, decided that the evidence was insufficient to warrant the removal of this woman's name from the Roll of Midwives. As the result of inspection, it was shown that 11 midwives were illiterate, but notes of their cases were kept either by themselves or were written for them by relatives or friends. Of the practising midwives 28 were foreigners and their knowledge of English was more or less imperfect. These midwives practise chiefly in the East End of London among the Jewish population; two of them however are Italians and practise in the Italian quarter in Saffron-hill, but follow Italian patients to other parts of London. Prior to being brought under supervision many midwives were unable to use the clinical thermometer, an instrument of which they had no knowledge before the Act came into operation. All have not yet learnt to do so, but such midwives use a thermometer which has upon it one red line indicating the normal temperature and another marking a temperature of 100.4 deg. The midwife knows that when the mercury reaches the higher mark the patient is feverish and that medical aid should be called in if the temperature is maintained. The fees charged by midwives vary considerably. In some cases a fee of 5s. is charged and one instance is known in which a midwife received as much as 25s. The payment made by Charities which employ midwives is usually 5s. per case, but a fee of 7s. Gd. per case in multiparous and 10s. in primiparous cases would be about the average. In many instances the fees are paid in advance and by weekly instalments. Puerperal fever.—All cases of puerperal fever, where it is said or where there is reason to believe that a midwife or an unqualified person was in attendance, were investigated, and full details of the illness were obtained. For this purpose early information concerning notified cases of puerperal fever is received from the Metropolitan Asylums Board, and weekly lists of all deaths which are or may be due to this cause, are received by arrangement from the office of the Registrar-General. During the year 148 such cases were investigated ; in 98 a certified midwife was in attendance and it was ascertained that 34 of these 98 cases proved fatal. It sometimes happens that symptoms of fever are not developed until after the midwife has ceased attending on the tenth day after labour, and that the midwife is continuing her work for some days before she hears that one of her previous cases is septic; second cases occurring in the practice of the same midwife however are comparatively rare. Disinfection is carried out by the Local Sanitary Authority. Of the 98 cases of puerperal fever that occurred in the practices of midwives information in 93 instances as to the date of the rise of temperature was ascertained, and the following table shows the day of the puerperium on which the rise of temperature was noted. Day of Rise of Temperature above 100-4°. No. of cases of puerperal fever in which rise of temperature occurred. Recoverv cases. Fatal cases. Total. On day of confinement 3 5 8 2nd day „ ,, 2 1 3 3rd day „ „ 10 6 16 4th day „ „ 151 2 17 5th day ,, 2 4 6 6th day „ „ 2 3 5 7th day ,, ,, 4 4 8 8th day „ ,, 2 3 5 9th day „ „ 4 1 5 10th day,, „ 2 — 2 After 10th day 152 3 18 No information „ 3 2 5 64 34 98 1 In 2 of these eases the rise of temperature was temporary, but a medical man was called id. 2 In 4 of these cases a temporary rise had been noted on the 3rd, oth, 6th and 8th days respectively, but no medical man was called. 89 One midwife had five cases in her practice during the year, but there appeared to be no connection between these cases and the patients attended in the intervals went on favourably. Two midwives had each three cases during the year—and in respect of both midwives there was reason for suspecting that they had conveyed infection from one case to another. Each of nine midwives had two cases of puerperal fever during the year. Information as to whether the patients had been previously confined was obtained in 64 cases of puerperal fever and of these 14 were found to be primiparse. Notification of Births.—With a view to bringing new-born infants under the supervision of medical officers of health, certified midwives were asked to furnish weekly lists of the cases attended by them. About 150 midwives (including most of those with large practices) voluntarily supply this information, the postage being paid by the Council. The lists are received by the Council and the names and addresses of the mothers are forwarded to the various medical officers of health concerned. In this way mothers can be visited on the average within 11 days after the birth of the child, i.e., just at the time when the midwife ceases her attendance and the mother is left to her own resources. These lists are also useful in affording information as to the number of cases attended by midwives and prove of value in enabling more accurate comparison to be made of the incidence of still births or puerperal fever occurring in the practice of particular midwives. In the 11 weeks of 1905 during which this system was in operation, 6,506 cases were attended by midwives furnishing lists Thus a yearly average of 30,000 children or nearly a quarter of the total number of births in London—and these almost exclusively of the poorest class—are brought under some kind of supervision as to management and feeding. Medical aid.—In all cases where a midwife is in attendance and medical aid is called in, she must give notice of the fact to the Local Supervising Authority stating the reason for such assistance. During the year 1905, 1,113 notices were received and the following were the reasons assigned:— Cases. General health of patient 47 Condition of child 222 Death of child or still born child 53 Abnormal presentations 151 Deformed or contracted pelvis 89 Prolapse of uterus, rupture or laceration of perineum 80 Adherent or retained placenta 103 Prolonged labour or uterine inertia 142 Ante partum hæmorrhage 32 Postpartum „ 34 Rise of temperature 56 Abortion or miscarriage 12 Flooding and loss of blood 11 Foul smelling discharge 6 Collapse, exhaustion 17 Abdominal pains or swelling of legs 12 Convulsions, fits and puerperal mania 10 Placenta prsevia 15 Puerperal fever, peritonitis and cellulitis 8 Other causes 13 Total 1,113 Still-births.—405 still births were notified Assuming that the proportion of still-births is the same among the midwives who send weekly lists as among those who do not, this would give a rate of approximately 15 still-births per 1,000 cases attended by midwives. The term still-birth is somewhat loosely used. A definition of the term has been suggested as including children of over seven months gestation. No such definition is used by midwives who often include as a still-born child a foetus of less than six months gestation. The cases of still-born children are investigated to ascertain (a) the age of child; (b) whether it was macerated. With regard to (a) information in 274 cases was obtained, viz.:— 3 died during birth. 118 wero of full term. 50 were of over 8 months gestation. 41 „ 7 33 ,, 6 ,, 29 were of under 6 months gestation. In addition to these cases, 52 were stated to be premature but no information as to the age was given. In regard to question (b) information was obtained in 279 cases, 161 of which were said to be macerated. Inquests.—In June, 1905, the London coroners were asked to notify any inquests to be held before them in which a patient or child, attended by a midwife, had died, and by the courtesy of all the London coroners the Council's inspector is allowed to attend the inquest and is often referred 11476 M 90 to where questions as to the rules to be observed by midwives are raised. From June to December, 1905, 33 inquests were attended, 22 on the bodies of children and 11 where the mothers had died in childbirth. In 23 of these inquests no blame was attributed to the midwife, but in 10 instances it was considered that medical help should have been summoned earlier. The causes of death in these cases were as follows:— Mothers. Puerperal fever and puerperal peritonitis 8 Syncope 1 Septic pneumonia 1 Heart failure from hæmorrage 1 11 Children. Atelectasis and weakness from prematurity 9 Suffocation 3 Injury at birth 2 Pneumonia 2 Congestion of lungs 1 Catarrh of stomach 1 Septic umbilicus 1 Exhaustion from diarrhoea 1 Congenital syphilis 1 Still born 1 22 Full reports on all these inquests were made, and where the midwife was at fault, she was cautioned by letter or was summoned to appear before the Midwives Act Committee. Unregistered women.—39 uncertified persons were reported to be practising as midwives and investigations were made. In many of these cases there was found to be no infringement of the Act and in others the infringement was due to ignorance of the law and the persons were cautioned. Legal proceedings were instituted in four cases and a nominal penalty imposed by the magistrate in two instances. Payment of fees to medical practitioners.—The Act requires that a midwife on recognising certain conditions specified in the Rules must decline to attend alone and advise that a registered medical practitioner be sent for. In many cases difficulty is experienced in obtaining this help and the doctor when so called cannot recover his fee as the patient is not in a position to pay it. The Poor Law medical officer is frequently appealed to, but under the Poor Law Acts although this officer may attend without an order in cases of emergency, he is not obliged to do so, and in actual practice an order is first obtained from the Relieving Officer, who has to ascertain that the case is a fit and proper one for relief. The delay that this system entails often leads to a patient being left without medical aid for several hours and may have fatal results. The question of payment of the fees of medical men called in emergency was under the consideration of the County Council, the Midwives Act Committee recommended the Council to adopt a scheme for the payment of these fees and a clause was included in the draft General Powers Bill, 1906 before its introduction, but at a later stage the clause was not proceeded with. Training of midwives.—The Midwives Act Committee of the Council, after consultation with the Education Committee, drew up a scheme for offering scholarships to students in midwifery. At the outset it was thought advisable to make the scholarships tenable only at institutions where internal cases were attended. From a list of these institutions in which the annual number of cases exceeded 500, four hospitals were selected, and the Council was recommended to grant scholarships tenable at these. The value of the scholarships was fixed at £25, and the condition was imposed that a six months' course of training should be undertaken, except in the case of nurses who had previously been trained in hospitals. Classes for midwives.—In order that midwives who were trained many years ago, or whose training had been deficient, might be brought to a higher standard of efficiency, evening midwifery classes were arranged in some of the Council's schools and midwives invited to attend. The Society for Promoting the Training and Supply of Midwives has rendered service to the Council in this connection by informing midwives of the existence of these classes. Shirley F. Murphy, Medical Officer of Health. December, 1906. To the London County Council. 91 Medical Officers of Health of London Sanitary Areas, in 1905. Sanitary area. Medical officer of health. Battersea G. Q. Lennane, F.R.C.S. Bermondsey R. K. Brown, M.D. Bethnal-green G. P. Bate, M.D. Camberwell F. J. Stevens, M.R.C.S. Chelsea L. C. Parkes, M.D. City of London W. Collingridge, M.D. Deptford H. W. Roberts, M.R.C.S. Finsbury G. Newman, M.D. Fulham J. C. Jackson, L.R.C.P. Greenwich E. G. Annis, M.R.C.S. Hackney J. K. Warry, M.D. Hammersmith N. C. Collier, L.R.C.P. Hampstead G. F. McCleary, M.D. Holborn W. A. Bond, M.D. Islington A. E. Harris, L.R.C.P. Kensington T. O. Dudfield, M.D. Lambeth J. Priestley, M.D. Lewisham A. W. Harris, M.D. Paddington R. Dudfield, M.B. Poplar F. W. Alexander, L.R.C.P. St. Marylebone A. W. Blyth, M.R.C.S. St. Pancras J. F. J. Sykes, M.D. Shoreditch L. T. F. Bryett, M.D Southwark G. Millson, L.R.C.P. Stepney D. L. Thomas, M.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. 11476 M 2 APPENDIX I. Diagram, A. London. 1 Variations in the Age-Incidence of Certain of the Principal Epidemic Diseases. The annual report for the year 1897 contained an Appendix (I.) giving account of the variations in the age-incidence of the mortality from measles, whooping cough, scarlet fever and diphtheria, and more particularly the changes of age-incidence which had occurred since the decennial period 1861-70 which was adopted as the standard of comparison. This period was especially selected on account of being the decennium immediately antecedent to the year in which the Elementary Education Act of 1870 came into operation. In the appendix referred to tables dealing with the figures for the years 1851-1896 were included, and in view of the fact that the figures for a further period of ten years are now available it is of interest to review the conclusion there stated in the light of the more recent behaviour of the diseases mentioned. The following tables, therefore, show the death-rates in successive periods at each age for each of the diseases referred to, and the increase or decrease per cent, in the death-rates of periods subsequent to the period 1861-70 when compared with the death-rates obtaining in that decennium. This is also shown graphically ia the accompanying diagram A. Table I. London. (A.) Measles—Death rates per 1,000,000 living. Period. All ages. 0— 1— 2— 3— 4— 5— 10— 15— 20 and upwards 1861-70 572 3,481 8,691 4,847 2,469 1,281 245 23 8 4 1871-80 508 3,646 7,712 3,643 1,988 1,044 256 18 6 4 1881-90 634 4,543 9,909 4,759 2,733 1,618 366 18 5 3 1891-1900 583 4,937 10,694 4,362 2,552 1,464 274 11 3 3 1901-05 447 4,181 8,793 3,513 1,820 1,088 187 8 2 2 (B) Increase or decrease per cent, of death rates at each age-period in 1871-80, 1881-90,1891-1900, and 1901-5, compared tcith the death rates at each age-period in 1861-70. 1871-80 —11.2 + 4.7 —11.3 —24.8 —19.5 —18.5 + 4.5 —21.7 —25.0 — 0.0 1881-90 + 10.8 + 30.5 + 14.0 — 1.8 + 10.7 + 26.3 + 49.4 —21.7 —37.5 —25.0 1891-1900 + 1.9 + 41.8 + 23.0 —10.0 + 3.4 + 14.3 + 11.8 —52.2 —62.5 —25.0 1901-05 — 21.9 + 20.1 + 1.2 —27.5 —26.3 —15.1 —23.7 —65.2 —75.0 —50.0 Table II. London. (A) Whooping Cough—Death rate per 1,000,000 living. Period. All ages 0— 1 1_ 2— 3— 4— 5— J 10— 15— d upwards 1861-70 876 10,145 11,237 5,720 2,941 1,520 268 12 4 1 1871-80 813 10,443 10,221 4,620 2,409 1,330 254 9 1 1 1881-90 690 9,504 9,010 3,951 2,280 1,246 221 6 1 1 1891-1900 ... 499 8,097 7,239 2,827 1,524 869 154 3 1 1 1901-05 352 6,210 5,482 1,910 1,031 493 102 1 0 0 (B) Increase or decrease per cent, of death rates at each age-period in 1871-80, 1881-90,1891-1900, and 1901-5, compared with the death rates at each age-period in 1861-70. 1871-80 — 7.2 + 2.9 — 9.0 —19.2 —18.1 — 12.5 — 5.2 —25.0 —75.0 0.0 1881-90 —21.2 — 6.3 —19.8 —30.9 —22.5 —18.0 —17.5 —50.0 —75.0 0.0 1891-1900 —43.0 —20.2 —35.6 —50.6 —48.2 —42.8 —42.5 —75.0 —75.0 0.0 1901-05 —59.8 —38.8 —51.2 — 66.6 —64.9 —67.6 — 61.9 —91.7 —100.0 — 100.0 2 Table III. London. (A) Scarlet fever—Death rates per 1,000,000 living. Period. All ages. 0— 1— 2— 3— 4— 5— 10— 15— 20 and upwards 1861-70 1,135 2,308 6,444 7,937 7,174 5,878 2,637 536 177 56 1871-80 601 1,149 3,269 4,057 3,916 3,288 1,402 254 81 30 1881-90 328 652 1,937 2,277 2,293 1,880 731 135 50 16 1891-1900 169 386 1,061 1,345 1,312 971 369 82 31 10 1901-05 95 226 646 858 770 475 221 43 19 6 (B) Increase or decrease per cent, of death rates at each age-period in 1871-80, 1881-90, 1891-90, and 1901-5 compared with the death rates at each age-period in 1861-70. 1871-80 —47.0 —50.2 —49.3 —48.9 —45.4 —44.1 —46.8 —52.6 —54.2 —46.4 1881-90 —71.1 —71.8 —69.9 —71.3 —68.0 —68.0 —72.3 —74.8 —71.8 —71.4 1891-1900 —85.1 —83.3 —83.5 —83.1 —81.7 —83.5 —86.0 —84.7 — 82.5 —82.1 1901.05 —91.6 —90.2 —90.0 —89.2 —89.3 —91.9 —91.6 —92.0 —89.3 —89.3 Table IV. London. (A) Diphtheria and Croup—Death rates per 1,000,000 living. Period. All ages. 0- 1— 2— 3— 4— 5— 10— 15— 20 and upwards 1861-70 430 2,109 3,911 3,281 2,558 1,731 504 71 35 26 1871-80 299 1,089 2,373 2,081 1,873 1,500 475 59 24 17 1881-90 419 1,175 3,108 2,975 2,875 2,398 798 100 32 20 1891-1900 534 1,392 4,015 3,784 3,816 3,360 1,270 180 45 20 1901-05 197 624 1,608 1,452 1,420 1,231 499 66 13 6 (B) Increase or decrease per cent, of death rates at each age-period in 1871-80, 1881-90, 1891-90 and 1901-5, compared with the death rates at each age-period in 1861-70. 1871-80 —30.5 —48.4 —39.3 —36.6 —26.8 —13.3 — 5.8 — 16.9 —31.4 —34.6 1881-90 — 2.6 —44.3 —20.5 — 9.3 + 12.4 + 38.5 + 58.3 + 40.8 — 8.6 —23.1 1891-1900 + 24.2 —34.0 + 2.7 +15.3 + 49.2 + 94.1 + 152.0 + 153.5 + 28.6 —23.1 1901-05 —54.2 —70.4 —58.9 —55.7 —44.5 —28.9 — 1.0 — 7.0 —62.9 —76.9 The diagram is based upon the figures contained in Tables I. (B), II. (B), III. (B) and IV. (B). In the case of each curve the distance of each successive point of the curve above or below the dotted line represents the increase or decrease per cent, in the death-rates at successive age groups obtaining in the period to which the curve relates compared with the corresponding death-rates obtaining in the period 1861-70. In the case of measles, whooping cough and diphtheria and croup, to ensure greater clearness and to avoid intersection of the curves, a separate dotted line is drawn for each curve, the dotted lines following the same chronological order as the curves, i.e., the first curve shown, for each of these diseases, relating to the period 1871-80, is drawn in relation to the first dotted line; the second curve (1881-90) in relation to the second dotted line, &c. In the case of scarlet fever each of the curves have been drawn in relation to the same dotted line, the use of more than one dotted line being unnecessary owing to the progressive decline of the scarlet fever death-rates at each age period. Each square in the diagrams represents 10 per cent. Referring to a similar diagram published in the 1897 report previously referred to, the following statement was made:— " It will be seen that there has been a tendency to relative increase of incidence of mortality both in measles and whooping cough on ages 3-, 4- and 5- as in the case of diphtheria. The increase at these ages is however not manifest in the case of scarlet fever. There has also been relative increase of incidence of mortality on the first two years of life in measles and whooping cough which again is not manifest in the case of scarlet fever. In seeking for an explanation of the relative increase of incidence of measles and whooping cough mortality upon the first two years of life the probability that it is the result of increased opportunity of infection due to increased density of population naturally suggests itself, children of this age being less easily protected from exposure to infection than before. Explanation is however still wanted for the relatively increased incidence on 3 the ages 3-, 4- and 5-. There is undoubtedly suggestion of some common cause operating at these ages to produce parallel results with regard to the three diseases—measles, whooping cough and diphtheria. In the case of diphtheria it will be observed that the increase also affects the age 10-, but that this is not manifest in measles or whooping cough. The number of deaths from these diseases at this age is, however, very small. It is difficult to explain the fact that scarlet fever has not been affected in a similar manner at these ages. Transference from diphtheria to scarlet fever, if proportionate at each age, would have the effect of increasing the incidence of scarlet fever mortality on the earliest years of life, and would in this way tend to obscure the result of increased incidence on ages 3-, 4- and 5- due to other cause, such as that which has produced this increase in the other diseases. Whether it will be subsequently found that the increasing feebleness of the scarlet fever virus, shown by the decrease in mortality, is operating to prevent this cause from being manifested, the experience of future years alone can prove. Apart from some such explanation as the above, it would be necessary to assume that the cause which produced these changes in the other diseases was for some reason inoperative in the case of scarlet fever." It will be observed that the present diagram shows that in the ease of measles and whooping cough with decreasing mortality at "all ages" the curves for the periods 1891-1900 and 1901-5 still maintain the characteristic features of the curves for antecedent periods when compared with the period 1861-70—i.e., in respect of both diseases the mortality in the first two years of life has declined less than at other ages; in the case of measles the decline at the school ages has also been retarded, whereas in the case of whooping cough the maintenance of the mortality at the school age compared with other ages is not so conspicuous. In this connection it should be pointed out that the decline in the whooping cough death-rate at " all ages " has been much greater than the decline in the "all ages" measles death-rate ; thus the whooping cough death-rate at " all ages " in the period 1901-5 was 59.8 per cent, below the corresponding death-rate in 1861-70, while the measles deathrate in the period 1901-5 was only 21.9 per cent, below the corresponding death-rate in 1861-70. Referring now to scarlet fever it will be observed that the curve of 1901-5 approximates closely to a straight line, and no modification of the statement made in the 1897 report appears to be necessitated by the later experience of the behaviour of scarlet fever in this respect. It should be noted, however, that the period 1861-70 was one of excessive mortality, and that the scarlet fever deathrate at "all ages " in 1901-5 was 91.6 per cent, below that of the period 1861-70, the decline being considerably greater than that previously referred to in the case of whooping cough. The experience of the behaviour of diphtheria in late years shows that while, as compared with 1861-70, the excessive incidence of mortality upon the school age is still a conspicuous feature in the diagram it was in the period 1901-5 with a declining rate of mortality at" all ages," much less marked than in 1891-1900., i.e., during a period of epidemic prevalence. It is worthy of note, however, that notwithstanding the fact that the diphtheria death-rate at " all ages " in the period 1901-5 was 54 2 per cent, below the corresponding death-rate in the period 1861-70, the death-rates at ages 5- and 10- were only 1.0 per cent., and 7.0 per cent, respectively below the rates at the same ages in the period 1861-70, The curves shown in the diagram suggest broadly that the incidence of mortality upon the school age tends to become most marked in periods of greatest prevalence. Thus in the case of measles the curve for the decennium of greatest prevalence, viz., 1881-90, shows the most marked incidence on the school age-period of life as does that for the decennium 1891-1900 in the case of diphtheria. It would therefore appear that in any estimate, as to the amount of observed increase in the mortality in any periods compared, which can be thought of as associated with increase of school attendance, account must be taken of the relative prevalence of the disease under consideration in the two periods ; and probably also consideration would have to be had for the question whether the tendency of the prevalence was in the direction of increase or decline. In connection with the increased incidence of diphtheria mortality at the school age-period of life referred to in the 1897 report, the following table shows that, whereas the diphtheria mortality at " all ages " and at the age-period 3—15 years began to decline subsequent to the year 1893, and has with but little interruption declined year by year since, the relatively increasing incidence of diphtheria mortality on the age-period 3—15 years (the rate of mortality at " all ages " being taken as 100) was continued until the last three years during which it has been distinctly lower, while the relative incidence of attack on the age period 3—15 years (the rate of attack at "all ages "being taken as 100) appears to have been maintained up to the present time. It may be that the maintenance of the relative incidence of attack on the school age, in spite of the fact that the relative incidence of mortalityat that age has declined, is due to more complete inquiry for cases of this disease among schoolattending children and, indeed, this view is supported by the fact that the case mortality at the ageperiod 3—15 years, which had for some years been showing in some degree greater decline than that of " all ages," showed a more marked decline during the last three years. No definite opinion can, however, be expressed upon this question which is rendered more complex by the introduction in recent years of the treatment of diphtheria with antitoxic serum. The experience of the last three years in London shows— (a) decrease in the " all ages " rate of mortality. (b) special decrease in the rate of mortality at ages 3—15 years. (c) decrease in the case rate at " all ages " and at ages 3—15. (d) a smaller decrease in the case rate at 3—15 years than at "all ages." (e) a greater reduction in the fatality of cases aged 3—15 years than is observed at "all ages." The decline in the "all ages" death rate referred to above is manifest also in the figures for 1903 and 1904 of England and Wales minus London. How much of this decline is due to the use of antitoxic serum cannot be stated, but it may be mentioned that this remedy has been used in the hospitals of the Metropolitan Asylums Board subsequent to the year 1894 and in increasing degree. 11476 N 4 London. Diphtheria. Year. Death rate per 100.000 persons living. Diphtheria and Croup.) Death rate at age 3-15 ("all ages " death Case rate per 100,000 persons living Case rate at age 3-15("all ages " case rate taken as 100). Case-mortality per cent. Case mortality at age 3-15 ("all ages" case mortality taken as 100.) "All ages." Age 3-15. rate taken as 100). "All ages." Age 3-15. '• All ages." Age 3-15. 1861 55.2 80.5 146 1862 59.0 95.2 161 1863 59.0 102.9 174 1864 51.6 78.4 152 1865 39.6 57.5 145 1866 40.2 56.9 142 1867 38.5 55.6 144 1868 36.4 57.4 158 1869 28.2 42.4 150 1870 28.6 44.9 157 1871 25.8 44.8 174 1872 26.3 49.0 186 1873 30.8 52.0 169 1874 34.7 61.7 178 1875 38.4 68.1 177 1876 28.6 51.5 180 1877 22.9 41.2 180 1878 32.0 62.6 196 1879 30.6 62.6 205 1880 30.6 61.6 201 1881 34.5 70.6 205 1882 44.7 92.7 207 1883 45.5 92.3 203 1884 42.7 86.5 203 1885 40.1 78.5 196 1886 34.4 70.0 204 1887 38.9 79.4 204 1888 44.2 98.8 224 1889 50.1 110.0 220 1890 45.6 97.4 214 1891 42.0 94.1 224 1892 51.1 114.1 223 196 433 221 23.5 24.4 104 1893 80.8 187.6 232 318 708 223 23.9 25.3 106 1894 65.7 155.7 237 257 649 253 24.3 23.2 95 1895 56.5 132.0 234 256 653 255 21.0 19.6 93 1896 63.2 153.9 244 312 835 268 19.3 17.7 92 1897 52.6 128.6 244 297 800 269 17.3 15.7 91 1898 40.8 100.4 246 265 733 277 15.1 13.4 89 1899 45.2 114.1 252 304 861 283 14.4 12.9 90 1900 36.0 90.5 251 266 753 283 13.3 11.8 89 1901 30.4 74.5 245 267 750 281 11.1 9.7 87 1902 26.2 65.2 249 234 666 285 10.8 9.5 88 1903 16.9 37.5 222 168 489 291 9.8 7.5 77 1904 16.4 36.8 224 155 443 286 10.3 8.1 79 1905 12.3 28.5 232 138 403 292 8.7 6.9 79 Shirley F. Murphy, Medical Officer of Health. December, 1900. APPENDIX II. London County Council. REPORT OF THE MEDICAL OFFICER (EDUCATION) FOR THE YEAR ENDED 31st MARCH, 1906. The duties of the Educational Section of the Public Health Department have been steadily followed during the year ended 31st March, 1906. There has been no departure involving the application of any new principle or fresh doctrine in the work, although it daily becomes more evident how important is this medical oversight in the schools, and how intimate its relations are with every part of the whole body politic. The general scope of the duties is still widely extending. Non-provided schools are now included, and arrangements have been made for extending the medical supervision to secondary schools and training colleges. In addition to their routine of school inspections the assistant medical officers have also given a certain amount of time to detailed records of subjects of fundamental importance to the welfare of children. Some of these matters are dealt with in this report, others are still incomplete. Quite outside of his duty to the Council, Dr. Hanson has attempted to get hold of boys from the moral side, by appealing to their manhness, and at great expense to himself, has demonstrated the possibility of utilising the forces which, if neglected, produce hooliganism, but which when given direction promise to react automatically to produce well-ordered and self-respecting citizens. Prospective legislation is likely to add greatly to the powers of the Council in respect to school hygiene, but apart from this a point has been reached where the question of rigid adhesion to the policy of completely excluding any medical treatment from the work of the Educational Branch of the Public Health Department may have to be very carefully reconsidered. Before another report is issued it is to be expected that the second International Congress for School Hygiene will have been held in London, and great gain will accrue to the whole subject of school hygiene in this country from the meetings to be held in August, 1907. EXAMINATION OP CANDIDATES. All teachers, instructors or schoolkeepers who are employed in the schools are examined in this department, and approved before commencing work. The following is a return of candidates medically examined from 1st January, 1905, to 31st March, 1906:— Candidates. Number who applied for examination and rere-examination . Number outstanding from 1904. Number examined and re-examined. Passed. Rejected. Withdrawn, etc. Outstanding on the 31st March, 1906. Unconditionally. Subject to Oculist's Report. Subject to Aurist's or Surgeon's Report. Subject to Dentist's Report. Subject to Successful Vaocination. Subject to re-examination before termination of Probationary Period. Head and AssistantTeachers — Males 508 8 443 428 9 3 2 _ _ i 57 16 Do. do. Females 1809 14 1632 1513 63 3 34 - 13 8 119 72 Pupil Teachers Males 146 5 144 115 14 1 2 4 - 2 6 — Do. Females 517 23 521 445 42 2 15 8 4 10 20 — Cookery and Laundry Instructresses, Schoolkeepers, &c. Males 120 2 113 112 — 1 — — — — 9 — Do. do. Females 84 - 81 79 1 — — — — 1 3 — Total Males 774 15 700 655 23 5 4 4 — 3 72 16 Females 2410 37 2234 2037 106 5 49 8 17 19 142 72 Grand Total 3184 52 2934 2692 129 10 53 12 17 22 214 88 12006 ' A 2 4 Scholarship Candidates.—The names of 3,746 scholarship candidates and 373 pupil teachers, a total of 4,119, were sent to the medical officer for medical examination and report from 20th June to 24th July, 1905. The medical examination of about 4,000 individuals, between 11 and 16 years of age, presented opportunities for many interesting and valuable scientific inquiries, but these had to be sacrificed to the immediate practical question of doing exactly the work required within the limited time at disposal and only notes of direct importance were made. Heights, weights, chest measurements, and such routine matters as the examination of urine or testing of colour vision were omitted as, by doubling the time, the cost of the examinations would have been doubled without a corresponding gain in the results for which the examinations were being made. It is necessary to know what end is in view in awarding scholarships, restricted and open. Restricted scholarships may be given to a special class such as the crippled, blind or deaf, not in the hope that the holders will return the outlay, but in the hope that the whole class may be stimulated to attain a higher level of work. In these cases, the individual holders are scarcely expected by their efforts to repay the cost of their education, but the existence of these scholarships is a stimulus to the whole class to do better work. The medical examiner in these cases will be right in passing all who can in any way benefit. Eighteen such scholarships were awarded, of which three girls had to be rejected on medical grounds, namely—one cripple, for progressive spinal disease ; one deaf, for very defective vision ; and one blind, for disseminated sclerosis of the nervous system, already in an advanced state. The open scholarships are given to children of certain mental attainments as a definite investment of public money, in the hope that the money so spent in education will be indirectly, but well repaid, by the advantages derived from the individuals later. If this doctrine be accepted we should refuse all who are at present unfitted and likely for the next few years to be unfitted to follow a studious hfe with advantage, and also all who are not likely to develop into efficient citizens. It has been necessary to hesitate in the application of this doctrine, as in some ways it would handicap more seriously many who are already at a disadvantage from liability to disease or damaged as a result of it. At the same time, the ordinary methods applied in a life insurance examination would not hold, for many of these individuals, although damaged, are lively to serve many years of useful adult life, especially those who are of better mental equipment and likely to avoid the various snares that reduce the expectations of hfe derived from experience of a general population. Some very doubtful cases who would have been unhesitatingly rejected as teachers, have nevertheless, been accepted as junior scholars because they would have to remain at school in any case till 14 years of age, and we were met by the position that if unfit for scholarships they should equally be considered unfit for school. The statement is not quite true, but it is an awkward one to avoid. Cases, therefore, have only been rejected where there was no prospect of useful citizenship being attained, or where the individual was likely to be damaged by a studious life. Probably it would be doing a service to the general welfare of the population if the scholarship scheme were further made an incentive to healthy living and physical education by fixing certain standards to be required in the medical examinations. The returns may be classified as follows :— Table I. Age Numbers sent up for examination— Totals. Fit; Referred, Rejected. Vaccinated. Unvaccinated. Vision. Dental. Throats. Tonsils. Hearts. Ears. Dirt. Miscellaneous. Totally. As teachers. Junior Scholars. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. 10 8 — — — — — — — — — — 16 1 1 — 1 — — — 11 545 32 61 17 41 6 7 2 9 3 1 964 53 135 9 50 11 o 77 26 9 10 12 47 6 18 7 5 1 — 1 — — — 44 4 7 6 — 1 1 4 1 — — 21 5 4 3 1 — — 2 — — — 11 1 1 2 — — — 3 — — — 915 691 43 83 "7 47 7 7 5 9 3 1 Girls 1,461 1,035 59 143 17 51 12 3 85 27 9 10 Totals junior scholars 1,656 102 226 44 98 19 10 90 36 12 11 5 Table I.—continued. Age. Numbers sent up for examination— Totals. Fit. Referred. Rejected. Vaccinated. Unvac- cinated. Vision. Dental. Throats. Tonsils. Hearts. Bars. Dirt. Miscellaneous. Totally. As teachers. Probationer Scholars. 13 — — — — — — — — 1 — — — — — — — — — 14 86 9 32 12 4 — — — — — 2 387 20 74 30 10 8 1 17 12 5 4 15 28 2 8 6 — 3 — 1 — — 1 295 9 41 33 3 1 3 10 5 3 1 16 3 — 1 — — — — — — — — 13 — 1 — 1 — — — — 1 Boys 197 117 11 41 18 4 3 — 1 — — 3 Girls 977 696 29 116 63 14 9 4 27 17 9 5 Totals probationer scholars 813 40 157 81 18 12 4 28 17 9 8 Special Scholars (Technical, &c.) 13 6 6 — — — 1 1 3 — — 1 — — — — — — — — — — — 14 17 — 5 5 — — — — — — — 1 — — — — — — — — — — 15 17 — 7 7 — — — — — — — 2 — — — — — — — — — — 16 9 — 6 7 — — — — — — — 9 1 6 — — — — 1 — — — 17 — — — — — — — — — — — — — — 1 — — — — — — — 18 2 — 1 2 — — — — — — — 8 — 3 3 — 1 — — — — — 19 10 — 2 1 — — — — 1 — — 7 — — 1 — — — — — — — 20 and over 6 — 1 1 — — — — — — — 2 — 1 — — — — — — — — Boys 123 67 6 22 23 — 1 1 3 1 — 1 Girls 55 29 1 10 5 — 1 — 1 — — — Totals Specials 96 7 32 28 — 2 1 4 1 — 1 Boys 1,235 805 60 146 68 51 11 8 9 10 3 5 Girls 2,493 1,760 89 269 85 65 22 7 13 44 18 15 Grand Totals 3.728 2,565 149 415 153 116 33 15 122 54 21 20 6 For comparison, the next table is given. It consists of the pupil teachers sent up for examination in the same period— Table II. Pupil Teachers. Age. Sent up for examination. Fit. Unfit- Vision. Dentist. Throat. Heart. Ears. Dirt. Miscellaneous. Rejected Vaccinated. Not Vaccinated. B. g. b. g. b. g. b. g. b g. b. g b. g. b. g. b. g. b g. 15 — — — — — — — — — — 9 — — — — — — — — — 16 36 1 12 3 — — — — 1 — 149 5 26 2 — 1 — 1 3 3 17 6 — 3 — — — — — — — 39 1 9 6 — 1 — — 3 1 18 2 — 1 3 — — — — — — 13 — 3 1 — — — — 3 — 19 3 — — — — — — — 1 _ 13 — — 1 — — — — — 20 and 4 1 — — — — — — — — over 3 — — — — — — — — — Boys 51 2 16 6 — — — — 2 — Girls 226 6 38 10 — 2 — 1 9 4 Grand Totals 373 277 8 54 16 — 2 — 1 11 4 The result of the examination of candidates for scholarships to the cripple, blind and deaf was— Table III. Age. Passed. Rejected. Cripple. Blind. Deaf. Cripple. Blind. Deaf. B. G. B. G. B. G. B. G. B. G. B. G. 14 — — —. — — — 1 — — — — — 15 — 1 — 2 1 1 — 1 — — — — 16 — 4 1 — — — 2 1* 1 — 1 1 Totals 4 7 4 1 1 1 * Unvaccinated. Fit candidates (vaccinated and unvaccinated).—Of the 3,728 scholarship candidates actually examined, 2,714 (70.3 per cent.) were passed as fit, but of these 149 (4.2 per cent, of the total) were unsatisfactory as regards vaccination. Candidates referred back.—Of the 908 (24.4 per cent.) scholarship candidates referred back on account of unsatisfactory conditions, most of them at once took steps to obtain relief, and thus the examination was the means of a considerable improvement in the conditions among this class. The following were the chief causes of reference :— Vision.—415 (11.1 per cent. of all) failed to obtain good vision (6/9 was accepted as a sufficient standard), but in all cases included here sufficient improvement was obtained from treatment or glasses to allow them to pass. Several cases who had only one useful eye were passed, as, except for a few occupations, good vision with one eye is sufficient for the purposes of life. In future, it would be advisable to ask for good vision (V—6/9 at least), if necessary wearing glasses, and not to accept any child requiring glasses beyond—6 d sph., or presenting astigmatism requiring cylinders higher than 3 dioptres, as such cases are unfitted for a studious life. Teeth.—In 153 cases (4.3 per cent. of all) seen the teeth were so bad that the scholars were required to see the dentist before being accepted, and many others were advised as to the necessity for dental care. Throat.—The conditions of enlarged tonsils or adenoids were so obvious in 116 cases (3-l per cent, of all) that they were referred until reheved. Heart.—During rapid growth functional disturbance of the heart is very common, and conditions of irregular or rapid heart and of functional valvular disturbance were referred in 33 cases, but the candidates were ultimately passed. 7 Dirt and vermin.—Chiefly pediculosis capitis were the cause of 122 cases (3.3 per cent of all) being referred back. Only 9 of these were boys. Some were still uncleansed on being seen a second time. 27 girls presenting themselves as probationer scholars were classed as dirty or verminous. Skin diseases were not included in this classification. Miscellaneous causes.—Ringworm (3), favus (3), and other skin diseases were noted. Enlarged thyroid gland was the cause of reference in several cases. Curvature of the spine, some cases with subnormal hearing, some with slight defects in speech, others presenting anaemia or debility, but the cases bad enough to be doubtful and require reference back under these heads were few. Cases rejected.—Of those rejected there were 41 (1.1 per cent. of all). In 21 the rejection was absolute, and in 20 it was conditional. The candidates were rejected as future teachers, but the Committee was asked to decide as to scholarship award. The chief cause of rejection was valvular disease of the heart. Rheumatic valvular disease of the heart was held to disqualify. Several cases, where indications of organic valvular trouble were present, in the absence of any rheumatic history, were passed, although they would have to be disqualified as teachers. General dehcacy, a phthinoid formation of chest, and the presence of traces of lung disease disqualified three. In two of these cases the father had recently died of phthisis. Other causes of rejection were high or progressive myopia, actual lung disease, old paralysis, and in one case general feebleness and debilitated health. Almost every doubtful case was seen and consulted over by the examiner and myself or my assistant before a decision was reached. In each case, when any further enquiry or appeal was made through any channel, on becoming aware of it, the child and parents were invited to attend for a further investigation. No decision to reject was arrived at except after the utmost deliberation, and until all facts had been taken into consideration. Medical examination of candidates for scholar ships.—Candidates for scholarships should be of good health and nutrition, and the expansion of the chest should be good. They should be examined as to personal cleanliness of the skin and hair, and as to condition of the teeth. No person should be acceptable who presents marked trouble due to obstructed nasal breathing, enlarged tonsils or adenoids, or who suffers from chronic discharges from the ears. Disease of the lungs or uncompensated valvular disease of the heart should not be admissible. Good hearing and vision (wearing spectacles if necessary as prescribed by a doctor) should be required. Concave glasses exceeding 6 dioptres and cylinders exceeding 3 dioptres should not be allowed. References.—In addition to the "First" examinations, 555 references have been dealt with; these relate to the health of employes already in the service of the Council. Special schools cases.—837 examinations have been made at this office owing to the fact that all cases nominated for admission to residential schools are seen by me; also cases referred from local centres who require detailed examination, particularly in regard to hearing and vision, and cases referred by magistrates and committees are seen here. VISITS TO SCHOOLS. The average number of visits to schools made each week for examinations and inspections by officers of the Public Health Department (Education) is as follows:— Special Schools. Ordinary Schools. Domiciliary and Special enquiries. Medical Officer and 24 Assistants 20 63 6 Twelve Nurses 126.2 120.4 Each of the residential schools has now to be visited at least once in three months by the Medical Officer (Education). THE GENERAL MEDICAL INSPECTION. The twenty local assistant medical officers (Medical Inspectors) appointed last summer began their duties on 1st September, 1905. Each of these officers has to visit the schools of one district, spending three school sessions weekly in such work and making a weekly report on the schools visited. This report is now for convenience returned on a printed form. The head teachers were instructed to make hsts of all the children known to them as being in any way defective and present them for medical inspection. Children suffering merely from defective vision were not to be included in' the lists. The general routine is for the Medical Inspector to visit the school department; go round the premises and see the classes at work : take note of all hygienic matters, and then inspect the children wnose names appear on the teachers' hsts. 8 On an average six sessions (half-days) are devoted to each school, that is about two sessions to each department; among the poorer schools sometimes as many as three or four sessions may be given to a department. The first selection of the cases to be seen was made by the teachers. It is obvious that only very marked cases of defect are likely to be thus noticed and that the beginnings of disease are the stages at which detection is necessary, not when such damage has been done that the child is suffering in its education. Between 20 and 30 per cent, of the cases submitted by the teachers were not suffering in any way. For instance, the children submitted for defective hearing, a condition which should be known to the teachers, varied greatly, some teachers presenting many cases, others none. Another teacher will say that he has no children requiring examination by the doctor, whilst in the next school a long string of healthy dunces may be presented. Speaking in the most general way, the teachers in the provided schools make a more careful selection than those in non-provided schools ; and whilst in particular instances the trouble and pains exerted by the teachers is very great, on the whole their assistance and willing co-operation is only secured in a minority of cases, least often among the boys and most often in the infants' schools. Some teachers regard the Medical Officer's work as inquisitorial, and a few of the non-provided school teachers have even objected to the doctor's visits, whilst others have expressed themselves as failing to see any use in it. A very short time may, however, be trusted to alter all this. Experience shows that medical inspection of schools extends and grows wherever it is introduced. The following up of the cases is as yet done in a very imperfect way. Much of the advice given is wasted. For instance, many of the children with offensive discharging ears have had this condition for months and the parents cannot be induced to get them treated, and yet the condition is one of the most fatal of the chronic troubles of childhood. Many of the cases seen, and neglected or refused treatment by the parents, are either attending school or are excluded for months or years through parental ignorance or indifference, which at present we are helpless to prevent. In some cases where hygienic conditions are at fault the Medical Officer of Health is informed and action taken ; in others the school managers are informed and something done in this way ; but where the teachers choose to exert themselves these difficulties seldom arise, and the physical and mental conditions in any school are to a large extent an index of the teachers' point of view in respect of their professional work. The systematic keeping of individual records of each child, which is the ideal to be attained, is not worth doing at present. In Germany, where the whole intellectual level of both teachers and parents is considerably above that in this country, a card system (" The Wiesbaden System ") is worked with good results. Every child is submitted to medical inspection in its first, third and fifth year of school hfe, and those requiring it are kept under more frequent observation. Two-thirds of the children referred in Mannheim during 1904-5 saw a doctor within 8 days, and 75 per cent, of the children in Leipzic were submitted to their own medical man before the school doctor's next visit. A register of some kind should be kept in each school, in which the Medical Inspector could make entries in respect to premises or individual children where he thinks action should be taken, and this register being submitted at each managers' meeting should also show the action taken and the ultimate result. The work of the medical Inspector would be made more effective through the keeping of such a register, and the school managers would also be enabled to exert a greater influence for the good of the children. The work of the medical inspectors in the various districts cannot be reported on at present so as to be assessed at its full value, or to do justice to its extent. To the doctors themselves the school work has proved of such interest that on an average they have taken very much more time and trouble over this service than the conditions of their appointment either demanded or expected. A great deal of work has been done in connection with special examinations, infectious diseases, the cleansing scheme, and other enquiries, but of the regular routine of school inspection the following tables give a survey. It should be added that visual troubles, except in the case of acute or dangerous diseases, were left out of consideration till the spring, and consequently are not returned in these figures, with the exception of certain serious cases ; dirt and vermin are left to the school nurses. Schools examined in regular medical inspection (three months, January to March, 1906). Number of Departments. Numbers on Roll. Children Examined. Provided schools 276 95,621 13,719 Non-provided 372 70,294 21,683 Totals 648 165,915 35,402 9 Routine medical examinations of scholars in the three months. Vision, Urgent cases. Hearing. Throat and Nose. Speech. Dirt. Physically Defective. Mentally Defective. Other objects. Provided, Schools. Returned as defective on head teachers' lists 320 1,704 — 1,451 — 2,753 1,438 — Returned by doctor— (a) From head teachers' lists 299 888 — 429 — 1,409 455 — (6) For special schools examination 2 3 — 5 — 35 307 — (c) From children examined in their classes 994 810 2,098 — 119 — — 1,440 Non-provided, Schools. Returned as defective on head teachers' lists 568 1,291 — 1,211 — 1,339 1,052 — Returned by doctor— (a) From head teacher's lists 371 1,017 — 584 — 668 375 — (6) For special schools examinations 7 18 — 2 — 34 335 — (c) From children examined in their classes 825 572 1,876 — 171 — — 743 In addition, observations were made of the conditions of the buildings and surroundings, and the following special conditions noted:— Departments reported on. Nature of Special Reports. Reports on matters of— Lighting. Ventilation Heating. Sanitation. Furniture. Provided schools 276 Good 86 73 64 61 55 Fair 34 20 17 10 21 Bad 34 25 17 5 5 Non-provided schools 372 Good 68 49 49 44 29 Fair 63 49 23 25 19 Bad 132 94 31 34 127 These reports have been made in a perfectly impartial manner by the twenty local assistant medical officers. They serve to show the lack of hygienic ideas still prevailing in some schools, also incidentally what a low standard in regard especially to lighting, ventilation and furniture has been satisfactory to inspectors and compatible with earning the Government grants. By setting out the table in the corresponding proportions for reports on 1,000 departments the conditions of the provided and non-provided schools is rendered more comparable. Nature of Reports. Reports on matters of— Lighting. Ventilation. Heating. Sanitation. Furniture. Provided schools (1,000 reports) Good 311 265 229 219 198 Fair 123 72 62 36 75 Bad 123 90 62 18 18 Non-provided schools (1,000 reports) Good 183 132 132 118 77 Fair 169 132 61 67 51 Bad 354 253 83 91 341 12006 B 10 Medical Inspection of Secondary Schools and Training Colleges.— The secondary schools and training colleges have now come under observation, but the experience gained in the elementary school only carries one a small way. An entirely new set of conditions arise. The pupils must be handled in a different way. The problems of overwork, nerve strain and exhaustion, comparatively unimportant in the older children of the elementary school, now assume great importance, and will have to be carefully studied. Education in the methods of learning and types of knowledge, rather than in masses of facts, is the most important work of these students, and although the crowded curriculum cannot be further discussed now, it is probable that one of the first general subjects undertaken will have to be the study of time-tables. It is important that in this new work plenty of time should be allowed for the acquirement of sound knowledge, and at present all that is being attempted is to carefully examine each pupil, noting the result in a case book, which will continue the whole school hfe as known to the doctor. The girls will have all routine inspection and examinations done by women doctors, unless these deem further consultation desirable. Matters of importance to educational hygiene will be noted, especially important functional matters, headaches, sleeplessness, mental fag, and so on. It is proposed in addition to institute a regular consultation hour, when any pupils with trouble or worry about their work may put down their names to see the doctor and have their minds relieved by suitable general advice, or where the teachers may consult with the doctor as to facts noticed or educational treatment to be followed with particular pupils. This service, worked in a commonsense way, will tend neither to self-consciousness nor hysteria, but will be the means of developing a knowledge of personal hygiene among the pupils, cause them to know when it is advisable to seek further medical treatment, frequently at an early stage of chronic troubles, probably prevent some illness, help to avoid the formation of bad habits, and perhaps save much futile and weary study. Already the examinations of the junior scholars show the usefulness of such work in that onethird are referred to medical or dental advisers. In examining the candidates for admission to the training colleges the need of a carefully-drawn standard of physical requirements is very evident. INFANT SCHOOLS. The scheme for the physical exercises in the infants' departments appears to be in an unsatisfactory position at present. Chiefly through the action of Government Inspectors, any drills or free standing exercises have been almost suppressed in some East End districts. This is very ill-advised, and a scheme of simple exercises to be recommended should now be issued. A definite position should be taken up on this matter, as under the careful superintendence exercised in the Council schools the infants are more likely to suffer from want of exercises than from their being overdone. The requirement of sewing as a subject in infants' schools has been maintained against all opposition for many years. The matter was taken up by the Council and after taking the opinions of teachers and superintendents it was decided that in future: There shall be no needle drill in infants' schools. There shall be no sewing of any kind below Standard I. Knitting shall be taught at the option of the Headmistress in the senior infants' class, i.e., between six and seven years of age, but knitting shall not be compulsory in any infants' department. A letter was to be written asking permission from the Board of Education to allow sewing to be omitted in the case of children between six and seven, but meanwhile the Code of the Board of Education was issued permitting this. With the removal of sewing there vanishes from the infant department the most objectionable of the mechanical and straining work done there. There is yet, however, much room for the development of spontaneity, particularly in the use of drawing and in the development of letter memories before formal writing lessons are attempted. PHYSICAL CONDITIONS. Measurements.—Some reference has been made to this subject in previous reports, and a scheme was proposed to obtain some idea, capable of statistical treatment, of the child's environment and its relation to educational progress. Curves derived from the measurements of about 3,500 children were given in the last report, and the importance of considering " out of school conditions " was shown by a study of the boys attending the Chaucer school. Some measurements were taken during the past year in connection with the school dinners scheme. All the children in several schools were examined, and also in neighbouring schools as controls, and for contrast children in some schools more remotely situated. The measurements taken represented about 20,000 children, and as some of the weighing machines in use were for English standards, two series of measurements were obtained. The results of last year's work give a third series. The comparisons of these three series are interesting as showing the variations in different groups of schools and also for comparison with groups of measurements taken elsewhere. In the present figures only children between the ages of seven and fourteen inclusive at the last birth day are taken. Group A (English measures originally), chiefly poorer class schools—Ackmar-road, Beaufort House, Glenister-road, Old Woolwich-road, and Columbia-road—includes 3,038 boys and 3,084 girls. Group B, 1906 (measurements taken on metric system), in the Acland, Burghley-road, Gipsyroad, Bellenden-road, Dulwich^ Hamlet, Bell-street, Buckingham-street, Rosendale-road, Honeywell- 11 road, Michael Faraday and Salter's-hill schools. With two exceptions these might be described as good suburban schools. The numbers in the age groups being dealt with are 4,677 boys and 4,174 girls. Group C, 1905 (measurements made last year), includes 2,119 boys and 1,594 girls at the ages considered. The sum of the three groups gives 9,834 boys and 8,852 girls, a total of 18,686 children aged seven to fourteen at their last birthdays. From these approximately correct averages may be obtained. The complete statistical treatment of the material has as yet been impossible in the time at disposal. Tables, however, are given showing the average height and average weight of boys and girls in each year of age, and the numbers in each group. The records were made on cards, each of which had a small portion snipped from the top righthand corner when the card was turned so that the child's name was upwards. This adds much to the convenience of orientation in handling them for analysis. The records on cards were noted by a system of marks:— 9834 Boys. Average heights in centimetres. Average weights in kilograms. Age last birthday. Series A. Series B. Series C. Totals. Numbers. Average heights. Numbers. Average heights. Numbers. Average heights. Numbers. Average heights. Series A. Series B. Series C. Totals. 7 159 115.9 417 116.3 86 114.7 662 116.0 21.84 22.26 21.30 22.02 8 460 119.5 674 121.8 251 119.1 1,385 120.5 23.25 23.90 22.71 23.47 9 563 124.7 760 126.2 285 123.2 1,608 125.2 25.43 25.96 24.20 25.46 10 436 129.1 710 131.1 346 127.7 1,492 129.8 27.48 27.81 26.73 27.59 11 440 133.6 635 135.9 386 132.4 1,461 134.3 29.48 30.60 29.34 29.95 12 506 137.2 704 140.1 364 137.6 1,574 138.7 32.00 33.30 31.51 32.46 13 438 141.9 642 145.4 307 141.2 1,387 143.1 34.60 36.96 34.43 36.40 14 36 144.3 135 151.9 94 144.5 265 148.3 37.02 41.00 35.52 39.23 Totals 3,038 4,677 2,119 9,834 Child's name. Teacher's estimate of mental capacity. Date of birth. Standard. School. Date. Age in years and months. Height to nearest centimetre without shoes. Weight to nearest tenth of kilogram without shoes. Condition of. Cleanliness. Clothes. Eyes. Teeth. Throat. Ears. 8852 Girls. Average heights in centimetres. Average weights in kilograms. Age last birthday. Series A. Series B. Series C. Totals. Numbers: Average heights. Numbers. Average heights. Numbers. Average heights. Numbers. Average heights. Series A. Series B. Series C. Totals. 7 181 115.7 328 115.2 35 116.0 544 115.4 21.27 1.ll 21.03 21.20 8 494 118.7 580 121.3 246 120.5 1,320 120.2 22.43 23.35 22.89 22.92 9 540 123.5 647 125.8 232 124.5 1,419 124.7 24.81 25.37 24.32 25.00 10 546 128.7 643 129.3 256 130.8 1,445 129.9 26.73 27.55 27.07 27.16 11 451 133.5 645 136.5 268 134.4 1.364 135.0 30.09 30.29 29.35 29.87 12 420 139.3 574 141.3 256 140.0 1,250 140.6 33.04 33.97 32.37 33.32 13 409 145.3 591 148.1 255 146.3 1,255 146.8 36.83 38.49 37.33 37.71 14 43 148.5 166 153.8 46 151.3 255 152.4 40.12 42.49 40.91 41.80 Totals 3,084 4,174 1,594 8,852 12006 b 2 12 The comparison of the three groups is interesting; series A and C, fairly corresponding in the general characters of the schools, also correspond in the measurements. Series B represents a considerably higher average level in the social surroundings of the children, and also greater average measurements. The next table is given for the sake of comparison; heights only are given as the weights were proportionate. It is to be noted that the London children were measured without shoes. The first column gives the average for all our London measurements. The second column gives the averages from a considerable number of American measurements made in 1890-97. The classical measurements of Boston children by Bowditch are given, and divided into two columns, non-labouring and labouring classes, showing similar diversity to our series A and B. Then two later sets of measurements are given. Those in Toronto, which, even when set out in three monthly intervals, correspond almost exactly to our series B measurements. Those in Chicago, the most recent are probably not representative of Chicago as a whole, but of better class schools, and could be matched in London by taking a suburban group of schools. Some measurements made in Lausanne are also given, and lastly a set made in Gohlis, a northern suburb of Leipsiz, separated from the city by a wide natural wooded park, the "Rosenthal," and having social conditions equal to our best group of schools, yet far below them in measurement, showing the effect, probably, of racial characteristics. Average heights in centimetres. Boys. London. F. S. Boas. Bowditch. Boas. Smedley. Combe. Hasse. Boston. Age. American generally. Toronto. Chicago. Lausanne. Leipzig Gohlis. Non-laboring. Laboring. 7 116.0 116.8 117.5 116.0 116.8 118.3 117.4 114.4 8 120.5 122.0 122.2 121.2 121.8 123.4 122.2 119.4 9 125.2 126.9 127.1 126.4 126.7 128.9 126.9 123.9 10 129.8 131.8 132.5 131.0 131.5 133.0 131.3 129.1 11 134.3 136.2 136.8 135.1 135.9 137.0 134.5 132.4 12 138.7 140.7 142.1 139.4 140.1 141.8 139.8 138.2 13 143.3 146.1 147.7 144.5 145.4 148.8 144.4 140.7 14 148.3 152.4 153.8 150.7 151.5 154.6 149.0 146.2 Girls. London. General American. Boston. Toronto. Chicago. Lausanne. Leipzig Gohlis. Age. / Non.laboring. Laboring. 7 115.4 116.1 116.3 115.4 116.0 118.5 116.3 113.7 8 120.2 121.2 121.8 120.6 120.7 122.8 121.2 117.7 9 124.7 1261 127.5 125.2 125.3 127.8 126.1 124.0 10 129.9 131.3 131.3 130.3 130.9 132.2 131.0 128.6 11 135.0 136.6 136.4 135.7 136.1 138.1 136.4 133.9 12 140.6 142.5 142.7 141.5 141.9 144.1 141.9 139.5 13 146.7 148.7 149.1 147.4 148.0 151.3 147.0 145.1 14 152.4 153.5 153.2 152.1 153.3 156.4 153.0 149.1 There is much of interest to learn from the analysis of these returns. By the time children have passed their tenth birthday, accident or chance, opportunity and ability, have distributed them all over the schools. The ten year olds in our results were distributed as follows:— Standards. I II. III. IV. V. VI. VII. Totals Girls Series A. 20 60 156 177 127 6 — 546 „ Series B. 19 33 234 251 94 12 — 643 Boys Series A 19 58 134 157 54 10 4 436 „ Series B 22 53 183 275 153 23 1 710 Totals 80 204 707 860 428 51 5 2,335 Of these 2,335 children, representing average samples, no less than 284 have got three years behind educationally, that is 12 per cent. of the whole are evidently not profiting as they should from the education offered. Taking series A alone, as the labour of reducing all the units of series B to metric measure would be unnecessarily great, the following table gives the distribution according to height and standard. 13 1347. Children of series B. Ten years old last birthday, giving standards. Heights centimetres. I. II. m. IV. V. VI. VII. Totals. Heights centimetres. Approximate inches. G. B. G. B. G. B. G. B. G. B. G. B. G. B. 106 — — — 1 — — — — — — — — — — 1 106 42 107 — — — — — — — — — — — — — — — — — 108 — — — — — — — — — — — — — — — — — 109 — — — — — — — — — — — — — — — — 43 110 — — — — — — — — — — — — — — — 110 — 111 — — — — — — — — — — — — — — — — — 112 — — — — — — — — — — — — — — — — 44 113 l — — — — — — — — — — — — — 1 — — 114 l — — — 1 1 1 — — — — — — — 4 — 45 115 2 — — 1 — 1 — — — — — — — — 4 115 — 116 — 1 3 — 3 — 2 — 1 1 — — — — 11 — — 117 — 1 1 2 4 — 1 2 — — — — — — 11 — 46 118 1 — 2 — 3 3 — 1 — 1 — — — — 11 — — 119 — — — 1 4 2 — — — — — — — — 7 — 47 120 — — 3 — 3 1 3 4 1 2 — — — — 17 120 — 121 — 1 4 3 2 4 2 5 1 — — — — — 22 — — 122 1 1 1 5 15 6 2 6 — 2 — — — — 39 — 48 123 3 1 2 3 11 5 1 5 — 3 — — — — 33 — — 124 — 1 — 5 10 13 5 8 2 — — 1 — — 45 — 49 125 1 1 1 2 12 10 8 13 2 4 — — — — 54 125 — 126 2 1 — 4 14 8 11 16 1 6 — — — — 63 — — 127 1 1 1 1 4 9 16 12 3 4 — — — — 52 — 50 128 — 1 3 4 10 16 21 16 4 8 2 2 — — 87 — — 129 — 1 1 5 19 10 11 14 4 4 1 1 — — 71 — — 130 1 3 2 6 15 7 20 14 6 13 — — — — 87 130 51 131 — 2 1 2 17 17 20 23 6 10 1 — — — 99 Mean Height. 132 2 1 4 2 12 12 15 18 8 16 1 — — 1 92 — — 133 1 1 — 1 13 8 17 14 6 12 — 3 — — 76 — 52 134 1 — — 1 13 5 14 19 6 5 — 1 — — 65 — — 135 1 1 1 — 7 14 18 13 4 10 — 2 — — 71 135 — 136 — 1 — 4 12 6 10 12 9 10 1 — — — 65 — 53 137 — 1 — — 7 3 5 8 5 8 2 3 — — 42 — — 138 — — 2 — 2 4 5 15 8 5 1 1 — — 43 — 54 139 1 1 — — 6 4 9 5 5 6 1 1 — — 39 — — 140 — — — — 3 3 8 7 2 3 1 — — — 27 140 55 141 — — — — 1 4 10 8 3 4 — 1 — — 31 — — 142 — — 1 — 5 3 5 3 4 4 — 1 — — 26 — — 143 — — — — 2 — 3 3 — 6 — — — — 14 — 56 144 — — — — 2 2 2 2 1 2 — — — — 10 — — 145 I 1 4 — I — 1 — — 8 145 — 146 — — — — — — 2 1 — — 1 — — — 4 — 57 147 — — — — 1 1 — 1 1 1 — 1 — — 6 — — 148 — — — — — — 1 — — — I— — — — 1 — 58 149 — — — — — — — — — — — — — — — — — 150 — — — — — — — 1 1 — — — — — 2 150 — 151 — — — — — — — — —' — 1 — — — 1 — 59 152 — — — — — — 1 — — — — — — — 1 — — 153 — — — — — — — — — — — — — — 1 — 60 The mean height of this group of children is 131.5 cm., about l.6 cm. higher than the average height. Setting out the table on a squared diagram of which each square horizontally represents a height of one centimetre, and each square vertically represents two scholars, marking the girls off above the central horizontal line of each standard and the boys similarly downwards diagram is obtained. The mean height being represented by the vertical white line on this diagram (Diag. 2), a very good idea of the distribution of children of this age group is obtained; the 12 per cent. dullards are also seen to be nearly all below the mean height, whilst the two or three per cent. exceptionally clever or precocious children are generally above the mean. A similar distribution of the other age groups shows that at any given age the taller children are found in the higher standards. Apparently mental efficiency, as measured by educational progress in school, is associated with physical efficiency as determined by growth. This is in accord with the facts noted by Dr. Porter in his measurements of St. Louis children, and since confirmed by other investigators. The distribution of 4164 of the girls of series B is given at each year of age in the various standards. Age. I II. III: IV. V. VI. VII. 14-15 — — — — 9 41 113 13-14 — — 15 39 125 194 214 12-13 — 9 52 79 162 196 75 11-12 — 17 118 181 237 81 9 10-11 19 33 234 251 94 12 — 9-10 54 147 339 98 8 1 — 8- 9 139 296 133 11 — 1 — 7- 8 228 88 11 1 — — — 14 And the average heights of these various groups are :— Age. L II. ' III, - IV. V. VI. VIL 14-16 — 151.4 153.1 154.2 13-14 — — 136.8 142.8 146.2 148.5 150.8 12-13 — 132.4 135.7 139.7 140.8 145.1 145.4 11-12 — 132.6 131.1 135.8 138.7 138.9 145.0 10-11 125.4 125.8 129.2 132.4 133.5 135.1 9-10 124.2 122.3 126.3 129.5 130.7 132.0 8-9 115.9 121.5 123.1 125.2 127.0 7-8 110.1 117.0 117.3 120.0 — — A similar table of average heights is obtained for the boys. 4677 boys. Age last Birthday. L II. III. • IV. V. VL VII. 14 141.5 148.9 151.2 152.5 13 — — 139.1 140.2 142.6 146.2 147.1 12 — 130.3 134.7 136.0 139.3 141.6 142.7 11 — 125.6 132.7 135.0 137.6 138.0 143.3 10 127.3 126.0 130.0 131.2 134.0 134.4 9 124.2 123.2 126.9 127.6 129.5 8 117.9 121.4 123.9 127.0 7 114.1 114.7 123.1 — — — Neglecting those over 14 years of age and those in Standard I. as subject to disturbing selection from external causes and therefore not representative, this table of average heights is represented graphically in diagram 3. 15 The first thing obvious is that at any particular age, the higher the standard of any group of girls at that age the greater the average height of the group. For instance, girls of ten to eleven if in Standard I. average 125.4 cm. in height, in Standard II. they are 125.8 cm., in Standard III. 129.2 cm., Standard IV. 132.4 c.m., Standard V. 133.5 cm., and Standard VI. 135.1 cm. high. And although it is to be remembered that with increasing age the drift of the children is both towards greater average height and higher standards, and consequently although these girls are 10.11 years old, it is probable that the age groups are not exactly comparable, those in the higher standards possibly averaging several months more than others in lower standards, and this alone would make a difference in height. To correct for this would be exceeding tedious, but may be omitted for obviously the whole amount of possible error would never reach a year's growth. The diagram shows that the effect is greater than this possible error. A group of children at any age and in any standard generally averages less height than the groups of children in higher standards, but one or more years younger. The ten-yearolds of Standard II. are not only smaller than the ten-year-olds of any higher standard, but are also less than the nine-year-olds in these higher standards. Again, these taller ten-year-olds of Standard III. are less than the small group of nine-year-olds in Standard IV. Or if older ages are taken, the 11-yearolds of Standard III. are smaller not only than those of higher standards, but also than the ten-year-olds of these same higher standards, and so on. The data for following up this enquiry are not available. Some estimate of the home conditions would have to be made, and probably this diagram expresses the effects of heredity and the pre-eminent power of the home environment towards which school is an auxiliary, sometimes an ameliorating influence. This inter-relation of hereditary and social conditions with educational results suggests the further necessity of obtaining not merely impressions, but data of a somewhat scientific order concerning the individual children, and some of the conditions of feeding, sleep, housing and heredity, as put forth in the suggestions in the Report for 1904. A chart is given on p. 10 (Diag. 1) showing the heights and weights of these 18,686 boys and girls at three monthly intervals from 7 to 14. Unless the physical measurements taken can be made applicable to individual scholars there is not likely to be any great educational benefit accrue from a regularly maintained series of anthropometric observations in schools generally. In London, where such great masses of children are being handled, measurements from time to time will be useful for purposes of comparison, but the tabulation and estimation of error (which has not yet been done with our figures) makes the task one of very great trouble. The systematic comparisons at repeated intervals of individual measurements with standard records may be of value as determining the condition of health of particular children, but regular anthropometric measurements must be looked on as of the nature of special scientific enquiries from which knowledge may be gained but which at present are not a routine necessity, for all children, in school work where so much that is useful and beneficial still remains to be done. Feeding Experiment.—A feeding experiment was suggested by the Executive Officer. It was intended to utilise the cookery centres for the provision of a limited number of cheap dinners in the schools. The scheme at first included five schools and later others were added. An attempt was made to utilise this experiment by observing fed and unfed children in these and other schools, but the conditions were quite unsuitable for the purpose and the results obtained indefinite. In first examining the children at two of the schools, Dr. Sears noted the nutrition of each, marking them according to a scale suggested in previous reports: 1 meant emaciation, 2 badly nourished, 3 indifferent, 4 good and 5 perfect nutrition. Infants under five years of age were not taken into account. Nutrition marks. 1 Emaciated. 2 Badly Nourished. 3 Indifferent. 4 Good. 5 Excellent. Total. Old Woolwich-road school Boys department — 10 173 105 11 299 Girls' department — 8 169 104 25 306 Infants-—Boys — 4 77 43 5 129 Girls — — 73 58 8 139 Total'for'school 0 22 492 310 49 873 Glenister-road school— Boys' department — 2 224 121 19 366 Girls' department — 3 158 140 25 326 Infanta—Boys — 7 127 34 2 170 Girls — 1 76 57 3 137 Special (M.D.)—Boys — 1 11 11 1 24 Girls — — 12 9 1 22 Total for school 0 14 608 372 51 1,045 These observations as to nutrition, 22 bad out of 873 at Old Woolwich-road and 14 out of 1,045 at Glenister-road, are in agreement with the feeding experiment at Buckingham-street, where 25 out 16 of an average attendance of 1,100 were regarded by the teachers of the various departments as being insufficiently fed. Dr. Sears selected certain children who were being regularly fed, others as controls poorly nourished, and also well-nourished controls, and examined and weighed them monthly, but the numbers were too few and home circumstances came in to such a degree that the results were indefinite and within the error of experiment. Buckingham-street school. At this school Dr. Rowntree took much trouble and ascertained the rate of increase at each quarter year of age of both boys and girls. He points out the difficulties in isolating conditions:—"At Buckingham-street one finds great variations in the children; the majority come from a very poor district which surrounds the school; this district is a small one, however, and is bounded by a much better part, which provides a class of children who, as regards physical condition, are above the average, many of them to a considerable extent." A certain number of children were fed free. The decision as to which were the necessitous rested entirely with the teachers, who had the advantage of more or less knowledge of the home life of the children. Children were found in the infants' department who were regarded as " bad cases," while their elder brothers and sisters had attracted no special attention. " Any precise data as to the influence for good brought about by the feeding in individual cases are impossible owing to the small number of cases in which any considerable number of meals had been given. In only one case had a meal been taken every day, while the majority had had about two or three per week." None showed any remarkable increase in weight. A few had remained stationary, as had many of the normal children, while certain children had actually lost weight, in no case more than a kilo, and in these no special circumstances could be adduced as the explanation. An investigation of all the children who had had a large number, over 35 meals, as regards increase in weight showed that this corresponded closely with the figure obtained for the whole school. There were so few being fed gratuitously that averages were out of the question ; they had gained in weight, but there was nothing noted that could be regarded as a wider variation than was found in investigating the children as a whole. DENTAL CONDITIONS. In the report last year allusion was made to the prevalence of dental troubles among children. The School Dentists' Society which has carried out careful investigations into the conditions of children in several residential and secondary schools, petitioned the Council in December, 1905. The petition asked for the appointment of properly qualified dental surgeons to all elementary schools so that dental inspection, advice, and preventative treatment might be regularly given from the earliest school age. The inclusion also in the code of instruction, under the head of general hygiene, of a short course of dental hygiene was suggested Both among children and the younger teachers, toothache and neuralgia are fruitful causes of absence from school. Except where pain drives the child to seek relief, neglect of the teeth is almost universal. It is exceptional to find children who use a tooth brush. Dr. Marion Hunter notes "Among 1,000 children, I found 2 who used a tooth brush," and Dr. Rowntree says " A few older children take credit for using a tooth brush on Sundays." In spite of the facilities which hospitals offer, he only found two cases among 6,000 who had had conservative treatment. Dr. Brincker found caries so general that he only noted those with more than four carious teeth. Dr. Hanson has attempted in two schools (Vallance Road and The Davenant) to make an estimate of the conditions of the teeth by a simple inspection of the mouths, and gives the following statement:— Ages. Children examined. Apparently healthy. At least one carious tooth. Three oarious teeth. Teeth requiring treatment. Conservative? Extraction ? 5 123 18 5 27 222 204 6 118 14 6 29 161 292 7 150 1 13 16 273 361 8 49 4 3 8 106 99 9 48 — 4 15 133 64 10 33 2 1 10 99 38 11 76 15 8 23 140 64 12 23 5 4 8 41 18 13 20 7 2 6 13 21 Dr. Niall has noted the condition of the teeth in three good class schools in Dulwich (1,645 boys 1,461 girls=3,106 children). Making a simple inspection he found that at 4 years of age 59 per cent. boys and 55 per cent. girls had apparently no disease present. This proportion decreased up till 9 or 10, when just less than 30 per cent., chiefly through loss of the milk teeth, appeared superficially to be free from caries. He alludes to the detailed examinations made by Mr. S. Spokes at Haileybury College, where 1,300 boys of the average age of 13 were found to be free from caries in only about 3 per cent, of the cases. In but few cases of the boys was there any evidence that the teeth were ever cleaned, although after 9 years of age the incidence of disease appeared Somewhat less among the girls. 17 The good result which would follow the inspection and care of the children's teeth is shown by the high percentage of children from the Lambeth Parish Schools apparently possessing perfect teeth Some of these children were born in the workhouse, but most were admitted between 7 and 9 years of age. On admission they undergo a dental inspection and have any treatment required. After that they are frequently inspected by a nurse, and twice yearly by a dentist. Each child cleans its teeth in the morning and last thing at night, and the result is that 76 per cent. of these workhouse children are free from obvious dental disease, whereas only 30 per cent. of the other children in the school are without noticeable caries. At Buckingham Street School, Dr. Rowntree noted the dental condition in 1,017 children and obtained results practically identical with those from the Dulwich schools. These inspections give results which shew the serious damage already done, and the evidence of this in an early stage would have undoubtedly been much greater had the medical Inspector used the methods with probe and mirror which a skilled dentist adopts in his work. The caries has different significance according to whether the temporary or permanent dentition is affected, and the correct recording of this is not always easy without dental experience. Most important with a view to the child's future is the condition of the first permanent teeth the " six year old molars." For this reason the full value of the facts will only be appreciated when they have been collected and analysed by a competent dental examiner. In continuation of the work of medical inspection done by Dr. C. J. Thomas at the Michael Faraday School, and recorded last year, Mr. C. Edward Wallis, who acts as dental surgeon to the Council's Industrial Schools, kindly volunteered to systematically examine and record the condition of the mouths and teeth of the children at this school. This examination is a record of actual conditions, and in contradistinction to the previous statements which are underestimated in that only obvious conditions presenting themselves on simple inspection have been noted by the medical examiners. The children were examined in groups according to the years of age. Charts were used based on those for the examination of Poor Law Schools by the British Dental Association in 1901, but amplified to shew any correlation between condition of teeth and physical condition. (The examination has been a very thorough one, each tooth being carefully inspected with a dental mirror, and tested with a probe.) Time so far has only permitted of 245 children being examined. The 245 children had on an average 3.9 carious temporary and 2.8 carious permanent teeth each. 9.3 per cent. had alveolar abscesses or fistulae discharging pus. 16.3 per cent chronic pharyngitis, 29 per cent. shewed chronic enlargement of tonsils, 61.2 per cent. had enlarged submaxillary lymphatic glands. Anaemia was noted in 37 per cent. Age approx. Boys born in. No. examined. Carious teeth temporary. Carious teeth permanent. Average per child carious. Temporary Permanent, Purulent alveolar abscess or dental fistulae. Chronic Pharyngitis. Enlarged tonsils. Enlarged Submax lymphatic glands. Anæmia. Boys. 9 1897 45 318 99 7.1 2.2 9 8 3 40 3 10 1898 43 225 107 5.2 2.5 3 1 8 37 8 11 1895 37 141 113 4.0 3.0 3 8 9 35 4 12 1894 39 62 158 1.6 4.0 1 9 22 39 7 Girls. 9 1897 44 251 112 5.7 2.5 4 7 14 36 39 10 1896 37 155 96 4.2 2.6 3 6 16 31 27 Total ... 245 1,152 685 27.8 16.8 23 39 72 218 88 Mr. Wallis notes that at the ages dealt with the permanent dentition is incomplete so that the incidence of dental caries is really worse than appears here. In most cases the permanent teeth become carious within two years of their eruption, which emphasises the necessity for dental treatment at an early age to preserve them. The most striking feature observed is the neglect of dental cleanliness, and absence of any evidence of dental treatment, beyond a few instances in which teeth have been extracted or broken. Only three of these 245 children possessed tooth brushes and showed signs of having used them regularly, and these three were practically free from caries. Bacterial deposits, tartar, remains of food, and every degree of malodorousness and sepsis were evident. Many children were suffering from undue retention of temporary teeth. Decomposing debris of food, and bacterial toxins produced in decaying teeth cavities become a constant source of ill health and debility. These causes are well recognised as the origin not only of chronic septic conditions, but also of conditions occasionally having fatal results. Most especially important is cleanliness of the mouth in children, as it has recently been shown by observations at the London Fever Hospital that the serious septic complications of scarlet fever, middle ear suppuration, septic adenitis, albuminuria, gangrenous stomatitis, septic gastritis, and so on are all much commoner and more severe where oral sepsis is marked. Anaemia was commoner among the girls than the boys in this school, but this difference of condition was not ascribed to dental conditions In most cases with extensive dental disease, the physical condition as shown by height and weight measurements fell below the average for their age. 12006 c 18 The out-patients' room of every hospital has large numbers of patients suffering from anæmia and chronic stomach troubles, and a certain number of patients in adult life who become victims of pulmonary tuberculosis probably reach this through debility, the result of chronic gastric disorder, resulting from want of teeth, and continual absorption of putrefying matter. Large numbers of young adults seen as candidates for our London teaching appointments have lost their useful grinding teeth, so that there is an extensive destruction of teeth going on quite early in life, affecting the individual's prospects; seriously damaging their wage-earning capacity, and even reducing some to a condition of semi-invalidism. The remedies for this are to be applied in early life, during the period of eruption of the permanent teeth, that is, for practical purposes during the whole of school life. These remedies are preventative, i.e., educational, which it is the duty of the educational authority not to neglect, but which duty is at present practically untouched, and curative by observation and treatment of the beginnings of disease in the teeth. Abroad, dental hygiene has a place in the school management. New York has recently started regular dental examinations of the children, and in Brussels a dental service has been in force since 1875. In Germany at Darmstadt, Wiesbaden, Mulhausen, and Strassburg, regular inspection of the teeth takes place, and Professor Jensen of Strassburg has described in a series of annual reports, the school work done there. At Ulm this year a dentist has been appointed whole time, and in Prague six school dentists have been set to work. The children are inspected and the dental condition recorded on a card; in cases requiring it the parents are notified to bring their children to the school dental institution where regular treatment is carried out. The District Inspector in discussing the report pointed out that there was a saving in attendance, as the time taken up in examination and treatment at the institution was less than that previously lost through absences for toothache. It is improbable that the English public are yet sufficiently educated to appreciate a dental inspection of school children, and to follow it up by treatment; without this it would be in great measure a waste of time. The measures then to be immediately undertaken are prophylactic and educational, and fall well within the scope of an educational authority. The very great importance of the subject requires impressing on parents and teachers, both in school and evening classes. The teeth of the child are affected by health in infancy, and even by the mother's health before birth. Their evolution is delayed by rickets, which it will be shown later affects a great proportion of our London school children. Food nowadays is too fine, too much milled and machined, and some coarse fibrous material is always required as an element in children's food. If there are to be school meals, tough fibrous vegetable material should occasionally form part of the meals. The subject of "teeth" would form an admirable object lesson. The softening of the teeth by vinegar and by acid foods such as pickles, the use of chalk to neutralise these things, and to polish the teeth, and finally the necessity for the tooth brush, are subjects to be impressed on the scholars. The majority of parents either could not or would not purchase tooth brushes. Each child at school should have its own tooth brush numbered and hung on a rack, and might be made to use it twice daily with great advantage. These suggestions are not put forward except from the consideration that it is extremely important that this matter should be followed up in a practical way. It would be a great advantage if the Council now added a dental surgeon to the medical staff, to make observations and supply suggestions for this branch of hygiene which is so extensive and important, and which requires an amount of expert knowledge which only a qualified dental practitioner can possess. PHYSICALLY DEFECTIVE IN ORDINARY SCHOOLS. The physically defective still in the elementary schools, omitting squint, harelip, cleft palate, and a few very minor defects, the effects of various troubles seen in the ordinary schools, have been considered by Dr. Rowntree. He took 14 schools representing an attendance of i4.098 children, and found 105 cases with noteworthy defects and who had not been transferred to cripple schools. Paralysis of various types 30 Tuberculous diseases 16 Congenital malformations 16 Rickets 31 Accidents and fractures 6 Spinal curvatures (marked) 3 Acute bone inflammations 3 105 Paralysis.—7 (4 girls, 3 boys) were cases of cerebral paralysis, 3 having both limbs on one side affected and 4 having the arm only, in 3 cases the right arm affected. In two cases the teachers were using great efforts to teach the children to write with deformed and atrophied right hands and neglected the education of the service of the serviceable left hands. 21 (9 girls, 12 boys) were cases of old infantile palsy. In most of these cases apparatus had been provided (irons), but in several cases these appliances were so heavy and uncomfortable that they had been discarded. 2 cases in boys were pseudo hypertrophic paralysis. 19 Tuberculosis, giving rise to physical defects of a marked character, was only noticed in 16 cases and all were healed or quiescent. The cases included: Spine 2, hip 6, knee 3, ankle 3, shoulder 1, elbow 1. This number of cases is very small, but must be accepted as representing the true state of the case, as it is excessively rare for tuberculosis of any of these parts to get well without leavirg fairly obvious traces of its presence in the class of children under consideration. On the other hand, experience shows that these are the commonest diseases treated in hospital. How is the discrepancy to be explained ; what becomes of these cases ? Some, with the disease active, are kept at home ; others, especially where the deformity is considerable, are in attendance at the special cripple centres, some in benevolent institutions. These can hardly account for all, and one is forced to the conclusion that these cases of surgical tuberculosis—the mortality of which per se is not great—in course of time disappear, succumbing not to their original disease but to some intercurrent affection which would probably leave a child without tuberculous taint unscathed. From our point of view the importance of tuberculosis is in the effects that remain after its cure. The results of treatment so far as eradication of disease is concerned were all that could be desired, but in many cases after-treatment had not been carried out, so that often great deformity had resulted, joints becoming ankylosed and knees which should have been straight being acutely bent. These results must be expected until sanatoria for surgical tuberculosis can be established where children may remain until completely cured, instead of as at present being admitted to hospital for operation and then sent out in splints to homes undesirable hygienically and wanting in the careful handling necessary for these cases. The best treatment would be a country invalid school intermediate between the hospital and the special school for physically defective children. Such invalid school of rest to which children could be sent for 3, 6, 9, or 12 months would be a great economic gain, especially as so many of the victims of tuberculosis are gifted with brains worth cultivating to the highest degree. In the "Wald Schule," as carried out in Germany, the children attend a day school in the pine forests, particularly around Berlin. Only the chronic cases of debility and early disease are admitted, and they are taught in small classes entirely in the open air. A mid-day two hours' sleep, as is common all over Germany, is allowed. Our climate raises difficulties in the way of such schools, but some special educational treatment is necessary for the debilitated children who require fresh air, sunlight, moderate school work of a literary nature and plenty of a recreative character to prevent the development of strumous or tubercular disease of a fatal or crippling kind. Congenital Malformations were of a very varied nature, deformities of the hands being the commonest. Five cases were girls with congenital dislocation of the hip. They were old enough for the maximum effect of the deformity to show, and none had had any surgical treatment except in one case. The shortening of the limb was not extensive and by thick soles or raising the boot they could all get about without difficulty, there was no pain, and one could not have recommended operation without considerable hesitation. Fractures.—In two cases of separation of the epiphysis at the lower end of the humerus the hand could not be raised to the mouth. Two cases of fracture of the femur walked with a limp. A case of fracture of base of the skull four months previously was interesting from the symptoms—impairment of memory and change for the worse in the character of the child who had become inattentive and fidgetty. Rickets..—Only 31 cases in this series presented marked evidence of rickets. Rickets, which may be said to be present in the majority of infants seen in London hospitals, profoundly affects the nutrition, being associated with retarded mental development, delay in the appearance of the teeth, and sometimes with lamellar cataract. It also leads to certain marked changes in the bones. Mr. R. C. Elmslie has studied the occurrence of rickets so far as the evidence of the bones affords. Between 3 and 8 years of age 1240 bovs and 1075 girls were examined and 158 bovs and 170 girls between 10 and 11. The proportions in percentages showing recognisable signs of past rickets were: Age. 3 4 5 6 7 Very marked deformity. Knockkneed. Bowed legs. Boys 38 40 25 15 4 1.7 l.0 Girls 36 23 18 9 4 1.0 0.7 Between 10 and 11, rickets could only be recognised with certainty in 1 out of 170 girls and 0 out of l58 boys. Only 7 per cent. of the cases of rickets were of such severity that treatment would be advisable for relief of the deformity. Only one case, a girl aged 13½ years, of the rare variety of "continued rickets" was seen. 12006 c 2 20 The effect on the growth is most marked apart from deformities. Where a family has been examined, the younger members being rickety, and the older apparently having escaped, the effect on height is very marked, the older ones approaching the average for their age, whilst the younger fall much short of this. "Normal' children in tame school classes. Rickety, but without any serious rickety deformity. Age. No. in group. Average age. Average height in centimetres No. in group. Average age. Average height in centimetren 3-4 21 3-7.6 93.1 31 3-6.9 90.7 4-5 42 4-5 99.7 48 4-4.2 95.0 5-6 66 5-6.4 106.1 39 5-5.3 101.7 6-7 125 6-5.2 109.8 70 6-5.5 106.3 254 188 The rickety infant is exceedingly likely to die before school age from bronchitis, laryngeal spasm, or in convulsions, if it contracts measles or whooping cough. Apart from a fatal event convulsions sometimes results in permanent damage. There is the mental and physical retardation also to be considered, to see that this serious nutritional disorder which is associated with improper feeding and debilitated mothers, is a serious factor in any deterioration of the public health. The most obvious remedy is education. The general want of appreciation of the hygienic needs of childhood is shown in many schools. The following extract form a school report by Mr. Bishop Harman completely expresses such conditions as found. "The children are of a respectable class. They are well fed and clothed, out are altogether a flabby and pappy lot. Almost all have palpable glands in the neck. The Head Teacher returned over 100 as defective; this seemed absurd until the children were examined, then the oft repeated note of 'delicate' is justified. The children are too respectable to play in the street. They have no near park or fields; their back gardens or house rooms are small, so they do not compare favourably, (save in cleanliness) with children in poorer quarters who play freely in the open air. The teaching of hygiene is needed in the district." PHYSICAL DEFECT AS A CAUSE OF BACKWARDNESS. Apart from those children classified on account of marked physical defects there are a number who are retarded in school on account of their physical condition. Dr. Hogarth in analysing the 600 cases of backwardness in Hoxton schools, discussed on page 44 found that physical defects or ill-health were directly responsible for 95 cases or 16 per cent. in 55 cases in spite of regular school attendance, and in 40 cases owing to prolonged absences and irregular attendance on account of illhealth. The same conditions acted as contributory causes in 91 cases, but only in 25 of these were the factors of considerable significance. Therefore, at the highest estimate, 120 cases or 20 per cent. of backwardness were chiefly due to physical defects, and 63 cases or 11 per cent. had physical defects as contributory causes. The defects noted were:— Backwardness from Physical Defects in 600 backward children. 300 Boys. 300 Girls. 600 Total. (i) Chief cause— General physical defects 9 7 16 Defects of special senses 11 21 32 General defect + defect of special senses 2 i 5 7 Absence (from ill-health or infectious disease) 15 25 40 Physical defects + absence 5 20 25 (ii) Above conditions as a contributory cause 35 31 66 Totals 77 109 186 21 A more detailed analysis of these causes and the way they influence education is of interest:— Nature of physical defect. Primary cause of backwardness in school. Contributory or secondary ■jauseof backwardness. Total. Prom defeot. By absence. Partly by defect and partly by absence. General physical defects— B. G. B. G. B. G B. G. General delicacy, anaemia, etc. ... 4 6 3 5 1 10 _ 8 37 Rheumatism, chorea, heart disease 2 1 1 3 _ 1 8 Brain fever, meningitis, etc. 1 _ 1 _ _ - 2 Lungs or chest ... 1 _ 3 3 _ 2 1 1 11 Dejects of special senses— Adenoids 2 11 _ _ 1 12 3 29 Deafness, otitis ... ... ... 1 3 _ _ 1 4 u 15 Defective vision, myopia, etc. 8 7 - - - o 11 28 General and special dejects— ... Adenoids and general delicacy ... 1 4 - - _ — _ 5 ' Deafness and bronchitis 1 _ . 1 Myopia and general delicacy _ 1 - _ - . 1 Intercurrent absences—■ Infectious diseases ... _ _ 1 4 21 8 Blight, ulcers of cornea, etc. ... - 1 5 21 3 4 30 Ringworm, scabies "bad heads" _ - 2 4 2 1 9 Operations, injuries 2 - 1 2 5 Total 22 33 15 25 5 20 35 31 18G The total number of girls whose progress has been retarded by physical defects exceeds the number of boys. This agrees with the impression obtained from casual school visits. A considerable number of the anaemic and delicate are kept away from school or even when in school are not considered fit to be " pushed on " with the other children. They are generally nervous children in a condition of irritable excitability. Of the 1,360 children in school altogether, " backward " and normal, defective vision only directly accounted for backwardness in 21 per cent, whilst 3'3 per cent, were backward solely due to defect of hearing. It is to be noted in this table that however the effects of the exanthemata may appear secondarily as backwardness due to anaemia, to otorrhoea or other such causes, yet the direct effects of the zymotics is apparently unimportant in later school life. So many children in a crowded district like Hoxton suffer these diseases either before school life or early in the infant department, that the time lost can easily be made up later, even two or three months' absence will not delay a child'?, progress from one standard to another unless it happens to come ;ust before the time for promotion. OUT OP SCHOOL WORK. " Nothing in the nature of work should be given to children, it injures their healths," thus wrote John Locke, the English father of school hygiene. The ease with which deformity may be impressed on growing structures is well known, but the impossibility of habituating a child's muscles to hard work, is not generally understood. A child under 14 cannot be " trained." It is without muscular reserve. All excess of energy is devoted to growth and development, and if a tax is placed on energy by getting muscular work out of a child, there are no reserve powers, and the child may suffer nutritionally in stunted growth and atrophied powers. It is easily damaged by attempts at long continued work without sufficient rest intervals. The muscles of a growing child are physiologically not adapted for economical use in labour. Arising out of an enquiry in the summer of 1905 into the proposed by-laws regarding the out of school work of boys, Dr. C. J. Thomas made an investigation into the conditions of 400 boys employed out of school hours. He points out that the numbers are insufficient for certainty, although sufficient to give important indications, and further that as all the examinations were done during a very hot part of the year, signs of fatigue, anaemia, irritability and loss of muscular tone were likely to be very manifest. A moderate amount of light work up to 20 hours weekly if distributed over the week does no evident harm, but above this, signs of ill-health show themselves. If, however, most of the work is done upon one day, less than 20 hours weekly may result in ill-health. 400 boys were selected by the teachers in 14 Boys' schools widely scattered over London and representing an attendance on the dates of examination of 3,864. Each boy was individually examined and notes made of the existence of anaemia, severe nerve signs, deformities of growth and severe heart signs. Fatigue—General reduction of muscular to.ie, relaxed orbiculares, head balance impaired,touch, attitude, alteration or loss of voice. Anaemia—Distinctly below normal. Severe nerve signs.—Excessive tremor, stammering, inco-ordinations, chorea, tics, altered reflexes. 22 Deformities.—Wry neck, flat foot, curvature of the spine, tilting of pelvis, unsymmetrical development. The extracts from the notes show how the results were tabulated. Reference number. Employment. Age. Standard. Retardt. Work hours weekly. Saturday hours. Fatigue. Anaemia. Nerve signs. Defect of growth. Heart signs. Remarks. Slight. Severe. Slight. Severe. K 150 Baker, 2 years 13.0 V 2 40½ 15½ X — — X — — X 2s. 6d. wkly. K 151 Milk, 3 weeks 12.5 V 1 39½ 12 X — X — — — — K 152 Harness cleaner, 2 years 13.3 V 2 14 4 X X X — Dinner hour K 153 Oil shop, 6 months 13.5 V 2 26 7 X — — — — X — Dinner hour K 154 Stores, 9 months 13.9 V 2 30½ 12½ X — — X — X — K 155 Milk 12.0 V 1 27 5½ — — — X — — Works for brother. K 156 Greengrocer 12.6 V 1 19½ 16½ X — — — X — — K 157 Doctor 12.4 V 1 38 10 X — — X — — — Dinner hour K 158 Newsagent 12.5 V 1 10½ ? — — — — — — — K 159 Shop orders boy, 1 year 12.8 V 1 40 15 — — X — X — — Basket Want offsleep is very prominent in the notes, " boy falls asleep in school," and many of these children "are got up to work before five in the morning. Many began work at comparatively early ages, some are noted as beginning at 7, 8 or 9. The holidays are often made the occasion of overwork. Immediately after the summer holiday a boy of 12 was seen with marked hysteria, globus hystericus, very emotional, wanting to cry all the time, marked tremors of the hands, tired and jaded appearance. Enquiry elicited that during the whole holiday he had been carrying half hundredweight sacks of coal from 8 a.m. till 9 p.m., and on Saturdays till midnight for two shillings a week. The notes also show the futility of the work from the point of view of wage earning, "gets a penny a day," "8 hours hard labour daily (woodchopping) for 2d. a week," "gets up at 5.30 a.m., is attending hospital for consumption." The majority of the parents did not need the children's wage. Dividing the boys into three classes according to the number of hours worked weekly the following results in percentages aie obtained:— Hours worked weekly. Actual Number of boys. Fatigue signs. Anaemia. Severe nerve signs. Deformities. Severe heart signg. All school boys of district (workers and nonworkers) 3,700 - 25 24 8 8 Working 20 or less hours 163 50 34 28 15 11 Working 20-30 hours 86 81 47 44 21 15 Working over 30 hours 95 83 45 50 22 20 This shows that whereas even work of 20 hours or less has an appreciable effect in increasing the amount of disease there is a very considerable increase in those working over 20 hours. Since, as will be apparent later, long hours on a Saturday and working during the mid-day interval have special dangers to health, boys working under these conditions have been left out in compiling the following table giving percentages presenting symptoms:— Hours worked/weekly. N umber of boys. Fatigue. Anæmia. Severe nerve signs. Deformities. Severe heart signs. All boys in several schools 3,700 — 25 24 8 8 Under 20 98 27 24 19 11 5 20-30 86 82 32 45 14 8 Over 30 22 86 41 64 23 18 Signs of ill-health in working boys, excluding those working over eight hours on one day or during the dinner hour. The elimination of boys working over 8 hours on Saturdays renders the amount of ill-health amongst those working under 20 hours weekly much less. Boys working over 8 hours on Saturday, or in dinner hour symptoms again expressed in percentages:— 23 [$###] Number of boys. Anaemia. Nerve signs. Deformities. Heart signs. All working over 8 hours on Saturday 182 50 45 23 21 Over 8 hours on Saturday, but less than 20 hours weekly 65 50 42 22 22 Over 8 hours on Saturday and over 20 hours weekly 117 53 47 24 22 All boys working in dinner hour 46 58 45 13 20 Working 8 hours on Saturday is as inimical as 30 hours during the week, and working through the dinner hour appears particularly productive of anaemia. Further analysis of the returns showed that boys who commenced work under the age of 11 suffered more severely than those commencing later, indeed many had broken down and had either to give up work or change employment. Analysing the different occupations, news-boys seemed the healthiest, this is obviously due to selection, and probably for a similar reason barbers' boys the unhealthiest. Great excess of anaemia in barbers' boys is undoubtedly directly resulting from much of their work being done in hot and gas-lit rooms. Percentage incidence of various diseases in trades:— Trade. Number. Anæmia. Nervous. Deformities. Heart Disease. All 330 40 40 17 16 Milk 63 41 46 19 21 Shop 134 38 44 26 21 Newsboys 52 35 27 6 8 Barbers 11 72 63 9 27 Retardation in school work was noted in 209 out of these 330 boys, 86 being one standard, 83 two standards, 37 three standards and 3 four standards behind that corresponding to their age. Girls are also overworked in many cases during school life. In one school, carefully examined for other matters, Dr. Marion Hunter noted 9 girls between 10 and 13 who averaged 28½ hours' work weekly out of school for a wage averaging a shilling a week and occasional meals. Want of sleep is most marked, and carrying considerable weights, even "minding babies," which sounds very harmless, is to an immature child who has to carry out a heavy baby, often the means of bringing about lateral curvature and flat-footedness that considerably impairs her future working powers. 24 It may be suggested that these precocious workers are children who have already suffered in the battle of life, whose parents are not well equipped mentally, that poverty has forced the children into this slavery, and that they are of an inferior type physically and mentally, so that apart from sentimental considerations this is not serious as a matter of national economy. It was, however, found, on making a detailed enquiry, that in two schools recorded in the last report, where the physique of the boys had been accurately noted, the children who subsequently went to do this kind of work were as follows:— Numbers. Considerably above average physique. Below average. Workers at "The Chaucer" 29 18 7 Leipsic-road 40 23 11 Total 69 41 13 Thus, only 26 per cent. were below the average physique, and of these below the average more than half were exceptionally brilliant mentally, although 17 per cent. of all were mentally below the average. These results show that this out-of-school work is a wanton dissipation of the children's powers, the chief national capital, and that the evil effect falls on the best of the children. This is in complete agreement with what I found in Bradford, that it was the sharpest and physically the best children who went off as half-timers. We must set up as an ideal the suppression of child labour below 12 years of age, and during school life regulate it to 20 hours weekly, and a maximum of 5 hours on any one day. PERSONAL CLEANLINESS. School Nurses.—The staff of school nurses numbering 12 had to be increased to 32 from April, 1906. It will also be necessary shortly to appoint a superintendent of nurses, as there is danger of the school work losing in efficiency if it is not well controlled and maintained at a uniform level in all parts of London. A more senior officer of good ability is required to deal directly with many matters which arise with teachers and parents, to smooth over difficulties, to arrange details with Divisional Superintendents, and to give attention to cases which come before the magistrates. Each nurse visits the schools in her district; examines the children for all forms of obvious uncleanliness and disease; advises the teachers in regard to exclusion of doubtful cases, and applies the Cleansing Scheme. In numerous instances children have been followed up at their homes and the influence of the nurse's visit has been seen in the parents taking a better view of their responsibilities, as ignorance is often the sole cause of uncleanliness and disease. His Majesty's Inspectors now frequently draw attention to the necessity for cultivating habits of personal cleanliness Recently in the case of a non-provided school His Majesty's Inspector stated that many of the children were in an unclean condition; that some were offensive both to their neighbours and teachers, and that unless considerable improvement was made in this very important particular the school could not be regarded as satisfactory. Speaking generally, the condition of non-provided schools is very bad in respect to cleanliness. Complaints are also received from parents that their children are compelled to sit with unclean children. The mere fact that such objectionable children should be in attendance shows that the school has to this extent failed in its aim. The labours of the nurses have been the means in a great measure of bringing to light the cases of favus, for which a special school is being provided. Often a nurse has to postpone her ordinary visits in order to give special attention to a school threatened with an outbreak of one of the gross infections, as for instance ringworm or scabies. It would be almost impossible to exaggerate the importance of the nurses' work. It has gained widespread approval, and has developed into a sanitary crusade which trains the children in habits of cleanliness and the associated self-respect. This is an educative force and does far more than a large amount of theoretical teaching of the elementary principles of hygiene unaccompanied by practice. The work has been seen by hygienists from other parts of the country and a number of local authorities have now followed the example of London in the appointment of school nurses, but these nurses must in all cases be under medical direction and have the support of a doctor for the many doubtful cases that arise. Up to the present the gross contagions alone have been dealt with by the nurses, but with the fuller medical supervision which will now be possible much useful work may be done by the nurses, in aiding the prevention of the spread of infectious diseases which play so much havoc not only with the health but with the attendance of the children. The duties already referred to are all connected with the prevention of spread of disease in schools and the inculcation of cleanly habits among the scholars. It is a prime duty of education authorities to spare no endeavour to make their schools healthy and the attendance of the scholars as free from risk as possible. Another principal which has been generally accepted is that it is the duty of authorities to discover remediable conditions in the scholars which prevent the latter from obtaining full benefit from the instruction given, to advise with 25 regard to the removal of such defects, and even conceivably to insist upon this as a necessary duty on the part of parents and guardians before the children are admitted to the classes. Cleansing Scheme.—Heads.—The number of unclean heads is steadily diminishing. Reports of various charitable societies and country holiday funds bear ample testimony to this. Managers, teachers and nurses speak in the highest praise of the good work being done in this direction. The Cleansing Scheme has been applied to 74 provided schools during the year with the following results:— Departments. Number of children examined. Clean. Verminous White cards. First notice. Red cards. Final warning. Proposed by nurse for exclusion. Excluded for prosecution. Boys 21,612 20,870 742 381 194 43 8 Girls 23,863 17,140 6,723 5,073 2,460 963 506 Infants 24,159 21.130 3,029 2,501 1,102 384 230 Mixed 2,528 2,171 357 345 119 77 35 Special 831 672 159 146 78 44 21 Total 72,993 61,983 11,010 8,446 3,953 1,511 800 The parents of 101 children have been prosecuted, and fines imposed varying from 1s. to 18s. and 2s. costs. In some cases the parents continue to neglect their children after prosecution and fine. At one school 10 children returned in an unclean condition, they were again excluded, and all returned in a fit state except two sisters. On the first occasion the parents of these two children were fined 10s., but as the unclean state was allowed to persist a further fine of 18s. and 2s. costs was imposed. Bodies and Clothing.—The Cleansing Scheme so far as unclean heads are concerned has worked satisfactorily, but constant reports were received from the teachers and nurses in regard to children who were bodily unclean and had verminous clothing. In some isolated cases action was taken by the sanitary authorities, but in most parts of London there is no public provision for the cleansing of such persons. With the co-operation of the medical officer of health an attempt has been made to cleanse the bodies and clothing of the children attending the provided schools in the Borough of St. Marylebone. The method adopted was similar to that for cleansing the heads. The nurse examined seven schools and found 65 children whose bodies and clothes were so verminous that they were unfit to be in school. The names and addresses of these children were sent to the medical officer of health, whose sanitary inspectors delivered cards stating that the children could have a warm bath and their clothes sterilised free of cost at certain hours on specified dates. Thirty-six of the children took advantage of these baths, 28 were cleansed by the mothers, and one left school. A number of these children continued to attend the baths. The following table shows the result of the experiment:— Schools. No. on roll. No. of children reported by nurse with verminous bodies.and clothes. No. of cards served by M.O.H. No. of children who took baths. No. of children cleansed by mother. Left school. Excluded for prosecution. 7 5,671 65 65 36 28 1 — It has now been decided to extend this scheme, and work it into the regular scheme co-operating with the borough council in those districts where arrangements for personal cleansing are already in force. There are children in every borough in London who require some provision for their cleansing, and for the disinfection of their clothes. Powers are now being asked for the whole of the Metropolis similar to those of the Glasgow Police Order Confirmation Act, 1904, so that if a child 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. The officers of the Education authority should deal with the matter up to the serving of the notice ; the matter should then be taken up by the local sanitary authority, but power should be reserved by the Council to take action on default of the sanitary authority. Ringworm.—Ringworm is a widely diffused disease. In the majority of cases little or no attention is paid to it after the first few weeks, and children are frequently absent from school for periods varying from twelve months to two years. The infectious nature of the disease does not appear to be fully recognised when it becomes chronic, and many children are sent to school whilst in an infectious state. Some of these cases are detected by the school nurses, and specimens of the hair sent to this 12006 D 26 office for microscopical diagnosis. The number of such specimens received during the year, which represent only doubtful cases, have been:— Number of specimens forwarded for examination. Found to be ringworm. Found to be Favus. No fungus found. Insufficient material. 988 597 104 257 30 These children would heretofore have continued to attend school, spreading the disease and ultimately causing much loss of attendance. During the same period many certificates were received from medical men, both in public and private practice, stating that children either were not suffering, or had recovered from the disease. In 72 of these cases the nurses were so doubtful of the children being really free from infection that they forwarded stumps for microscopical examination. Ringworm was found in 66 cases, favus in 4 cases, and in the remaining 2 cases the microscopic examination was negative. All cases are regarded as infectious where broken off stumps are found after careful examination of the scalp with a lens, and where such stumps on removal and after being washed with ether and mounted for a few minutes in 10 per cent. potash solution show abundance of spores of ringworm. Ringworm, then, is widely spread. It exists in several varieties. Some cases are very obstinate, and most cases are infectious for long periods. It is not fatal; scarcely ever disables the patient, and tends to spontaneous recovery about the end of school life, but the interruption of school work is a very serious matter. The following courses might be followed: (a) neglect the disease altogether; (b) continue the present policy of exclusion; or (c) adopt a very rigorous policy of repression, necessitating the provision of ringworm classes. The policy of exclusion should be continued for the present and the question of the formation of ringworm classes be considered when the favus school has been in working order for a time and when their use could be supplemented by centres for treatment. Favus.—A year ago it was recorded that in a small district of the East End we knew 79 cases of favus in school children, and that it had been decided to open a "favus school." The arrangements have all been waiting the completion of the buildings, which are to be ready in June.* The ease with which cases can be missed and the practical impossibility of cure were mentioned. Since then Dr. Bertram Abrahams has turned his attention to this disease. He was given willing and intelligent help by the teachers in all departments and he has examined every child in 21 schools of the Whitechapel, Stepney, Mile End, Shoreditch, Commercial-road and St. George's districts. Each child was inspected, and any which presented suspicious spots had hairs removed and microscopically examined after treatment with caustic soda solution. Gram's method of staining the fungus was applied as a confirmatory test. A few cultures were also kindly made for him by Dr. I. M. Bernstein in the clinical laboratory of the Westminster Hospital. Hairs were also taken from all cases which had been re-admitted as cured. Prevalence.—In the schools examined, despite the fact that 79 had been excluded during the previous year, 51 fresh cases were found. The attendance in these schools represented roundly 6,600 boys, 6,400 girls and 9,200 infants. Total 22,200. In 225 cases hairs were repeatedly examined and in 66 the fungus found. Including cases excluded previously there were 90 altogether, or 0.4 per cent. Of the 66 there were 30 boys, 16 girls, 19 in infants and one in a special school. Thirty-nine of the cases were seen in the lower four standards of the boys' and girls' schools, and 62 of the 66 were in children of foreign parents, but this is not out of the way considering the large alien population of this area. Of seventeen children who had been permitted to return to school as cured the fungus was found in eleven. In one case already excluded as favus no fungus could be found. Clinically very few cases presented the typical yellow cups, and the "mousy" odour described as characteristic was not once detected except where crusts were present. The diagnosis without microscopical examination was impossible in many cases, especially when treatment by ointments had modified the appearance. Frequently favus was complicated with impetigo, which added to the difficulty of diagnosis. In one case the character of the disease was masked by a growth having the appearance and structure of papilloma. Yellow crusts were often met with not due to favus, but an orange tint generally was associated with the fungus. The subjects of favus were often found to be children of poor physique and low nutrition. The disease does not appear to be highly contagious as only two pairs of cases occurred in the same family, although another case had a brother already excluded for the disease. Some of the worst cases were the single affected members of large families. Some of the cases observed had persisted for years; two-thirds of those returned to school as cured were found still affected. The disease appears sometimes to wear itself out, particularly if the general health improves, but no case was seen in which cure could be ascribed to medical means. The duty of the Council is to protect the healthy. Cases of favus are, therefore, permanently excluded, and soon they will be under education in a special school. The great cost of the special * The school was opened 6th June, 1906, with 61 scholars: SCARLET FEVER NOTIFICATIONS RECEIVED WEEKLY. DIPHTHERIA NOTIFICATIONS RECEIVED WEEKLY. SCARLET FEVER NOTIFICATIONS RECEIVED WEEKLY. Diagram 8. Mean Notifications, 382 Per Week. Mean Notifications, 142 Per Week DIPHTHERIA. NOTIFICATIONS RECEIVED WEEKLY. diagram 9 mean Notifications, 126 Per Week. Mean Notifications, 38 Per Week. 27 arrangements justifies this school being treated as a school for physically defectives, but the Board of Education fail to appreciate this and it has to be conducted as an ordinary school. The possibility of difficulties in regard to attendance can be foreseen as likely to arise out of this official treatment which may destroy the value of the attempt to prevent diffusion of the disease in this country. In addition to the Council's action, Dr. Abrahams points out that modern treatment by means of the X-rays affords a means whereby the disease could probably be eradicated in a comparatively short time, and that it would be a charitable and humane action if some liberal minded citizen would at a comparatively small cost establish an institution in this area where such treatment could be given. The continuous neglect of the majority of these cases, and the want of power to protect the public against offenders makes it probable that the whole question of diseases which, whilst highly objectionable from the public health point of view are not fatal, will require legislative treatment by drastic powers being given to some authority to deal with such matters as favus, ringworm and verminous conditions in a direct and effective way, compelling treatment and if necessary isolation until cured, or, at any rate inoffensive to others. It is almost certain that ringworm schools will have to follow the favus schools, and that the question of treatment by the Council will also have to be faced. In addition to the cases dealt with in this enquiry the nurses have submitted specimens from doubtful cases, or from cases supposed to be cured. These specimens are sent to the Medical Officer's laboratory with ringworm and other specimens, and a positive diagnosis of favus was sent out in 104 cases thus submitted during the year. INFECTIOUS DISEASES. Notifications.—Charts are given to show the weekly notifications of scarlet fever and of diphtheria for (a) all persons and (b) for children attending public elementary schools. The notifications of the last class cease during the holidays, with the result that the accumulation is charted for the first week after the holiday. This has simply been stated in the charts as it occurs without any attempt at correction or distribution. The weekly notifications are also shewn in percentages above and below the mean. There was a slight excess in the prevalence of scarlatina during the autumn of 1905, which gave rise to some anxiety lest an epidemic should be threatening. At no place was there any serious outbreak, but cases were distributed all over London, and there was no evidence of school influence. The general rule being the appearance of three, four or five cases singly in different classes and almost simultaneously in a school. The discussion of school influences, the meaning of the holiday remission of notified cases, and the mode of spread of scarlatina must be left over for the present. School closures.—The following table shows the closures during the year :— Department. DISEASE. Diphtheria. Scarlet Fever. Measles. Mumps. Whooping Cough. Chickenpox. No. of classrooms closed No. of departments closed. No. of classrooms closed No. of departments closed No. of j class- rooms closed No. of departments closed No. of class-rooms closed No. of lepartments closed No. of classrooms closed No. of dpartments No. of classrooms closed No. of departments closed Boys' P. — 1 — — — 1 — — — — — — N.-P. — — — — — — — — — — — — Girls' P. 1 2 2 — — 1 — — — — — — N.-P. — — — — — — — — — — — — Mixed P. — — — — — — — — — — — — N.-P. — — — — — 1 — — — — — — Infants' P. — 4 6 1 71 12 1 1 — — 2 — N.-P. — 1 1 2 19 16 — — — 1 — — In the case of measles, the disease for which most frequent class closure is required, the cases in infant's schools were distributed through the year as follows :— Month. 1905. 1906. April. May. June. July, Aug. Sept. Oct. Nov. Dec. Jan. Feb. March. Classrooms P. 4 10 8 4 — 2 11 8 2 — 18 4 N.-P. 3 4 5 1 — — — 2 — — 2 2 Departments P. 1 2 2 — — — 4 2 — — — 1 N.-P. 2 — 4 — — — — 4 1 2 3 1 Schools affected P. 5 9 9 3 — 2 9 9 — — 16 5 N.-P. 4 4 9 1 — — — 6 1 2 5 3 12006 D 2 28 Miscellaneous Closures.—One Non-provided (Infants') department was closed on account of Whooping Cough and Chicken Pox. Disinfection and cleaning.—In no case did closure involve a longer period than two days. Department. Disease. Diphtheria. Scarlet Fever. Measles. Measles and Mumps. Class room. Department. Class room. Department. Class room. Department. Class room. Department. Boys' — 1 — — — — — — Girls' — 1 — — — — — — Jun. mixed — — — — — — — 1 Infants' 1 1 — — — 1 — 1 Physically defective — — — 1 — — — — Method of School Closure.—The practice of school closure has been considerably modified as a result of the work done in the last few years, in observing the progress of disease in the schools, and chiefly through the measles enquiry in Woolwich and our experience with the bacteriological laboratory in the case of diphtheria. Certain diseases, such as enteric or typhoid fever, erysipelas, and puerperal fever are frequently the cause of trouble through sanitary inspectors serving a uniform notice for all contagious diseases. In this notice children from the house where the patient is, are forbidden to attend school. For these diseases this is unreasonable, and in the case of the last two diseases, an absurd requirement. Children coming from such houses and not themselves suffering need not have any quarantine imposed. The diffusion of scarlet fever by school means is probably in great measure not very evident in our returns. The extent of the diffusion is much less in any particular school than would be expected, and the precise mode of diffusion and spread of scarlet fever is the next question which must come up for careful study. At present the infectiousness of such cases before the child vomits or the rash appears is probably considerably overrated. A child without other symptoms but with the rash just appearing is possibly not very infectious; where, however, there is any suspicion of scarlet fever any child who vomits at school should be sent home at once, the room should be cleared of children for the day ; the ejected matter promptly removed, and strong disinfectants used, as it is unsafe to regard this material as other than a source of contagion. This rule applies to all grades of schools. Cases occur frequently where a scholar has been away for a day or two with a disease diagnosed as cold, sore throat, influenza or some such ailment without scarlatina being suspected ; later the child is found to be " peeling " in school. Where the child is otherwise well, it appears to be quite non-contagious to judge from the failure in appearance of subsequent cases, but for the child's own sake it is always excluded, and scarlatina notified. The really dangerous "carrier cases" are of the type described first by Dr. Newsholme where a convalescent from this disease has some suppurative or catarrhal conditions remaining. The commonest of these conditions being aural or nasal troubles, and apparently some small latent patch of suppurating surface about the natal sinuses or turbinal bones may keep up a condition of infectiousness for months. These are the most serious cases in regard to school attendance, and what school diffusion of this disease occurs is probably chiefly due to convalescents. Beyond the disinfection in the case of sickness referred to above, general school disinfection for scarlatina must rarely be required. In the case of diphtheria the same danger of convalescent" carriers " arises and in this case the carriers can be detected bacteriologically. Our experience is that for practical purposes the detection of the Klebs Löffler bacillus in the throat, nose or ear of any school child, however well the child itself may appear, requires the exclusion of the child till it is free from the organism. The converse does not always hold, but for all practical purposes in school work a positive or negative finding, if confirmed, may be assumed to be a sufficient, though not absolute, guide in the case of school attendance. To other organisms than the Klebs Löffler bacillus we do not attach importance. The neglect of many practitioners has been gross in this matter of diphtheria. Some doctors have certified children as free from diphtheria on mere inspection, even in some cases where they knew the child had been excluded a few hours previously. In one district our methods were rendered almost unavailing by the ignorance or carelessness of the medical men whose certificates we have hitherto felt bound to accept. In the interests of the public health it was thought desirable to take the feeling of the medical officers of health for the various metropolitan boroughs on this question. The suggestion of Dr. Annis was put forward, namely, that when diphtheria was suspected in a district, cases of sore throat or diphtheria should not be allowed to return to school until a medical certificate based on a bacteriological diagnosis had been submitted to the school authorities. Most of the medical officers agreed at once, but as there were practical difficulties likely to arise, and as many explanations of detail were wanted, a conference was desirable. The opportunity was offered at a meeting of the Metropolitan Branch of the Incorporated Society of Medical Officers of Health. This branch includes in its membership all 29 the metropolitan medical officers of health. There the whole treatment of diphtheria in regard to school attendance was discussed, and the following important resolutions passed, as a basis of action— (i.) " That in the opinion of this Branch it is not possible in the absence of a bacteriological examination to decide that a child is free from the infection of diphtheria." and further as regards the school attendance— (ii.) "In the event of the prevalence of diphtheria in any district any child excluded for sore throat should not be re-admitted to school without a medical certificate of freedom from infection, based on a bacteriological examination." Ultimately the Council passed the following resolution:— "That the Education Committee be authorised to refuse during the presence of diphtheria in any district re-admission to school of children excluded on account of diphtheria or sore throat until such children shall have obtained a medical certificate of freedom from infection, based on a bacteriological examination." In case of diphtheria becoming prevalent in any district the teachers will therefore be instructed not to re-admit any child who is absent from sore throat or diphtheria until they receive a certificate of freedom from diphtheria, based on the results of a bacteriological examination. Such certificate can be given by a private doctor, or will be given by the medical officer of health, free of cost, and it is advisable that special arrangements should be made so that specimens or cultures taken from school children, submitted by doctors or medical officers of health can be examined and reported on, free of cost, at the Council's present laboratory in connection with this department. It will also be advisable to gradually prepare an emergency staff to cope with any possible future epidemic outbreak of diphtheria, by training some of the school nurses, under careful supervision, in the precautions to be taken and the manner of making culture specimens for bacteriological testing. The Council approved of an instruction to the teachers—that no child who had been in an infectious diseases hospital should return to school for at least a fortnight after discharge. Since that rule was established, the Metropolitan Asylums Board on discharging patients from hospital have furnished them with instructions that they should not resume attendance for three weeks. A wise precaution, which, however, appears to give a somewhat longer period than required, and in consequence no suggestion has been made to alter the fortnight exclusion we require. A number of other diseases which, although infectious or contagious, are not classed under the Notification of Diseases Act, require consideration. The chief of these are measles, German measles, whooping-cough, mumps, and chicken-pox. Measles and whooping cough are exceedingly fatal diseases to very young children. Mumps is a nuisance, and excepting for exceedingly rare complications, as it has prevailed in London in my time, is a very trivial disease, so trivial that the majority of cases are returned to school in a couple of days or so with the medical assurance that nothing is wrong. As we know this disease at present it scarcely requires any regulation in regard to attendance, and any attempts to control outbreaks by exclusion would be rendered futile by the prevalent action of medical men. German measles and chicken-pox are also trivial, save that small-pox is occasionally seen so modified by vaccination that it is taken for chicken-pox, a risk which, considering the increasing proportion of unvaccinated children in the poorer class schools, has to be borne in mind, as such a case might give rise to serious or even fatal cases of small-pox. Other communicable diseases such as infectious ophthalmia, trachoma, ringworm, favus, scabies and various parasitic affections are all of so gross nature that isolation of individuals would always be advisable, school closure never. Following on what has been written about measles derived from its close study during the past three years in the Woolwich district, new rules have been adopted. As measles does not seem to spread unless between 30 to 40 per cent. of the children have not previously suffered, and ceases to spread when only 15 to 20 per cent. remain unaffected, it follows that this disease, under the conditions which hold at present in London, may be neglected in schools above the infant department. Children attending schools above the infant department if they are known not to have had the disease, and have been exposed to it, may be incubating it, and therefore should be excluded till the incubation period is over, otherwise attendance need not be interrupted. The School Management Code has now been modified in regard to these diseases, and is as follows:— "(vi) Children suffering from the following diseases must be excluded from school for the undermentioned periods:— " Measles, for at least one month. " Mumps, for one month. " Chicken-Pox, for at least two weeks, or until every scab has fallen off the scalp or body. " Whooping Cough, for as long as the cough continues and not less than five weeks from the commencing of the whooping. "(vii) Children coming from houses in which either measles, mumps, chicken-pox, or whooping cough exists must be dealt with as follows:— " (a) Children in schools other than infants' schools who have not had the disease and all children in infants' schools must be excluded. " (6) Children in schools other than infants' schools who have had the disease need not be excluded. "(viii) Children living in infected houses and excluded from school under section (vii) (a) must absent themselves for the undermentioned periods:— " Measles (i) Children attending other than infants' schools, until the Monday following the expiration of 14 days from the occurrence of the first case. (ii) Children attending infants' schools until the Monday following the expiration of 14 days from the occurrence of the last case. 30 " Mumps, for such time as the medical attendant dealing with the case deems necessary, or in cases where there is no medical attendant, for three weeks. " Chicken-Pox, for two weeks. " Whooping Cough, for two weeks." It is just possible that some little friction may occur locally in the working of these rules till they get known, but on enquiry it was found that they met with general approval from the Metropolitan Medical Officers and were in force a year ago in Brighton, and subsequently in Bristol. The general rule is to accept the suggestions made by the local sanitary authority or the medical officer of health in all cases even if such suggestions differ from the Code. It is to be hoped, however, that all these regulations will soon be modernised to agree with the Council's Code. Disinfection of school rooms where closure has taken place is generally carried out by the local authority, but a feeling is now gaining ground that in the case of measles the value of disinfection is scarcely worth its cost. In certain other diseases which, whilst extremely objectionable, are not fatal, especially in the case of people who allow their children to be habitually verminous, or send them to school with contagions, or refuse to adopt means to get rid of such disorders as scabies, ringworm or favus, some power is necessary for compelling such people to cease the nuisance that they cause other persons. The Paddington Borough Council have drawn attention to this, more particularly in the case of ringworm, which now should be regarded as capable of cure in a month by the use of Rontgen rays. It will be seen that in the working of these rules considerably increased discretion is given to the teachers. This is as it should be, but it is almost asking too much to require teachers to act against their own personal interests in decisions which are doubtful. When a question arises in matters of infection it is always best to adopt the safest course and exclude the child, but such a course penalises the teacher by reducing the attendance, and it is on attendance that grading and salary depend. Whether the school is closed for epidemics, or whether the attendance is reduced by illness, not only have the local Education Authorities to suffer indirectly through the illness, but they have rightly to continue to pay teachers' salaries and school expenses. It is therefore unjust that the share of these expenses in thelmperial Grant formerly paid under Article 101* of the old codes should have been withdrawn. Apart from this failure to contribute the just share of the cost of the school, which came roughly to some 2 per cent. of the grants, it is a premium on a teacher to act in doubtful cases against the public interest, and indirectly the step forward in the bacteriological selection of carrier cases suspected of diphtheria will cause increased cost through loss of attendance grant. The time has now come with the progress of knowledge, especially in the last four years, to reopen this question and to press on the Board of Education the necessity for allowing the epidemic grant as a national insurance against the school diffusion of disease, and a means of allowing sufficient prolongation of the convalescence period where children have been suffering from zymotic diseases. In connection with infectious diseases, insufficient attention appears to have been given to movement of the child population. On looking through the reports of suburban or rural districts, and also of charitable societies, one is struck with the frequency with which outbreaks are traced to visitors from London. It is not at all improbable that the majority of the whole child population of London has some sort of a journey to the country in the summer. During the summer holidays possibly a reduction of 20 per cent. takes place in the class forming the elementary school population. This is a point on which some enquiry will be made during the summer as it has very obvious bearings on the relations of infectious disease, the schools, and the public health. SMALL-POX AND VACCINATION. During the spring a few cases of small-pox occurred in several schools in the north-east district. A girl, D.W., aged 10, was found to be suffering from small-pox on February 17th; she had been in attendance at Teesdale-street school on February 9th. Another girl, 0.C., who had been last at school on February 8th, was also found to have small-pox. As they resided in widely separated districts and there was a possibility of an outbreak showing itself within a few days the school was visited by Dr. Tyrrell, who examined the children, and at the same time, acting on my instructions, ascertained by inspection what children were vaccinated. The numbers arc of considerable interest. Teesdale-street Council school, February, 1906. Department. Number on Roll. Children suffering. Children excluded. Vaccinated Not vaccinated. Percentage not vaccinated. Doubtful. Boys' 337 — 1 209 121 35% 7 Girls' 368 2 2 225 93 27% 16 Infants' 427 — — 232 152 39% 8 Unfortunately, the scientific question of protection from small-pox by vaccination is not clearly distinguished from the other question of whether vaccination should be compulsory by law. The question of the enormous protection afforded by vaccination against small-pox must be taken as a fact as soundly established as any matter of scientific importance in our daily life, the other subject 31 may be a highly debateable matter, but the two things are entirely distinct. It was thought inadvisable to make it appear that the school authorities were in any way trying to effect compulsion in the matter of vaccination and, therefore, on the report of these proceedings going to the Council, they resolved (April 3rd, 1906)— " That no examination of children attending schools maintained by the Council, with a view of ascertaining whether they have been vaccinated or not, be held unless the authority of the Council and parents to conduct such an examination shall have been previously given." Meanwhile, in a neighbouring school, several cases had occurred. but the threatened outbreak died away. It is probable that the risk to an unvaccinated person at present in London is very slight. The majority of the population is vaccinated, and where small-pox occurs it is at once surrounded as it were by a hedge of vaccinated persons,except perhaps in the more crowded and poorer districts, where a person may go about suffering from a slight attack, infectious but unnoticed, as so commonly happens with tramps. Although some writers have tried to establish a mode of diffusion of small-pox by the air, grosser means are more likely, and probably the risk of even an unprotected person coming in contact with small-pox is, as has been said, at the present time comparatively small. Small-pox in School Children in the last Epidemic.—During the discussion, Sir Shirley Murphy submitted for the information of the sub-committee a memorandum showing the incidence of small-pox attacks and deaths upon vaccinated and unvaccinated children of school age in London, based upon the experience of the small-pox epidemic of 1901-2. The following table shows the small-pox cases and deaths of children aged 5-13 years in the hospitals of the Metropolitan Asylums Board classified with regard to the conditions as to vaccination:— AgePeriods. Vaccinated. Unvaccinated. Doubtful.® Cases. Deaths. Cases. Deaths. Cases. Deaths. 5—7 23 0 228 50 9 1 7—10 75 1 298 43 18 4 10—13 131 2 224 48 18 3 *Cases in which no vaccination cicatrix has been observed, but in which the evidence as to vaccination is inconclusive. These figures relate solely to London small-pox cases and deaths. In order to arrive at the true relative incidence of small-pox upon persons vaccinated and upon those unvaccinated these figures need to be considered in relation to the vaccinated and unvaccinated population in London, and an accurate estimate of these two populations is a matter of some difficulty. It is, however, possible to obtain from figures given in the Local Government Board's reports what must be regarded as a maximum estimate of the unvaccinated members at the school age of the London community at the time of the last epidemic. The reports in question show the number of children remaining "unaccounted for" as regards vaccination out of the total births in each year, and it has been assumed for the present purpose that the proportion is maintained during the periods of school life under consideration. No allowance can be made by this method for children vaccinated at a later date than that for which the returns of the vaccination officers were compiled, and on this account, therefore, the estimated figures of the unvaccinated population are obviously exaggerated, and to whatever extent the exaggeration occurs the calculated incidence of small-pox upon the unvaccinated population is correspondinglv diminished. The populations thus calculated are shown in the following table:— Population at ages 5-13, years, 1901. Age periods. Vaccinated. Unvaccinated. 5— 7 131,726 45,468 7—10 214,911 50,575 10—13 216,826 35,268 These populations when applied to the cases shown in the above Table give the following rates :— Case and death rates per million living. Age period. Vaccinated. Unvaccinated. Case rate. Death rate. Case rate. Death rate. 5— 7 175 0 5,015 1,100 7—10 349 5 5,892 850 10—13 604 9 6,351 1,361 32 If the cases among persons whose vaccination is reported by the Metropolitan Asylums Board as "doubtful" be included with the vaccinated, the following rates are obtained:— Cases and death rates per million living. Age period. Vaccinated, including doubtful cases. Unvaccinated. Case rate, Death rate. Case rate. Death rate. 5— 7 243 8 5,015 1,100 7—10 433 23 5,892 850 10—13 687 23 6,351 1,361 It will be seen, therefore, from these tables that among unvaccinated children aged 5-7 years the small-pox case rate was 29 times greater than that among vaccinated children of the same age. Among children 7-10 years the unvaccinated case rate was 17 times greater than that among vaccinated children at the same age, and at the age 10-13 years the unvaccinated case rate was 11 times greater than that among vaccinated children of the same age. If the "doubtful" cases be included among the vaccinated the relative figures are as follows:—Age 5-7 years the case rate among the unvaccinated children was 21 times greater than that among the vaccinated at the same age; age 7-10 years 14 times greater; and at the age 10-13 years 9 times greater than that among vaccinated children at the same age. The corresponding ratios obtained by comparison of the rates of mortality in the two classes are as follows:— Among children aged 5-7 years the death rate among the unvaccinated was 1,100 per million living, while no deaths occurred among the vaccinated. Among unvaccinated children aged 7-10 years the small-pox death rate was 170 times greater than that among vaccinated children of the same age, while among the unvaccinated children aged 10-13 years the small pox death rate was 151 times greater than that among vaccinated children of the same age. And even including the "doubtful" cases among the vaccinated the death rate among nonvaccinated cases still shows a similar enormous preponderance. The question of whether vaccination is a powerful protective against the effects of small-pox is not one that requires further discussion. The quite different question of whether an individual either for himself or his children is willing to take part in protecting the community against smallpox by bearing the trifling risk involved in vaccination, or whether avoiding this inconvenience he takes the slight, but considerably greater risk of suffering or dying from small-pox is entirely a matter for the individual to settle for himself according to his sense of duty to himself and his fellow men. The Council having considered the subject, decided that in event of an outbreak of small-pox occurring in any school no enquiry was to be made as to whethei children attending the school had been vaccinated or not, but the school was to be carefully watched day by day. Vaccination Of Teachers.—The rules of the Board of Education requiring vaccination in all pupil teachers and candidates for the teaching profession have now been altered, and those candidates who are prepared to urge the plea of conscientious objections will be excused. There is considerable risk to a teacher of coming in contact with small-pox. In spite of the requirement of vaccination in the past the only two cases I have ever known of small-pox in teachers occurred in both cases in men who somehow had escaped vaccination. The first case died. The last is said to have escaped vaccination through illness, at the time it was demanded, having led to the requirement being overlooked. DIPHTHERIA. In our schools during 1905-6 diphtheria has continued to show the diminished prevalence which has been characteristic here in the last few years. In February, 1906, there was a decided increase in prevalence, and some fear was entertained that this might be a manifestation of a generalised and increased susceptibility likely to lead to widespread epidemic. Fortunately, through the exertions of the Medical Officers of Health, particularly in the three South London districts threatened, and with some extra help allowed by the Council for school visitation, the outbreaks remained localised, and the number of schools giving rise to anxiety steadily diminished. Of the 21 schools requiring special enquiry during the year, 12 were under observation in February and March. During the year, 982 cultures were made from children seen in school, and 95 of these showed the presence of the KlebsLöffler bacillus, 183 shewing other pseudo-diphtheroid organisms (Hoffman, etc.). As the benefits of the method of dealing with outbreaks of diphtheria in school are not yet fully appreciated, and some are to be found who doubt their efficacy, the following particulars of each school may be given briefly. From April to June, 1905, three schools only showed signs of becoming foci of dissemination. 33 Eglinton-road school (Woolwich) had had an excess of cases of diphtheria in the girls' department in the previous year; the cases in the time now under review were practically confined to a single class of eight-year-old girls. On April 8th the whole class of 45 children was examined, and in four cases cultures of Klebs Löffler bacilli found. These were excluded, but cases showed again, and on April 18th 38 children were tested, four "carriers" then detected, and it was found that a child who had escaped examination on the previous occasion, had returned to school in the interval, the mistress having admitted her because the absence was ascribed to an accident to her foot. This child was found to be a carrier, and all the fresh cases had occurred since her return to school. On this date the teacher of the class suffered from a slight sore throat, which her medical attendant notified as having diphtheria bacilli associated with it. Under these circumstances the class was closed over the Easter vacation. The whole class was again tested on June 28th, and neither diphtheria nor even pseudo organisms were then found in the cultures. In this case diphtheria continued to affect a single class over a considerable period without spreading to the other classes, and suggests some special class dissemination as by particular educational means such as pencils or "penholders. Pencil biting is a very common habit, and as these materials are collected at noon to be redistributed in a couple of hours, it is evident that they may act as vehicles of infection, and may serve to explain the fact that diphtheria is but rarely contracted by a neighbour, even when the children are sitting in the objectionable dual desks, but arises at new spots dotted over the class-room. Grafton-road (Islington, N.)—During April, 1905, some cases of diphtheria occurred amongst the infants; out of 33 cultures one boy was discovered to be a carrier, and on his exclusion the outbreak ceased. Monteith-rond {Bromley and Bow).— Owing to defective notification a number of cases had occurred at this school and the disease become widespread without our knowledge. Cultures were taken from 51 children on July 7th, and among them six carriers discovered in the upper classes of the infants' department. Being spread over several classes, pressure of other work made it impossible to undertake the large amount of work required here for complete suppression, so the school was closed till the summer vacation. From September to December eight schools came under observation specially on account of diphtheria. St. Mark's (Kennington).—Several cases were notified in children whose absence began after September 18th. On September 28th, two carrier cases were detected. One of these was a girl who had been away for 14 days previous to September 18th with tonsilitis. There can be no doubt that she suffered in reality from mild diphtheria. These two cases were in class A, and with their exclusion no further cases occurred; there having been eight cases and three exclusions in this outbreakbetween September 18th and 29th. Nine days later (October 6th), a further case occurred in class B, and the local authority interfered unnecessarily by closing the department for 14 days. Some time after reassembling another case showed on November 2nd, but no further school spread took place. Marner-street (Bromley and Bow).—Information was received on October 8th, that a child in the girls' department had died of diphtheria, and a wake had been held, which a number of her school fellows had attended. Immediate enquiry was made; 29 school girls had visited the house; they were all tested, and seven found with Klebs Löftier bacilli. Of these seven girls five had actually kissed the dead child. The exclusion of these children prevented any extension of an outbreak which might have been serious. Brompton schools (Kensington, S.),—Ten cases of diphtheria were notified on October 18th, and nine of these were in children aged 5 to 7. Investigation showed that one girl in whose class most of the cases had occurred, and who had been absent with sore throat, was a carrier of diphtheria bacilli. After her exclusion on October 20th, the outbreak ceased to have the characters of being school spread, although sporadic cases cropped up irregularly in different parts of the school for some time without it being possible to trace any connecton between them through the school. William-street, (Fulham).—An upper class of the Infant's department having had several cases, 33 of the children were bacteriologically tested, and six found to be harbouring the bacillus. On excluding them the outbreak terminated. William-street class C. Diphtheria, October, November, 1905. Dates. Oct. 13. Nov. 9. Nov. 10. Nov. 13. Nov. 20. Nov. 22. Six months subsequently. Last attendance of notified cases of diphtheria 2 1 1 1 1 — No further cases Excluded on account of diphtheria in house — — — 1 — — Excluded as result of bacteriological cultures — — — — — 5 Union-street (Woolwich).—Much illness and some diphtheria being reported, a visit of enquiry was made on December 11th, 35 infants being examined, nine presented Klebs Löffler bacilli. Measles and whooping-cough were also prevalent, and, as the children seemed in a condition of low vitality and 12006 34 likely to be disposed to aid dissemination of infections disease, the department was closed till the Christmas vacation. Lombard-wall (Greenwich).—Seven cases were notified from the infants' department immediately before the Christmas vacation. On December 18th cultures were taken from 17 children and four found to be carriers and excluded. In addition to the cases of diphtheria notified, some others had been absent for sore throats, which, it may be assumed, were mostly cases of unrecognised diphtheria. During the closing period other unrecognised cases probably occurred, for on the re-opening of the school, further cases occurred in different parts of the infant school, and there were absences for sore throat, which the Medical Officer of Health, Dr. Annis, ascertained to be diphtheritic. The school was frequently visited and carrier cases found in diminishing numbers during February and March. Practically every school absentee was followed up with great energy by Dr. Annis, who was able to demonstrate that a very large proportion of the sore throats which accompany a notified outbreak of diphtheria are really mild cases of this disease, recognisable only by bacteriological means, yet infectious. The work was rendered more arduous by the attitude of a few local practitioners, who, after the Klebs Löffler bacillus had been isolated from the throats of children, refused to look upon them as diphtheritic, and remained apparently unconvinced when other members of the family suffered from undoubtedly clinical diphtheria The neighbouring schools, particularly Glenister-road, Fossdene-road and Dreadnought-street, were carefully watched. One or two carrier cases were detected and excluded, and any school diffusion appeared to have been effectually prevented. Brandlehow-road (Wandsworth).—Five cases having occurred in the Infants' department, an investigation was begun on January 23rd. Several children had been absent with sore throat, one still in school showed a typical follicular tonsilitis, but gave, however, a pure culture of the bacillus. Nine other children gave unsatisfactory cultures, and were excluded. It was learned that in this school the drains had been temporarily obstructed and the basement flooded some weeks previously; so, although we have never had any evidence of diphtheria being diffused by faulty drainage, thorough disinfection of the basements was ordered. All these measures were aided by the co-operation of Dr. Caldwell Smith, the Medical Officer of Health., and no further case of diphtheria has occurred in the school. Wood-street (Woolwich).—An outbreak showed itself here at the end of January. On the 30th, the children were examined, and cultures showed three carrier cases among the six-year-old children. In this case the teacher had showed great discretion in at once excluding all children showing the slightest sign of ill-health, and notifying them. These were followed up by Dr. Davies, the Medical Officer of Health and, with this help what threatened to be a serious outbreak at once subsided. Wood-street, Woolwich. Class F. Ages 6-7 Infants. Diphtheria. Jan. 19. Jan. 22. Jan. 23. Jan. 24. Jan. 25. Jan. 26. Jan, 30. Six months subsequently. Number of cases 1 1 3 1 1 1 — 0 Excluded as result of bacteriological tests — — — — — — 3 0 Gordon School (Woolwich).—During the week previous to February 7th, six cases were notified. On enquiry several previous cases of sore throat came to light. Cultures were taken from these cases, and five still presented Klebs Löffler bacilli—having been mild cases of diphtheria who had returned to school whilst still infectious. A diminution in the occurrence of cases followed, and then a few recommenced, still almost entirely confined to the six-year-old class. Considerable alarm took place, and the attendance dropped in all departments; six further cases of carriers were detected and notified, and to reassure the parents the school was allowed to be closed for three weeks. Here again 23 out of the 27 cases were in the highest class (six-year-old) of the infants' and four of the six cases in the boys' department were in the lowest (eight-year-old) class. Hugon-road (Fulham).—Three recent cases having occurred in one class of nine-year-old girls, Dr. Stevenson visited here in February. No case was detected, but on a second visit three sisters who had previously been absent with sore throat, were found to give a positive result in each case. One of these girls was a member of the class affected. After their detection there were no further cases. Vauxhall-street (Kennington).—A letter was received on February 23rd, from the head mistress that there had been in the previous week two cases of diphtheria in one class and several of sore throat. On examination of the children of this class one carrier was found and three others were also excluded as doubtful. No further case occurred. This child who was excluded on account of known diphtheria, both clinical and bacteriological, was taken to an isolation hospital, but because she did not appear ill was admitted only to an observation ward, and was later sent out with an intimation to the Medical Officer of Health that it had not been a case of diphtheria. The hospital authorities offered no evidence that any bacteriological test had ever been applied. This multiplicity of authorities in London responsible for the isolation of cases of infectious disease is one of the greatest of the difficulties which those engaged in preventive medicine have to encounter. When the late authority gave permission to establish a small bacteriological laboratory, a systematic attempt was begun to control diphtheria in the schools by a scrutiny of the returns from the head teachers, and a wide testing of all suspects by bacteriological means. It was then pointed out that diphtheria seemed to be on the ebb of one of its epidemic phases. Waves of greater and less incidence spread over many years are part of the natural history of the disease, and the tendency to ascribe the * DIPHTHERIA. INCLUDING MEMBRANOUS CROUP 1892-1905. diagram 10. Mean Notifictions. 1892-1905-912 per month. Mean Notifications. 1892-1905-912 per month. 35 increasing prevalence of diphtheria to increasing school attendance receives a check in view of the still increasing attendance, with a steady decrease in notifications of the disease. Coincident with the attempted control of diphtheria in the schools by exclusion of suspects detected by bacteriological means, there was a considerable decline in the monthly notifications in London. On comparing the behaviour of diphtheria in the London school area with its behaviour in other large adjoining centres of population, it is found that this drop in the numbers of notifications in 1903 occurred only in London and West Ham. In others, such as Croydon or Willesden, no such drop took place. In West Ham this drop was followed by a considerable rise, but in the London area the low level attained in 1903 has been maintained. That this is due to the increased hygienic oversight of the Council in provided schools is almost to be expected. Although, as at West Ham, a slight increase is noticed in the number of weekly notifications, there is, as was pointed out in the last Annual Report, in spite of cases detected which would otherwise have escaped notice, an actual decrease in cases from provided schools with increase among the others. Thus had it not been for the work done in the provided schools, and this year to some extent also in the non-provided, an increase instead of decrease would probably have been the case. Further, although more than half the children of school age are upon the roll of provided schools only one third of the notifications come from these schools, in spite of the increased vigilance of both teachers and doctors in looking for slight cases. The following figures may be of interest regarding the incidence of diphtheria in London since our bacteriological examinations began in the provided in 1903, and last year in the non-provided schools. Carrier cases detected. Average weekly notifications per 100,000. All ages. Children at school ages. Children in Provided Schools. 1902-3 — 42 13.6 9.3 1903.4 58 2.9 9.7 6.7 1904-5 60 2.9 9.6 5.6 1905-6 95 2.7 8.3 5.4 The Council has now approved of the measures, referred to on page 29, to effect further security of the schools from infection. MEASLES. The deductions drawn from the study of measles during the past three years have been put in force in the new regulation referred to under school exclusions for infectious diseases. There has been no extensive outbreak during the past year. Two schools may be noted as a having contributed somewhat anomalous records. St. Thomas (Marylebone W.), Boys' department.—It is very unusual to have many cases in a senior department. Several cases occurred here, and Dr. Stevenson investigated them thoroughly. All the cases presented the symptoms of measles, and had been so diagnosed by medical men. The first cases were two brothers towards the end of February, then the first crop of six cases in their class-room, March 7th to 9th. The second crop came on March 19th. This is a school which escaped the last considerable epidemic in the district four years ago. It has no poor nor neglected children. Of 53 boys aged 8-12 in the room where the first cases occurred, only 25 had had measles, there was at least 34 per cent. of the class unprotected when the disease broke out, and assuming that the 13 boys who still give a negative measles history are unprotected, this reduces the number to 20 per cent. still unprotected. This exactly agrees with what was deduced in previous reports from the spread of measles among younger children, namely, that the disease tends to spread whenever a class has accumulated between 30 and 40 per cent. unprotected, till the proportion has been reduced to 15 to 20 per cent. unprotected. Goodrich-road (Dvlwicli).—In December, 1905, there was a very mild epidemic of 170 cases in the infant department, which has a roll of 420, whilst only one case occurred in the boys', and four in the girls' department. Dr. Alice Johnson reports that the last outbreak being in 1901, the boys and girls had been through it, whilst the infants were generally unprotected. Some cases had feverish colds in November, but these had not been diagnosed as measles by the doctors in attendance. The first case of measles reported was on December 4th. A few cases in this class constituted the first crop. The second crop presumably began on December 19th, and showed itself from then on through the holidays, and exhausted the material, there being only two cases later. This is an example of a case which used to be quoted as showing the efficacy of school closure—the fact being not that the closure affected the result, but that the material was nearly exhausted by cases infected previously and becoming ill during the holiday. 12006 E 2 36 Classes. A. B. 0. D. E. F. G&H. Ages of children 5-6 4-5 5-0 6-7 3-4 5-6 6-7 Roll 70 68 67 74 42 39 91 Number of cases 32 32 42 10 11 13 28 Date of first case 19.12.05 15.12.05 21.12.05 21.12.05 19.12.05 21.12.05 Date of last case During Christmas _ Holiday 8.1.06 Holiday 10.1.06 Number known as previously having measles 7 37 20 35 10 11 20 Number escaped 37 6 16 16 17 6 39 These two schools, investigated after the outbreak, serve also to show the difficulty of then getting definite information. Measles Enquiry in "Woolwich.—Measles was less prevalent in Woolwich than in the previous year. Small outbreaks occurred which it is important to record, as they are of considerable interest and demonstrate the value of knowing the measles history of the children. If the Suggestions of the new Education Bill become law, opportunity will be given for acquiring this information from the parents on a child's admission to school. In the last report on the Woolwich enquiry it was shown that amongst non-closing schools— in Burrage-grove especially, and in Union-street—the records demonstrated that although measles had appeared, it had not extended, and an excess of children were left unprotected. At Bloomfield-road measles had not appeared in 1904-5. Here there was gathered another accumulation of unprotected children. Again, at Bostall-lane the records contained a very large number of children who had been saved from contracting measles during the year by repeated early closing of classes, and at Vicarageroad in the Babies class closure had been successful in postponing attacks. In these five schools the chief trouble arose in this inter-epidemic year. Such records forewarn the school doctor, so that he is also fore-armed. At Burrage-grove (Woolwich), where in class F, for instance, 38 out of 66 children were unprotected, measles came in May and rapidly spread in the manner stated last year. In May 13 cases occurred in this department, and 60 in June. At Union-street, (Woolwich) where 33 babies escaped in the previous year, measles appeared in December, and 30 cases occurred. Bloomfield-road had a comparatively extensive outbreak in May. At Bostall-lane (Woolwich), with its numerous unprotected classes, measles continued to break out and be checked by closure month by month. At length an outbreak has appeared unchecked by closure, and will be detailed in a future report. It also constitutes the first outbreak in the district amongst children above the infant department. At Vicarage-road (Woolwich), in June 14 children and in the following January 12 children suffered amongst those reported last year to have escaped owing to successful closure. Closure or exclusions also took place in Conway-road, Earl-street, Purrett-road, The Slade, Timbercroft-road and The Gordon. In some instances the exclusion of children who had not previously had the disease was alone necessary. This power of discrimination is a valuable result of knowing the measles distribution in a school. At Timbercroft-road (Woolwich), where practically all the unprotected children in 1904-5 took measles, closure of a class took place in November. It was afterwards reported, however, that the complaint had been wrongly diagnosed in the child on whose account the closure had been asked for. It was suggested in last year's report that a warning to parents of unprotected children might be useful in any classes where measles has appeared, that they might be on their guard, and might also be impressed with the danger of the disease and its early infectivity. Cards have therefore been prepared for distribution and are now in use. [M.O. 19A.] LONDON COUNTY COUNCIL. Notice to The Parent or Guardian of From WOOLWICH. The Head Teacher (Infants' Dept.) firhnnl As a case of measles has occurred among the scholars in the class which your child attends,, it is possible that may have contracted the disease. As it requires about twelve days for measles to develop after infection, you are requested to pay particular regard to the state of your child's health during the NEXT THREE WEEKS, and upon the slightest sign of illness to abstain from sending to school. Date __ Signature. NOTE. Measles may be a very serious illness in young children, and many die from it. The early symptoms are those of a cold, which may be at first slight, there is generally running at the eyes and nose, sneezing anti possibly cough. Many children lose their lives because parents allow them to go out of the house, thinking that the indisposition is only a slight cold, when it is really measles. 37 For the closing half of the Woolwich district and the rest of London, the following card has been printed, and it is hoped to limit the disease by giving a card to each non-protected child when measles has appeared, urging the parents to be watchful, and to keep their children at home on the slightest symptoms of the premonitory catarrh being noticed. It is clearly right that the authorities, who alone can gain the earliest information, should at once inform the parents of children likely to be attacked, which this card serves to do. [M.O. 19.] LONDON COUNTY COUNCIL. Notice to The Parent or Guardian of From The Head Teacher (Infants' Dept.) School. As a case of measles has occurred among the scholars in the class which your child attends, it has been decided to close the class till Measles is an infectious disease. You are therefore cautioncd, in the event of your child showing any signs of this disease, to keep from contact with other children or from exposure in public places until a fortnight shall have elapsed after exposure to infection. A child who appears only to have a slight cold may have contracted measles and be dangerous to others. Any child who has contracted measles must not resume school attendance for one month. Date Signature. VISION. The acuity and other visual conditions have been treated in some detail in previous reports Attention has also been paid to the prevalence of trachoma and other contagious conditions. At present nothing further is to be added. It is noticeable how much trivial conditions of a temporary nature affect the vision. In suburban schools where cleanliness is attended to, and recurrent external eye diseases, corneal ulcerations, phlyctenulae, blepharitis, and other conditions are infrequent, a very high percentage of good vision is attained. Similar conditions hold in isolated country schools where there is a comparative absence of the numerous sources of germs of low contagious power, which readily attack the debilitated children in densely populated centres, or living in small and overcrowded rooms. The selection of children with defective acuity having been made, and cards of warning sent home, in a few cases the teachers make it their business to follow this up, but in the majority of cases the facts are merely registered and no further action taken. Even when the teachers are anxious they have to contend with much. Parents dispute the fact of bad vision, or are indifferent, or make many excuses for delay. The mother cannot afford time for hospital. She goes to work, or there are too many at hospital and some get put off. They fear the glasses will break, the girls especially have a prejudice against glasses, or the father is out of woik or too poor to pay for glasses. Sometimes glasses are obtained and not worn, especially in cases of hypermetropia, where improvement is not at once manifest; generally, if broken, the parents will not replace them, but the great fact is that when their children have been to hospital and have had glasses prescribed, many people are too poor to pay for them, reasons such as the following being given: " Father out of work two years, glasses 7s. 6d." " Widow loses a day's work whenever girl goes to hospital, child now ordered glasses, 7s. 6d." " Husband earns 27s. a week, rent is 8s., eight children and one ordered glasses which will cost 7s. 6d." " The woman has five children. The two boys have broken their glasses, which cost 7s. 6d. each. Her husband has £1 a week, and she earns 5s.," and so on. Spectacles from Hospital.—Again, cases are frequently seen of ridiculous corrections by bifocal lenses, and of children being made to wear spectacles quite unnecessarily. As, for instance, a boy, aged 14, was prescribed bifocal spectacles which cost fifteen shillings. The glasses to be worn constantly were upper parts for distance R and L plane, lower parts for near R and L + l.OD spherical. But this boy could have been spared the constant wearing of glasses by presciibing R and L + l.OD spherical for near work only, and these could have been got anywhere for a half-crown. Another case seen in the same week was a deaf girl of 11, who had extensive and old scarring of a permanent nature in both cornea:. Recently she had been prescribed bifocals, which cost fifteen shillings. They corresponded with what could be made out of the movements of the shadow test, concave glasses for the right eye and convex for the left, but vision was only ,,BC with or without the spectacles, and she might have been spared buying such expensive and useless glasses, of which indeed she looked over the top. Another boy seen a few days later wearing concave sphero-cylinders of between —2.0 and —3. OD had to be told that they were likely to be harmful. They had been prescribed two years previously after three visits to the same ophthalmic out-patient room as the two previous cases. He made three more visits and this time returned, wearing convex lenses. 38 On the day of writing this, a young girl was seen who, at the same place, had been prescribed bifocals. The glasses were R and L upper distance —0.5D sph.—0.5 D.Cyl. and lower section for near work—0.5 D.Cyl. They cost fifteen shillings and she cannot manage home work with them. A pair of simple cylinders for constant wear would have been as efficacious, caused her less disturbance in her work, and saved her parents at least ten shillings in cost. More of such cases might be narrated to show that it is not on account of caretul work or well thought-out prescriptions that patients' parents are so often asked to pay as much as fifteen shillings for glasses which the child may break in a week whilst still unused to their care. No hospital surgeon in London or elsewhere should habitually prescribe bifocal spectacles for children. It is an absurdity showing a want of appreciation of the optical needs and physiological powers of children, as well as some ignorance of human nature. Accurate measurements of the refraction are a necessity, but approximate corrections are quite sufficient for elementary school children, and rarely is it necessary to prescribe two pairs of spectacles or their equivalent. Even in hypermetropic astigmatism the young child should first be accustomed to distant glasses, and then scarcely ever will it be necessary to have increased spheres added. The class of child especially who attends hospital does not need fine corrections, and simple spheres, or, less frequently, simple cylinders should do all that is wanted. Cases of squint, which is a very serious visual defect, are of course excepted from this generalisation. For spherical glasses, tough bridges are wanted to the frames, as otherwise the brittle frames are snapped in a week and all the trouble has been expended in vain, as they are rarely replaced. On the other hand cylinders must have strong and rigid frames. One or two children can be found in almost any school whose vision can be improved perhaps a couple of lines of the test type by a little manipulation of the frames to bring the axes of the hospital spectacle eyes into the same line and restore the cylinders to their correct axial positions. The Voluntary Association For Providing Spectacles.—Having regard to the excessive cost of spectacles at hospital price, and to the fact that the law does not yet empower the Council to provide glasses, the members of the Special Schools Sub-Committee decided to form a voluntary association, of which Miss Susan Lawrence is secretary. It is called the Association for Providing Spectacles for Children in the London Elementary Schools. Where, from family reasons, any child with defective vision cannot obtain glasses, a prescription card of this Association is given to the child by the head teacher. On attending hospital the child presents the card to the prescribing surgeon, and if he is willing to help it to get glasses, he fills in the card, which is then returned to the teacher, who sends it to the Chairman of Managers. The Chairman communicates with the optician to the Association who, when sufficient children require glasses, attends the school and fits the frames. The glasses are the property of the Association, and are kept at school until paid for, unless the surgeon has ordered them for constant wear, when they are given at once. Most hospital surgeons are now aiding the work of this voluntary association. In some cases when this help is refused, it means that the hospital work has been in vain, for the child cannot procure the glasses, and may have to go to another hospital where it will be more charitably treated. The spectacles provided by the Association cost, for ordinary spherical lenses, tenpence a pair as against the hospital prices three or four times as great. For cylinders or their combinations there is a correspondingly great reduction. These frames are good enough for the first pair for any child wearing spheres, and where it is these or nothing will be of great service educationally to the children. Elaborate frames and glasses of costly construction are almost wasted on such children; to insist on their parents purchasing such, as a result of the hospital advice, is an injustice which to a great extent mars the charity for which the hospital exists. The refraction work done, almost necessarily under great difficulties and pressure in the ophthalmic out-patient rooms, has been frequently referred to by the oculists. It is neither entirely satisfactory to the hospital authorities nor to the patients, and would greatly relieve the charities if it could be elsewhere disposed of. For this reason it is mentioned on page 44 as a reason why public provision is desirable for the determination of refraction in elementary school children with visual errors and for its correction where necessary by providing spectacles of a suitable kind and at a reasonable cost. SPECIAL SCHOOLS. Provision is made for special education of children unfitted for the elementary schools by reason of special defects. This provision is under the Blind and Deaf Act of 1893, and the Defective and Epileptic Act of 1899. Between 1 and 2 per cent, of children are included in this group. Some of these children have been allowed to go on attending at non-provided schools till the extension of medical inspection has caused many of them to be examined with a view to special education. A formal examination is provided under the Act of 1899, and the parents or guardians, His Majesty's Inspector of Schools, and the child's teacher should all be given the opportunity of attending. The number of these examinations continually increases. During the past year 415 have been held, with the following results :— 89 Massed for Number of Examinations. Numbers Examined. Mentally Defective. Physically Defective. Blind. Deaf. Elementary School. Imbecile. invalids and Epileptics. April 25 322 104 54 — 6 79 10 69 May 39 444 126 61 4 6 137 14 96 June 27 392 132 56 6 7 93 12 86 July 24 363 108 58 2 7 88 16 84 September 40 528 136 104 6 3 143 15 121 October 44 688 272 90 12 11 164 20 119 November 52 740 262 103 11 19 187 21 137 December 37 472 169 66 3 4 120 12 98 January 37 388 140 57 5 6 104 10 66 February 44 536 185 82 2 17 167 12 71 March 46 681 204 88 6 28 222 21 112 Total 415 5,554 1.838 819 57 114 1,504 163 1,059 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 1905- 6 415 5,554 1,838 819 57 114 1,504 163 1,059 Last year + or - +76 + 506 + 77 + 43 - 4 + 54 +288 +15 j 33 Certain cases are either examined at once at the head office, or when referred there for more detailed investigation, not always possible at the various centres. There were 837 such individual examinations, but excluding cases seen in connection with transfers to or from residential schools and a few cases seen two or more times, there were 615 cases educationally disposed of as follows:— Deaf. Blind. Mentally Defective. Deaf. I Blind. Imbecile and Blind. Elementary Invalids and Epileptics. Mentally Defective Imbecile. High Myopia. Industrial Schools. Boys 43 24 8 6 — 88 52 20 4 7 13 Girls 39 34 7 5 1 133 79 18 2 13 11 Total 82 58 15 11 1 221 131 38 6 20 24 There is an immense amount of work in the recording of over 5,000 cases of all variety of defects and anomalies. Under our present system much of this is lost, as for the purposes of study or analysis the handling of the material becomes so laborious, and it is proposed in future to file these records on cards with the detailed notes taken. The cases seen at the office have been gone through and notes made on the groups arranged under the following headings:— Heredit.—Heredity referred to in connection with feeble-mindedness on p. 42, is also apparent on looking through the notes of these cases seen at the office. It is a subject which may have very important sociological bearings in the near future. Neglecting cases where a brother and sister, or two of the same sex in a family are affected, there are still sufficient marked cases to indicate the frequency of heredity in degenerative conditions. The first case noted is that of a boy of 12½, deaf and somewhat defective mentally, his sister is deaf and dumb, his brother of 14 is strongly suspected of having drowned a younger sister to pawn some of her clothes and was a few days later caught in the act of attempting murder on a small boy. He is now in a criminal lunatic asylum. The next family is a mother with myopia and her three daughters with some myopia, degenerative retinal (macular) changes and associated nervous troubles, all the ten brothers of these three girls are healthy. In another family three out of six children have retinal degeneration, associated with mental defect. A boy blind with cataract has his father, three unmarried aunts and grandfather in a similar condition. Then occur a mother and three daughters with congenital cataracts. Congenital or hereditary deaf mutism is represented during the past year by notes of families where deafness is common among parents or relatives, and where sixteen families include 46 children who are deaf mutes. The "Institutions for the Deaf," which bring deaf people together, are chiefly responsible for the marriages of deaf mutes, and a considerable proportion of the resulting deaf mutism in children. The subscribers to such institutions are really aiding the increase of conditions which they hope to alleviate. Every obstacle should, therefore, be raised to prevent the operation of these mischievous establishments. Deafness.—Deaf children submitted for examination at the office numbered 285; of these 141 were girls and 144 boys. Girls to the number of 26 and 44 boys were transfers—that is, cases submitted 40 with a view of transfer from a deaf school to a residential, or to some school of a different kind. Of the other 215 classified according to their hearing, the educational disposal was as follows:— Classification Educationally. Sent to Deaf Schools. Deaf and Defective for Homerton. Blind School. [Special School. Imbecile. Invalid. Elementary Schools. Otherwise disposed. I.—Total deafness without speech— 40 girls 38 1 — — 1 — — 42 boys 39 1 — — 1 1 — — II.—Remains of hearing but no speech— 22 girls 15 2 1 4 18 boys 13 3 — 1 — 1 — — III.—Some hearing and some speech— 17 girls 9 — 1 3 1 3 — — 10 boys 5 4 — 1 — — — — IV.—Hard of hearing with useful speech— 1 .4 36 girls 5 1 — 1 1 2 23 3 30 boys 5 1 — 2 — — 21 1 f these, 3 girls were exempt from school, 1 boy sent to industrial). The majority of children in group I were cases of hereditary congenital deaf mutism. The next two groups were mostly cases of neglected middle ear suppuration, the results of colds or acute fevers. Scarlatina does not figure very largely at present as a cause of bringing children into the deaf schools. The last group is almost entirely cases due to throat deafness from neglected adenoids or nasal obstruction; they had been submitted by teachers as unfit for ordinary school work, and this very correctly. Many of them were so improved during the month or two of probation given before sending them to a deaf school, that they were rendered fit for the elementary school. Strictly speaking, none of these 44 children would have been sent to the elementary school had any more suitable place been available. In none of these cases could hearing for speech be taken as more than a fifth off normal. A forced whisper heard at 25 yards is normal hearing for school children. Eight cases were assigned to meningitis. In five of these it was a sudden illness about the age of three. The child was taken either with fits or vomiting, and recovered, but was unable to walk steadily for some time, and was stone deaf, rapidly losing speech. Two others had meningitis of which no account beyond the name of the disease could be given, and one boy of five had had "tubercular meningitis" diagnosed and been "unconscious for months." All these cases presented absolute nerve deafness. In America, cerebro-spinal meningitis is the commonest cause assigned for total deafness, but it is a very rare disease in this country. It is to be remarked that of the whole 615 cases seen, 33 have alien names, and of these 15 are cases of deaf mutes, three being so mentally defective that two of them were rejected as imbeciles High Myopia.—In looking through the notes of the cases which have been seen at the Head office 44 are cases of myopia, varying from 6 to 16 dioptres in children between 5 and 15 years of age; 31 were girls and 13 boys, although it is generally understood that both sexes are equally disposed to myopia. In doubtful cases the manner of disposal of these children was to explain the nature of the disorder to the parents, to point out the kind of education suitable, and to recommend them to consult their medical advisers and let us know their decision as to education. The children were treated as follows: 13 (4 boys, 9 girls) as invalids, temporary or permanent, 15 (5 boys and 10 girls) sent to blind schools to be educated, wearing opaque shades during school time, 2 girls to special schools (one deaf and one feeble-minded). Other 14 (4 boys and 10 girls) were sent to the ordinary elementary schools, but with advice to the parents as to eye hygiene and a recommendation to the schools to excuse the child from all fine eye work and reading, writing or drawing. Some teachers objected that this was impossible, but that was merely because they took a very narrow view of a teacher's duties. It was noteworthy that in very few of these cases had any surgical treatment been considered, although several were suitable for operation. None of the 14 cases sent to the elementary schools were really suitable for these schools, and the 15 sent to blind schools went against the parents' wish in most cases; at least half of the 13 recorded as invalid might also have been in school had a school existed adapted to such cases. At the same time, it is quite certain that school conditions are not the cause of this variety of myopia. In at least 40 out of the 44 cases, if the parents refused the educational treatment offered them, nothing further could have been done, as there are no proper educational facilities for these children, and, it may be added, there are twenty times the number of other eye cases equally in need of schools adapted to their conditions. 41 Congenital Syphilis.—In 50 of the 615 cases submitted for my examination, there was strongly-marked evidence of inherited specific disease (congenital syphilis). These 50 are only the children whose lives have been so ruined that they were deemed unfit for school, but there remain hundreds who are still able to attend school or are invalided for a time, but for whom special education does not need to come in question. It was very difficult to assign places to some of the 27 girls and 23 boys thus noted ; for instance, 15 of them had degrees of blindness and deafness combined. Three 13-year-old children, previously intelligent, were undergoing mental degeneration of the most marked kind, unfitting them for any education. The educational treatment allotted to these children was as follows:— Invalided. Blind Schools. Deaf. Homerton. Elementary School. Various Special. 27 Girls 11 7 4 — 4 1 23 Boys 9 4 1 2 5 2 Epileptics.—It is scarcely realised how urgently definite provision for all classes of epileptics is wanted in London. In 100 cases examined during the year, epilepsy was scheduled as the chief trouble. Here, as is so frequently the case, multiplicity of authorities results in an impasse. Were all public authorities for special purposes under the ultimate direction of the County Council, this great and crying evil of no accommodation existing, except for wealthy or pauper epileptics, would soon be removed. An epileptic is always a source of trouble and distress, not only to himself but to others. The attacks are often exceedingly alarming, and when, as is frequently the case, a whole household, perhaps of tired workers, is roused night after night by shrieks of a relative; or when they are subject to recurrent though transient attacks of aberration, violence, or even more persistent unreasonableness and wilfulness by epileptic children, life becomes a burden. Its weight is no less heavy because the complaints are not organised by associations or published to the world. The great unseen burden exists, and the ever present fear of accident, or possibly of the criminal or even murderous outbreaks we hear of, presses hourly on thousands in London, who are too poor to pay the charges required for relief, or not poor enough, or the sufferer not bad enough to compel the guardians to do their duty. The appeals and complaints of harassed or worn-out relatives which come almost daily make it necessary to urge on every one the necessity of this question being dealt with, and at once. So far as school children are concerned, the duty of providing the special education lies with the Council, as education authority. Education for epileptics, in most cases, can only be properly managed in residential institutions. The ordinary schools are thereby freed from interruption, the patients safeguarded from accident, and the lives of their immediate relatives freed from an intolerable strain and anxiety. Considering that heredity is a more marked feature in epilepsy than perhaps in any other disease, the question of custodial or other preventive treatment must come up in future, but at present does not in any way complicate the educational question. Whatever ultimate methods may be adopted children will always have to be separately cared for, housed, and educated, apart from older patients. Epileptic children will be best treated in a school colony, which should be large enough to admit of classification, and to which every case, however complicated, may be sent. The late authority in 1903, entered into some negotiations with the National Society for the Employment of Epileptics. It was proposed that the Society and School Board should co-operate in establishing an epileptic school in connection with the Chalfont Colony. There was no particular advantage in such a school being established there, and serious disadvantages in want of control, and the scheme was not carried through. During last year, the chairman of the special schools sub-committee and some of the members had a conference with various Council officials in regard to special school accommodation, and it was then suggested that the Christian Social Union, which maintains homes for epileptics at Lingfield, would make arrangements for boarding and educating the children sent by the County Council. There has been some negotiations with representatives of the Lingfield Homes and a suggestion has been put forward as to an arrangement for increasing the accommodation by at least 200 places to provide for these children. Meanwhile, as a temporary arrangement, a few places are being paid for, but they are quite inadequate in number, and at present, practically every case which cannot be kept at a day school, has to be scheduled as epileptic and 85 per cent. written off as unfit for school, losing education and often running the streets. No arrangements will be satisfactory unless all epileptic cases can be taken, however degraded, troublesome or afflicted they may be. Probably the very cases which are most urgent will remain on our hands, unless the Council itself makes provision and manages the whole care and education of London epileptic children. It is a permanent problem, which will remain with us, and one not suitable for temporary treatment. Epileptics scheduled during 1905-6. 12006 F 42 For Elementary School. For M.D. School. Invalid. Imbecile. Remain at Special School Excluded unfit. Total. Boys 7 3 29 3 2 11 55 Girls 9 3 33 3 2 8 58 THE ASSOCIATIONS OP MENTAL DEFICIENCY. Enquiries were made by Miss E. Sayer, M.B., into the family history and surroundings of 100 consecutive cases of mental deficiency occurring in the special schools for Mentally Defectives. Then, in order to make a comparison between the conditions affecting the mentally defective and the normal child similar enquiries were made concerning 100 children from corresponding ordinary schools. In order to avoid selection every seventh name on the register was chosen. Careful enquiries at the homes and the compilation of a genealogical tree for every child, assigning all the facts that could be obtained from the enquiry, afforded the data for the following statements. Some reason was given why the mentally defective child should, to its own disadvantage, vary from the normal in 98 per cent.of cases. Causes assigned— Accident in childhood involving injury to head 4 per cent. Repeated illnesses (damaging special senses and preventing attendance at school) 5 per cent. Difficult labour (in each case lasting three days and being terminated by instruments). One head still bears strong evidence of delayed face presentation 3 per cent. Accident to or iLlness of mother during pregnancy. Severe fall 2 per cent. Typhoid 1 per cent. (7 other children and parents all normal). Esbolics 1 per cent. Other illnesses 4 por cent. Cruelty (knocked about by drunken husband) 6 per cent. 14 per cent. One parent mentally defective 34 per cent. One parent insane 2 per cent. One parent epileptic 3 per cent. One parent drunkard 42 per cent. One parent syphilitic 6 per cent. Additional disadvantages from which the mentally defective child suffers will be shown to be poverty, hereditary diseases, and exhaustion of the mother, owing to the rapidity with which an abnormally large number of children are born. Home Surroundings.—In 4 per cent. of normal and in 40 per cent. of mentally defective there is a history of abject poverty occasionally, and notably at the time of the birth of the child. By this is meant the father being out of work, family living in one room on insufficient food, the mother earning some money by doing some "odd jobs." In several cases the woman said she did not have enough to eat during the whole of the pregnancy. Size of Family.—The following table shows that the average normal family is five, whereas in families where mentally defective cases occur it is 7'6. These figures are, however, not final as the mothers interviewed were of all ages from 24 years onward. 100 families of each class. No. children alive. No. M.D. No mbecile. No. with tubercular; disease. No. dead. Assigned cause of death. Still-born. Miscarriages. Total. Specific fevers. Convulsions teething. Tubercle. Consumptive bowels. Various causes. Nofmal 387 0 0 2 84 33 19 1 3 28 12 23 506 76% 16% 39% 2% 4% M.D 467 24 4 10 176 26 48 13 14 75 17 101 761 64% 22% 14% 2% 13% *Not including the cases investigated. The mothers of mentally deficient children thus have larger families, but a larger percentage die the majority of these doing so in the first year of life, a much smaller proportion (14:39) dying of specific fevers later. Although probably a considerably greater proportion of these are included under "various causes" among the mentally deficient than among the normal. In addition to the increased chance of pregnancy (especially in those families where there is poverty, drunkenness, or mental deficiency of the parents) there is a greater likelihood to miscarry (13:4). Among the sisters and brothers of the 100 mentally deficient children there were 4 imbeciles and 24 other mentally defectives. 43 M.D. Insanity. Suicide. Epilepsy. Alcohol. Consumption. Heart. Cancer. Delicate. Poverty. Syphilis. Normal children— Parents 2 — — — 6 3 2 2 14 4 ? Family history — 7 2 6 1 36 8 13 — — ? Mentally defective children— Parents 34 2 2 3 42 13 3 — 18 40 6 Family history 3 29 5 8 7 53 10 8 — — 1 Whilst 65 per cent normal children have both parents normal in intelligence and physique, this is only noted for 22 per cent, mentally deficient children, and some of the latter had parents debilitated by poverty but organically sound. Mental Deficiency.—34 per cent. of mentally deficient children have one parent mentally deficient, i.e., obviously below the average in general intelligence, and although they had been to school were unable to read and write at all or only very little. Two of these cases suffer from delusions and their sanity is doubtful, 2 per cent more died insane, 2 per cent. committed suicide, 3 per cent. epileptic. Alcoholism.—A definite history of drunkenness of one parent obtainable in 6 per cent. normal, 42 per cent. mentally deficient children. Consumption.—2 per cent. of the normal and 13 per cent. mentally deficient children have one parent in consumption, of the latter eight are already dead. Family History.—Owing to the greater intelligence of the informants this can usually be obtained further back and with greater completeness in the normal cases. Especially more prevalent among the relations, not counting brothers and sisters of mentally deficient children one finds consumption (53:32) and insanity (29:7). Among normal children there are more case3 of death of relatives from old age, bronchitis, heart failure, and also cancer. The numbers in this enquiry were comparatively small, but the time required to obtain the facts was considerable, and although another observer is making a similar enquiry, to eliminate the personal equation, and to check these results it is evident that what may be termed "errors of experiment" can scarcely come in here to such an extent as to vitiate, or even materially modify the general deductions as to the very close associations of mental defect or drunkenness in the parents, with mental defect in the child, and the prevalence in the family histories of such children of poverty, high infantile death rates, phthisis, and insanity to a far greater degree than in the case of normal children in the same rank of life. PUBLIC PROVISION FOR MEDICAL TREATMENT OF CERTAIN CHILDREN. Apart from the question of cruelty arising out of the neglect of treatment for certain diseases, such as the non-notifiable infectious diseases like ringworm and favus or trachoma, there are also some chronic troubles, particularly certain eye affections and discharging ears which require remedy. In addition, there is the whole subject of dental care, which applied during school life would profoundly influence the public health, but which will always be unsatisfactory until actual dental treatment is given in connection with the schools. Favus is a very good illustrative disease to take. A certain number of cases attend hospital, of which a very few are cured, some after a short attendance give up, or are said to be cured, and the disease speedily relapses; others never have treatment and refuse to have it. The Favus School Nurse reports a family of six. One attends the school, four other children are at present infected, and the parents will not seek any treatment. The condition is simply neglected. The disease was practically incurable till recently. It can now be cured by the use of the Rontgen rays. The apparatus is costly and delicate. Its use requires expert knowledge, it can never become general among medical men. The prevention of diffusion of favus is a duty of the Public Health Department, and we are attempting this in the schools, but the provision of treatment for this disease is essentially a public duty, and should not be left to private charities. The question is likely to become acute in connection with the new Favus School, where about one-third of the children are receiving no treatment. Again, in the case of ringworm, present methods are dealing most superficially with the nuisance. In spite of pressure no attempt is made to treat probably half of the cases known to the nurses. Even if treated assiduously, many cases are exceedingly protracted. Here, again, the Rontgen rays treatment is the most satisfactory method After a time with ordinary methods many cases become chronic. The parents neglect them, and the dootors are glad to see the last of them. The only logical course to pursue is either to neglect ringworm altogether or to provide public means of treating it thoroughly. We require ringworm classes to be formed, to which all cases, after the lapse of a certain time allowed for treatment and the chance of cure, should be sent on becoming chronic, and 12006 F 2 44 a certain number of centres to which cases could go from the ringworm classes for treatment. It is quite impossible for the general hospitals to deal with a disorder of this magnitude. To the Educational Authority the saving in loss of grant will pay the capital expense in a few months. In the cases of ringworm and favus there seems a clear field for public treatment of all affected children, and it is quite possible to define the limits of treatment. There are, however, other diseases where the result of treatment to be obtained at hospitals is so unsatisfactory that it would be almost advisable that public provision should be made for these cases, the only difficulty being the restriction of the class of cases to be treated. The determination of the refraction of school children where ocular defect is suspected, and the provision of spectacles where necessary, at a reasonable price, would much relieve the work of the hospitals, and also save many children from the suffering and damage that so often results from the treatment of the "qualified optician." All cases seen complicated by other than refractive trouble could be referred for further treatment elsewhere. Powers should be obtained by the Council for this purpose. The treatment of discharging ears may be looked upon as practically impossible to be managed at the hospitals, patients will not attend daily, beds cannot be afforded, and possibly not more than ten per cent. of the cases get advice or treatment that results in any permanent benefit, and yet it is a most dangerous condition, The actual risk of neglect here has been compared by one of the most eminent of our surgeons to that of carrying a dynamite cartridge in the pocket. Every child with this condition, whether the result of infectious disease or a mere cold, requires treatment following up until the discharge ceases. An invalid school where regular treatment can be followed out is required for these cases. Every case should be passed in until cured. Such a school need not be residential. Here, again, a difficulty arises, as many cases which resist protracted treatment would have to be passed on elsewhere for operation. The question of invalid schools of recovery, seaside schools, or country convalescent schools for scholars in failing health or threatened by early tuberculous disease is one of the greatest economic importance, as a preventative of disease, which at present is allowed to gradually establish itself in many children, and render them permanently inefficient. Children should be taken there and kept till healthy, not merely relieved from the moat urgent symptoms and sent out again to drag away months till urgent symptoms again supervene, as is the common history of such cases at present. Should section 24 of the Education Act now under consideration in Parliament become law it will probably be advisable to abandon the principle of "no treatment" in connection with the Public Health Department and by public provision of treatment for certain common conditions such as those referred to above free the hospital authorities from the crowds of common cases, which at present they cannot manage even to their own satisfaction CAUSES OF BACKWARDNESS IN THE STANDARDS. The children who are backward in their standards form a serious item in the roll of schools in some districts. The cases, however, where the retardation amounts to as much as 3 years of school life are not very many. Dr. Critchley noted in 18 Battersea schools that the number of children over 10 years old in Standard I. was 57, and he put the cause down roughly to mental defect in 22 cases, merely backward 20, and dull 15. Particular schools are known where there is a considerable excess of defective or backward children, and in most of these cases this has come about by a process of selection. A school may be recently opened in a district, there is some inaccessibility or other feature which has prevented it being filled as readily as other schools, so that the teachers of other schools are enabled to select children admitted to their schools, whilst all the others drift to this particular school. This process of selection should be further developed by the institution of intermediate schools, and with a curriculum on a lower intellectual plane than the ordinary elementary school. The educational importance of backwardness and its causes has suggested its investigation in the schools of Hoxton and Haggerston by Dr. A. H. Hogarth. The term "bacKwardness" generally connotes a certain lack of intelligence and is often euphemistically employed for mental dulness. An arbitrary criterion of backwardness was, therefore, taken by assuming that a normal child who began schooling at 4 or 5 years of age would reach Standard I. by 7 years of age, and thereafter progress a standard annually, passing out of Standard VII. and the school at its fourteenth year. All children who fail to pass through the standards in this way are abnormal in that they do not obtain the full benefit of their education. It is quite possible that a boy of 14 years of age in Standard V. may be more intelligent than a boy of the same age in Standard VII.; but the one has not obtained the full benefit of his education, whilst the other has done his best. Even the boys in a school who are sharpest in other respects may be backward in relation to schoolwork, especially when they are wage earning for the greater part of their time out of school. In this enquiry, then, all who failed to pass up to their standard at the regular age were considered backward. Fourteen schools were visited, with a roll of 9,500 children, 8,450 being present. Of these 2,900 were backward according to the above definition—1,400 boys and 1,500 girls, approximately one third. Although these figures may appear very high, the tendency was to keep them as low as possible, and in every case a child was given 9 or 10 months' grace as far as age was concerned, so that no child was 45 considered over age who was less than 7 years 9 months old at the time when he ought to have been promoted to Standard II., or less than 8 years 9 months old when he should have been promoted to Standard III., and so on. As the investigations were dated from October, 1905, it was easy to take all children over the age limit, that is 8 years in Standard I. and so on, who had not received their promotion in the previous July. With the co-operation of the teachers each child was submitted to an individual examination. A preliminary testing of 100 children was made to gain experience, but these records were not included. So far, only 600 children, 300 boys and 300 girls, have been examined. These represent, except for 30 girls and a few absentees, all the over-age children in the standards of two schools in Hoxton. The number present on the days of examination was 660 girls and 700 boys, and of these 42 per cent. boys and 50 per cent. girls fell within the definition of backward. One of these schools, credited with being the worst in the district, had 53 per cent. boys and 66 per cent. girls backward, but other schools of the 15 in the district have as high a percentage. The other school had 33 per cent. boys and 36 per cent. girls, so that the two schools together may be taken as about representing an average of the district. So far as could be ascertained, neither the teachers nor teaching could be in any way blamed for the amount of backwardness found. The points noted regarding each child were:— 1. The number of previous schools attended, the various standards passed, and the child's age on admission to its present school. 2. The general physique and previous health, especially during school years. 3. The efficiency of the special sense organs as channels of education. 4. The mental capacity. 5. Regularity of attendance, and any previous prolonged absences. 6. Miscellaneous information, chiefly from teachers, regarding home circumstances or any other matters likely to affect the child's school progress. The estimate of the mental conditions was indirectly checked by one of the Council's inspectors independently who, without being informed of the particular enquiry, reported on the individual mental attainments of the scholars. His judgment agreed with that of the medical observer in 67 per cent.; he thought the children mentally worse than the doctor had done in 18 per cent. and somewhat better in 15 per cent. It was difficult to keep the classification within bounds and yet do justice to the variety of causes, and the most important point was to gauge this mental capacity. The children were classified as:— Quick-witted and intelligent, and either equal to or above the average of their standard in mental attainments, or Slow-witted and dull, and below the average of their standard. A hard and fast line was drawn between these two classes, and in very few cases was there any difficulty in deciding whether a child was to go above or below the line. The investigation then followed similar lines for each class. Classification of Backward Children.—Group I. Intelligent but backward children. Children of average intelligence:— (а) Backwardness in the lower standards, or on admission to present school, without any obvious cause. For the most part due to natural dulness in infancy with later mental development, and in a few cases due to lateness of first school attendance, or possibly want of correlation between infants and higher departments. (б) Physical deficiencies, not causing absence from school. i. General diseases, real or imaginary, ansemia, fits, general delicacy, the dread of St. Vitus' dance, the "overpressed" and neurasthenic children. ii. Affections of special senses. Hearing, vision, etc. (c) Social and moral deficiencies. i. Of parents. Bad environment, poverty, neglect and worse. ii. Of the child. Laziness, moral weakness. (d) Non-attendance. i. Ill-health, prolonged absence, frequent absence. ii. Intentional or avoidable. iii. Frequent change of school. Group II.—Dull and backward.—Children whose intelligence is below the average of their standard. (a) Mental incapacity. i. Amentia, i.e., idiocy, imbecility, cretinism, etc. ii. Mentally defective, i.e., suitable for special schools. iii. Natural dulness not secondary to any obvious cause, i.e., physiological. (b) Physical deficiencies (not causing absence). i ii As in class I. (c) Social and moral deficiencies. i. ii. As before. iii. (d) Non-attendance. i. ii As before. iii 46 In no case was an associated condition accepted as the cause of backwardness unless it was shown that the child was kept back a year or more owing to that particular condition. For instance, the object was not to find how many children were suffering from short sight, but to find in how many cases short sight was the cause of backwardness. Again, the first heading in Group I. of the classification covers a large and definite class of children whose backwardness was probably caused by earlier physiological dulness, and who, at the time of the examination, had just crossed the line separating the bright and dull, or who had actually become sharp. This late mental development generally occurs about 10 or 12 years of age in Standard II., III. or IV., and often appears as the satisfactory result of much labour and individual attention on the part of the teacher. In this group are also included not more than 5 per cent, of all backward children who did not go to school till late in life, or who possibly from some flaw in correlation between the two departments had been left another year in the infants' school. The group of physical defects is dealt with in some detail on p. Group II., consisting of the dull and backward children, includes all those who are a drag on the rest of the class, and make very little progress in the standards. Mental incapacity has been divided into three heads; the first two do not come into consideration here, as they should not be in elementary schools, or only in special classes. The remainder constitute a large proportion of the dull children and suffer from so-called physiological or natural dulness, not secondary to any known cause. Of the 600 children examined, 370, or 61.7 per cent., were placed in Group I. as intelligent children and capable of deriving benefit from instruction; while of the remaining,230,or 33.3 per cent., were placed in Group II. as, in addition to being a hindrance to the progress of the class and a tax upon the teacher, they are not capable of deriving material benefit from the ordinary routine of the elementary schools. With regard to Group I., the 370 intelligent but backward children, it was found that 41 per cent, boys and 34 per cent, girls had been dull children in their infancy or in the lower standards, while 27 per cent, boys and 26 per cent, girls were backward as the result of prolonged or frequent absences, unavoidable or intentional, and of these, frequent change of school accounted for nearly half. Physical defects of general or special organs accounted for 9 per cent, of the boys and 8 per cent, of the girls, and not more than 3 per cent, of the boys and 4 per cent, of the girls were backward directly on account of social or moral disadvantages of their home life or their own incorrigibility. The remaining 20 per cent, boys and 28 per cent, girls were grouped under various combinations of these causes. Of the dull children, the mental condition has not been fully analysed yet, but of the 230 cases, 67 boys, or 58 per cent., and 50 girls, or 43 per cent., were naturally dull without any circumstance to account for it, while, in addition,5 per cent, of the girls were recommended for transfer to Special Classes. Only 4 boys (3.5 per cent.) had any serious physical defect, which was found chiefly as general delicacy in 16 per cent, of the girls. Of both boys and girls, 6 per cent, were dull owing to absence from school through ill-health or other reasons, and only 3 boys (2.6 per cent.) and 5 girls (4.3 per cent.) suffered almost entirely through moral or social disadvantages. The remaining 34 boys and 28 girls had their dulness and stupidity much aggravated either bv physical defects or irregular attendance. Causes of backwardness :— 370 Intelligent 230 Dull 600 Total. B. G. B. G. A. Primary 1. Amentia — — — — — mental 2. Mental deficiency — — — 0 0 incapacity 3. Natural dulness (infancy or present time 70 03 07 50 250 B. Physical 1. General diseases 7 4 2 4 17 defects 2. Special senses . 9 11 2 10 32 1 + 2 both 2 1 — 5 8 C. Social or 1. Of parents 1 3 1 2 7 moral 2. Of child 3 4 2 o 11 defects. 1+2 both 2 1 — 1 4 D. 1. lii-health 10 25 5 — 40 ance. 2. Intentional 4 3 — 2 9 3. Change of school 34 20 2 4 00 1 + 2 both — — — i 1 1+3 both 2 1 — — 3 Various A + B 8 3 9 1 24 A + C 4 3 0 3 10 tions of A + D 9 19 13 8 49 causes B + C 1 _ 2 1 4 assigned. B + D 7 17 2 8 34 C + D 5 5 — 3 13 A + B + D — — 2 — o A + 0 + D — 1 — — 1 B + 0 + D — 1 — 1 2 Unclassified 1 — — — 1 185 185 115 115 6OO 47 No mention has been made of under-feeding, because it is impossible to decide from the child's appearance whether he is improperly fed or not, unless he is actually suffering from starvation, and, indeed, whilst improper feeding may make a difference in a child's intelligence, it cannot be said to be sufficient to make a naturally intelligent child dull, and this was the only point for consideration in the enquiry. The fallacies of the enquiry were not numerous as there were few matters of opinion, it was matters of fact which were recorded. The only point open to doubt was whether a child was intelligent or dull, and with the help of the teachers there seemed little opportunity for error in this respect. The calculation of percentages from only GOO cases of course involves fallacy, but only the general indications were required and the insufficient data can be further extended. The obtaining of a reliable past history of the child, family history and earlier school history sometimes made difficulties. The facts known to the teachers were generally, however, sufficient. There are some considerations regarding fallacies in the estimation of backwardness that might arise from different systems of promotion in different schools which would cause this enquiry to give an underestimate of the backward; but to the children concerned this will, ultimately, make little difference, as their school education ceases at 14 years of age, and after being employed for two or three years as van boys, scavengers, rag-pickers, factory girls or hawkers they come gradually to unemployment and have forgotten most of what was taught at school. Finally, the children at present in the elementary schools may be divided into three classes according to their mental capacity. 1. Those who, being intelligent, derive considerable benefit from their education during school life. 2. Those who, being backward, fail to derive much benefit from their education, chiefly because they leave school at 14 years of age, and have never reached the higher standards. 3. Those who, being dull, derive little or no benefit from the practical system of instruction in the elementary schools. In the Hoxton and Haggerston schools not more than 65 per cent. belong to the first class, and a large number of these potentially able to reach Standard VII. fail to do so, or only stay a few months before leaving. This is shown by the small number at the beginning of the school year on the rolls of Standard VII. and ex-VII., which, together, should contain at least the same number of children as any other standard, but by the end of the second quarter these numbers have dwindled to almost nothing. The remaining 35 per cent. and more are divided between classes 2 and 3, and if it is fair to form an estimate from the two schools examined, about 21 per cent. belong to class 2, and 14 per cent. to class 3. In some of the schools class 3 is considerably higher, and it probably does not fall below 10 per cent, generally of the children in the elementary schools. SCHOOLS FOR BACKWARD CHILDREN. At present there are in the ordinary schools a considerable number of children who will leave without getting beyond Standards I. and II., or at most Standards III. and IV. These children are actually hindering the others in their classes, whilst they benefit little from the ordinary school methods, but the cases of retarded development who ultimately become useful citizens, do not usually present defect to this extent. Other children present educational peculiarities. Dr. Fisher, in the schools of Deptford and Lewisham, examined 2,166 children submitted by the teachers. Speaking of the acquisition of the three R's he refers to 386 children seen for various grades of mental dulness, of these 70 children over the age of 8 years, 10 at the age of 8, 3 at the age of 9, 2 at the age of 10, 1 at the age of 11 could not do such simple sums as 2 + 3, 3 + 4, or 5 + 6 correctly, and one boy of 10 could not add 1+2. Of these 70 children some showed an idea of numbers yet could not always name letters correctly ; of these there were 2 at the age of 8, and 3 others at the same age could only read a few two-letter words, but could multiply 3 by 5 or divide 12 by 4 correctly. An instance is a girl of 8; she added 26 + 13 + 2, answering 41 correctly, but could name but few letters. She could write her own name Violet, but could not name the first letter and called the 1, h, after years at school. In addition to these, there are numbers of children who present conditions which are relatively permanent in school life, and which render them unfit for ordinary school work, but who cannot be profitably educated in the particular methods of the special schools. A. The semi-deaf.—There is a considerable number of children hard of hearing, who have either retained speech or gained it, who will not make progress in the ordinary school even if placed in the front rows and on whom the training of the deaf school is wasted. B. Semi-blind.—There is a very large number of children who for two, three or four years of school life are useless so far as ordinary school tasks are concerned, but who have retained vision or will regain it to such an extent that to teach them as "blind" will be wasted effort. C. The nervous, debilitated, delicate and semi-convalescent children.—There is a pressing need for relief from educational tasks on a certain section of the school community, not as an educational question, but rather as one affecting the public health, so far as the burden can be lightened in the case of those upon whom it presses hard, particularly the debilitated and nervous children. In the second report to the late authority, my estimate of the total number of children unfit for the ordinary elementary school was 10 per cent. Since then, although perhaps hardly comparable, 48 I find that detailed examination of children in Charlottenburg has resulted in 12.8 per cent. being returned as unfit for the ordinary German elementary school. Dr. Hogarth estimates 14 per cent. of the children he has examined in the Hoxton district as unfit for ordinary school methods of education. Instead of naming these schools "intermediate" or "backward," I think they might be termed "Fourth Standard " schools, and the attainment of the ordinary scholastic Standard IV. be regarded as their aim in such matters as reading and writing. Children should be transferred to these schools on the certificate of the medical officer or Council's school inspector. Possibly, attendance could not be enforced without special legislation. Education in these schools should be in small classes, 30 pupils being a maximum ; formal class teaching should be abandoned as much as possible and each child encouraged to independent action ; handwork should be used extensively and concrete things talked about, drawn, and described; no books should be used, writing and printing being entirely confined to blackboards and chalk; arithmetic and numbers should be dealt with as an oral subject, and exercise, handwork and drill should form a considerable proportion of the school time table. The majority of the children turned out of such schools will be actually damaged, being defective or dull in some respects, and they will probably have as much education as will be required in any walk of life they are likely to follow. I know from observation that many children who have passed through the elementary schools and attended fairly well, are found half a dozen years later to be practically ignorant of the three R's which they say they have forgotten. If any child, through a mistake in judgment, were placed in one these schools it would not be injured, as in a very short time its capacity would enable it to be transferred to the oidinary school. The institution of Lower Grade or Fourth Standard schools to suit the mental level of those who become "hewers of wood and drawers of water" would add to the efficiency of the ordinary school and possibly relieve the upper classes of the present Special Schools. TEMPERANCE. Alcohol.—The direct teaching of temperance has been advocated in schools, but this is not a subject which appeals to children or in which dogmatic teaching is likely to be even useful. Probably more will be done to keep boys from alcoholic stimulants and tobacco by the practical advice that boys who want to shoot well must avoid these sources of unsteadiness, than by any amount of textbooks or teaching. American experience has been that the subject of teaching of temperance with which the schools were flooded a few years ago, requires to be considerably curtailed and legislation in some cases has, been required to do this. Continental efforts in this direction are made in all the elementary schools ; both in France and Germany enquiries by teachers have shown that considerable numbers of young children are given ardent spirits almost habitually, a condition almost unheard of in this country. This, however, is a subject on which the teachers could obtain reliable information, if it is necessary. Tobacco.—It has been evident lately that there is a great increase in cigarette smoking among young people. Cigarette manufacturers hold out inducements in the way of photographs, foreign stamps or prize coupons to children to purchase these cigarettes. Boys, even as young as ten years of age, have been seen in our examinations with tobacco stained fingers. The definite effect of tobacco, apart from the initial sickness and nausea, is difficult to assess. We believe that it interferes with nutrition and growth, and particularly with the evolution of the highest nervous centres which are attaining full functions in later childhood, so that the moral character is apt to be weakened. Palpitation and inability for exertion are frequently seen and it is said that in addition to mere slackness, which is common, a peculiar condition of indifference and apathy is noticed in many boys who smoke. In addition to this there is sometimes difficulty in vision, the acuity presenting great variations from normal and the writing being affected. This is capable of demonstration, an illustration showing samples of the writing of two cigarette smoking boys in the same class is given, showing the deteriorated writing, and later recovery on giving up tobacco:— 49 A.H., aged 12, Standard IV. Vision recorded in 1904 as 6/12. In March 1905 it had fallen to 6/18. The first specimen of writing was then made, shewing want of alignment, and some ataxic characters. It did not appear to be due to any colour scotoma, although this was not actually tested. Cigarette smoking to a considerable extent was acknowledged by the boy, who abandoned the habit. At the succeeding school testing he was absent suffering from scarlatina, but on return had normal vision, no tremor and wrote the specimen as illustrated. J.S., aged 13, in the same class, had normal vision recorded in 1904, but only 6/24 in March, 1905. He had similar handwriting and smoking habits to his friend and equally recovered on abstaining. At the school inspection in February, 1906, the second specimen was written. His vision normal and hands steady and the teacher stated that there was considerable improvement in character. A boy who wants to do accurate work of any kind will eschew tobacco. But for the full development of the highest mental qualities which make up the moral control, as well as for the sake of good physique, there should be legislation to prevent the use or purchase of tobacco by young persons. 11045 G 50 SCHOOL BATHS. The last report urged the need of school baths for cleansing purposes. Quite apart from instruction in swimming, shower baths were suggested as likely to be the most economical so far as the quantities of heat, water and space were required. The use of baths as part of a general training in physical education has been strenuously advocated by Miss Margaret McMillan, and Mr. Fels generously offered to put £5,000 at the disposal of the Council to establish a centre in which these ideas and methods of education could be carried into effect. Although practical difficulties arose which prevented the full scheme being adopted, an alternative one has been suggested. Meanwhile, the question of school cleansing baths has been thoroughly considered, and its importance made evident. A recent report* has been made to the Council on visits made by the medical officer( Education) and the Assistant Educational Adviser to over 30 schools in various parts of Germany and Holland. Shower baths are now being installed in new schools there, and have been added to most old ones, so that wherever there is a permanent water supply, even in small places of 4,000 or 5,000 inhabitants, school shower baths are found. The arrangements vary from a simple rose douche over a zinc tub in dark concreted cellars, to light and airy marble-lined bathrooms. The usual accommodation is for about 30 children at a time, and they are douched for 10 to 15 minutes with water, the temperature of which beginning at 95 deg. or 100 deg. F., is gradually lowered to about 65 deg. F. Soap, with towels, and loin cloths are generally provided, and laundry apparatus for quick drying is also installed. The general arrangements of a school bath with shallow troughs in the floor and water tubes to supply the shower, is shown in the sketch:— An arrangement for accurately regulating the temperature of the douches is fixed on the wall of the bathroom, and at one end of the room some separate cells, each with a rose douche overhead, are provided for the use of older children, particularly the girls. This general trough and separate cell arrangement appears to be the best from all points of view. 51 A general sketch-plan of a similar school is, therefore, given to show these arrangements:— In some parts of the country, for religious reasons, common bathing is objected to by a considerable proportion of the population; and in certain schools arrangements for separate bathing cells are made. The diagram illustrates such a cell system as seen in some of the Cologne schools. The objections to this system are the want of supervision, the initial cost, and the difficulty of keeping the bathrooms thoroughly clean. Whilst in Germany a bathing-room is only intended for the school in which it is installed, in Holland a centre system has been tried, and the plan given is of a centre which serves 22 schools, with a water consumption of about 16 litres per head. It has been so successful that another is to be erected. 52 School baths for cleansing purposes are advisable in all districts where the majority of the homes are not provided with house baths. No public provision of swimming baths can either sanitarily or economically supply the needs fulfilled by these shower baths for school children. Both teachers and doctors in Germany agreed that good effects of the douches could be observed directly and indirectly in the children, more especially as regards— i. Better and cleaner clothes chiefly as regards underclothing, with an increased selfrespect in the children. ii. Diminution of verminous conditions in the children, and noticeable results of this in absence of irritation and restlessness during school work. iii. Considerable improvement in the condition of the classroom atmosphere. iv. A tonic effect of the baths in sharpening up the school work is also very generally asserted to be quite noticeable. James Kerr, Medical Officer (Education). APPENDIX III. London County Council. FRIED FISH SHOPS, FISH CURERS', AND MARINE STORE DEALERS' PREMISES. Report of the Medical Officer on the methods adopted for the conduct of the businesses of fried fish seller, fish curer, and marine store dealer, and as to whether these businesses should be added to the list of offensive businesses scheduled under Section 19 of the Public Health (London) Act, 1891. Ordered by the Public Health Committee to be printed, March 22nd, 1906. The Business of a Fried Fish Seller. The frying of fish has been a familiar source of annoyance and a cause of frequent complaint in this country for the last half century. In London, as long ago as the Exhibition year of 1851, there were a few fried fish shops, the situation of which can be vouched for by veterans in the trade. Fifty years ago, however, fried fish was commonly sold in association with baked potatoes (an oven being attached to the frying stove), or with bread, and the trade is said to have been well-nigh revolutionised about thirty years ago when the practice of combining the sale of fried fish with that of "a la mode," or chip, potatoes was introduced from France. Mayhew ("London Labour and the London Poor"), writing in 1861, speaks of the preparation of fried fish by street sellers as a trade then established for some years, and computes there were then some three hundred persons carrying it on. He says:—"The fish fried by street dealers is known as 'plaice dabs' and 'sole dabs,' which are merely plaice and soles—dab being a common word for any flat fish. . . . The supply is known in the trade as 'friers,' and consists of the overplus of a fishmonger's store, of what he has not sold overnight, and does not care to offer for sale on the following morning, and therefore sends to the costermongers, whose customers are chiefly among the poor. . . . .Many of the 'friers' are good . . . . but some are very queer indeed, and they are consequently fried with a most liberal allowance of oil, which will conceal anything . . . . The fish to be fried is first washed and gutted; the fins, head, and tail are then cut off, and the trunk is dipped in flour and water, so that in frying, oil being always used, the skin will not be scorched by the, perhaps, too violent action of the fire, but merely browned. . . . . the fish is cooked in ordinary frying-pans. . . . . The fried fish sellers live in some out-of-the-way alley, and not infrequently in garrets ; for among even the poorest class there are great objections to their being fellow-lodgers on account of the odour from the frying. . . . . Their residences are in some of the labyrinths of courts and alleys that run from Gray's Inn-lane to Leather-lane, and similar places between Fetter and Chancery Lanes. They are to be found, too, in the courts running from Cowcross-street, Smithfield, and from Turnmill-street and Ray-street, Clerkenwell, also in the alleys about Bishopsgate-street and the Kingsland-road, and some in the half-ruinous buildings near the Southwark anil Borough Roads. . . . . A gin-drinking neighbourhood, one coster said, suits best, for people haven't their smell so correct there." From such humble origins the trade has grown to its present considerable dimensions, gradually encroaching upon more and more respectable neighbourhoods, and appealing to a clientèle possessed of more and more critical tastes. In 1888, 250 addresses of fried fish shops appear in the Post Office Directory, and in 1906 this number has grown to 600, while the inquiries of the Council's inspectors show that within the County of London the number of such shops is at least 1,057 and probably extends to upwards of 1,200. The annual amount of fish of all kinds brought into London is said to have increased from some 90,000 tons in 1854 to considerably more than twice that amount at the present time, but these figures afford no guide to the expansion of the fish-frying trade, which deals almost exclusively with plaice, haddock, and, in less degree, skate. It may be noted that, according to Mayhew, plaice and haddock constituted only about 10 per cent. of the wet fish annually consumed in London fifty years ago, while in 1904 they constitute about 30 per cent. of the total wet fish landed in England and Wales, and probably a larger percentage still of the fish consumed in London. The great extension of the supply of cheap fish to the large towns is indicated by the fact that the amount of fish carried by railway in England has increased from 250,000 tons in 1885 to 486,575 tons in 1904, while the aggregate net tonnage of first class trawlers has increased from 19,030 in 1893, to 65,338 in 1904. It might have been anticipated, perhaps, that as the trade gradually emerged from obscure nlleys into the light of day, more and more objection would have been raised on the score of 2,000—21.5.06. [A. S. 78 2 nuisance, but concurrently with the extension of its appeal to class after class rising in the social scale, improvements have been gradually introduced, and in many respects the trade has been transformed from what it was in the early days in London. The cotton-seed oil now used in fish frying is undoubtedly of better quality than that employed at first, and in many instances it is superseding dripping, which, however, is still the mainstay in certain localities. Moreover, improved forms of stove have come into use, and, on their own initiative, or under pressure from the Sanitary Authorities, fryers of fish have in several instances adopted methods designed to minimise nuisance caused by escape of offensive vapours into the outer air. Dr. Ballard, writing in 1876, says:—"It is a petty trade, but, nevertheless, is a source of considerable nuisance in some neighbourhoods, the offensive smell of the oil boiling and fish frying spreading often, not only through the whole length of the street where the shop is situated, but sometimes into adjoining streets also. When the shop is situated in a street occupied by poor persons of the class who purchase such food, complaints of the smell are rarely, if ever, made; but passengers are annoyed by it, and so also are the tenants of houses of the better class who chance to reside in the neighbourhood. For it is not only in poor streets that such shops are to be found. There is, I believe, scarcely a health officer in London who has not at some time been called upon by the Authority under which he acts to advise as to an appropriate remedy for this nuisance. The difficulty in dealing with it lies in this, that the pan, or fixed shallow iron vessel in which the fish is fried by a fire beneath, must be always open to view, and to allow of the necessary manipulation. The ordinary remedy suggested and adopted in a great many places has been the provision of a hopper above the pan, which hopper is intended to catch the fumes as they arise, and to convey them by an opening above into some adjoining chimney. "But for various reasons the remedy has not proved always very effectual; the faultiness partly consisting in the defective draught of the chimney, partly upon the hopper not being brought low enough or far enough forward over and in front of. the pan, and partly depending on the fact that, the process being conducted in the open shop, the wind entering the shop, and draughts of air, interfere with the due operation of the hopper. A more effectual arrangement would be to conduct the operation in a closed outhouse, or other place where draughts of air could not so interfere, to bring the hopper well down and forward, and to close in the sides, having only the front part of the pan open for observation and necessary manipulation. The chimney of the fire should be so constructed as to obtain a good upward draught, and should be carried up above the roofs of adjoining houses." The Council's inspectors have visited 1,057 premises, this number representing more than two-thirds of the total number of fried fish shops in London. Their inquiries show that the business of frying fish for sale, as ordinarily carried on, needs to be considered from two points of view. In the first place, the frying itself, unless it is conducted with due precautions, involves escape of vapour and offence to passers by, and it is the nuisance so caused which is the occasion of the instruction under which I am now reporting. In the second place, the gutting and cleansing of the fish and the methods adopted for dealing with offal and refuse need to be considered. In the course of carrying on these operations, effluvium nuisance is also apt to arise; but the point of main importance here would appear to be the need of safeguarding the reasonable cleanliness of an article of food. A close study of the conditions under which the trade is at present carried on inevitably leads to the conclusion that the health of the population of London is jeopardised to a far greater extent by risk of contamination of the fish itself than it is by the escape of offensive vapours, although the latter are the source of the complaints ordinarily made by the public concerning premises upon which fish are fried. It is deserving of mention, inasmuch as the sale of fried fish is commonly associated with that of "chip potatoes," that the potatoes are not as a rule peeled, and, generally speaking, less care is exercised in regard to excluding diseased potatoes than appears to be desirable. A question of very great importance arises in connection with the inspections made by the Council's officers. At certain times of the year, and more particularly from April to July, large quantities of small and immature plaice are brought to market. These fish, for some reason or other, are specially apt to be found in a state of decomposition on arrival at the retailer's premises. It may be that immaturity, or the source from which the plaice are obtained, favours this; or, again, less care may be exercised with reference to fish which are, no doubt, looked upon as only a little distance removed from offal. The larger fish, it may be noted, are often gutted immediately upon being caught to preserve them from decomposition ; but the gutting of these small fish is said not to be a practicable undertaking, and it is certainly not, as a rule, carried out prior to the fish reaching the retail vendor. The marketing of undersized fish seems to have been a burning question for a long time past, for, in the Guildhall Library, there is an ancient petition showing the case of the fishmongers in and about the City of London as to a Bill brought before Parliament concerning Billingsgate. This document contains reference to the "Horselydown and Harwich fishermen, the promoters of the now Bill, who have set up a new way of dealing, and buy fish caught by others, ofttimes unseasonable and unsizable, not fit to be sold." Question has from time to time been raised in Parliament as to the expediency of adopting measures for the prohibition of the capture, landing, or sale of fish under a certain size, but the matter has only been considered from the point of view of protecting the young fish, in order that the continuance of a supply of fish may not be jeopardised. The subject has, however, a public health aspect also. Small fish in a decomposing condition have on more than one occasion been 3 found by the Council's officers packed in trunks, with a layer of larger fish on top; and there can be no doubt that under the conditions as to inspection which at present exist, the decision as to whether such fish shall be fried or not practically rests with the retail vendor. As regards nuisance from vapours, consideration may be given to the following points:— A.—Materials Used in Frying.—Fish is fried in either dripping or cotton-seed oil. In some cases a mixture of both is used, generally in the proportions of one-half of each. In a few instances, fish is fried in dripping and the potatoes in oil. Ordinary dripping is the fat which drips from meat during roasting, plus a small quantity of the extractives, in the form of gravy, which has not been separated. It is more or less hard, according to the amount of mutton fat contained in it, and on fracture is rather rough in appearance. The dripping used for fish frying may have been obtained in small quantities either from butchers' shops or public institutions, or from butchers' fat, and may be rendered by the fish fryer himself. It is, however, chiefly supplied by a number of firms, usually fat or tallow melters, who specially prepare dripping for this business. In such cases it is usually darker in colour and more oleaginous than ordinary shop dripping. In some instances a tallowy-looking kind is used, which is said to be imported from Australia. Fish fryers' dripping may be regarded as blended fat made up of dripping from hotels and shops, and, from fresh butchers' fat. Cotton-seed oil, one of the cheapest of the fatty oils, is largely used for fish frying. It is also said to be sold under the disguise of such names as "table oil," "salad oil," "sweet nut oil," and thus is used for other edible purposes. It is obtained on a large scale from the seeds of various kinds of cotton trees, cultivated in the United States, Egypt, &c. After decortication, the seeds are pressed in hydraulic presses. The crude oil from the presses is heated to 120° F., and intimately mixed with caustic potash solution—only so much caustic potash being added as to combine with the colouring matter and the free fatty acids in the oil. The mixture separates into two layers— the upper being a decolourised oil, the lower a heavy mucilage of a brown or black colour. The supernatant oil is drawn off and washed with warm water; the edible oil is not bleached with chemicals. The finer grades of oil are used for edible purposes, the lower grades for soap-making. It is said that cotton-seed oil, being one of the cheapest fatty oils, is hardly liable to adulteration ; but, when the price of linseed oil and maize oil is lower, admixture with these oils may occur. Cotton-seed oil is fluid at ordinary temperatures, is of a brownish colour, and has a characteristic oily smell. The semi-solid kind of cotton-seed oil was found on the premises of one fish-fryer, but this probably contained an excessive amount of cotton-seed stearin. Cotton-seed oil is used in nearly all the fried fish shops in the East-end of London and is preferred, because the fish when cold looks better and is more moist. The dripping or oil is heated to a temperature of from 350° to 380°F. The temperature was taken by the Council's inspector in upwards of 40 cases whilst the business was going on, and these temperatures include instances of:— Max. Min. Cotton seed oil only in the pan 406° F 346° F. Dripping „ „ „ 402° 300° Fish frying in the oil 374° 322° „ „ dripping 378° 306° „ „ oil and dripping 350° 328° Potatoes „ oil *382° 230° Potatoes frying in dripping 306° 236° „ „ oil and dripping 290° (the only observation). N.B.—When oil or dripping alone is being heated in the pans, and the temperature reaches 400° F., a smell of charring is given off and a large quantity of blue fume noticeable. When the fish and potatoes are put into the pan, particularly in the latter case, a large quantity of vapour is given off, both from the potatoes and from the water from the batter† around the fish. This vapour carries with it minute particles of fat and oil, which, on condensation, are deposited. There is ample proof of this in the numerous instances in which the hoods and chimney breasts were found to be thickly coated with oil and soot, and the ventilation openings into the chimney flues and shafts, were in consequence, clogged up. Such deposit is further shown in the streaks of black oily liquid on the walls, the numerous oily globules on the ceilings of the frying-rooms and shops, and the dirty oily deposit on the fascia boards above the openings over the shop windows. In other instances, the vapour, probably aided by the high temperature due to the heat from the furnace and gas jet under the hood, had carried further, and condensed in the external shafts : indeed, in one notable instance, the vapour had fallen on to the roof, leaving an oily, sooty deposit. These facts point to the conclusion that the vapour from furnaces in which oil is used is carried away in larger quantity, and carried further before being condensed than is the case when dripping is used; indeed, vapour from oil is productive of much more dirty conditions in all respects. An important factor in the case is the fluid condition of the oil at ordinary temperatures. Although it is not a volatile oil, its characteristic smell permeates the atmosphere of the premises even when frying is not going on. When the water has evaporated from the fish and potatoes, a blue fume is given off in * Potatoes only just added to very hot oil. † The batter consists of flour and water, and into this the fish is dipped previous to being placed in the oil. 4 variable quantity, dependent largely upon the degree of heat of the fires. This fume is quite familiar to those who have seen kitchen fat melted in coppers by direct fire heat on fat-melters' premises. It is probably due to the charring of the layer of fat or oil next to the pan. Currents are set up by the heat and by the moisture on the fish and potatoes, and gradually the whole mass of fat and oil becomes darker in colour and charged with the bluish coloured fume. In support of this conclusion it was observed that when the tires were first lighted and the temperature of the fat or oil became high (before fish or potatoes were put into the pans), a large quantity of blue fume was given off". The temperature being much higher when neither fish nor potatoes were in the pans, the stillness of the mass and absence of moisture led to increased charring. B—The Furnace and Frying Apparatus.—One of the best forms of apparatus in use at the present time is made of enamelled metal, fitted with movable copper pans, heated by gas The heat can be so readily adjusted that burning or "firing" of the oil or dripping need never occur, and the pans and every part of the apparatus can be most effectually cleansed. The cost of working this form of apparatus is greater than when a coal or coke-heated furnace is employed. An ordinary two-pan gas-heated apparatus, with one pan in use at midday and both at night, including four shop lights, consumed 55,000 cubic feet of gas in the quarter ending December. The gas costs 2s. 2d. per 1,000 feet, and deducting 13s. as the estimated value of the gas consumed by the four shop lights, the net cost of the gas consumed by the frying apparatus was £5 6s. If the apparatus had been heated with coal, probably 3 tons would have been used, and, estimating the cost at £1 per ton, the total cost would have been £3. Another form of apparatus in much more common use is a brick furnace, faced with glazed bricks heated by coal or coke. The prevalent method of dressing or lapping the metal furnace top over the inner edge of the pan is objectionable on the following grounds:— 1. The space between the dressing or lapping and the pan allows cracklings, frying debris, and other matters to accumulate: in some cases the frying has caused these matters to be forced under the bed of the metal top and actually raised it from the brickwork. 2. It is impossible to thoroughly cleanse the pan without removing the furnace-top, and it follows that this is very seldom done. 3. The oil boils up between the dressing or lapping and the sides of the pan on to the brickwork and fireclay of the bed. In the event, therefore, of there being a crack or fault in the fireclay or brickwork the oil might reach the fire with dangerous results. 4. These conditions cause effluvium. The frying pans should be flanged all round the outer edges, and set with the flanges overlaying raised edges of the metal furnace top or bed, which should be constructed of white metal (see Plate 1, Fig. 5), similar to that usually employed on the top of metal furnaces. The advantages of this form of pan and setting are:— 1. When the oil boils over, it runs over the flanges on to the metal furnace top and is held there. It is impossible for it to reach the brickwork or the fire, hence there is no risk of " firing." 2. The inner surface of the pan is fully exposed to view, there is no overlapping metal work to retain cracklings, frying debris, or other solid matters, and the surface can be readily and efficiently cleansed. For cleansing purposes it would be better if the flue doors were fixed at the sides of the chimney breast, instead of in front. The flues could then be more conveniently cleansed, the furnace top, pans and fittings would not be so liable to get soiled, and oil and dirt would not accumulate on the doors and frames as when the flues arc fixed in front. Brick furnaces vary in height from 2 ft. 6 in. to 3 ft. 6 in. The latter height is preferable. If the furnace is built low, a larger opening is required between the front of the hood and the furnace top in order to enable the attendant to watch the frying. This is objectionable, inasmuch as such a large opening makes it more difficult to properly dispose of the vapours. Where practicable it is desirable to fix the fireplaces at the ends of the furnace, and not in front as is usually the case. This suggested position of the fireplace would add to the comfort of the attendant, and, where females are employed, there would be much less chance of their clothing coming into contact with the fire. It would also conduce to the floor being kept in a more cleanly condition. The usual practice is to stoke these furnaces with a combination of soft coal and coke; bur, anthracite coal would be preferable, as it burns without smoke or fumes, is perfectly clean and free from dust, and its heating power is well known. C—Appliances for Dealing with Offensive Vapours.—In a very large majority of the premises inspected hoods for the purpose of collecting the vapours evolved in the process of frying were in use, but they were, as a rule, defective in one or more of the following respects:— 1. They were not designed in such a way as to ensure the efficient gathering up and proper disposal of the vapours. 2. Their ventilation generally was inadequate and inefficient. 3. The mouth of the hood was not large enough to properly cover the furnace. 4. The distance or space between the mouth of the hood and the furnace top was too great. 5. The ends between the mouth of the hood and the furnace top were left open, thus allowing draughts to sweep across and carry the vapours through the shop into the external air. Plate 1. FISH FRYING FURNACE showing method of destroying offensive vapours. Plate 2. side elevations of frying furnaces and hoods as now used. 5 In many instances it is supposed that the flue doors act as outlets for the vapours collected by the hood, but in actual practice these doors, owing to the liability to soot falling and the interference with the draught of the tires, are seldom open. They are usually fixed on a line with the mouth of the hood, and, consequently, if they were left open, only a small portion of the vapours would reach them. The hood should be constructed of smooth white sheet metal, or a combination of noncorrosive metal and glass. The mouth of the hood should at least be equal to the length and width of the furnace in area, and should be so constructed that it is not more than 18 inches above the front of the furnace top. In order to prevent draughts sweeping across, the sides of the hood should be made to meet the furnace top. The lower or narrower the opening in front between the hood and the furnace the more efficiently will the vapours be drawn off. The shape of the hood should be such as to allow of a large gathering capacity, it should slope or taper towards the point of outlet which should be at least 9 in. in diameter, and should communicate either with a flue, lined with 9 in. glazed pipes, discharging in the usual way above the ridge line of the building or (and this would appear to be the better method) with a flue constructed so as to convey the vapours beneath and through the furnace fire, so that all offensive smell is effectually done away with before the products of combustion escape into the outer air. One of the Council's inspectors found in operation in Greenwich an experimental stove in which the vapours were being thus conveyed by means of a duct through the furnace fire. This method of dealing with the vapours, although carried out in a very crude fashion in this instance (the stove, admittedly, being merely a makeshift) would appear capable of development in such a way as to altogether minimise risk of nuisance. Should it be found practicable thus to deal with the vapours, applying in fact the principle already for many years successfully adopted in dealing with the far more offensive vapours evolved in various trade processes—bone boiling, fat melting, &c.—it may be anticipated that a ready means of abating any cause of offence from fish-frying will be at hand. The plan of carrying out the method of destroying offensive vapours, which it is suggested might with advantage be adopted, is illustrated by Plate I. Figure 1 (Plate I.) shows a front elevation of a fish-frying furnace the external facing of which is constructed of glazed bricks, and also the chimney breast at the back of the pans covered by the hood. The hood is constructed of the usual white metal, and the sides are closed in by thick glass panels (see Figure 2) to admit light; these are framed in white metal, and serve to connect the hood with the metal furnace top. The furnace has two frying pans, heated by coal or coke fires at the sides. The fireplace on the left, which is shown in Figure 2, is specially constructed with a close-fitting ash chamber door, and this fire draws its supply of air for combustion from the atmosphere of the shop, through the front of the hood (at A in Figure 4). The current of air passes in the direction of the arrows in Figure 4 into the duct at point B; thence passing down between the usual smoke flues as shown in Figures 3 and 4, it enters the side of the ash chamber immediately below the fire-bars, and passes through the fire as shown in Figure 3. The smoke from the tire enters the usual flue (see. Figure 3), and, passing up, discharges through a ventilating chimney cowl into the outer atmosphere. The air duct, at the bend nearest the ash chamber, is provided with a small outlet discharging intoa drip drawer (shown in Figures 3 and 4) to collect condensed oil and steam. The height of the furnace from the floor to the top of the metal furnace bed is 3 feet 6 inches, and the opening between this and the hood is 18 inches. The arrangement described above should draw the fumes and vapours from the frying pans and also from the shop and cause them to be consumed in the fire. D.—Draught Screens.—It is usual for the flues to be built in one of the side walls, at right angles to the shop front, hence, in a very large number of instances, the furnace is necessarily fixed in the shop. The window front is open in some cases, and, in others, the glass is cut out along the ceiling line, or open fanlights are provided over the entrance door, and, at the back there are one or more door openings leading to the rear. These openings, and their position in relation to the furnace and hood, have an important bearing on the action of iho latter, inasmuch as they create draughts, and carry away the vapours from the furnace into the external air. Id may be found that, with the wind in a certain direction, the vapours are blowing out of shops on one side of the street, whilst from the shops on the other side no vapour escapes (the vapour being driven through the back part of these shops). Of course, a great deal depends upon the force of the wind outside. Where necessary, the furnace and hood should be surrounded by a screen or partition. The screen should be built up to the ceiling and constructed of metal and glass, or of wood and glass, and should enclose the furnace and hood for a distance of 30 inches all round. The counter in the shop will usually form the screen line, and a small sash window or slide should be provided in the screen for serving purposes. In order to facilitate cleaning, all woodwork on the inside of this screen should be covered to a height of 3 feet 6 inches with hard, smooth, and non-corrosive metal, and the floor within this area should be made of some jointless impervious and non-combustible material. Turning now to the second series of observations—those relating to the gutting and cleansing of fish, and to the measures necessary for obviating risk of contamination—the cleansing or storage of fish, under existing circumstances, is frequently carried on in dark cellar basements, in rooms 6 in aerial communication with stables, water-closets, or living or sleeping rooms, or in places exposed to sun and weather. A proper structure or place should be provided for the purposes in question. The walls should be constructed of brick or similar material, rendered on the inner surfaces with cement to a height of 6 ft., and finished with a smooth trowelled surface; it would be preferable to face the walls with glazed bricks. The inner woodwork and fitttings should be covered to a height of 6 ft. with smooth sheet non-corrosive metal. The floor should be laid with a smooth jointless impervious paving and sloped to an external gulley. The gutting bench or table should be constructed of smooth and impervious material—e.g. slate, marble, or glazed earthenware. Glazed lights should be provided equal to 1/10th of the floor space, also permanent ventilation openings equal to 1/25th of the floor space should be fixed in the sides, ends, and roof. A sufficient number of offal vessels or receptacles should be provided. They should be constructed of galvanised iron of not less than 16 gauge, or of some equally suitable non-absorbent material, and provided with strong, close-fitting, air-tight covers. Such vessels or receptacles, when not in actual process of removal, should be kept inside the cleansing place. The maintenance of cleanliness in the cleansing place and shop itself is a matter of great importance. So far as the shop and cleansing place are concerned, it may be pointed out that:— All parts of the furnace, hood, pans, and utensils should be cleansed daily and kept in a good state of repair. The walls, floor, ceiling, partitions, counter, fittings, and appliances should at all times be kept in a clean condition and in good state of repair. The floor, cemented walls, metal work, gutting bench, potato machine, and all other fittings, utensils, offal receptacles, and appliances should be thoroughly cleansed with hot water either at the close or beginning of every working day. All parts of the structure, fittings, and appliances should be kept at all times in a thorough state of repair. The walls above the cement rendering, ceiling or under-side of roof, should be thoroughly limewashed with hot limewash four times in every year—that is to say, between the first and tenth days of the months of March, June, September, and December. The methods of dealing with offal, &c., demand to be carefully seen to. Empty fish boxes, barrels, baskets, or packages should be removed from the premises within forty-eight hours of their arrival, and while on the premises should not be stored in any open yard or space, so as to cause a nuisance. Gut, skins, offal, garbage, filth, or other refuse products should be immediately placed in the refuse receptacles, and such receptacles, whilst containing such refuse, should be kept closely covered. All refuse should be removed from the premises at least once in every twenty-four hours. Finally, the yard paving and external surfaces should be kept in a cleanly condition, and in a good state of repair. The drains, water-closets, and all sanitary conveniences should be kept at all times in proper order, and in a cleanly condition, and a proper and sufficient water supply should be provided to the premises. No animal should be kept in any place in which gutting, cleansing or frying of fish, preparing potatoes, &c., is carried on. The investigations made by the Council's Inspectors show that at the present time the conditions under which fish is cleansed and stored are, as a rule, most unsatisfactory, both as regards the unsuitability of the structure of the premises used, and the manner of conducting the business processes in question. Numerous instances were found in which floors and walls were fouled with decomposing fish slime and excremental matter, and the portion of the wall adjoining the bench on which cleansing and gutting of the fish was effected was that commonly found to be at fault. Frying and cleansing were carried on in basements, badly lighted, ill-ventilated, and in a filthy condition. Refuse was stored in leaky and uncovered receptacles (e.g. old fish boxes and tubs), and kept until putrid and offensive in yards which were unpaved or in which the paving was defective, and in which stagnant and offensive pools of water were observed. There were accumulations of house refuse on the floors of the cleansing rooms or in the yards in which gutting and cleansing was being carried on. The use of dark and ill-ventilated basements and want of regard for ordinary precautions as to cleanliness may be mentioned as evils which were especially met with, and which most urgently call for remedy. Recommendations.—Various suggestions may be made as to the methods to be adopted for remedying the conditions under which the frying of fish is at present carried on in London, it has been suggested that the Council might obtain the assent of the Local Government Board to the addition of this trade to those already scheduled under Section 19 of the Public Health (London) Act, 1891. Even if it were possible to adopt this plan, however, there would be the difficulty that any person desirous of establishing anew the business of fish frying would be compelled to make application to the Council for sanction and a formal hearing of the application would then of necessity be held, as stipulated in Section 19 of the Act. This method appears a very cumbrous one for dealing with a trade so extensively carried on in London as is the trade in question, and, although possessing some advantages, I foresee that serious objection might be taken to it. Apart from this, under Section 21 of the Act, the owner of a fried fish shop can be required by the Sanitary Authorities to adopt the best practicable means for abating any nuisance that may arise; were the question one merely of nuisance caused by escape of offensive vapour, the application of the provisions of this section by the Sanitary Authorities would probably be sufficient to effect the end in view. 7 A third course which might be adopted would be to apply for power to make by-laws regulating the conduct of the business, such by-laws to include clauses directed towards preventing nuisance arising from the escape of vapour, and also clauses dealing with conditions which may involve risk of contamination of the fish. It seems to me, on the whole, that the third course would be the most satisfactory to adopt. Summary of inquiries made by the Council's Inspectors in 1905-6:— Total number of premises inspected 1057 Number of frying places in basements 9 Number of cleansing places in basements 118 Number of cleansing places in open back yards or temporary structures therein 848 Number of instances in which fish was bought at Billingsgate 849 Number of instances in which fish was bought from the Coast 127 Number of instances in which fish was bought from the Coast and Billingsgate 81 Number of instances in which cotton seed oil was used 629 Number of instances in which dripping was used 404 Number of instances in which dripping and cotton seed oil were used 31 Number of instances in which the furnaces were constructed of iron 218 Number of instances in which the furnaces were constructed of brick 827 Number of instances in which gas heated furnaces were used 23 Out of 814 cases there were 655 instances of fixed pans, and 155 instances of movable pans. Number of instances in which the hoods were obviously insufficiently ventilated 782 Number of instances in which walls, &c., were deficient in impervious surfaces 731 Number of instances in which the paving of the frying place was defective 19 Number of instances in which the paving of the cleansing place was defective 99 Number of instances in which the paving of the yard was defective 127 Number of instances in which the water supply was inadequate 1 Number of instances in which the offal was stored so as to cause nuisance, or stored in improper receptacles 703 Number of instances in which the offal was said to be collected daily by a contractor 751 Number of instances in which the offal was said to be collected daily by dustmen or scavengers 66 Number of instances in which the offal was said to be collected less frequently by a contractor 141 Number of instances in which the offal is disposed of so as to be a probable source of nuisance 18 Number of instances in which dirty conditions generally were found 327 The price of oil varied from 15s. to 22s. per cwt. The price of dripping varied from 25s. to 32s. per cwt. The actual time fish was said to be fried varied from 1 minute to 25 minutes. As a rule, the time in question was from 3 to 10 minutes. 8 The Business of a Fish Curer. The total number of fish-curing premises in the County of London probably amounts to 550 ; of these 504 were visited by the inspectors. This latter number included 52 where a wholesale trade was carried on, and 155 with a fried fish shop attached; in the remainder the ordinary business of a retail fishmonger was generally carried on Very little curing was carried on at the fried fish premises, and information went to show that for some years past the curing part of the business had been declining. The general tendency seemed to be for fish to be increasingly cured at the fishing ports by firms making a speciality of the business, and for less fish to be cured in London by the retailer. The herring appears to be the principal kind of fish cured in London. It is a food which, after curing by " bloatering," is largely patronised by all sections of the working class, and to some extent by the middle class. It is a very common sight to see "bloaters" exposed in the windows of cheap coffee and dining-rooms throughout the county; and it is a general practice to grill or cook the bloaters before they are gutted. Next in importance to the herring is the haddock. For some years past the price of this fish has gradually increased, so that the poorer section of the population are unable to profitably use it to the extent to which they formerly did. Owing to the intensity of modern fishing, the size of the fish has decreased in comparison to the quantity caught, with the result that large quantities of immature fish ("chats") are now put on the market; these fish are practically unfit for curing, and are chiefly bought by fish fryers. In addition to herrings and haddocks the inspectors' reports make mention of the curing in exceptional instances of mackerel, cods' roe, salmon, and sprats. The herring is cured in London in two ways, by canning and by bloatering. No investigations were made into the canning trade. Bloaters are ungutted herrings, which may or may not have been "sprinkled" or salted previous to their arrival at the curing place. The fish for the wholesale trade are usually brought from the market or railway before noon. In the curing places are long shallow wooden vats, in which the fish are rubbed with coarse salt, which removes the mucous and scales; they are then washed and soaked in brine tubs and afterwards "speeted"—i.e. transfixed on sticks and put to drain on racks. After draining, and drying to some extent, they are placed in the smoke-holes, and the fire or smoke is started between 7 and 8 in the evening. The fire is regulated from time to time, and about three in the morning the traps and ventilators are thrown open, and afterwards the doors, to permit of the fish being properly cooled; the fish are then packed in boxes and marketed at Billingsgate or elsewhere the same morning. The fire and smoke is made with pine, elm, and oak sawdust; and in large smoke-holes dry oak, beach, and hornbeam wood logs are burnt with sawdust. Small retail shops usually cure two or three times a week, and owing to the small quantity required, and the small size of the smoke-hole, only sawdust is used for the smoking. In a small number of instances the herrings are merely "wind" or air-dried in the shop windows, or in open sheds or buildings in the rear of shops. It has been said that some street costers cure herrings by air-drying in their living or sleeping-rooms, but no single instance of this was actually found ; in one instance, however, curing was being carried on in a horse stable at Hackney Wick. In Scotland and the North of England the fish are pickled in brine from 12 to 20 hours, and then smoked for about the same time. These bloaters, however, do not suit the taste of the London consumer. In the process of haddock curing, the first thing is to head, gut, and split the fish; the bellies are washed, the blood, the sound, and the black belly skin being removed. After washing, they are more or less salted, according to the curer's requirements; they are then "speeted" and hung in the smoke hole, and cured in a somewhat similar way to bloaters. The haddock curer uses smoke holes smaller in area than the herring curer, and more draught is allowed ; more moisture is given off from the haddock, and it is important that this should be carried off to prevent the fish "dropping." The fish is hung well up away from the fire, and this causes the "pickle" to become fixed, and gives the fish a bright appearance. London cured haddocks are noted for quality in the market. Curing places.—In 10 per cent. of the places the gutting and cleansing is done in open back yards, often defectively paved, and in 60 per cent. in temporary wooden shelters or sheds, not fitted with impervious surfaces, and in some cases totally unsuitable for the conduct of the business. In 3 cases basements, in 16 cases stables, or places in aerial communication with stables, were used; in 28 cases a w.c. was inside, or was in aerial communication with the curing place; in 3 cases fowls or other animals were kept; and at one wholesale place no less than 5 cats were kept on the premises. There were 102 instances of defective floors; 2 instances of unpaved floors; 297 instances in which the walls were not provided with impervious smooth surfaces; and 16 instances in which the light was very insufficient. Where the walls were unprovided with impervious smooth surfaces, they were generally caked or splashed with decomposing fish scales and filth. The gutting benches were generally constructed of wood, absorbing filthy liquids, and so giving rise to nuisance. In a large number of instances there was a general want of cleanliness and supervision. Smoke-holes or kilns.—In 237 curing places in the Eastern district, there were 606 smoke-holes or kilns, an average of 2.97; taking an average of 2 only for the whole county, there are probably over 1,000 smoke-holes in London. Sixty-three smoke-holes were constructed of wood, 359 were a combination of wood and brick (usually a back or side wall of brick), and the Plate 3. Section of an ordinary Smokehole (wood on brick foundation). 9 remainder wood on a brick foundation, (see Plate 3), and only 75 were built with brick or ironwork A little under 30 per cent. had shafts or chimneys, and of this number 41 were not sufficiently high to disperse the smoke properly without causing a nuisance. In four instances the smoke holes were in horse stabies, and in a number of instances they were inside the curing places. Herrings give off a quantity of oil in drying, and in consequence the inside walls of the smoke-holes are thickly coated with a dark oily deposit; no attempt was apparently made to cleanse the inner surfaces of the smokehole. Yards.—Unpaved yards were noted in 10 instances, 26 were only partly paved, and 102 were defectively paved. It was found a common practice to store empty fish barrels, boxes, and baskets in the open yards, and this must give rise to grave nuisance—more especially in hot weather. In many cases the yards were in a dirty condition, and the keeping of poultry and dogs did not improve matters. Drainage.—In 15 instances the drainage was doubtful or defective. The practice of having drain inlets inside curing places should be abandoned where possible, and surface drains should be provided and made to discharge on to external drain inlets. Water supply.—Two uncovered cisterns were found in curing places, and there was one instance in which a proper water supply was not provided. It is desirable that means for heating water should be available to facilitate the proper cleansing of the premises. Waste offal.—In 375 instances the offal was said to be removed daily by contractors, and in 15 cases by dustmen or scavengers. In 282 cases it was stored so as to be a source of nuisance ; and in 70 cases was kept in improper receptacles. Out of 237 premises in the Eastern district, 215 were found to have uncovered receptacles. No attempt appeared to be made to systematically cleanse the receptacles, except in those cases where the Local Authorities removed the offal. General.—The results of the whole inquiry appear to show the desirability of:— 1. The provision of properly-constructed brick buildings, on or above the ground level, for curing and drying places, having smooth impervious inner walls and floors to facilitate cleansing. 2. The provision of properly-constructed brick or metal smoke holes or kilns, provided with an outlet or shaft discharging above the eaves of adjoining buildings. 3. The provision of smooth, jointless, impervious paving to all yards or surfaces liable to be fouled by fish offal and refuse. 4. The provision of impervious smooth receptacles, provided with air-tight covers, for the storage of offal and refuse. 5. The daily removal of fish offal and refuse. 6. Adequate supply of water, and the provision of means for heating water for cleansing purposes. 7. The daily cleansing of paving, impervious surfaces on walls, gutting benches, fittings, utensils, and offal tins. 8. The prohibition of:— (a.) Places in aerial communication with water closets being used for gutting, curing, drying, or smoking purposes. (b.) Animals being kept in aerial communication with gutting, curing, drying, or smoking places. (c.) The curing, drying, smoking, and storing of fish in dwelling-rooms, sleeping- places, stables, and open yards. (d.) The storage of fish empties for more than 24 hours after being received on the premises. 9. Systematic inspection of premises. There would obviously be advantage in dealing with this trade on the lines suggested in the case of fish frying; that is to say, by the County Council obtaining power to make by-laws regulating the trade, to be enforced by the Borough Councils. Summary of Inquiries as to Fish Curing Premises in the County of London. Total number of premises inspected 504 Number of premises on which fish curing and drying only are carried on 70 Number of premises on which fish drying only is carried on .. 9 Number of premises on which fish curing and drying are carried on in conjunction with an ordinary fishmonger's business 303 Number of instances in which fish curing is done on fried fish shop premises 155 Number of instances in which herrings only are dealt with 23 Number of instances in which haddocks and herrings only are dealt with 387 Number of instances in which other kinds of fish are dealt with 97 Number of instances in which the fish is obtained from Billingsgate 405 Number of instances in which the fish is obtained direct from the Coast 18 10 Number of instances in which the fish is obtained direct from the Coast and also from Billingsgate 77 Number of instances in which the smokeholes are constructed of:— (a) Brickwork or ironwork 75 (b) Partly brickwork or ironwork, and woodwork 359 (c) Woodwork only 63 Number or instances in which there are no chimneys to the smokehole 328 Number of instances in which the chimneys are of insufficient height 41 Number of instances in which there are chimneys to the smokeholes 157 Number of premises deficient as regards impervious surfaces to walls, &c. 297 Number of premises having unpaved yards 10 Number of premises having unpaved curing or cleansing places 3 Number of premises having partly unpaved yards 26 Number of premises having defective paving in yards 102 Number of premises having defective paving in curing places 102 Number of premises without a proper and sufficient water supply I Number of premises with inadequate, doubtful, or defective drainage 15 Number of instances in which refuse is collected daily by a contractor 375 Number of instances in which refuse is collected daily by dustmen or scavengers 15 Number of instances in which refuse is stored so as to be a probable source of nuisance 282 Number of instances in which insufficient or improper receptacles are in use 70 Number or instances in which nuisance appears to be caused by:— (a) Smoke 118 (b) Other causes 149 11 The Business of a Marine Store Dealer. The business of keeping a marine store or rag and bone shop, unlike that of a fried fish vendor, is one which tends to steadily decline in importance in London—thus the number of marine stores, as stated in the Post Office Directory, in 1875 was 590; in 1892 it was 460; in 1898, 360; and in 1906, 330. The marine store dealer, properly so-called, purchases, as a rule, old metal, bottles, crockery, and, it may be, rags, grease, bones and other domestic refuse. According to Mayhew, the chief distinction between a "rag and bottle" and a "marine store" shop is that the "marine store shopkeepers (proper) do not meddle with what is a very principal object of traffic with the rag and bottle man, the purchase of dripping, as well as of every kind of refuse in the way of fat or grease. The marine store man, too, is more miscellaneous in his wares than his contemporary of the rag and bottle store, as the former will purchase any of the smaller articles of household furniture, old tea caddies, knife boxes, fire-irons, books, pictures, draught and backgammon boards, bird cages, Dutch clocks, cups and saucers, tools and brushes." It seems desirable as far as practicable to abandon the use of the term "marine store dealer," inasmuch as the number of persons who obtain waste material from ships' stewards or deal in articles exclusively required on board ship is comparatively small, and the class of trade which really requires to be considered from the point of view of production of nuisance is that in which waste materials liable to decomposition are collected and stored, and this altogether independent of the fact of the origin, nautical or otherwise, from which they may be derived. Ballard, writing in 1876, says that the nuisances which arise from such places are very familiar to Medical Officers of Health, and in discussing the danger to health from them he particularly emphasises the question of the conveyance of disease by infectious rags. The Council's Inspectors have found that the articles stored are, in many instances, infested with vermin; and, in some cases, undoubtedly there is risk that persons living on premises adjoining a ragshop may be exposed to serious annoyance on this account. The Council's Inspectors visited 431 premises out of a possible total of some 600 in the County of London. At 23 of these a large wholesale trade was carried on, and at 374 the business was merely of a small retail character. At two premises fat melting was carried on; rags alone were dealt with in 38 instances; in the remainder, rags, bones, paper, and metals were all dealt with; and in 245 instances fat also was collected and stored. In 36 instances Tags, bones, fat, &c., were received either from dust contractors or dustmen. As regards the class of premises used, in 52 cases warehouses, railway arches, or other buildings distant from dwelling-houses were employed as store places. In 86 cases basements were used. The lighting of the premises was noted to be inadequate in 68 instances, ventilation was insufficient in 59, defects in paving were met with in 171, and dirty conditions were frequently observed. As a rule, the type of premises utilised was found to be a small shop, with dwelling-rooms on the upper floor occupied by the shopkeeper and his family, the lower part of the house and basement being used for the purposes of the business. In addition to the articles above referred to as being stored, in a number of instances, rabbit and hare skins and leather cuttings were brought to the premises, and, in a few shops, boiled horse flesh for "cats' meat" was sold. Sources of Materials.— Rags are collected by wholesale dealers from retail shops, from barrowmen, dust wharves and dustmen, also from retailers who bring in their purchases. The retail dealer buys house clearings on order, or buys over the counter in small quantities. He is sometimes a barrow-man, calling on more or less regular customers, and picking up parcels of odds and ends on his round. New rags and cuttings are obtained from dressmaking and tailoring establishments, and are, as a rule, set apart as being more than generally clean. Mixed rags are collected from the houses of the upper and middle classes by dealers; the poorer classes take the rags to the retail shops and sell them over the counter in small lots. The rags from these various sources vary as to the degree of dirt and vermin presented—from clean to being very filthy and verminous. Not infrequently dealers refuse to buy rags on account of their filthy condition. Fat, bones, and rabbit and hare skins are obtained in a similar manner—collection by dealers; they are also bought over the counter from small customers, and derived from dustmen's sortings. The quantity of fat obtained in the poorer districts is very small, the fat is often rancid and the bones covered with mould—both giving off an offensive smell. In a number of instances dealers refuse to buy bones, and, in a less number, fat also. Storage of Materials.—Rags, loose and in bales, were found stored in all parts of the premises —in the shops, ground and upper floors, in passages, sheds, yards, and in many cases in the open yard. Basements were used as rag stores in 20 per cent. of the total premises inspected. In some cases, owing to roofs of sheds being leaky, and to unpaved or badly paved surfaces, the rags were found to be very damp or wet, and gave off an offensive, musty smell, this being particularly the case with the large accumulations of dustmen's rags found on certain premises. Fat was, in numerous instances, kept in tubs, and the bones in sacks in the shops; more frequently bones were stored in sacks in the open yards, and in several instances they were stored in heaps on unpaved and uncovered portions of the yards. In some cases fat was stored in wooden tubs and in metal receptacles (covered and uncovered) in yards. In a few cases bones were found in tubs and sacks 12 on the footway of streets, outside the shops. Hare and rabbit skins are kept in shops and sheds, usually being hung up to dry on racks or hooks. In one instance a coke tire was being used to dry them. There is commonly a quantity of blood and connective tissue about the skin of the head, which becomes decomposed, and in drying gives off an offensive smell, noticeable on the premises and in several cases outside. Instances were found of storage places (including basements) so full of rags that it was impossible to see the condition of the interior, and basements were found to be difficult of access owing to the entrance being either through a small trap-door in the floor of the shop or through staircases and passages filled with rags and lumber. Rag-sorting.—Rag-sorting was carried on in 44 per cent. of the premises visited in groundfloor and upper rooms, basements, sheds, and in covered or open yards. The sheds, in some cases, were either unpaved or had defective paving, and usually there was found a heap of dirt from the rags underneath the sorting screen, as well as other heaps of rag-sorting refuse—apparently the result of accumulation for long periods. Disposal of Rags, Bones, and Fat.—The greater part of the rags from retail shops are sold in bales, sorted or unsorted, to wholesale dealers, and finally find their way into the hands of a few very large wholesale dealers, chiefly in the East End and the Borough. Large quantities of these rags are sorted in the warehouses, and are sent in large bales by rail, the cotton rags to paper mills, and the woollen rags to shoddy mills in Yorkshire. Fat and bones are collected more frequently than rags by tallow-melters and bone-boilers, who chiefly carry on business within the County of London and at Stratford, and employ their own vans for periodical collection. It may be remarked here that large quantities of fat which might otherwise find their way into the marine stores, are collected by fat-melters and washcollectors, and removed to the pig-feeding localities in the extra-Metropolitan areas. A few large wholesale dealers send bones away by rail. Removal of Fat and Bones from Shops.—With regard to the periodical removal of rags fat, and bones from marine stores, the following information was obtained:— Out of a total of 205 premises at which inquiry was made, it was found that in the case of 133 fat and bones were removed weekly or less often, and in 72 they were removed at shorter intervals. General Results of Inspectors Inquiry as to Condition of Premises.— The walls, ceilings, and floors of the shops and storage places were frequently found to be dirty, the infrequency of cleansing being due no doubt in large measure to the premises being constantly full of rags, old furniture, and miscellaneous articles of all kinds. With regard to sheds and yards, much of the offensive smell was due to unpaved or badly paved surfaces, to the accumulation of dirt derived from the sorting of rags, to the stacks and heaps of uncleansed bottles, jars, metal, and miscellaneous litter—these conditions rendering cleansing almost impracticable—to the storage of fat and bones in wooden or uncovered receptacles and the storage of bones on unpaved and uncovered portions of the yards. On some of the premises the tubs and sacks in which fat and bones were stored were dirty, and gave off an offensive smell. Special mention should be made of the foulness of dustmen's sortings and the dirty conditions caused by their being stored and sorted. It seems desirable that, having once been removed by the local authorities, these materials should not again be brought into the neighbourhood of dwelling-houses, as was the case at many of the 36 premises on which dustmen's rags, &c., were being dealt with. In several instances in which the house rags were very dirty, the smell given oft' was extremely offensive—a smell akin to that from dirty and overcrowded dwelling-rooms. In two instances the basement rag stores had recently been flooded by the sewage from overcharged sewers. There were numerous instances of offensive smell on the premises which arose from damp and dirty rags in imperfectly paved sheds with leaky roofs. Having regard to the defective structural conditions found, the large amount of material liable to decomposition manipulated on the premises, the peculiar offensiveness of the dirty rags, the risk of infection from them, and the extent to which tney favour the collection of vermin, the dirty conditions existing on many premises, the large amount of foul materials from dust-bins dealt with, and the extent to which, more particularly in hot weather, nuisance from these various causes is experienced, I think it desirable that some further attempt should now be made to bring these premises under special supervision. Recommendations.—The business could, no doubt, be scheduled under Section 19 of the Public Health (London) Act, 1891, but this, as I have pointed out already in the case of fried fish shops, would be a cumbrous method of dealing with premises of which such a large number exist in London. The plan of treating this trade as ejusdem generis with the offensive trades has been adopted in Cheltenham and Southend-on-Sea; but it may be pointed out that the procedure under the London Act differs in some respects from that under the General Public Health Act of 1875, which is operative outside London, and these differences would render the application of Section 19 in London more restrictive, and it might perhaps be argued oppressive, than is the case under the less stringent section of the Public Health Act of 1875. It seems to me, therefore, that the better course would be, as in the case of fried fish shops, to endeavour to obtain power to make by-laws to control the conduct of any business in which refuse containing animal and vegetable matter liable to decomposition is stored. In the definition of such business, it would of course be desirable to include manipulation of materials such as fat, bones, rabbit-skins, &c., and rags. 13 The following points are mentioned for consideration as needing to be dealt with by by-laws :— Walls.—The inner surface of the walls of every room or place used in connection with the business should be constructed of such material as will effectually prevent the harbouring of vermin. Floors.—The floor surface of every room or place used in connection with the business should, as far as practicable, be paved with jointless, impervious paving, and all wooden floors should be close jointed and caulked. Ventilation.—All receiving, sorting and storing places should have permanent openings to the external air for ventilation, in the proportion of 18 square inches for every 100 square feet of floor space, and should be so placed as to secure efficient ventilation of the whole of the premises Lighting.—All receiving, sorting, and storing places should be provided with means of lighting equal to one-tenth of the floor space in the form of permanent window lights. Repairs.—All walls, ceilings, roofs, floors, fittings and utensils should at all times be kept in a thorough state of repair. Storage, &c.; obstruction to light, &c.—No rags, paper, or other material should be so stored as to obstruct the light and ventilation of any receiving, sorting, or storing place. Improper Storage.— No rags, leather cuttings, skins, bones, or fat should be stored in any open yard or space. Receptacles for Fat, &c.—All bones and fat should be kept in properly covered air-tight metal receptacles and the contents should be removed from the premises at least twice a week from May to October, and at least once a week during the remaining months of the year. Rag-sorting Debris.—All rag-sorting debris should be swept up and put into suitable covered receptacles at the close of every working day, and be removed from the premises at least once in every week. Cleanliness.—All floor surfaces, fittings, utensils, and window lights should be thoroughly cleansed as often as may be necessary to ensure thorough cleanliness, and to prevent the harbouring of vermin. Lime-washing.—All walls, plastered ceilings, and inside roofs should be thoroughly limewashed, and all wood surfaces cleansed, at least four times a year, viz. during the months of March, June, September, and December. Summary of Inquiries as to Marine Stores in the County of London. Number of premises inspected Number of premises on which a large wholesale trade is carried on 23 Number of premises on which both a wholesale and retail trade is carried on 38 Number of premises on which a retail business only is carried on 374 Number of instances in which rags (or rags and metal only) are dealt with 38 Number of instances in which rags, bones, pepper, metal, &c., are dealt with 391 Number of instances in which fat also is dealt with 245 Number of premises on which fat melting is carried on :— (а) Kitchen stuff 1 (b) Edible fat 1 Number of premises on which there exist unsatisfactory appliances for fat melting 1 Number of cases in which rags, &c., are collected from retail shops 37 Number of cases in which rags, &c., are collected from private houses and are bought over the counter only 341 Number of cases in which rags, bones, fat, &c., are received from dust wharves or dustmen 36 Number of premises on which rag sorting is carried on 184 Number of instances in which rags are disposed of to mills direct 25 Number of premises from which rags, &c., are collected by wholesale dealers 325 Number of premises from which rags, &c., are removed by the occupier to wholesale dealers 45 Number of marine stores, comprising warehouses, railway arches, &c., apart from dwelling houses 52 Number of cases in which basement premises are used as rag stores 86 Number of premises having buildings with slated or tiled roofs 79 Number of premises having boarded roofs or ceilings 140 Number of premises having plastered ceilings 220 Number of premises having buildings with roofs of wood and felt, or galvanised corrugated iron 89 14 Number of premises having brick, walls (plastered or matchboarded) 425 Number of premises having buildings with sides of wood or corrugated galvanised iron 116 Number of premises with unpaved shed, yard or basement 70 Number of premises having defective paving in shed, yard, or basement 92 Number of premises having impervious paving in shed, yard, or basement 109 Number of premises with insufficient means of lighting 68 Number of premises with insufficient means of ventilation 59 Number of premises on which dirty conditions were found:— (a) Offensive accumulations of rags, bones and fat 38 (b) Accumulation of rag sorting debris 28 (c) Improper storage of fat, bones, and rags 76 Number of cases in which there were probable causes of nuisance to the neighbourhood from : — (a) Kind of materials dealt in 24 (b) Improper storage 101 (c) Fat melting 1 (d) Use of basement rag stores 85 (e) Defective structure of buildings (including paving) 105 (f) Dirty condition of yards, floors, &c. 84 March, 1906. Shirley F. Murphy, Medical Officer of Health, APPENDIX IV. 12006 London County Council. PHYSICAL DETERIORATION. Report by the medical officer on the resolutions of the Inter-Departmental Committee on Physical Deterioration which have been referred by the Council to the Public Health Committee for consideration. (Printed by order of the Public Health Committee, 2nd November, 1905.) I propose to deal seriatim with the several recommendations of the Physical Deterioration Committee referred to me for report. (2) Register of sickness. The Committee report that it appears to them " in the highest degree desirable that a register of sickness not confined to infectious diseases should be established and maintained." They suggest utilisation of the official returns of poor law medical officers, and of the records of sickness kept by hospitals, and other charitable institutions throughout the country. The fact that a national system of registration of sickness is needed has, during the last two hundred years, become gradually more and more obvious. Already in the early part of the 18th century, it appears, proposals to establish such a system were made, and Dr. Rumsey in 1844, Dr. Liddlo in 1848, Dr. B.W. Richardson in the early fifties and the Metropolitan Association of Medical Officers of Health in 1857 attempted to construct schemes of the kind upon a practical basis. The returns of the association last referred to related to both outdoor and indoor cases treated by poor law medical officers, and the circulation of the tables was undertaken by the General Board of Health. The information obtained was never of a very complete character, and the returns were not continued for much more than a year. Still as Dr. Newsholme remarks in referring (in a paper read before the Statistical Society in 1896) to this effort, it is a " significant fact that nearly 40 years ago a department of the government was actively engaged in collating and circulating information as to various kinds of sickness in the metropolis." An attempt of a similar kind to the above was made in Manchester in 1860 by the Sanitary Association of Manchester and Salford, and weekly returns with quarterly and annual reports were published for 20 years, the observations extending to an area occupied by a population of nearly 400,000 persons. Moreover, from 1859 onwards, owing mainly to the exertions of Dr. Rumsey and Dr. Ransome the subject of the registration of sickness was frequently reported upon by Committees of the Social Science Association and the British Medical Association. In 1857, Sir John Simon, then medical officer of the Privy Council, urged that " certain broad information ought periodically to be given as to the quantities and kinds of sickness treated by the several destitution authorities and by the several medical charities of the country." It was arranged in 1868 that returns, which were then made in five towns and in the district of Marylebone, should be compiled upon a uniform plan. Mr. Goschen, in receiving a deputation of the British Medical Association in 1870, said that the arguments in favour of the registration of disease were very clear and strong and that everyone must accept them, and the report of the Royal Sanitary Commission in the following year shows that the importance of sickness returns was fully recognised by the Commissioners. One outcome of the Commissioners' report was the compulsory appointment of medical officers of health, and this, as Mr. C. E. Paget remarks in his " Wasted Records of Disease," was " the first kind of positive recognition given by any Government in this country to the need for reliable registration of disease." The annual reports of medical officers of health were to be transmitted from all parts of the country to the central authority, and provision was thus made for furnishing this first instalment towards the keeping of a record of prevailing diseases. The need for further information was apparent however; for instance, Dr. Farr in his 35th report, while noting the value of annual reports of medical officers of health, urged that weekly returns of sickness should be procured from every district. He said " the thing to aim at ultimately is a return of the cases of sickness in the civil population as complete as is now procured from the army in England. It will," he adds, " be an invaluable contribution to therapeutics as well as to hygiene." j.t.s—1000—29-11-06. [6511 2 A further advance was that made when Huddersfield, in 1876, followed by Bolton in 1877, and then by other towns, obtained compulsory notification of certain forms of infectious disease. A general Act, the Infectious Diseases Notification Act, was passed in 1889, empowering authorities to put notification in force, and the duty of enforcing notification was made obligatory throughout the country in 1899. The Physical Deterioration Committee are now clearly of opinion that the time is ripe for taking a further step. They point out that in the poor law records there has practically run to waste in this country " an enormous mass of information which, had it been arranged and analysed on suitable lines, would have been simply invaluable to the Committee at the present juncture." The Committee therefore recommend that the tabulation and analysis of the Poor Law Returns should be entrusted to the General Register Office. It is obvious that such tabulation and analysis should be done by a central authority, but inasmuch as to carry out the work for the entire country would be a large undertaking, and as it might perhaps be thought well to make a beginning by dealing with the figures for a compact and more or less homogeneous area such as the County of London, the Public Health Committee may like to consider whether any help which they can afford could be immediately utilised for assisting to initiate a very desirable new departure. At the present time the returns of infectious disease in London are, with the sanction of the Public Health Committee, tabulated in my department, and the tabulated statement is sent to the Registrar-General and published by him in his weekly, quarterly and annual reports. It would no doubt be practicable to adopt a similar system with regard to cases of illness at public institutions, and to furnish a weekly statement showing total sickness, and cases of sickness of certain special kinds, brought newly under treatment in infirmaries, hospitals and dispensaries. The value of a return of this sort giving information as to cases, for example, of diarrhoea, measles, whooping cough, phthisis, pneumonia, rheumatic fever, syphilis and cancer, would be very great, and if its importance were once demonstrated for London, this would, no doubt, lead to its extension after no great interval of time to the rest of the country. (3) Advisory Council. The Committee emphatically recommend the creation of an Advisory Council, the composition of which should be modelled to some extent on Le Comite Consultatif d'Hygiene Publique de France ; such a council, the Committee think, would be "of great assistance, especially to the Local Government Board, and would supply the knowledge and stimulus which are necessary to give the public health side of the Board's administration a prominence, which the multiplicity of its other functions may have tended to obscure, and to attract to its work that measure of public interest and support which has perhaps been lacking hitherto." The present constitution of the French Consultative Committee referred to above is determined by Article 25 of an enactment passed in 1902. It consists of 45 members ; 24 are chosen ex officio on account of their occupying positions in which they may be held to be brought into touch with public health questions ; the remainder are appointed by the ministry, six being selected from a list of nominations made by six academies and corporations, and 15 being chosen as possessing medical, public health, engineering, chemical or legal qualifications. The Committee appears to exercise some of the functions which at the present time devolve upon the Local Government Board in this country, and it may be questioned whether had there been in France a central authority, already exercising all the powers of the Local Government Board, it would have been deemed necessary to constitute a distinct advisory body. The Physical Deterioration Committee (paragraph 64) introduce their recommendation as regards an Advisory Council in connection with that concerning an anthropometric survey. They suggest that a council representing the Departments of Stat6 within whose province questions touching the physical well-being of the people fall, with the addition of members nominated by the medical corporations and others, would apply the information derived from the labours of the Anthropometric Survey Bureau" with the whole weight of Government authority and scientific prestige behind them." It is, to begin with, open to question whether a council of 45 members, constituted after the model of the French Council, would be a body well suited for the special purpose of advising upon the information derived from the survey. But while advising on the survey is the raison d'etre of the Advisory Council, its functions are intended by the Physical Deterioration Committee to include that of acting as a " useful auxiliary" to the Central Government in watching "the play of local administration throughout the country" and bringing "influence to bear on backward districts." This is, of course, a most important function of the Local Government Board at the present time. The Physical Deterioration Committee consider due prominence has not been given to the exercise of this function in the past, and indeed that " the mass of routine work in which the Local Government Board is immersed affords it little time for the consideration of questions of public policy in the sphere of health, and may render it slow to assume the responsibility of applying new principles of administration." It may be pointed out that the function specially under discussion, far from being a new principle of administration, was the principle upon which emphasis was laid at the outset, and it is enunciated with precision of detail in the Public Health Act of 1848. As to whether the exact amount of prominence desirable has been given to the exercise of this function there may be room for discussion, but if more prominence is necessary it may be urged that it can be better given by a Government department, armed with knowledge as to local circumstances and responsible to Parliament, than by a Council without the necessary means of obtaining knowledge and without the authority and influence which direct representation in Parliament implies. The French Advisory Council is in large degree reminiscent of the General Board of Health, constituted under the Act of 1848, the history of whose failure has been traced by Sir John Simon 3 in his " English Sanitary Institutions," and was ascribed by him, in the main, to want of direct touch with Parliament. The more rapid levelling up of backward districts would undoubtedly be facilitated, if, in the first place, the Local Government Board were relieved of some of its purely local administrative duties, and additional powers were conferred upon such bodies as county councils with extension of the principle of acting in default which is already in operation in London ; and in the second place if it were found practicable to enhance the prestige of that branch of the Board's administrative work concerned with public health. Various proposals have been made with a view to the accomplishment of the last-named object ; the main drawback to the suggestion of the Physical Deterioration Committee with regard to an advisory council appearing to be that, instead of enhancing the prestige of the central executive authority, it would tend to diminish it. (4) and (12) Overcrowding. The Physical Deterioration Committee believe " the time has come for dealing drastically with this problem" and advocate an experimental effort by the local authority in certain of the worst districts, in the direction of fixing a standard, and notifying that after a given date no crowding in excess of such standard would be permitted. The Public Health Committee of the Council has always acted upon the lines here laid down, and has urged from time to time upon local authorities the need of remodelling and enforcing by-laws regulating houses let in lodgings, and, when necessary, has not hesitated to recommend the Council to make representations to the Local Government Board concerning defaulting authorities. Though the attempt is still occasionally made to represent that enforcement of these by-laws would unduly interfere with the privacy of the home, the fact is becoming more and more generally appreciated that the only real objectors to the by-laws are the owners of insanitary property. There have been difficulties, notably as to exemption clauses—as to the definition of the word "landlord"—as to requiring notice to be given to owners under particular circumstances, etc., etc.; but during the 14 years which have elapsed since the passing of the Public Health (London) Act, 1891, much useful work has been done under the by-laws by a few enterprising authorities, and at the present time the borough councils of London, generally speaking, are showing an increasing desire to put them in operation. In an appendix to their report the Physical Deterioration Committee print a statement, prepared for the Committee with the assistance of the Local Government Board, of the law as to insanitary and overcrowded house property. (5) Labour Colonies and Public Nurseries. The Physical Deterioration Committee recommend, as a last resource for dealing with habitual vagrants, compulsory detention in labour colonies, the children being lodged in public nurseries. Similar treatment as regards children might, it is suggested, be applied to the children of parents who have " proved unfit to discharge their obligations to those they bring into the world." With a view to the enforcement of parental responsibility,''the object," the report of the Committee states, " would be to make the parent the debtor to society on accont of the child and to empower the local authority to charge the former with the cost of a suitable maintenance, with the farther liability in case of default of being placed in a labour establishment under State supervision until the debt is worked off." A departmental committee on vagrancy has recently been collecting evidence concerning labour colonies, and I think the Council would do well to have before it that committee's report before expressing any opinion. With regard to public nurseries, the recommendation needs to be considered in connection with recommendation (44), which is as follows— (44) Creches. "Wherever it was thought desirable, owing to the employment of married women in factories or for other reasons, to establish municipal creches, girls over 14 might be made to attend occasionally and the teaching of infant management to such girls should be eligible for aid from the grant for public education." A report on creches prepared by the chief officer of the Public Control department was printed by order of the Public Control Committee on 8th July, 1904. That report and recommendation (44) have already been considered by the Education Committee, who state in a memorandum, dated 5th April, 1905, addressed to the Public Health Committee, that they have informed the Public Control Committee " they offer no opinion as to whether it is desirable to establish crshes, but in the event of the Council establishing creches, and provided that the staff and general arrangements are such as would offer available demonstration to girls of school age as to the management of children, the Committee would be prepared to arrange for selected girls from the Council's housewifery centres to visit the creces. The Committee will remember that the conference of representatives of sanitary authorities held at the County Hall on 18th July, 1903, unanimously resolved that it was "desirable that 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, etc., provided, and the food of the children, and that the London County Council be requested to insert in their General Powers Bill for the session 1905 a clause to confer such powers upon the said borough councils." The following recommendation was made in a report, dated 7th July, 1905, by the Public Control Committee to the London County Council- 4 " That it be referred to the Parliamentary Committee to take the necessary steps for promoting in the next session of Parliament a bill to enable the metropolitan borough councils (1) to provide and maintain creches for the reception of young children and to make charges for the accommodation so provided and food for the children; and (2) to contribute towards the maintenance of creches established by voluntary effort; " The consideration of this report stands adjourned. It appears to me to be quite clear that there is a demand for creche accommodation in London, and that if creches are not provided by representative bodies a certain small section of the population must necessarily make shift for themselves, either by paying small sums to neighbours or by resorting to the creches provided by voluntary societies. Creches, from a health point of view, are undoubtedly to some extent an evil, in so far as they may tend to the discouragement of breast feeding, and, by aggregating susceptible children, to spread of infectious disease, but in the light of experience they must be looked upon as a necessary evil, and under proper management the good they do may be made to outweigh the harm. The existing creche provision is reported to be inadequate for the needs of London, and, speaking generally it is capable of being considerably improved upon in certain matters of detail. There would therefore, in my opinion, be advantage in obtaining powers to enable metropolitan borough councils to provide and maintain creches. If creches are provided, recommendation No. (44) might advantageously be acted upon, and I observe that the Education Committee are prepared to co-operate in giving effect to this recommendation. (11) Reporis from local authorities. The Committee recommend that such reports compiled " according to certain specified requirements " should be furnished to the central authority, and thus form a basis of comparison between different districts. The Local Government Board already prescribes the form in which reports of medical officers of health are to be made. Apparently the Committee think that in order to emphasise responsibility reports of local authorities should also be prepared upon somewhat similar lines and in such a manner as would facilitate comparison being made as regards such questions as " infant death-rate, number of cellar and back-to-back dwellings, with the tale of occupants in each dwelling and the minimum amount of cubic feet allowed for each person, the character of the water supply and sewerage arrangements and the means for the disposal of refuse, and any cognate matters, information on which would afford a clue as to the character of the administration." The paragraphs 121-123 of the Committee's report in which this matter is discussed appear to show that they did not have before them in any detail the system of reporting at present adopted, and if the Committee had had brought to their notice the Memorandum of the medical officer of the Local Government Board on Annual Reports with its appended tables, they would have seen that the need of a system of reporting " according to specified requirements " was already fully appreciated by the Board. It is, however, capable of some development, and I may mention that recently, with a view to obtaining a statement on a uniform plan from medical officers of health as to workshops, I brought this question before the metropolitan medical officers of health, and a form was agreed upon, which, with some modification, has been adopted by the Home Office and Local Government Board. In the same way a form has also quite recently been prepared for reporting upon the frequency of inspection of, and proceedings as to, premises, such as cowsheds, houses let in lodgings, etc., and upon the administration of the by-laws. This form has been adopted by many London medical officers of health and is embodied in their annual reports. (13) Medical inspection of factories. The recommendations made under this head are to the effect that— " The existing powers of certifying factory surgeons should be extended (1) so as to enable them to examine employees for purposes of qualification at a later age than 16 ; (2) so as to enable them to re-examine when necessary at definite intervals. Further, even if it be necessary that inspectors of factories and medical officers of health should have to some extent co-ordinate powers with regard to insanitary conditions in factories, an arrangement should be made whereby each authority should notify to the other any defects that may be apparent, although coming within the other's province. Similarly it should be the certifying surgeon's duty to notify to the factory inspector or the medical officer of health, as the case may be, such defects as may come under his notice." The first two recommendations relate to questions concerning which I have no administrative experience, and I can only say that on general grounds it is clear that certain advantages would accrue from effect being given to them. But the Committee do not define the frequency of inspection or on whose initiative it should take place. As regards the third recommendation as to exchange of information concerning insanitary conditions, the Committee may like to have before them the fact that the factory inspector administers the special provisions of the Factory and Workshop Act in factories, while the duties of local authorities are thus stated in a Home Office memorandum— " In the case of factories the duties of a district council are few. The council is charged with the duty of seeing that every factory in its district is provided with means of escape in case of fire ; and also has special duties in regard to bakehouses and domestic factories. These duties, which apply also in the case of workshops, will be further referred to below. Another duty in regard to factories, though not arising under the Factory and Workshop 5 Act, is (in districts where Part III. of the Public Health Acts Amendment Act, 1900, is in force) the enforcement of the requirement in section 22 of that Act as to the provision of suitable and sufficient sanitary conveniences, and (elsewhere) the enforcement of section 38 of the Public Health Act, 1875." I am not prepared to say it is desirable there should be a specific requirement to the effect that each authority should notify to the other any defects which may be apparent, as recommended by the Physical Deterioration Committee. It is not presumably intended, for instance, that the one authority should communicate to the other, matter in which only the first authority is concerned. There would no doubt be advantage in the two authorities being in touch with one another in connection with the proposed remedy of defects which might conceivably be held to concern both authorities. With regard to the final proposal, I doubt the advisability of imposing upon the certifying surgeon the duty of notifying defects brought to his notice, to the factory inspector or medical officer of health. If he only hears of such defects at second hand the advantage of his acting as intermediary is not apparent, and if he is to make examination as to the existence of defects he would be merely acting in substitution of an officer upon whom this duty is already imposed. (16) Workshops. The Physical Deterioration Committee urge that the inspection and supervision of workshops, as distinguished from factories, should be strengthened. On the question whether this duty should be undertaken by the local authority or the Home Office, the Committee say they are not in a position to make a definite recommendation. They call attention, however, to the propriety of making employment of children and young persons in workshops dependent, as it is in factories, on a medical certificate. There is undoubtedly still need for strengthening supervision of workshops, though much has been done in this direction in London in the last 12 or 14 years. The Act of 1891 excluded workshops, as far as sanitary provisions are concerned, from the operation of the Factory Acts and brought them under the Public Health Acts. I am not aware of any grounds for concluding there would be advantage if the supervision of workshops were taken from local authorities and transferred to a central department of government. The Committee point out that while 376,278 children and young persons were examined in factories in 1901, only 413 were examined in workshops, the former examinations being made as a matter of routine, the latter only at the request of the occupier or in cases in which the Secretary of State may make a special order. The extension of the certifying surgeon's inspection to workshops would, as the Physical Deterioration Committee say, " be a formidable undertaking," but they are of opinion that it "calls for the earnest consideration of the department concerned." Probably the need of protecting children working near machinery has emphasised the importance of medical inspection in the case of children working in factories. (17) Alcoholism. The Physical Deteriation Committee emphasise the need of " bringing home to men and women the fatal effects of alcohol on physical efficiency" and of training teachers to give rational instruction in the laws of health, including the demonstration of the physical evils caused by drinking. This recommendation has been referred by the Council to the Education and Public Health Committees. The Public Health Committee has had under consideration the desirableness of publishing a statement (similar to that brought to the notice of the Physical Deterioration Committee) regarding the ill effects which result from excessive indulgence in alcohol. The solicitor has, however, advised that there was no power to spend money in the manner suggested, and the Committee reported to the Council to this effect on 14th March last. (21) Cooking-grates. The Physical Deterioration Committee point out that " in tenement houses often only one room in the whole house contains a grate of proper service for cooking, with the result that a large number of tenements do not contain the requisite apparatus for the preparation of food." The Committee will remember that it recently had before it a report by Dr. Young on " Houses Adapted as Tenement Houses," in which this question was considered. I pointed out in connection with Dr. Young's report that, as the result of inquiry made by the Council's inspectors, it was found that— " Of 739 tenements of one, two, three and four rooms, in a third of the tenements there was no oven in which food could be baked, the fire-grate being the same as that provided when the house was originally constructed, or of the same kind and not more adapted for cooking purposes than an ordinary bedroom grate. This condition was found especially in tenements of one room, more than half of which were so circumstanced ; in tenements of two rooms about a quarter were without coal fire or gas ovens for cooking purposes, but in tenements of three or four rooms an oven heated in one or other of these ways was always found to be provided. In tenements of one room in which an oven was found, this oven was almost always heated by a coal fire, in exceptional instances the oven was associated with a gas stove, and in one or two instances the tenement had both. In tenements of two rooms provided with an oven, in about 85 per cent. the oven was heated by the fire grate, in about 6 2 per cent. there was a gas cooking stove, and in about 12 per cent. there were both. In tenements of three or four rooms an oven was found, with a single exception, in association with the coal fire-grate, and in 16 per cent. of these tenements there was also a gas cooking stove. It was often found that no provision had been made for carrying off the products of combustion of such gas stoves." I raised question on the results thus detailed as to whether each tenement should not be required to be provided with a cooking stove. In giving evidence before the Physical Deterioration Committee, I drew attention to this subject and that Committee has arrived at the conclusion that the law should require a grate suitable for cooking to be provided in every tenement let for the occupation of a family. (22) Adulteration. The Committee say "it would be highly expedient that the Local Government Board should be authorised to fix a standard of purity for all foods and drinks in the same manner as standards for milk and butter have been fixed by the Board of Agriculture." No evidence was taken by the Committee on adulteration and the question of fixing standards of purity, is, it appears to me, one which needs to be considered in some detail before deciding as to the application of this method in particular instances. (23) Infantile mortality and employment of women. The recommendations of the Committee under this head were based on the evidence of Miss Anderson, the Home Office inspector. This officer suggests that light would be thrown on the relationship between excessive infantile mortality and employment of women in factories if certain particulars as to rates of infant mortality in localised areas in industrial towns, and in particular industries throughout the country, together with particulars as to the occupations (if any) of all mothers (married or unmarried), were shown in the Registrar-General's records. The question as to the desirability of preparing tables of the kind referred to will no doubt be considered by the Registrar-General. The matter is one which is perhaps of less importance in London than in some of the industrial centres of the north. (28) Milk supply. The Physical Deterioration Committee consider that the existing law as to control of milk supplies should be more completely enforced. Until 9th November, 1900, the County Council enforced the Dairies, etc., Orders of 1885 and 1886 and the regulations made thereunder ; from that date the enforcement of the regulations and the registration of milk vendors was transferred to the borough councils, the enforcement of other provisions of the Order remaining with the Council. To give effect to the Dairies, etc., Order of 1899 relating to the milk of a cow certified by a veterinary surgeon to be suffering from tubercular disease of the udder, the Council appointed a veterinary surgeon in July, 1899, and systematic inspection of cows in London cowsheds has since been made. In the General Powers Bill of 1903 power to slaughter cows suspected to be suffering from tubercular disease of the udder was obtained by the Council. The need of issuing a new order in place of the orders of 1885 and 1886 has long been apparent, and indeed, before the passing of the London Government Act of 1899, the Public Health Committee approached the Local Government Board on the subject. The question has not been settled as yet, the Board desiring to await the report of the Tuberculosis Commission which is still sitting. Until a new order is issued there must necessarily be a certain amount of difficulty in administration owing to overlapping of jurisdictions ; there are, beyond this, certain amendments which it is desirable should be made, and the Local Government Board has before it some suggestions made by the Public Health Committee. Proposals relating to improvement of milk supply have been included in the Council's Bills, but have not yet become law. The Physical Deterioration Committee make certain further suggestions as to the issuing of orders on the initiative of the Local Government Board in default of such action by urban and rural authorities (no doubt outside London); as to county councils being empowered to act in default of local authorities ; and as to its being the duty of the Local Government Board to intervene in the ultimate resort. With these recommendations the Public Health Committee will no doubt be in sympathy. (30) Milk depots. The Physical Deterioration Committee think that the milk supply should pass through as few hands as possible, and that milk depots should be formed in every town, obtaining their supply direct from the farms. They think this could be done " without recourse to direct municipal action," but add " that in all improvement bills promoted by local authorities the insertion of provisions dealing with the milk supply within their area should be insisted upon." At the conference of sanitary authorities held at the County Hall in July, 1904, it was resolved " that it was desirable that the metropolitan borough councils should be empowered at their discretion to provide in their various 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." A private bill, the Milk Depots (London) Bill, 1905, was however introduced, and the Parliamentary Committee reported on this bill to the Council on 11th April, 1905 (p. 1379). The Council approved the principle of the bill, but the bill did not become law. 7 (31) Sterilisation and Refrigeration. The Physical Deterioration Committee recommend an investigation by a small body of experts into the whole subject of sterilisation of milk. An inquiry such as the Physical Deterioration Committee have in mind would presumably best be undertaken by a Government Department or Inter-Departmental Committee. The Committee referred to me for consideration, in connection with the Physical Deterioration Committee's report, a letter, dated 21st December, 1904, from the town clerk of the Metropolitan Borough of Woolwich, dealing with several of the recommendations contained in the report of the Inter-Departmental Committee. The principal point raised, so far as the recommendations now before the Public Health Committee are concerned, is with regard to the need for the amendment of the regulations under the Dairies and Cowsheds Orders. As already stated, this question was fully considered by the Public Health Committee some years ago, and a communication was addressed to the Local Government Board on the subject. Shirley F. Murphy, Public Health Department, Medical Officer of Health. 8, St. Martin's-place, 2nd November, 1905. • •