43/3 London County Council. PUBLIC HEALTH-COUNTY OF LONDON. REPORT of the PUBLIC HEALTH COMMITTEE of the LONDON COUNTY COUNCIL, Submitting the REPORT of the MEDICAL OFFICER OF HEALTH OF THE COUNTY FOR THE YEAR 1906. (Printed by order of the Council.) PRINTED BY SOUTH WOOD, SMITH & CO., LTD., 93 & 94, LONG ACRE, W. C. 14911 London County Council. Report of the Public Health Committee, submitting the report of the Medical Officer of Health of the County of London for the year 1906. In submitting the report of the Medical Officer of Health of the County of London, we are glad once again to be able to state that the death rate (15.1), which was equal to that of the previous year, was the lowest on record. As we pointed out last year, the death rate has fallen nearly 30 per cent. since the coming into operation of the Public Health (London) Act, 1891, and, if comparison be made between the years 1905 and 1906, on the one hand, and the decennial period 1891-1900, on the other, it will be found that, as the result of the diminished death rate there has been an estimated gain to the community in each of the two recent years of some 19,000 lives, and this represents a gain in " life capital " of some three-quarters of a million years of life. The infant mortality rate was very slightly in excess of that of the previous year. In correspondence with the less favourable meteorological conditions of 1906, the deaths attributable to epidemic diarrhoea and infective enteritis were about one-third higher than in the preceding year. Epidemic diseases.—The death-rate from the principal epidemic diseases was slightly higher— 193 per 1,000 persons living—than in the year 1905. Only 31 cases of smallpox were notified. Measles, however, showed a slight increase, as did also scarlet fever and diphtheria. In the case of the two last named diseases, particulars concerning the spread of infection in connection with school attendance are given by the Medical Officer. Enteric fever was again at a low ebb in London. The Medical Officer gives account of attacks following the consumption of particular articles of food, and refers to the fact that infection from person to person is frequently mentioned as a cause of the disease. The subject of the control of pulmonary phthisis is discussed by the Medical Officer at some length, especially in relation to the desire which is not infrequently expressed that cases of this disease shall be dealt with much in the same way as cases of dangerous infectious diseases. The Medical Officer further refers to the conclusions of the Royal Commission on tuberculosis, with reference to the question of the amount of risk to man of bovine tuberculosis, and, in this connection, we are able to report that we have now under consideration the question of the administration of the powers conferred upon the Council by the General Powers Act of last session. Removal of refuse.—The need for the more systematic control of the removal of offensive trade refuse has been before us for many years past, and we hope, as the Council is aware, to obtain further power with regard to this matter. The hot summer brought prominently to our notice the subject of fly nuisance, particularly in certain localities in which large accumulations of house refuse were collected in course of removal from London. This subject is receiving our further attention. Houses let in lodgings.—The revision of the by-laws regulating houses let in lodgings, which was made necessary owing to decisions of the High Court on 3rd February, 1904, has now been, for the most part, accomplished, and, with few exceptions, the Borough Councils are now in a position to carry on the important work of requiring that houses occupied by a number of families shall be maintained in a proper state of cleanliness and sanitation, under codes of by-laws which have recently received the Local Government Board's sanction. A report on the water supply to the upper floors of tenement houses appears as an appendix to this report. The necessary powers for improving the water supply in houses used as tenement houses were given in the past session of Parliament. A report on " block dwellings " also appears as an appendix to this report. Common lodging-houses.—The report contains statistics as to mortality rates at different ages and from various causes of death among common lodging-house inmates. Inspection of food.—The Medical Officer refers to the need of ensuring greater efficiency of the supervision over London food supplies, and to the desirableness of establishing a system of inspection iv. at various points of entry of foodstuffs into London. A report on this subject appears as an appendix to this report, and a further appendix contains particulars as to the amounts of various food materials which arrive in London by rail. Inspection of school children.—Appended to the report of the Medical Officer of Health is the report of Dr. Kerr, giving account of the work done in the schools in this connection. (Signed) E. Baxter Forman, Chairman. County Hall, Spring Gardens, S.W. 12th December, 1907. FIFTEENTH ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH OF THE ADMINISTRATIVE COUNTY OF LONDON. TABLE OF CONTENTS. Part I.— page Population 5 Marriages 5 Of minors, per cent. of total marriages 6 Births 6 Rates per 1,000 persons living and legitimate births per 100 married females (aged 15-45) in sanitary areas 7 Deaths 7 Crude and corrected rates in Military areas 8 Crude and corrected rates in sanitary areas calculated on Equalisation of Rates' populations 9 Deaths at the sever A age-periods in sanitary areas 10 London mortality in the year 1906 compared with the mortality in the decennium 1891-1900 10 Infant mortality 12 Deaths at all ages from certain diseases and groups of diseases 19 Rates from all causes and from specified causes in sanitary areas 20 Principal Epidemic Diseases 20 Smallpox and Vaccination 22 London vaccination returns 25 Number of children for whom certificates of conscientious objection together with the number of children not finally accounted for per cent. of births 25 Measles 26 Mortality among children at ages 0-5 in sanitary areas 27 In relation to overcrowding 28 Deaths at the several age-periods in sanitary areas 28 Scarlet Fever 30 Scarlet fever and elementary schools 31 Age and sex distribution 32 Diphtheria 33 Comparative case-rates in sanitary areas 35 Diphtheria and elementary schools 35 Age and sex distribution 37 Whooping-cough 37 Typhus 39 Enteric Fever 40 Age and sex distribution 41 Diarrhoea 44 Erysipelas 45 Puerperal Fever 47 Influenza, Bronchitis and Pneumonia 48 Phthisis 48 Crude and corrected death-rates in sanitary areas 49 Deaths at the several age-periods in sanitary areas 49 In relation to overcrowding 50 Cancer 53 Crude and corrected death-rates in sanitary areas 54 Deaths from sarcoma, carcinoma, and cancer {otherwise undefined) at the several age-periods in sanitary areas 54 In relation to overcrowding 56 Cerebro-spinal Fever 56 Anthrax 56 Meteorology 56 Part II.— Dairies, Cowsheds and Milkshops 57 Tuberculosis of the udder in cows 57 Offensive Businesses 59 Nuisances 61 Smoke nuisance 61 Nuisance from stable manure 62 Removal of house refuse 62 Removal of offensive matter 63 Nuisance from sewers 63 Nuisance from rivers and canals 63 Housing of the Working Classes Act, 1890 63 Proceedings under Part I. of the Act 63 Proceedings under Part II. of the Act 64 Proceedings under Part III. of the Act 64 Provision for persons displaced by street improvements 64 Proceedings by district councils 64 Proceedings in respect of houses represented under Part II. of the Act as unfit for human habitation 65 Death-rates among persons resident in County Council buildings 65 Common Lodging Houses 66 Death-rates among inmates of common lodging-houses 67 Seamen's lodging-houses 68 Aliens Act, 1905 68 14911 a 2 TABLE OF CONTENTS—continued. page Houses let in Lodgings 69 Water supply to tenement houses 71 Houses infested with Vermin 71 Revenue Act, 1903 71 Underground Rooms 72 Overcrowding 72 Factory and Workshop Act, 1901 73 Table showing proceedings of sanitary authorities under the Factory and Workshop Act 74 Inspection of Food 76 Sale of Ice cream 79 Disinfection 80 Shelters 80 Mortuaries 81 Cleansing of Persons Act, 1897 81 Water Supply 81 London Equalisation of Rates Act, 1894 82 Midwives Act, 1902 83 Sanitary Inspectors 89 Medical Inspection of School Children 90 Medical Officers of Health of London Sanitary Areas 91 Appendices— I.—Tabular statement showing, number of tenements, rents, etc., in block dwellings in the several sanitary areas of London. II.—Report of the Medical Officer (Education) for the year ended 31st March, 1907. III.—Report on water supply to tenement houses. IV.—Extracts from a report to the Public Health Committee on Food Inspection. V.—Report on Inspection of Food by Riparian Sanitary Authorities. VI.—Report on the sanitary staffs of the metropolitan sanitary authorities. LIST OF DIAGRAMS. facing page. Diagram I.—Marriages, 1851-1906 6 „ II.—Births, 1851-1906 6 ,, III.—Deaths (all causes) 1841-1906 7 ,, IV.—Infant Mortality, 1858-1906 12 „ V.—Smallpox (mortality) 1841-1906 22 „ VI.—Measles (mortality) 1841-1906 26 ,, VII.—Measles and Whooping-cough (monthly deaths) 1891-1906 26 „ VIII.—Scarlet Fever (mortality) 1859-1906 30 ,, IX.—Scarlet Fever (admissions to hospitals of Metropolitan Asylums Board, per cent. of total notified cases in London) 1890-1906 30 ,, X.—Scarlet Fever (monthly notified cases and case-mortality) 1891-1906 31 „ XI.—Diphtheria and Croup {mortality) 1859-1906 33 ,, XII.—Diphtheria (admission to hospitals of Metropolitan Asylums Board, per cent. of total notified cases in London) 1890-1906 33 ,, XIII.—Diphtheria (monthly notified cases and case-mortality) 1891-1906 34 ,, XIV.—Whooping-cough (mortality) 1841-1906 38 „ XV.—Typhus (mortality) 1869-1906 39 „ XVI.—Enteric Fever (mortality) 1869-1906 40 ,, XVII.—Enteric Fever (weekly notified cases, 1906, and mean weekly notified cases, 1890-1906) 40 „ XVIII.—Enteric Fever (monthly notified cases and case-mortality) 1891-1906 40 ,, XIX.—Diarrhoea, Dysentery and Cholera (mortality) 1841-1906 44 ,, XX.—Phthisis (mortality—males and females) 1851-1906 48 REPORT OF THE MEDICAL OFFICER OF HEALTH. 1906. PART I. The temperature of the air was, on the whole, slightly above the average during 1906, excess occurring in every month except February, April, June and December, and being especially marked in the months of August and October. The rainfall was also slightly above the average during the year as a whole, but from March to September inclusive was below the average in each month except June. The marriage-rate (17.1) was slightly above the marriage-rate of the previous year (16.9), which was the lowest on record. The birth-rate (26.5) was the lowest on record in London since the institution of civil registration. The death-rate (15.1) was equal to that of the previous year, which was the lowest on record. The infant mortality-rate was below the average, but slightly in excess of that of the preceding year. The number of deaths from diseases of the respiratory organs was considerably below the annual average number of the preceding ten years. The number of deaths from phthisis, diphtheria, whooping cough and measles was markedly below the average, but the deaths from phthisis, diphtheria and measles showed an increase upon the number of deaths in the preceding year. The death-rate from whooping cough was the lowest on record. The deaths from diarrhoea and cancer were above the ten years' average. Population. The population of the Administrative County of London, estimated to the middle of the year 1906, was 4,721,217. The populations of the City of London and cach of the metropolitan boroughs, as constituted by the London Government Act of 1899, estimated to the middle of 1906, are shown in the following table— Sanitary areas.—Populations (middle ot 1906). Sanitary area. Estimated population (middle of 1906). Sanitary area. Estimated population (middle of 1906). Paddington 148,913 Shoreditch 116,108 Kensington 180,952 Bethnal Green 130,609 Hammersmith 120,679 Stepney 307,176 Fulham 161,965 Poplar 170,673 Chelsea 74,672 South wark 209,143 Westminster, City of .. 173,905 Bermondsey 128,629 St. Marylebone 128,580 Lambeth 315,774 Hampstead 89,633 Battersea 179,622 St. Pancras 236,455 Wandsworth 273,381 Islington 344,987 Camberwell 274,132 Stoke Newington 53,217 Deptford 115,495 Hackney 230,721 Greenwich .. 105,350 Holborn 55,805 Lewisham 148,463 Finsbury 97,466 Woolwich 127,345 London, City of 21,367 Marriages. The number of marriages in the Administrative County of London in 1906 (52 weeks) was 40,412, giving an annual rate of persons married of 17.1 per 1,000 persons living. The marriage rate in successive periods has been as follows— Marriage-rates. Period. Marriage-rate per 1,000 persons living. Period. Marriage-rate per 1,000 persons living. 1851-60 20.6 1902 17.8 1861-70 20.3 1903 17.5 1871-80 19.1 1904 17.0 1881-90 17.6 1905 16.9 1891-1900 17.8 1906 17.1 1901 17.6 6 The accompanying diagram (I.) shows the marriage rate in each year since 1850, in relation to the mean marriage rate of the period 1851-1906. In the year 1906 among the males 3.5 per cent. married were under 21 years of age, and among the females 12.9 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. It will be seen that both in London and in England and Wales the proportion of male and female minors in every 100 marriages has been diminishing for a number of years :— Marriages of tumors 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 .44 15.0 5.0 16.0 1902 4.0 14.1 4.7 15.4 1903 3.8 13.7 4.6 15.2 1904 3.7 13.9 4.6 15.3 1905 3.6 13.0 4.4 14.7 Births. The number of births registered in the Administrative County of London in 1906 (52 weeks) was 124,880, giving a birth-rate of 26.5 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 1906 is the lowest recorded rate in London since the institution of civil registration. The birth-rate in successive periods has been as follows:— London—Birth-rates. Period. Birth-rate per 1,000 persons living. Period. Birth-rate per 1,000 persons living. 1851-60 33.6 1902 28.41 1861-70 35.4 1903 28.31 1871-80 35.4 1904 27.71 1881-90 33.2 1905 27.01 1891-1900 30.3 1906 26.51 1901 28.81 The corresponding figures for England and Wales are shown below:— England and Wales—Birth-rates. Period. Birth-rate per 1,000 persons living. Period. Birth-rate per 1,000 persons living. 1851-60 34.2 1902 28.6 1861-70 35.2 1903 28.4 1871-80 35.5 1904 28.0 1881-90 32.5 1905 27.2 1891-1900 29.9 1906 27.0 1901 28.5 The accompanying diagram (II.) shows the London birth-rate in each year since 1850, in relation to the mean birth-rate of the period 1851-1906. For the purposes of these rates the births in the principal lying-in institutions have been distributed to the district to which they belong. Diagram I Marriages. Mean Marriage-rate 1851-1906 8.6 per 1000. D'Hnm " Births- Mean Birth-rate 1851-1906 32-6 per 1000. Diagram III Deaths (all Causes). Mean Death -rate 1841 -1906. 21 4 per1000 living 7 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 1901-5 and in the year 1906 :— Birth-rates in sanitary areas. Sanitary area. Births, 1906 (52 weeks). Birth-rate persons per 1,000 living. Legitimate births per 100 married females aged 15-45. 1901-5. 1906. 1901-5. 1906. Paddington 3,375 23.6 22.7 19.5 18.8 Kensington 3,457 20.4 19.2 18.9 17.6 Hammersmith 3,112 27.2 25.9 21.0 19.8 Fulham 4,853 32.7 30.0 21.5 19.8 Chelsea 1,593 22.2 21.4 19.2 18.6 Westminster, City of 2,977 18.3 17.2 16.4 15.2 St. Marylebone 2,718 22.1 21.2 18.4 17.7 Hampstead 1,473 17.6 16.5 16.4 15.3 St, Pancras 6,122 27.7 26.0 20.6 19.3 Islington 8,767 27.2 25.5 20.7 19.4 Stoke Newington 1,105 21.7 20.8 18.2 17.4 Hackney 5,694 27.0 24.7 21.7 19.9 Holborn 1,239 22.4 22.3 18.0 17.5 Finsbury 2,938 31.8 30.2 24.5 23.3 London, City of 355 14.2 16.7 16.2 18.0 Shoreditch 3,963 34.7 34.2 26.5 26.2 Bethnal Green 4,488 35.2 34.5 27.7 27.1 Stepney 10,811 36.7 35.3 28.6 27.4 Poplar 5,384 34.0 31.6 26.9 25.0 Southwark 6,225 32.8 29.8 24.0 21.8 Bermondsey 4,075 33.3 31.8 26.4 25.3 Lambeth 8,270 27.4 26.3 20.9 20.1 Battersea 4,688 28.8 26.2 20.9 19.0 Wandsworth 7,199 26.8 26.4 21.1 20.8 Camberwell 7,020 27.7 25.7 22.1 20.6 Deptford 3,292 29.8 28.6 22.6 21.7 Greenwich 2,672 27.3 25.4 22.3 21.1 Lewisham 3,466 25.8 23.4 20.5 18.7 Woolwich 3,549 29.7 27.9 21.9 20.5 London 124,880 28.0 26.5 22.1 20.9 Deaths. The number of deaths in the Administrative County of London in 1906 (52 weeks) was 71,155, giving an annual death rate of 15.1 per 1,000 persons living. The London death-rate in successive periods has been as follows :— All Causes—Death-rates. Period. Death-rate (All Causes) per 1,000 persons living. Period. Death-rate (All Causes) per 1,000 persons living. 1841-50 24.8 1901 17.12 1851-60 23.7 1902 17.22 1861-70 24.4 1903 15.22 1871-80 22.5 1904 16.12 1881-90 20.5 1905 15.12 1891-1900 19.l2 1906 15.12 The death-rate in each year since 1840 in relation to the mean death-rate of the period 1841-1906 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. Tbe 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 1906. 1 See footnote (1) page 6. 2 Theso 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. 8 All Causes—Death-rates per 1,000 persons living. Town. Estimated Population (middle of 1906.) Crude death-rate per 1,000 persons living. Death-rate per 1,000 persons living (corrected for age and sex distribution). 1896-1905. 1906. 1896-1905. 1906. London 4,721,217 17.31 15.11 1821 15.91 Liverpool 739,180 22.4 20.6 24.0 22.0 Manchester 637,126 21.9 19.2 24.4 21.4 Birmingham 548,022 19.8 16.8 21.3 18.1 Leeds 463,495 18.5 15.6 20.2 17.0 Sheffield 447,951 19.3 16.4 20.8 17.7 Bristol 363,223 16.5 14.5 17.0 14.9 West Ham2 301,617 17.4 15.7 18.6 16.8 Bradford 288,544 17.2 16.1 19.0 17.8 Newcastle-on-Tyne 268,721 20.4 17.1 22.0 18.4 Hull 262,426 18.3 16.9 18.8 17.3 Nottingham 254,563 18.1 16.1 19.1 17.0 Salford 234,077 217 18.3 24.0 20.2 Leicester 232,111 16.3 14.3 17.4 15.3 London had therefore (comparing the corrected death-rates) both in the decennium 1896-1905, and the year 1906 a lower death-rate than any of these towns except Bristol and Leicester. The following table enables comparison to be made of the death-rates of London with the death-rates of several foreign towns3:— All Causes—Death-rates per 1,000 persons living. Town. 1896-1905. 1906. Town. 1896-1905. 1906. London 17.31 15.11 St. Petersburg 25.5 25.5 Paris 18.8 17.5 Berlin 17.5 15.8 Brussels 16.2 14.6 Vienna 20.0 17.5 Amsterdam 15.6 13.7 Rome 19.1 18.7 Copenhagen 17.1 15.6 New York 19.7 18.3 Stockholm 16.3 13.5 It will be seen that in the decennium 1896-1905 the London death-rate was exceeded by the death-rates of Paris, St. Petersburg, Berlin, Vienna, Rome and New York, and in 1906 was lower than that of any except Brussels, Amsterdam and Stockholm. 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 1906 ; the mean death-rates for the period 1901-54 are also shown for the purposes of comparison. Crude and corrected death-rates5 (All Causes), per 1,000 persons living, in the County of London, and the several sanitary districts. Area. Standard deathrate. Factor for correction for age and sex distribution. Crude death-rate per 1,000 persons living. Corrected deathrate per 1,000 persons living. Comparative mortality figure (London, 1,000), 1901-5. 1906. 1901-5. 1906. 1901-5. 1906. England and Wales 18.19 1.0000 — — — — — — London 17.31 1.0511 16.1 15.1 16.9 15.9 1,000 1,000 Paddington 17.04 1.0677 13.8 12.5 14.7 13.3 870 836 Kensington 16.88 1.0778 14.5 13.8 15.6 14.9 923 937 Hammersmith 17.47 1.0414 15.4 14.8 16.0 15.4 947 969 Fulham 17.39 1.0462 15.5 13.7 16.2 14.3 959 899 Chelsea 17.56 1.0361 16.2 15.7 16.8 16.3 994 1,025 Westminster, City of 16.22 1.1217 14.5 12.9 16.3 14.5 964 912 St. Marylebone 17.08 1.0652 16.6 14.9 17.7 15.9 1,047 1,000 Hampstead 16.13 1.1280 10.2 9.4 11.5 10.6 680 667 St. Pancras 17.40 1.0456 17.3 15.9 18.1 16.6 1,071 1,044 (Continued on next page.) 1 Including deaths of Londoners in the Metropolitan Workhouses, Hospitals, and Lunatics 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. 2 As extended in 1905. 3 All death-rates in this report relating to foreign towns are calculated upon figures published by the Registrar General. 4 Owing to the changes consequent upon the London Government Act, 1399, the death-rates in the present metropolitan boroughs cannot be shown prior to the year 1901. 5 All death -rates in this report relating to metropolitan sanitary areas are fully corrected for institutions, see footnote (2), page 7. 9 Area. Standard deathrate. Factor for correction for age and sex distribution. Crude death-rate per 1,000 persons living. Corrected deathrate per 1,000 persons living. Comparative mortality figure (London, 1,000). 1901-5. 1906. 1901-5. 19"6. 1901-5. 1906. Islington 17.51 1.0391 15.3 14.7 15.9 15.3 941 962 Stoke Newington 17.43 1.0438 13.1 11.5 13.7 12.0 811 755 Hackney 17.46 1.0420 14.7 13.3 15.3 13.9 905 874 Holborn 16.90 1.0766 19.2 18.0 20.7 19.4 1,225 1,220 Finsbury 17.57 1.0355 21.0 20.7 21.7 21.4 1,284 1,346 City of London 16.55 1.0993 17.8 17.3 19.6 190 1,160 1,195 Shored itch 17.34 1.0493 20.4 19.6 21.4 20.6 1,266 1,296 Bethnal-green 18.01 1.0102 19.4 18.9 19.6 19.1 1,160 1,201 Stepney 17.41 1.0450 19.3 17.7 20.2 18.5 1,195 1,164 Poplar 17.64 1.0314 18.7 17.6 19.3 18.2 1,142 1,145 Southwark 17.41 1.0450 19.9 18.1 20.8 18.9 1,231 1,189 Bermondsey 17.76 1.0244 19.8 19.7 20.3 20.2 1,201 1,270 Lambeth 17.63 1.0320 16.1 15.0 16.6 15.5 982 975 Battersea 16.96 1.0728 14.9 13.4 16.0 14.4 947 906 Wandsworth 17.25 1.0547 13.1 12.8 13.8 13.5 817 849 Camberwell 17.54 1.0373 15.0 14.6 15.6 15.1 923 950 Deptford 17.31 1.0511 15.7 16.1 16.5 16.9 976 1,063 Greenwich 17.82 10210 14.3 13.5 14.6 13.8 864 868 Lewisham 17.46 1.0420 12.3 12.0 12.8 12.5 757 786 Woolwich.. 17.02 1.0690 14.1 13.1 15.1 14.0 893 881 It will be seen from the foregoing table (comparing the corrected death-rates) that the death-rate (all causes) was, both in the period 1901-5 and the year 1906, highest in Finsbury (21.7 and 21.4 respectively per 1,000 persons living), and lowest in Hampstead (11.5 and 10'6 respectively, per 1,000 persons living). For the purposes of the calculation of the death-rates in the above table the populations of the several metropolitan boroughs have been estimated on the assumption that the rate of increase in the last intercensal period has been since maintained. The correctness of this assumption is open to doubt, especially in view of the fact that five years have elapsed since the census of 1901, and the estimate of the populations used needs to be checked by figures obtained on some other assumption. Such figures are furnished by the populations calculation by the Registrar General for the purposes of the Equalisation of Rates Act, these populations being calculated from the number of rated houses in each borough. The following table shows the populations estimated by the two methods referred to and the resulting deathrates for the year 1906. It will be noted that the death-rate of the County of London remains practically the same whether one or the other population be adopted. Death-rates in sanitary areas per 1,000 persons living in 1906, calculatcd (a) on Registrar General's Annual Summary population and (b) on Equalisation of rates population. Sanitary area. Population. Crude Death-rate Corrected Death-rate (a) Annual Summary estimate. (b) Equalisation of Rates' estimate. Calculated on (a). Calculated on (b). Calculated on (a). Calculated on (b). Paddington 148,913 145,338 12.5 12.8 13.3 13.7 Kensington 180,952 182,748 13.8 13.7 14.9 14.8 Haminersmith 120,679 118,025 14.8 15.1 15.4 15.7 Fulham 161,965 154,692 13.7 14.3 14.3 15.0 Chelsea 74,672 70,907 15.7 16.5 16.3 17.1 Westminster, City of 173,905 172,085 12.9 13.0 14.5 14.6 St. Marylebone 128,580 129,215 14.9 14.8 15.9 15.8 Hampstead 89,033 87,005 9.4 9.7 10.6 10.9 St. Pancras 236,455 231,236 15.9 16.2 16.6 16.9 Islington 344,987 336,848 14.7 15.1 15.3 15.7 Stoke Newington 53,217 51,813 11.5 11.8 12.0 12.3 Hackney 230,721 222,399 13.3 13.8 13.9 14.4 Holborn 55,805 54,666 18.0 18.3 19.4 19.7 Finsbury 97,466 102,651 20.7 19.6 21.4 20.3 City of London 21,367 25,003 17.3 14.8 19.0 16.3 Shoreditch 116,108 117,383 19.6 19.4 20.6 20.4 Bethnal Green 130,609 128,660 18.9 19.2 19.1 19.4 Stepney 307,176 290,770 17.7 18.7 18.5 19.5 Poplar 170,673 169,494 17.6 17.7 18.2 18.3 Southwark 209,143 197,859 18.1 19.0 18.9 19.9 (Continued on next page.) 14911 B 10 Sanitary area. Population. Crude Death-rate Corrected Death-rate (a) Annual Summary estimate. (b) Equalisation of Rates' estimate. Calculated on (a). Calculated on (b). Calculated on (a). Calculated on (b). Bermondsey 128,629 128,951 19.7 19.6 20.2 20.1 Lambeth 31.5,774 307,764 15.0 15.4 15.5 15.9 Battersea .. 179,622 172,329 13.4 13.9 14.4 14.9 Wandsworth 273,381 296,020 12.8 11.8 13.5 12.4 Camberwell 274,132 266,245 14.6 15.0 15.1 15.6 Deptford 115,495 113,051 16.1 16.4 16.9 17.2 Greenwich 105,350 101,922 13.5 13.9 13.8 14.2 Lewisham ... 148,463 158,381 12.0 11.2 12.5 11.7 Woolwich ... 127,345 134,825 13.1 12.4 14.0 13.3 London 4,721,217 4,668,315 15.1 15.2 15.9 16.0 Reference to this table shows that in the case of nine districts, viz., Fulham, Chelsea, Finsbury, City, Stepney, Southwark, Wandsworth, Lewisham, and Woolwich, the difference in the death-rates obtained is more than 0'5 per 1,000 living. In five of these districts, viz., Finsbury, City, Wandsworth, Lewisham and Woolwich the adoption of the " equalisation" populations gives a lower death-rate, while in the four remaining districts the death-rate is increased. The following table shows the number of deaths1 (All Causes) occurring at several ages in each of the sanitary areas of the Administrative County of London during the year 1906 (365 days) — All Causes—Deaths at the several age-periods in sanitary areas—1906 (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 355 79 23 19 9 485 36 23 26 40 95 166 218 251 251 206 77 1,874 Kensington 458 136 51 27 28 700 37 15 39 40 144 211 250 313 360 294 108 2,511 Hammersmith 428 91 41 30 25 615 50 26 20 36 93 148 152 208 237 151 50 1,786 Fulham 660 148 61 40 25 934 49 26 26 56 112 159 217 204 235 159 47 2,224 Chelsea 212 71 30 14 7 334 14 13 9 16 69 89 134 132 186 138 36 1,170 Westminster, City of 332 90 35 24 15 496 34 16 31 42 126 228 282 337 356 242 70 2,260 St. Marylebone 324 83 36 22 15 480 35 19 38 41 105 188 209 258 285 218 66 1,942 Hampstead 116 30 7 11 10 174 17 4 11 21 30 61 82 118 151 133 41 843 St. Pancras 761 217 89 66 40 1,173 89 52 67 82 218 350 427 429 465 328 101 3,781 Islington 1,100 318 159 72 42 1,691 94 44 62 114 275 388 529 609 670 504 136 5,116 Stoke Newington 114 19 12 4 4 153 15 5 9 11 34 48 73 75 90 73 34 620 Hackney 687 179 77 30 24 997 67 38 61 80 172 216 288 332 427 316 107 3,101 Holborn 148 52 13 8 9 230 13 8 13 13 52 126 121 138 159 101 25 999 Finsbury 474 208 76 56 29 843 33 33 52 23 109 154 182 228 197 141 34 2,029 London, City of 37 12 6 5 60 7 8 10 9 26 36 50 52 55 43 18 374 Shoreditch 651 210 80 40 32 1,013 53 24 29 40 116 205 242 218" 191 130 35 2,296 Bethnal-green 703 237 64 39 30 1,073 58 38 32 53 146 183 240 229 214 184 52 2,502 Stepney 1,465 541 195 87 71 2.359 126 61 88 111 307 438 502 573 551 303 74 5,493 Poplar 820 257 90 56 35 1,258 68 46 45 64 133 226 258 313 352 215 40 3,018 Southwark 910 296 112 67 39 1,424 S3 42 69 69 206 384 412 381 419 263 50 3,802 Bermondsey 630 245 70 66 43 1,054 64 32 39 54 142 209 248 243 256 175 43 2,559 Lambeth 1,098 279 99 52 53 1,581 104 68 82 80 262 339 435 581 650 440 142 4,704 Battersea 590 178 54 27 34 883 62 39 43 69 144 173 221 265 267 170 59 2,395 Wands worth 883 154 69 43 39 1,188 65 46 54 67 201 265 321 404 450 328 129 3,518 Camberwell 917 276 116 75 35 1,419 103 47 81 103 236 243 373 454 447 389 142 4,037 Deptford 479 145 67 39 24 754 45 19 30 39 76 134 153 180 218 168 59 1,875 Greenwich 324 69 41 20 19 473 49 16 29 34 83 95 135 145 189 141 49 1,438 Lewisham 396 92 31 24 13 556 44 13 31 37 98 126 164 214 244 195 75 1,797 Woolwich 391 76 30 18 20 535 50 25 34 37 114 141 179 191 217 128 38 1,689 London 16,463 4,788 1,834 1,081 769 24,935 1,564 846 1,160 1,481 3,924 5,729 7,097 8,075 8,789 6,276 1,937 71,813 London mortality in 1906 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 1906. The figures for the year 1906 are fully corrected for institution deaths (see footnote (2), page 7), 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. 1 See footnote (2), page 7. 11 Death-rates per 1,000 living at the several age-periods in 1906 as compared with those of the decennium 1891-1900. Age-period. Males. Females. Mean deathrate 1891-1900. Death-rate 1906. Difference per cent. Mean deathrate 1891-1900. Death-rate 1906. Difference per cent. 0— 71.97 52.17 —27.5 61.99 44.51 —28.2 5— 4.97 3.41 —31.4 5.17 3.38 —34.6 10— 2.46 1.82 —26.0 2.48 2.05 —17.3 15— 3.47 2.90 —16.4 2.94 2.19 —25.5 20— 4.59 3.40 —25.9 3.46 2.63 —24.0 25— 7.36 5.39 —26.8 5.65 4.04 —28.5 35— 14.22 10.55 —25.8 10.68 819 —23.3 45— 2314 1905 —17.7 1712 14.20 —17.1 55— 40.68 34.78 —14.5 31.01 25.75 —17.0 65— 77.78 7414 — 4.7 63.44 5615 —11.5 75— 15413 141.87 — 8.0 134.56 121.22 — 9.9 85 and upwards 284.10 347.49 +22.3 265.77 307.02 + 15.5 All ages ... 20.88 16.49 -21.0 17.88 14.07 -21.3 It will be seen from this table that the rate of mortality in 1906 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 lifetime of males and females in groups of ages corresponding to those age-groups to which the deaths relate. The following table shows the results thus obtained from the London Life Table, 1891-1900:— Table I. Mean future lifetime of males and females in groups of ages, calculated from the London Life Table, 1891-1900. Age-group. Males. Females. Age-group. 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 3.02 319 In the following table the number of deaths occurring in the year 1906 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 1906. 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 :— 14911 B 2 12 Table II. Lives and "Life-capital" gained or lost in 1906, as compared with the decennium 1891-1900. Age-group. Deaths calculated according to mean death-rates of 1891-1900. Deaths occurring in the year 1906. Gain ( + ) or loss (—) of lives in the year 1906, by fluctuation of mortality. Gain (+) or loss (—) of "life capital" in the year 1906 by fluctuations of mortality. Males. Years. 0— 18,569 13,461 + 5,108 + 256,217 5— 1,139 782 + 357 + 17,811 10— 532 393 + 139 + 6,340 15— 754 630 + 124 + 5,116 20— 1,038 769 + 269 + 9,966 25— 2,845 2,084 + 761 + 23,629 35— 4,154 3,083 + 1 071 + 25,683 45— 4,702 3,870 + 832 + 14,768 55— 5,026 4,297 + 729 + 9,003 65— 4,452 4,244 + 208 + 1,660 75— 2,732 2,515 + 217 + 1,065 85 and upwards 515 630 - 115 - 347 All ages—Males 46,158 36,758 + 9,700 + 370,911 Females. Years. 0— 15,980 11,474 + 4,506 + 241,792 5— 1,197 782 + 415 + 22,194 10— 547 453 + 94 + 4,634 15— 713 530 + 183 + 8,224 20— 938 712 + 226 + 9,180 25— 2,574 1,840 + 734 + 25,242 35— 3,450 2,646 + 804 + 21,620 45— 3,889 3,227 + 662 + 13,266 55— 4,550 3,778 + 772 + 10,754 65— 5,135 4,545 + 590 + 5,251 75— 4,175 3,761 + 414 + 2,223 85 and upwards 1,131 1,307 - 176 - 561 All ages—Females 44,279 35,055 + 9,224 + 363,819 Total—Persons 90,737 71,813 + 18,924 + 734,730 It will be seen from the preceding table that during the year 190G, as compared with the decennium 1891-1900, there has been a saving of 18,924 lives, representing a gain to the community of 734,730 years of " life-capital." Infant Mortality. The deaths of children under one year of age in the Administrative County of London during 1906 (52 weeks) numbered 16,307, being in the proportion of 131 per 1,000 births. The proportion in successive periods has been as follows :— Deaths under one year of age per 1,000 births. Period. Deaths under one year of age per 1,000 births. Period. Deaths under one year of age per 1,001) births. 1841-50 157 1901 1481,2 1851-60 155 1902 1401,1 1861-70 162 1903 1301,2 1871-80 15S 1904 1451,2 1881-90 152 1905 1301,2 1891-1900 158 1906 1311,2 The accompanying diagram (IV.) shows the infant mortality in each year since 1857 in relation to the mean infant mortality of the period 1858-1906, and also the infant mortality in each year after exclusion of the deaths from premature birth, which would in all probability be affected in greater degree than the deaths under any other heading by the more complete registration of recent years. 1 See footnote (2) page 7. 2 Seo footuote (1) page 6. Diagram IV Infant Mortality, (Deaths under one year of age per 1000 births.) Mean Death - rate 1858 -1906 141 per 1,000 births. Mean Death - rate 1858 -1906 155 per 1,000 births 13 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. Town. 1896-1905. 1906. Town. 1896-1905. 1906. London 1501 1311 West Ham 167 150 Liverpool 180 172 Bradford 159 152 Manchester 183 167 Newcastle-on-Tyne 167 151 Birmingham 185 168 Hull 170 160 Leeds 172 151 Nottingham 181 171 Sheffield 182 158 Salford 192 159 Bristol 138 127 Leicester 176 168 London had therefore both in the period 1896-1905 and in 1906 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 1901-5 and for the year 1906:— Sanitary areas—Deaths under one year of age per 1,000 births. Sanitary area. Deaths under one year of age, 1906. (52 weeks) Deaths under one year of age per 1,000 births. 1901-5. 1906. Paddington 355 123 105 Kensington 456 145 132 Hammersmith 430 145 138 Fulham 649 143 134 Chelsea 212 135 133 Westminster. City of 328 118 110 St. Marylebone 317 134 117 Hampstead 113 95 77 St. Pancras 753 137 123 Islington 1,089 127 124 Stoke Newington 113 115 102 Hackney 676 132 119 Holborn 149 138 120 Finsbury 469 160 160 London, City of 36 134 101 Shoreditch 644 173 163 Bethnal Green 697 150 155 Stepney 1,453 150 134 Poplar 821 154 152 Southwark 895 158 144 Bermondsev 623 159 153 Lambeth 1,086 138 131 Battersea 591 138 126 Wandsworth 873 120 121 Camberwell 910 133 130 Deptford 472 136 143 Greenwich 318 131 119 Lewisham 391 112 113 Woolwich 388 120 109 London 16,307 1392 1312 It will be seen from the foregoing table that both in the period 1901-5 and the year 1906 Shoreditch (173 and 163 respectively) had the highest infantile death-rate and Hampstead (95 and 77 respectively) had the lowest. The reports of Medical Officers of Health of the several sanitary areas of the Administrative County for the year 1906 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 different 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. 1 See footnote (1) page 8, 2 See footnote (2) page 7. 14 Infant mortality during the year 1906. Deaths from stated causes in weeks and months under one year of age (365 days). 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 Manths. 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 ­ ­ 1 ­ ­ 3 Measles ­ — 3 1 4 3 4 3 4 19 30 41 63 80 82 87 420 Scarlet Fever ­ ­ ­ ­ ­ ­ 2 ­ 1 2 ­ 2 1 4 4 2 18 Diphtheria and Croup ­ ­ ­ 1 1 1 ­ 1 3 2 3 7 6 10 13 12 59 Whooping Cough 1 1 5 8 15 31 37 29 31 38 49 48 49 56 62 57 502 Diarrhœal Diseases— Diarrhoea, all forms Enteritis (not tuberculous) Gastritis, Gastrointestinal Catarrh 10 38 70 88 212 420 464 549 496 492 387 383 308 296 232 229 4,468 Wasting Diseases— Premature Birth 1,463 223 193 99 1,978 152 41 21 3 4 ­ 2 2 1 3 1 2.208 Congenital Defects 290 80 45 26 441 62 37 14 14 9 6 8 9 4 5 4 613 Injury at Birth 100 4 2 1 113 ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ 113 Want of Breast-milk Atrophy, Debility, Marasmus | 360 134 145 124 763 366 297 220 133 91 68 53 54 33 28 24 2,130 Tuberculous Diseases— Tuberculous Meningitis 1 ­ 1 2 4 6 10 13 24 31 24 27 20 25 28 29 241 Tuberculous Peritonitis: Tabes Mesenterica 1 1 3 5 10 21 32 30 23 18 17 16 13 19 14 12 225 Other Tuberculous ­ ­ 2 8 10 12 30 18 16 30 19 27 12 23 22 27 246 Diseases Erysipelas ­ 2 7 5 14 13 3 5 4 5 5 1 ­ ­ ­ ­ 50 Syphilis 14 16 24 15 69 52 33 27 12 7 6 6 7 6 4 4 233 Rickets ­ ­ ­ ­ ­ 3 ­ 3 5 8 3 5 9 13 11 7 67 Meningitis (not Tuberculous) 4 5 2 ­ 11 16 19 24 24 34 36 30 23 30 32 | 23 302 Convulsions 108 71 46 26 251 74 51 37 46 35 43 19 24 34 23 23 660 Bronchitis 11 25 50 39 125 153 123 84 75 84 85 53 69 64 54 74 1,043 Laryngitis 1 ­ ­ ­ 1 1 1 1 ­ 2 5 2 4 3 1 2 23 Pneumonia 13 25 27 31 96 101 113 96 85 100 121 133 130 132 108 120 1,335 Suffocation, overlaying 87 15 19 18 139 96 63 49 31 14 13 3 5 1 2 1 417 Other causes 212 67 72 48 399 107 57 55 50 55 49 51 41 49 46 50 1,009 Total (All Causes) 2,683 707 722 545 4,657 1,690 1,417 1,279 1,080 1,080 970 917 849 884 774 788 16,385 Comparison may be made between the totals in this table and those of a similar table included in the Annual Report for 1905. The figures of the two years are as follows :— Period. 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.0 5-6 Months. 6-7 Months. 7-8 Months. 8-9 Months. 9-10 Months. 10-11 Months. ! 1-12 Months. Total Deaths under one year. 1905 2,886 808 667 564 4,925 1,796 1,411 1,211 1,033 983 932 853 880 846 821 706 16,397 1906 2,683 707 722 545 4,657 1,690 1,417 1,279 1,080 1,080 970 917 849 884 774 788 16,385 Total 5,569 1,515 1,389 1,109 9,582 3,486 2,828 2,490 2,113 2,063 1,902 1,770 1,729 1,730 1,595 1,494 32,782 The figures of 1906 differ from those of 1905 in the following particulars. In 1905 the number of deaths decreased in each successive week of the first month of life ; in 1906 the number of deaths in the third week exceeded those in the second. In 1905 the decline in successive months was interrupted by an increase in the number of deaths in the ninth month of life ; in 1906 there was no interruption until a month later, and another manifested itself in the twelfth month. Explanation of the increase in the number of deaths in the third week of life in 1906 is to be found in the main in the deaths from wasting and diarrhœal diseases ; deaths from measles, whooping cough and tubercular disease are largely responsible for the interruption in the decline in the tenth month, and bronchitis and pneumonia in the twelfth month. When the total of the two years is considered it is seen that there is decline in 15 each successive period except in the tenth month. The greatest risk of dying from diarrhoea appears to be in the third and fourth months of life, and of bronchitis in the second month of life. If this be so, increase of births some 3-4 months before the diarrhoea period and 1-2 months before the period when respiratory diseases are prevalent would affect the figures of mortality. For further consideration of this question a record of dates of birth instead of registra ion is needed. Any correction necessary for this purpose would not, however, materially alter the fact that the number of deaths from diarrhoeal diseases progressively increases from the first month of life until the fourth month of life is reached, and then progressively declines in each succeeding month. This must be due more to the variation in resistance than to difference in exposure to infective agencies. It is notorious that infants fed on cow's milk are more liable to death than infants which are breast fed, but, as Dr. Howarth, of Derby, has shown, this liability manifests itself in death from a variety of causcs, and the suggestion, therefore, is that it is related to diminished power of resistance, as the result of unnatural feeding. How far a diminished power of resistance is caused by increase of temperature must as yet be mere matter of speculation, but it is interesting to note that the London figures of the last twentytwo years show that taking the average result over the whole period an increase or decrease of 1 per cent. in the mean temperature of the summer quarter is attended by an increase or decrease of some 6 per cent. in infant mortality. This will be seen from the following figures, but it is obviously impossible to say how much diminished resistance and how much increase of infective agency may have contributed to this result. Infant mortality in relation to temperature. (Third quarters of years compared.) Year. Deaths under 1 year of ago per 1,000 births. Mean temperature. Deg. F. Mean = 100. Deaths under 1 year of age per 1,000 births. Mean temperature. 1885 187 59.1 93 97 1886 220 61.2 110 101 1887 230 61.0 115 101 1888 169 57.6 85 95 1889 183 58.9 91 97 1890 195 59.4 97 98 1891 183 59.3 91 98 1892 170 59.2 85 98 1893 207 61.9 103 102 1894 163 58.6 82 97 1895 220 62.3 110 103 1896 228 60.4 114 99 1897 242 60.9 121 100 1898 259 62.7 129 103 1899 277 63.0 138 104 1900 219 61.8 109 102 1901 203 61.7 101 102 1902 149 59.1 75 97 1903 139 59.8 69 99 1904 208 61.2 104 101 1905 171 61.8 85 102 1906 187 63.3 93 104 Mean 1885 1906 2004 60.65 100 100 The following Life Table, which is based upon the figures shown in the table on page 14, shows the probability of living for one month at each month of the first year of life and the number of survivors at the beginning of each of the first twelve months of life out of 100,000 born. The figures shown in the last column are taken from a similar table published in my last annual report, and will enable comparison to be made between the two years 1906 and 1905 in this respect:— 16 London—1906. Life Table for the first 12 months of life (based on the mortality of the year 1906). Age-period. Registered deaths. 1906. Probability of living for one month. 1906. Number living at the beginning of each month of age. 1905. Number living at tho beginning of each mouth of age. x 12 1906. Px 12 l x 12 l x 12 0—1 month 4,657 .96298 100,000 100,000 1—2 months 1,690 .98607 96,298 96,115 2—3 „ 1,417 .98817 94,957 94,701 3—4 „ 1,279 .98919 93,834 93,594 4—5 „ 1,080 .99077 92,820 92,647 5—6 „ 1,080 .99069 91,963 91,841 6—7 „ 970 .99156 91,107 91,076 7—8 „ 917 .99196 90,338 90,354 8—9 „ 849 .99249 89,612 89,693 9—10 „ 884 .99212 88,939 89,011 10—11 „ 774 .99307 88,238 88,357 11—12 „ 788 .99290 87,627 87,722 0—1 year 16,385 — 87,005 87,177 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:— Deaths at each interval of age (under one year) from All Causes in sanitary areas in 1906 (365 days). Sanitary area. 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 Mrnths. Total under 1 Year. Paddington 56 15 16 13 100 41 28 36 29 28 15 20 8 25 11 12 353 Kensington 84 18 14 19 135 44 38 26 24 23 26 28 28 35 22 23 452 Hammersmith 82 11 14 13 120 42 42 27 35 36 25 27 24 19 22 14 433 Fulham 126 17 28 25 196 59 49 52 43 48 45 36 31 32 27 31 649 Chelsea 31 14 12 7 64 19 25 15 15 7 14 10 14 11 8 9 211 Westminster, City of 64 22 21 13 120 39 36 22 22 9 20 17 9 11 8 10 323 St. Marvlebone 73 11 18 17 119 31 30 28 12 10 14 12 7 27 21 11 322 Hampstead 26 11 4 5 46 14 9 6 5 8 7 5 2 3 2 4 111 St Paneras 111 28 45 21 205 86 72 63 54 43 47 41 38 42 25 37 753 Islington 182 42 49 35 308 120 108 96 67 67 56 55 51 51 54 50 1,083 Stoke Newinaton 33 4 3 6 46 18 6 4 8 6 5 5 4 4 4 7 117 Hackney 146 32 39 20 237 73 47 50 47 55 37 32 46 33 33 31 721 Holborn 21 6 5 2 34 12 7 8 11 10 15 6 8 13 13 10 147 Finsbury 68 21 22 11 122 44 50 43 38 25 22 18 26 29 30 27 474 London, City of 5 2 2 2 11 3 1 ­ 2 2 1 2 1 2 1 4 30 Shoreditch 81 27 18 13 139 66 68 55 48 49 40 42 42 42 34 26 651 Bethnal Green 113 40 32 16 201 59 57 44 35 52 48 50 32' 40 42 36 696 Stepney 208 53 62 52 375 159 152 98 88 98 81 87 76 85 81 74 1,454 Poplar 98 33 31 26 188 87 79 63 50 70 38 56 52 53 41 45 822 Southwark 136 31 32 30 229 88 67 89 64 61 46 58 52 50 38 53 895 Bermondsey 90 24 28 16 158 70 54 46 47 48 47 39 33 25 33 24 624 Lambeth 177 48 44 38 307 127 77 95 66 69 70 66 55 48 56 52 1088 Battersea 93 34 36 18 181 61 44 51 31 36 40 35 29 28 26 26 588 Wandsworth 164 44 45 33 286 88 78 71 50 62 59 43 37 29 37 34 874 Camberwell 130 36 32 42 240 77 74 71 66 69 63 51 61 55 43 72 942 Deptford 71 37 12 21 141 56 32 40 38 35 26 24 25 22 18 15 472 Greenwich 55 10 12 11 88 28 27 21 23 15 18 17 18 25 26 14 320 Lewisham 72 13 20 10 115 48 35 38 36 19 19 17 19 23 6 16 391 Woolwich 87 23 26 10 146 31 25 21 26 20 26 18 21 22 12 21 389 London 2,683 707 722 545 4,657 1,690 1,417 1,279 1,080 1,080 970 917 849 884 774 788 16,385 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 17 of infant mortality obtaining for groups of districts (arranged on the basis of the amount of overcrowding shown by the census of 1901) can be compared:— Infant mortality and overcrowding1—1906. Age-period. Proportion of overcrowding1 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 22.7 22.1 20.4 20.9 21.2 1-2 weeks 5.7 5.7 5.7 4.7 6.4 2-3 „ 5.8 5.5 5.8 6.1 6.0 3-4 „ 3.8 4.8 4.3 4.3 4.1 Under 1 month 38.0 38.1 36.2 36.0 37.7 1-2 months 11.9 13.2 14.2 13.3 14.8 2-3 „ 9.1 9.8 12.4 10.8 14.7 3-4 „ 8.3 10.2 10.3 11.5 10.8 4-5 „ 7.4 8.8 8.6 8.7 9.4 5-6 „ 6.9 9.1 8.5 7.6 10.1 6-7 „ 6.9 8.1 7.3 7.5 8.6 7-8 „ 5.2 7.2 7.6 7.2 8.9 8-9 „ 5.0 7.3 6.6 6.4 7.9 9-10 „ 4.8 6.6 7.1 8.1 8.8 10-11 „ 3.7 6.3 6.0 5.9 8.4 11-12 „ 4.9 6.5 5.8 6.8 7.4 0-3 months 59.0 61.1 62.8 60.1 67.2 3-6 „ 22.6 28.1 27.4 27.8 30.3 6-9 „ 17.1 22.6 21.5 21.1 25.4 9-12 „ 13.4 19.4 18.9 20.8 24.6 0-12 months 112.1 131.2 130.6 129.8 147.5 It will be seen from the foregoing table that there is a marked difference in the mortality among children under one year of age when the least and most over crowded groups of districts are compared. This agrees with the figures in a corresponding table published in my last annual report dealing with the year 1905. If the figures for each of the trimesters are considered in this connection, it will be seen that the same behaviour of the mortality is observable, but the differences in the mortality between the least and most overcrowded groups is least marked in the first three months of life and increasingly marked in each of the succeeding periods 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:— Infant mortality and overcrowding1—1906. Number of group of districts in order of overcrowding. Comparative mortality 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. 104 124 132 145 III. 106 121 126 141 IV. 102 123 123 155 V. 114 134 149 184 These figures are in agreement with those published in my last annual report, and the experience of a further year suggests that the results are not accidental. The small variation in the mortality shown for the several groups among children aged 0-3 months may possibly be due to more complete registration of births aud deaths in the better circumstanced districts. The registration of deaths of young children has probably been more complete in recent years, and any improvement which may have taken place in this respect would presumably be more marked in the better-circumstanced districts in London. The following figures, showing the deaths of children aged 0-1, 1-2, and 2-3, 3-6, 6-9 and 9-12 months per cent. of the deaths of children aged under one year in the periods 1839-46 1 The term "overcrowding" is used to apply to that proportion of the population shown by the census figures of 1901 to be living more than two in a room in tenements of less than five rooms. 14911 c 18 and 1005-6, lend support to the hypothesis of improved registration, such hypothesis being apparently the most probable that can be advanced to account for the relatively high mortality in the period 1005-6 among children in the first month of life. Infant mortality (1830-46 compared with 1005-6.) Period. Months. Total under 1 year of age. 0-1 1-2 2-3 3-6 6-9 9-12 Total deaths (males and females). 1839-46 1,8175 8,918 6,543 16,730 14,338 13,852 78,556 1905-6 9,582 3,486 2,828 6,666 5.401 4,819 32,782 Comparative figures (all ages taken as 100). 1839-46 231 114 83 213 183 176 1,000 1905-6 292 106 86 204 165 147 1,000 In numerous districts in London efforts are being made to limit infant mortality by visits to the mothers of new-born infants, and by endeavours to improve the conditions affecting infant life. In the majority of districts this work devolves upon a woman sanitary inspector ; but in a few districts voluntary workers undertake this duty. In the absence of a system of notification of births, the County Council supplies to medical officers of health the addresses of women who have been attended by midwives. For this purpose a large majority of the midwives in London communicate weekly to the Council's Public Health Department a list of all the cases which have been attended by them, and in this way medical officers of health were in 1006 put in possession of addresses of 30,749 women who had been confined, the information reaching them within less than a fortnight of the confinement. The annual reports of medical officers of health supply interesting accounts of the work which is being done in this connection in the several districts. Value is undoubtedly attached by the medical officers of health to the services performed by the health visitors in visiting the homes of newly-born infants. The result of these efforts may be expected to manifest itself later in the London statistics of infant mortality, but the experience of some years will be required before sound inferences can be drawn. In four districts, viz., Battersea, Finsbury, Holborn and Woolwich, these efforts are supplemented by the supply of modified milk in suitable cases. In Battersea and Woolwich the milk is supplied from depots owned by the Borough Councils ; the Battersea depot has been established more than five years, while the Woolwich depot was opened in November, 1906. The milk depot in Finsbury has been established by a voluntary society, which is advised by the medical officer of health of the borough, and the milk is pasteurized and modified at the farm from which it is received. In Holborn arrangements have been made for supplying, on the order of the medical officer of health, modified milk provided by a large dairy company. The effect of the supply of milk from the Finsbury depot is discussed by Dr. Newman in an excellent chapter on infant mortality. He states that the children supplied with milk came as a rule from poor houses, that 60 per cent. of them "were ill at the time of admission, many of them were very seriously ill and some of them dying." Nevertheless the mortality of the infants supplied by the depot, ill and frail though they were, was less than half the infant mortality of all the children born in Finsbury at the same time." And again, "taken as a whole, however, it is abundantly evident that the depotfed children suffered much less from epidemic diarrhoea, and all other diseases, than other artificiallyfed children in the borough, and even when they were attacked had a much lower mortality. And yet nearly all the depot children were of the very poorest classes; all of them were artificially fed; all were living at home and subject to precisely the same external conditions of life as other infants in the borough, and together they formed a selected class of the weakest and most frail an " unfit residuum," so to speak, of the children born in Finsbury. But they received pure milk and proper supervision, and so they survived." The value of the milk depot does not depend only upon the quality of the milk supplied therefrom. "Each child fed on depot milk," Dr. Newman states, "is visited in its own home. In this way a direct personal influence is brought to bear on the mother, and homely advice is given and precautions taken as to the management of the infant. Sanitary conditions and their effect on the health of the child are noted. . . . I attribute much of the success of the depot to these personal visits and assistance." Dr. McCleary, the medical officer of health of Hampstead, who, in a similar office in Battersea, had experience of the milk depot in that borough writes strongly in favour of the provision of an establishment of this kind in the Kilburn ward of Hampstead, and he, too, insists upon the value of the personal visits and the advice which is given in association with its administration. Dr. Sykes compares the position which the Borough of St. Pancras occupied in respect of infant mortality in the third quarter of the year in relation to the seventy-six large towns of England and the London sanitary areas in 1904, 1905 and 1006. A system of visitation to the homes of newly-born children was instituted in 1904, extended in 1905, and accompanied by the institution of the voluntary notification of births in the third quarter of 1906. The work of visiting was undertaken by women inspectors, assisted by ladies who volunteered for this purpose, their efforts in the main being directed 19 to the encouragement of breast feeding during the suckling period of infancy. In the first year St.Pancras stood fortieth in the order of these towns, i.e., thirty-nine had a lower infant mortality; in the second year it was thirty-fourth, and in the third year sixteenth. Compared with the other London sanitary areas, St. Pancras was twenty-fifth in 1904, eighteenth in 1905, and thirteenth in 1906. Obviously, the three years' experience does not suffice for precise inferences, but the altered position of St. Pancras is none the less of much interest. Dr. Sykes writes: "The reason for the reduction of infant mortality in St. Pancras is, in my opinion, due to an increase in breast feeding. It is extremely difficult to demonstrate this in figures, but inquiries indicate that maternal functions are being better fulfilled, and the constantly reiterated advice to thousands of mothers to breast-feed must be having this salutary effect." The importance of breast feeding is insisted upon by medical officers of health, and the proportions of children breast-fed and hand-fed are shown in a number of the annual reports. In an analysis of 1,127 deaths of infants in Finsbury, Dr. Newman found that the mothers lived at home in 77 per cent., and in 88 per cent. the houses were either well kept or fairly Well kept; but only 30 per cent. of the children were breast-fed, and if deaths due to epidemic diseases be considered, only 14 per cent. of the children were wholly breast-fed. A National Conference on Infantile Mortality was held in London in June, 1906, the conference having as its president the Right Honourable John Burns, M.P., President of the Local Government Board, and as its chairman Mr. Evan Spicer, Chairman of the London County Council. Several important papers bearing on the subject were read, and various resolutions were adopted. The resolutions related to the following subjects:—the teaching to girls in the public schools of elementary hygiene with reference to the dietary and rearing of infants, the establishment of milk depots, the notifications of births, the insurance of infant lives,the limitation of employment of women shortly before and after childbirth, the amendment of the Infant Life Protection Act and of the Dairies, Milkshops and Cowsheds Orders, and the employment of specially trained women as an adjunct to public health work. The Secretary of State has since invited medical officers of health to a conference at the Home Office on the employment of women shortly before and after childbirth. 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 1906 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. Number of deaths, 1906, compared with the annual average deaths of the preceding decennium, 1896-1905. Cause of death. Diminution in 1906. Excess in 1906. Smallpox 168 Measles 477 — Scarlet Fever 35 — Typhus 2 — Influenza 140 — Whooping Cough 702 — Diphtheria 829 — Pyrexia (origin uncertain) 3 — Enteric Fever 281 — Diarrhoea — 609 Pneumonia — 144 Erysipelas — 43 Tuberculous Phthisis Phthisis 1,038 — Tuberculous Meningitis 88 — Tuberculous Peritonitis Tabes Mesenterica 249 — Other Tuberculous diseases (including Scrofula) 60 — Cancer — 476 Premature Birth 381 — Diseases of Nervous system Diseases of Circulatory system 1,999 — Diseases of Respiratory system 2,713 — Diseases of Digestive System 616 — Diseases of Urinary system — 116 Childbirth and Puerperal Septic Diseases 61 — Accident 480 — Homicide 18 — Suicide — 32 All other Cause 845 — Net diminution 9,765 1 For purposes of comparison deaths from Infective Endocarditis are included under this heading. 14911 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 (2) page 7) but are uncorrected for differences in the age and sex constitution of the population. In the case of phthisis and of "cancer," viz., carcinoma, sarcoma, and cancer (otherwise undefined) "factors for correction for differences in age and sex constitution" have been calculated, but these factors and the corrected death-rates are shown on pages 49 and 54 respectively. Death-rates 'per 100,000 living from All Causes, and from Specified Causes, in each of the several sanitary areas, 1906 (365 days). Sanitary area. Measles. Rheumatic Fever. Carcinoma. Sarcoma. Cancer (not otherwise defined). Tabes Mesenteric. Tuberculous Meningitis. Phthisis. Other Tuberculous and Scrofulous Diseases. Pneumonia. Other Respiratory Diseases. All other Cause. All Causes. Paddington 11 7 70 7 36 7 13 114 15 87 140 752 1,259 Kensington 44 9 56 6 36 14 17 129 11 129 127 810 1,388 Hammersmith 47 9 70 8 41 17 23 124 7 121 102 911 1,480 Fulham 33 6 55 4 27 11 16 113 16 130 101 861 1,373 Chelsea 78 5 72 9 35 11 17 157 20 143 159 861 1,567 Westminster, City of 10 4 62 6 32 9 18 139 12 138 103 767 1,300 St. Marylebone 37 5 49 5 52 11 12 157 20 112 148 902 1,510 Hampstead 11 3 67 12 30 3 10 66 10 65 59 605 941 St. Pancras 41 6 64 6 36 12 22 182 20 165 148 897 1,599 Islington 57 6 52 7 50 11 24 122 14 139 138 863 1,483 Stoke Newington 21 8 58 9 36 11 6 98 4 81 101 732 1,165 Hackney 28 6 40 5 36 16 18 131 26 98 110 830 1,344 Holborn 47 7 65 4 47 5 20 240 18 172 188 977 1,790 Finsbury 124 10 55 4 27 12 43 214 21 208 209 1,155 2,082 London, City of 14 28 94 _ 42 9 19 183 33 140 108 1,080 1,750 Shoreditch 63 7 47 3 22 23 33 205 37 193 179 1,165 1,977 Bethnal Green 45 9 53 10 34 20 44 224 27 192 178 1,080 1,916 Stepney 59 7 58 9 26 14 25 172 35 184 169 1,030 1,788 Poplar 64 9 49 4 23 12 26 155 21 160 216 1,029 1,768 Southwark 45 8 59 3 26 13 34 207 21 204 173 1,025 1,818 Bermondsey 75 8 62 12 23 17 27 199 35 232 192 1,107 1,989 Lambeth 24 11 67 8 25 8 19 136 20 133 140 918 1,509 Battersea 26 10 49 6 41 9 19 127 19 95 121 811 1,333 Wandsworth 23 4 50 4 44 9 18 100 12 106 87 830 1,287 Camberwell 40 12 53 7 38 10 22 125 18 127 144 877 1,473 Deptford 61 8 61 10 25 3 21 127 18 115 153 1,021 1,623 Greenwich 28 5 45 7 24 9 19 121 15 118 104 870 1,365 Lewisham 14 5 60 8 27 8 15 84 13 92 101 783 1,210 Woolwich 25 12 54 4 35 12 17 134 19 101 112 801 1,326 London 41 8 57 7 34 11 22 144 19 138 138 902 1,521 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, pyrexia1 and diarrhœa during 1906 (52 weeks) was 9,047, giving an annual death-rate of 1.93 per 1,000 persons living. The death-rates in successive periods have been as follows:— Principal Epidemic Diseases. Period. Death-rate per 1,000 persons living. Period. Death-rate per 1,000 persons living. 1841-50 5.20 1901 2.222 1851-60 5.13 1902 2.2l2 1861-70 5.23 1903 1.752 1871-80 3.86 1904 2.142 1881-90 3.05 1905 1.702 1891-1900 2.682 1906 1.932 It will be seen from the following table that in the decennium 1896-1905 London had a lower death-rate from these diseases than any of the undermentioned English towns except Bristol, Bradford, and Newcastle-on-Tyne, and in 1906 was exceeded by the death-rates of all except Bristol. 1 Origin uncertain. Originally described as simple continued fever. 2 See footnote (2) page 7. 21 Principal Epidemic Diseases—Death.rates per 1,000 persons living. Town. 1896.1905. 1906. Town. 1896.1905. 1906. London 2.311 1.931 West Ham 3.39 3.17 Liverpool 3.29 3.62 Bradford 1.85 2.03 Manchester 3.10 3.09 Newcastle.on.Tyne 1.98 2.23 Birmingham 2.93 2.78 Hull 3.00 2.93 Leeds 2.53 2.23 Nottingham 2.50 2.10 Sheffield 3.29 2.92 Salford 3.91 3.23 Bristol 1.91 1.56 Leicester 2.62 2.38 The following table shows that the London death-rate from the first six of these principal epidemic diseases, viz., smallpox, measles, scarlet fever, diphtheria, whooping cough, and fever (including typhus, enteric fever and pyrexia), exceeded the death-rates of all the undermentioned foreign towns except St. Petersburg in the decennium 1896.1905, and in 1906 exceeded all except Amsterdam, St. Petersburg and New York. Six Principal Epidemic Diseases—Death.rates per 1,000 persons living. Town. 1896-1905. 1906. Town. 1896-1905. 1906. London 1.501 0.991 St. Petersburg 3.13 3.78 Paris 0.77 0.50 Berlin 0.99 0.78 Brussels 0.64 0.64 Vienna 0.99 0.82 Amsterdam 0.87 0.99 Rome 0.99 0.83 Copenhagen 0.82 0.60 New York 1.28 1.10 Stockholm 0.93 0.54 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 1906, and the death-rates for the period 1901-5:— Principal Epidemic Diseases.—Death.rates in sanitary areas. Sanitary area. Deaths, 1906 (52 weeks.) Death-rate per 1,000 persons living. 1901-5. 1906. Paddington 193 1.56 1.30 Kensington 280 1.54 1.56 Hammersmith 257 2.13 2.13 Fulham 388 2.67 2.40 Chelsea 151 1.40 2.03 Westminster, City of 145 1.06 0.84 St. Marylebone 164 1.59 1.28 Hampstead 51 0.71 0.57 St. Pancras 392 2.05 1.65 Islington 555 1.69 1.62 Stoke Newington 58 1.24 1.10 Hackney 363 2.00 1.58 Holborn 80 1.82 1.44 Finsbury 349 2.60 3.59 London, City of 23 0.90 1.08 Shoreditch 362 3.11 3.13 Bethnal Green 333 2.58 2.55 Stepney 840 2.72 2.74 Poplar 503 2.96 2.95 Southwark 462 2.72 2.23 Bermondsey 377 2.74 2.94 Lambeth 532 1.87 1.69 Battersea 327 2.15 1.82 Wandsworth 435 1.59 1.60 Camberwell 514 1.83 1.88 Deptford 310 2.14 2.69 Greenwich 196 1.80 1.87 Lewisham 215 1.35 1.45 Woolwich 192 1.59 1.52 London 9,047 2.012 1.932 1 See footnote (1), page 8. 2 See footnote (2), page 7. 22 It will be seen from the foregoing table that the death-rate from the principal epidemic diseases was, in the period 1901-5, highest in Shoreditch (3.11), and lowest in Hampstead (0.71); in the year 1906 Finsbury (3.59) had the highest death-rate, the lowest again obtaining in Hampstead (0.57). The death-rates from these diseases during each of the four quarters of the year 1906 were as follows : First quarter, 1.42; second quarter, 1.44; third quarter, 3.62; and fourth quarter, 1.22 per 1,000 persons living. Smallpox and Vaccination. There were no deaths from smallpox in the Administrative County of London during the year 1906; 3 deaths were, however, attributed to cowpox. The death-rates from smallpox in successive periods have been as follows:— Smallpox. Period. Death-rate per 1,000 persons living. Period. Death-rate per 1,000 persons living. 1841-50 0402 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 1906 – The smallpox death-rate in each year since 1840 in relation to the mean smallpox death-rate of the period 1841-190G 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:— Smallpox. Year. Cases notified. Case-rate per 1,001) persona 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 1906 31 0.007 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 1896-1905 the London death-rate was higher than that of any, except Liverpool, West Ham and Hull; in 1906 London had no deaths from smallpox, Hull being the only large town where an appreciable death-rate obtained. Smallpox—Death-rates per 1,000 persons living. Town. 1896-1905. 1906. Town. 1896 1905. 1906. London 0.032 2 West Ham 0.06 – Liverpool 0.03 0.00 Bradford 0.01 – Manchester 0.01 – Newcastle-on-Tyne 0.01 – Birmingham 0.00 – Hull 0.08 0.04 Leeds 0.00 – Nottingham 0.01 – Sheffield 0.00 – Salford 0.00 – Bristol 0.00 0.00 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. 1 See footnote (2), page 7. 2 See footnote (1), page 8. Smallpox. Diagram V 23 The following table shows that the London smallpox death-rate was in the decennium 189C1905 higher than that of any of the undermentioned foreign towns except Paris, Brussels and St. Petersburg, while in 1906 Paris, St. Petersburg, Berlin and New York were the only towns where any smallpox deaths occurred. Smallpox—Death-rates per 1,000 persons living. Town. 1896-1905. 1906. Town. 1896-1905. 1906. London 0.031 1 St. Petersburg 0.09 0.04 Paris 0.04 0.00 Berlin 0.00 0.00 Brussels 0.03 — Vienna 0.00 — Amsterdam 0.00 — Rome 0.00 — Copenhagen 0.00 — New York 0.02 0.00 Stockholm 0.00 — In this table 0.00 indicates that the deaths were too few to give a rate of 0.005 ; where no death occurred — is inserted. The following table shows the smallpox cases notified, deaths, case-rates, and death-rates in the year 1906, the case-rates in the decennium 1896-1905, and the death-rates in the period 1901-5 in the several sanitary areas of the Administrative County— Smallpox—Case-rates and death-rates in sanitary areas. Sanitary area. Notified Cases, 1906 (52 weeks). Case-rate per 1,000 persons living. Deaths, 1906. (52 weeks). Death-rate per 1,000 persons living. 1896-1905. 1906. 1901-5. 1906. Paddington 1 0.1 0.0 — 0.03 — Kensington — 0.1 — — 0.02 — Hammersmith — 0.1 — — 0.05 — Fulham — 0.1 — — 0.02 — Chelsea — 0.1 — — 0.02 — Westminster, City of — 0.2 — — 0.06 — St. Marylebone — 0.2 — — 0.05 — Hampstead — 0.0 — — 0.01 — St. Pancras — 0.3 — — 0.10 — Islington 1 0.1 0.0 — 0.04 — Stoke Newington — 0.2 — — 0.04 — Hackney 9 0.2 0.0 — 0.07 — Holborn — 0.8 — — 0.26 — Finsbury — 0.3 — — 0.09 — London, City of — 0.2 — — 0.07 — Shoreditch — 0.4 — — 0.14 — Bethnal Green 6 0.6 0.0 — 0.11 — Stepney 4 0.6 0.0 — 0.19 — Poplar 2 0.5 0.0 — 0.13 — Southwark — 0.3 — — 0.09 — Bermondsey 1 0.3 0.0 — 0.07 — Lambeth — 0.2 — — 0.04 — Battersea — 0.2 — — 0.03 — Wandsworth — 0.1 — — 0.02 — Camberwell 6 0.2 0.0 — 0.05 — Deptford 1 0.2 0.0 — 0.06 — Greenwich — 0.1 — — 0.05 — Lewisham — 0.1 — — 0.02 — Woolwich — 0.3 — — 0.06 — Port of London — — — — — London 31 02 0.0 — 0.072 — 2 In this table 0.0 indicates that the cases were too few to give a rate of 0.05; whore no cases occurred — is inserted. 1 See footnote (1) page 8. 2 See footnote (2) page 7. 24 The following table shows the number of cases of smallpox notified in London in each week of the year 1906— Smallpox—Weekly notified cases—1906. Week ended. No. of cases notified. Week ended. No. of cases notified. Week ended. No. of cases notified. January 6 – May 12 September 8 – „ 13 1 19 3 „ 15 — „ 20 – 26 – „ 22 — „ 27 – June 2 3 „ 29 — February 3 – 9 1 October 6 — „ 10 – 16 1 „ 13 — „ 17 2 23 6 „ 20 — „ 24 1 30 1 „ 27 — March 3 3 July 7 — November 3 — „ 10 1 14 — „ 10 — „ 17 1 21 — „ 17 — „ 24 5 28 — „ 24 — „ 31 – August 4 1 December 1 — April 7 – 11 — „ 8 — „ 14 – 18 — „ 15 — „ 21 1 25 — „ 22 — „ 28 – September 1 — „ 29 — May 5 – The occurrence of actual cases of smallpox in London during the year may be thus summarised. In February five cases were reported and removed to hospital, two in Hackney, one in Bethnal Green, and two in Stepney. Of the Hackney cases, the first to become known was a girl aged ten years, the daughter of a man who occupied a boot and shoe factory. Inquiry showed that two sisters of this girl and two fellow-workers (one living in Bethnal Green) had recently suffered from mild attacks of smallpox, the nature of the disease not having been recognised. The first of these (the Bethnal Green resident) contracted the disease in the preceding December during a visit to Devonport, and was the first case of this group. The case removed to hospital from Bethnal Green was a child aged ten years, who had been in contact with the Hackney cases. This child attended the Teesdale-road school, which is about seven hundred yards distant from the Mowlem-street School, to be subsequently referred to. The two persons attacked in Stepney were a brother and sister. The source of infection was unknown, although it was thought likely that exposure to infection occurred during visits to Hackney, where cases had been previously notified. During March there were seven cases in London. Two of the cases (occurring in Stepney) were associated with the two Stepney cases of the preceding month. One lived in the same tenement house as those two people, and the other was a friend who visited them. The remaining five cases were all in Hackney, and occurred in one family. On inquiry, it was found that the father and four sons (named H)—three of whom were Mowlem-street scholars—were suffering from well-marked smallpox; the children had never been vaccinated, and the father only in infancy. A still younger child, who had been vaccinated recently, escaped. The source of infection could not at the time be ascertained, but in May smallpox was found in the family next door, the children going to the Mowlem-street School. During the month of April only one case of smallpox was notified, that of a sailor living in a seamen's lodging house in Poplar; he had recently come in a vessel from New Zealand, calling at Barcelona, Las Palmas and Cardiff. He went on shore at Barcelona, and also slept a night in Cardiff, arriving in London the next day. No further case occurred in the lodging-house. In May five cases were notified, one in Hackney and four in Bethnal Green. The case in Hackney was that of an unvaccinated boy (W. B.), who lived next door to the H. family, and attended the Mowlemstreet School. After this boy's removal to hospital, the mother stated that two other of her children had had an eruption on their faces and arms some weeks before. Though the children were twice vaccinated after the case notified had gone to hospital, the operation failed on each occasion, making it probable that the eruption on these children had been that of smallpox. Examination of the H. children in school led to the opinion that they may, on their return, have infected the boy just mentioned, and there is some reason for thinking that they in their turn had been infected by the first two cases of the B. family. Of the four cases from Bethnal Green, the first was that of a Mowlem-street school-girl, who later infected her sister, a silkworker; and the second case was a Mowlem-street schoolboy notified as suffering from chickenpox, but who was sent later to the smallpox hospital. He also infected his sister, a leather-worker. During the month of June there were eight cases, one in Paddington, one in Hackney, five in Camberwell, and one in Bethnal Green. The case in Paddington was that of a woman who had recently come from Plymouth, where the disease was prevalent. The Hackney case was that of a man who had been working in Bunhill-row, and who in all probability had contracted the disease there from a Camberwell boy, whose illness was not discovered until five other cases occurred in his home. The case in Bethnal Green was that of a dressmaker, who, though living in close proximity to the houses from which cases had been removed during May, could not be proved to be connected with those cases. 25 One more case of smallpox occurred during the year, in the month of August. This case was removed to the South Mimms Private Smallpox Hospital. The person attacked was a traveller, who arrived in Islington from Bilbao a few days before being taken ill, having probably there contracted the disease. Thus, so far as could be ascertained, 34 cases of smallpox occurred in London in 1906. During the year the services of Dr. Wanklyn, of the Council's Public Health Department, were requisitioned to assist in the diagnosis of 35 cases of suspected smallpox. These included one group of four patients and one group of three patients, all suffering from smallpox; one group of five suffering from chickenpox, and another group of five suffering from scabies and impetigo. Of the eleven smallpox cases, one group of five cases was due to a case which had been unrecognised for several weeks, and another group of five was due to another group which had similarly remained unrecognised. There were 27 cases of smallpox admitted to the hospitals of the Metropolitan Asylums Board; of these 9 were vaccinated, 16 were unvaccinated, and 2 were included in the "doubtful" class. There were no deaths in the hospitals from the disease during the year. 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:— Vaccination. Year Children not finally accounted for (including cases postponed) per cent. of total births. Year. Children not finally accounted for (including cases postponed) per cent. of total births. 1872 8.8 1889 11.6 1873 8.7 1890 13.9 1874 8.8 1891 16.4 1875 9.3 1892 18.4 1876 6.5 1893 18.2 1877 7.1 1894 20.6 1878 7.1 1895 24.9 1879 7.8 1896 26.4 1880 7.0 1897 29.1 1881 5.7 1898 33.0 1882 6.6 1899 27.7 1883 6.5 1900 25.8 1884 6.8 1901 24.1 1885 7.0 1902 21.3 1886 7.8 1903 20.7 1887 9.0 1904 19.1 1888 10.3 The percentage 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, 1.0; 1904, 1 1. During these years, the proportion of children exempted by certificate of conscientious objection, together with the proportion of children not finally accounted for in the several Unions, has been as follows:— Number of children for whom certificates of conscientious objection were obtained together with the number of children not finally accounted for per cent of births. Metropolitan Union. 1898. 1899. 1900. 1901. 1902. 1903. 1904. Bethnal-green 67.0 48.2 49.2 52.2 44.1 44.9 42.8 Camberwell 41.2 29.7 23.0 20.0 21.4 21.8 23.6 Chelsea 17.3 14.9 16.0 13.4 14.9 13.9 10.0 Fulham 15.4 12.6 13.7 12.0 11.8 12.7 11.5 St. George, Hanover-square 11.1 9.0 7.1 5.8 7.5 5.1 4.9 St. George-in-the-East 34.6 35.0 33.5 30.6 29.7 27.7 15.7 St. Giles and St. George 32.5 33.0 33.6 30.7 27.1 24.9 17.9 Greenwich 17.2 14.2 13.8 12.6 11.1 11.1 10.4 Hackney 49.0 38.6 40.4 38.5 26.1 25.5 26.9 14911 (Continued on next page). D 26 Metropolitan Union. 1898. 1899. 1906 1901. 1902. 1903. 1904. Hammersmith 13.8 11.7 9.1 8.3 9.4 7.2 7.4 Hampstead 15.4 10.3 11.0 10.0 9.2 9.5 9.2 Holborn 43.8 31.8 28.5 27.6 23.2 20.7 20.4 Islington 31.1 29.2 26.2 21.6 17.7 17.0 15.9 Kensington 13.5 10.2 9.2 9.0 7.2 6.6 6.6 Lambeth 30.6 25.2 20.6 22.2 20.4 21.0 16.9 Lewisham 27.8 22.6 20.7 15.7 13.5 15.4 14.0 London, City of 25.4 18.3 14.2 11.3 11.3 11.8 13.0 Marylebone 18.0 20.9 17.7 14.6 12.5 10.8 10.4 Mile End Old Town 68.9 69.9 68.0 66.1 58.8 59.8 47.3 St. Olave (Bermondsey) 32.5 23.6 21.8 18.0 17.5 16.3 16.6 Paddington 14.7 14.6 13.5 11.0 10.1 11.7 12.7 St. Pancras 36.7 36.1 32.9 32.8 26.2 25.3 23.1 Poplar 63.6 50.1 49.0 49.1 44.2 46.9 45.4 Shoreditch 68.8 52.4 53.0 44.7 36.4 36.6 34.8 Southwark 32.6 30.3 27.6 26.8 25.4 24.9 24.3 Stepney 48.6 46.9 44.4 44.3 37.2 35.8 32.9 Strand 25.2 19.7 19.2 16.1 19.0 18.6 15.0 Wandsworth and Clapham 32.2 25.1 23.0 20.5 19.2 17.2 16.3 Westminster 17.4 14.8 12.2 13.3 13.4 12.1 11.0 Whitechapel 11.8 14.5 13. 1 10.5 9.5 10.1 9.1 Woolwich 10.2 8.3 7.5 9.8 9.7 7.1 7.2 London 34.4 28.7 26.8 25.2 22.1 21.7 20.2 Measles. The deaths from measles in the Administrative County of London during 1908 (52 weeks) numbered 1,909, as compared with 1,709 in 1905. The death-rates from this disease per 1,000 persons living in 1906 and preceding periods have been as follows:— Measles. Period. Death-rate per 1,000 persons living. Period. Death-rate per 1,000 persons living. 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 0.491 1881-90 0.64 1905 0.371 1891-1900 0.581 1906 0.411 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 in recent years, the death-rate of children under five years of age deserves to be stated. The following table shows the death-rate from measles of children at this age in successive periods:— Measles—Mortality among children at ages 0—5. Period. Death rate per 1,000 children living at ages 0—5. Period. -rate per 1,000 children living at ages 0—5. 1851-60 3.89 1902 4.421 1861-70 4.18 1903 3.901 1871-80 3.65 1904 4.301 1881-90 4.74 1905 3.191 1891-1900 4.82 1906 3.571 1901 3.701 The death-rate in each year since 1840 in relation to the mean death-rate of the period 1841-1906, calculated on the population at all ages, is shown in diagram VI. The monthly deaths from measles in relation to the mean of the period 1891-1906 is shewn in diagram VII. The following table shows the deaths and death-rates from measles in 1906 (52 weeks) in each of the sanitary areas of the County:— 1 See footnote (2), page 7. Measles. Diagram VI Measles & Whooping1 Cough, (Deaths 1891-1906.) Diagram VII 27 Measles—Death-rates in sanitary areas. Sanitary area. Deaths, 1906 (52 weeks). Death-rate per 1,000 persons living. 1901-5. 1906. Paddington 16 0.32 0.11 Kensington 81 0.37 0.45 Hammersmith 57 0.49 0.47 Fulham 53 0.56 0.33 Chelsea 58 0.32 0.78 Westminster, City of 17 0.23 0.10 St. Marylebone 47 0.35 0.37 Hampstead 10 0.11 0.11 St. Pancras 96 0.49 0.41 Islington 193 0.41 0.56 Stoke Newington 11 0.22 0.21 Hackney 65 0.40 0.28 Holborn 25 0.43 0.45 Finsbury 123 0.60 1.27 London, City of 3 0.12 0.14 Shoreditch 75 0.69 0.65 Bethnal-green 60 0.57 0.46 Stepney 175 0.56 0.57 Poplar 108 0.58 0.63 Southwark 95 0.72 0.46 Bermondsey 94 0.74 0.73 Lambeth 77 0.39 0.24 Battersea 41 0.61 0.23 Wandsworth 66 0.37 0.24 Camberwell 112 0.41 0.41 Deptford 69 0.50 0.60 Greenwich 31 0.36 0.29 Lewisham 21 0.23 0.14 Woolwich 30 0.21 0.24 London 1,909 0.451 0.411 In the distribution of measles mortality throughout the year 1906 the highest death-rate obtained in Finsbury (1.27) and the lowest in the City of Westminster (0.10). For the period 1901-5, Bermondsey (0.74) had the highest measles death-rate, and Hampstead (0.11) the lowest. The deathrates from this disease in the four quarters of 1906 were as follows—first quarter, 0.58; second quarter, 0.65; third quarter, 0.22; and fourth quarter, 0.18 per 1,000 persons living. The following table shows the measles death-rate at ages 0-5 obtaining in the several sanitary areas of the County of London during the year 1906.1 Measles—Mortality among children at ages 0-5 in sanitary areas—1906. Sanitary area. Death-rate1 per 1,000 children living aged 0-5, 1906. Sanitary area. Death-rate per 1,000 children living aged 0-5, 1906. Sanitary area. Death-rate1 per 1,000 children living aged 0-5, 1906. Paddington 1.14 Stoke Newington .. 2.04 Bermondsey 5.70 Kensington 5.31 Hackney 2.43 Lambeth 2.15 Hammersmith 3.99 Holborn 5.55 Battersea 2.13 Fulham 2.42 Finsbury 9.76 Wandsworth 2.04 Chelsea 9.00 London, City of 2.47 Camberwell 3.40 Westminster City of 1.31 Shoreditch 5.01 Deptford 4.87 St. Marylebone 4.22 Bethnal Green 3.31 Greenwich 2.14 Hampstead 1.42 Stepney 4.35 Lewisham 1.34 St. Pancras 4.00 Poplar 4.69 Woolwich 1.93 Islington 4.85 Southwark 3.66 London 3.57 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" 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:— 14911 1 See footnote (2), page 7. D 2 28 Measles and overcrowding, 1901-6. Proportion of overcrowding in groups of sanitary areas. Measles death-rate at ages 0-5 years 1901-6, per 1,000 living. Under 7.5 per cent. 2.251 7.5 to 12.5 „ „ 3.571 12.5 to 20.0 „ „ 4.131 20.0 to 27.5 „ „ 4.801 Over 27.5 „ „ 4.481 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 1896-1905 the London death-rate exceeded that of any of these towns except Manchester, Sheffield, West Ham, Hull, and Salford, and in 1906 was higher than the death-rates of Birmingham, Sheffield, Bristol, Hull, Nottingham and Leicester. Measles—Death-rates per 1,000 persons living. Town. 1896-1905. 1906. Town. 1896-1905. 1906. London 0.512 0.412 West Ham 0.54 0.43 Liverpool 0.47 0.78 Bradford 0.33 0.44 Manchester 0.73 0.75 Newcastle-upon-Tyne 0.40 0.63 Birmingham 0.45 0.40 Hull 0.53 0.24 Leeds 0.46 0.59 Nottingham 0.43 0.02 Sheffield 0.55 0.17 Salford 0.84 0.80 Bristol 0.47 0.39 Leicester 0.33 0.35 The following table shows that in the decennium 1896-1905 the London measles death-rate was higher than that of any of the undermentioned foreign towns except St. Petersburg, and in 1906 exceeded all except Amsterdam and St. Petersburg. Measles—Death-rates per 1,000 persons living. Town. 1896-1905. 1906. Town. 1896-1905.  London 0.512 0.412 St. Petersburg 0.62 0.82 Paris 0.26 0.21 Berlin 0.21 0.25 Brussels 0.19 0.18 Vienna 0.44 0.31 Amsterdam 0.36 0.45 Rome 0.30 0.32 Copenhagen 0.18 0.21 New York 0.19 0.28 Stockholm 0.15 0.05 The following table shows the number of deaths from measles at several age-periods in each of the sanitary areas. For the purposes of this table deaths occurring in public institutions belonging to London have been distributed to the sanitary areas in which the deceased had previously resided. (See footnote 2, page 7). Measles—Deaths at the several age-periods in sanitary areas—1906 (365 days). Age-period. 0— 1— 2— 3— 4— Under 5. 5— 10— 15 and upwards. All Ages. Paddington 4 9 1 1 – 15 1 16 Kensington 31 31 8 4 3 77 1 – 1 79 Hammersmith 14 20 9 6 3 52 5 – – 57 Fulham 10 22 6 7 6 51 2 1 – 54 Chelsea 13 26 10 5 3 57 1 – – 58 Westminster, City of 1 11 1 2 1 16 — – 1 17 St. Marylebone 10 24 6 4 1 45 2 – — 47 Hampstead 5 2 1 1 1 10 — – — 10 St. Pancras 29 43 14 6 5 97 — – — 97 Islington 36 75 39 22 8 180 13 1 1 195 Stoke Newington 2 5 1 1 1 10 1 – — 11 Hackney 14 29 13 3 3 62 3 – – 65 1 See footnote (2), page 7. (Continued on next page.) 2 See footnote (1), page 8. 29 Age-period. 0— 1— 2— 3 — 4— Under 5 0— 10— 15 and upwards. All ages. Holborn 9 12 – 3 1 25 1 – 26 Finsbury 21 57 19 13 5 115 5 1 – 121 London, City of – 3 – – – 3 – – – 3 Shoreditch 12 35 13 5 8 73 – – – 73 Bethnal Green 14 28 4 6 7 59 – – – 59 Stepney 43 84 34 11 6 178 3 – – 181 Poplar 28 45 12 11 6 102 7 – – 109 Southwark 22 45 22 5 – 94 1 – – 95 Bermondsey 10 47 14 15 8 94 2 – – 96 Lambeth 19 36 12 2 4 73 4 – – 77 Battersea 11 23 11 – 1 46 – – – 46 Wandsworth 15 23 12 5 4 59 3 – 1 63 Camberwell 27 49 19 7 4 106 4 – – 110 Deptford 13 27 19 5 4 68 3 – – 71 Greenwich 5 12 4 3 2 26 4 – – 30 Lewisham 8 9 – 2 2 21 – – – 21 Woolwich 7 11 5 3 3 29 3 – – 32 London 433 843 309 158 100 1,843 69 3 4 1,919 Information as to the occurrence of cases of measles is in the main derived by medical officers of health from school teachers, and in more than one report it is stated that this information is being more completely supplied than formerly. This source of information is necessarily closed during the holidays. The numbers of cases which become known to the medical officers of health is shown in most of the reports, and the following figures are thus supplied:– Measles. Sanitary area. No. of cases of measles. 1906. Sanitary area. No. of cases of measles. 1906. Sanitary area. No. of cases of measles. 1906. Paddington 592 Hackney 1,101 Lambeth 1,581 Kensington 853 Holborn 370 Battersea 882 Hammersmith 627 Finsbury 1,036 Wandsworth 1,453 Fulham 496 Shoreditch 449 Deptford 1,007 Chelsea 225 Bethnal Green 591 Greenwich 482 Westminster 362 Poplar 892 Lewisham 349 Hampstead 333 Bermondsey 685 Wollwich 825 Islington 1,935 In a few reports the value of disinfection after measles is discussed, and Dr. Brown, the medical officer of health of Bermondsey, states that, as the result of a circular letter he addressed to medical officers of health, he found that only in thirteen boroughs was disinfection carried out on a large scale. In reply to questions as to the value of disinfection in seventeen instances, there was either no opinion expressed on this point, or various reasons were given for thinking that it was not of much service. In eight instances opinion was in its favour, but in five of these the opinion was qualified by the word "educationally." The question of hospital provision is mentioned in a few reports, and the wish has been expressed that the Metropolitan Asylums Board should receive cases of this disease. It is not probable that this proposal would receive any large acceptance as a practical measure for limiting the spread of the disease. The question of the reduction in fatality which might result from the better nursing of children suffering from measles is also discussed. Dr. Davies endeavoured to secure for this purpose in Woolwich the assistance of the District Nursing Association, but their staff was insufficient for the purpose, and he writes that " many lives would doubtless be saved if all cases of measles which were seriously ill could have skilled nursing, but the Borough Council has power neither to provide such nursing nor even to contribute to the Nursing Association and help them to provide it." In this connection, the question may be considered whether the " medical assistance," in section 77 of the Public Health (London) Act, which a sanitary authority, with the consent of the Local Government Board, may provide for the poorer inhabitants of their district, includes the assistance of a sick nurse. Such assistance would be especially valuable in cases where lung complications arise. This is an especially frequent cause of mortality in cases of measles, amounting, as Dr. Newman shows for Finsbury, to 85 per cent. of the cases in which death occurred. Reference has in former reports been made to observations in Woolwich as to the value of the immediate closing of classes on the appearance of measles, for which purpose the Borough was divided into two nearly equal districts, in one of which closure of classes in infant schools was resorted to 30 immediately a case of measles was notified, and in the other only the ordinary measures of excluding children coming from infected homes were adopted. Comparing the prevalence of measles in each of these districts in the four years 1903-6 with the prevalence in an antecedent period, 1901-2, he finds that "although closure of classes appears to have had the effect of greatly limiting the increase of measles in the Eastern district compared with the Western, it must be admitted that the total result of closure has been much less than might have been hoped for," and he attributes this to the fact that "there is no satisfactory system by which a teacher becomes aware of the cause of the absence of a pupil." Commenting on the smaller mortality from measles in Woolwich in later years, he attributes this result to a more hygienic treatment of children who are attacked as the result of advice which is given to the parents by the sanitary anthority. There is some indication that measles is now being regarded more than formerly by parents as a serious malady, and Dr. Dudfield states that it was found in Kensington that a larger proportion of the cases was attended by a medical man. Reference to Dr. Kerr's report (Appendix II.) shows that 52 classrooms and 15 departments in the infants' departments of provided and non-provided schools were closed during the year on account of measles prevalence. Scarlet Fever. The cases of scarlet fever notified in the Administrative County of London during 1906 (52 weeks) numbered 20,329, compared with 19,461 in 1905. The number of deaths registered from this cause was 533 in the year 1906 (52 weeks), compared with 549 in 1905. The scarlet fever case-rates, death-rates and case-mortality for 1906 and preceding periods arc shown in the following table:— Scarlet Fever. Period. Death-rate per 1,000 persons living. Case-rate per 1,000 persons living. Casemortality 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 1906 0.112 4.3 2.6 The death-rate in each year since 1858 in relation to the mean death-rate of the period 1859— 1906 will be seen on reference to diagram VIII. The monthly case-rate and case-mortality in each of the years 1891-1906 in relation to the mean of the whole period is shown in diagram X. It will be seen from the following table that in the decennium 1896-1905 the London scarlet fever death-rate was lower than that of any of the undermentioned English towns, except Bristol and West Ham, and in 1906 was exceeded by the death-rates of Liverpool, Manchester, Sheffield, Bradford, West Ham, Salford and Leicester:— Scarlet Fever—Death-rates 'per 1,000 persons living. Town. 1896-1905 1906. Town. 1896-1905 1906. London 0.121 0.113 West Ham 0.12 0-13 Liverpool 0.29 0.25 Bradford 0.16 014 Manchester 0.19 0.18 Newcastle-on-Tyne0 0.13 0.06 Birmingham 0.21 0.10 Hull 0.13 0.05 Leeds 0.18 0.07 Nottingham 0.14 0.07 Sheffield 0.20 0.49 Salford 0.33 0.19 Bristol 0.12 0.08 Leicester 0.15 0.22 The following table shows that the London scarlet fever death-rate was, both in the decennium 1896-1905 and the year 1906, exceeded by the death-rates of Stockholm, St. Petersburg, Berlin, Vienna and New York:— 1 The Infectious Disease (Notification) Act came into force in 1889. 2 See footnote (2), page 7. 3 See footnote (1), page 8. Diagram VIII Scarlet Fever. — Diagram IX Number of admissions to Hospitals of the Metro.'n Asylums Board per cent of total cases notified in London 1890-1906. Diagram X Scarlet Fever. 31 Scarlet Fever—Death-rates per 1,000 persons living. Town. 1896-1905. 1906. Town. 1896-1905. 1906. London 0.121 0.11 St. Petersburg 0.53 0.82 Paris 0.05 0.103 Berlin 0.22 0.14 Brussels 0.03 0.08 Vienna 0.14 0.13 Amsterdam 0.02 0.10 Rome 0.01 - Copenhagen 0.10 0.01 New York 0.21 0.12 Stockholm 0.15 0.13 The following table shows the scarlet fever cases, deaths, case-rates, and death-rates for the year 1906, the case-rates for the decennium 1896-1903, and the death-rates for the period 1901-5 in the several sanitary districts of the County :— Scarlet Fever—Case rates and death rates in sanitary areas. Sanitary area. Notified cases, 1906. (52 weeks). Case-rate per 1,000 persons living. Deaths, 1906. (52 weeks) Death-rate per 1,000 persons living. 1896-1905. 1906. 1901-1906. 1906. Paddington 717 3.2 4.8 18 0.07 0.12 Kensington 470 2.7 2.6 11 0.09 0.06 Hammersmith 437 3.4 3.6 15 0.08 0.12 Fulham 674 4.5 4.2 18 0.10 0.11 Chelsea 271 3.1 3.6 9 0.08 0.12 Westminster, City of 537 2.6 3.1 14 0.07 0.08 St. Marylebone 396 3.0 3.1 14 0.11 0.11 Hampstead 387 2.8 4.3 5 0.05 0.06 St. Pancras 798 4.0 3.4 32 0.13 0.14 Islington 1,392 4.1 4.0 37 0.10 0.11 Stoke Newington 135 3.8 2.5 1 0.06 0.02 Hackney 1,049 4.7 4.6 22 0.09 0.10 Holborn 138 3 4 2.5 3 0.07 0.05 Finsbury 449 4.6 4.6 15 0.16 0.15 London, City of 113 31 5.3 7 0.06 0.33 Shoreditch 627 4.0 5.4 19 0.13 0.16 Bethnal Green 650 5.2 5.0 22 0.18 0.17 Stepney 1,219 4.5 4.0 37 0.12 012 Poplar 571 41 3.4 13 0.12 0.08 Southwark 1,470 4.4 7.0 45 0.15 0.22 Bermondsey 990 4.9 7.7 29 0.19 0.23 Lambeth 1,264 3.5 4.0 28 0.10 0.09 Battersea 1,048 4.7 5.9 24 0.09 0.13 Wandsworth 1,069 3.9 3.9 19 0.08 0.07 Camberwell 1,161 4.4 4.2 25 0.11 0.09 Deptford 643 50 5.6 15 0.13 0.13 Greenwich 567 3.8 5.4 17 0.06 0.16 Lewisham 557 3.5 3.8 14 0.08 0.09 Woolwich 525 4.5 4.1 5 0.07 0.04 Port of London 5 — - - London 20,329 4.0 4.3 533 0.112 0.ll2 It will be seen from the foregoing table that the scarlet fever death-rate was in the period 1901-5 highest in Bermondsey (0.19) and lowest in Hampstead (0.05), and in the year 1906 was highest in the City of London (0.33) and lowest in Stoke Newington (0.02). The scarlet fever death-rates obtaining in London in the four quarters of the year 1906 were as follows:—first quarter, 0.11; second quarter 0.12 ; third quarter, 0.09 ; and fourth quarter, 0.13 per 1,000 persons living. In relation to the number of cases in the preceding year 1905, there was increases in 1906 in all the western districts except Fulham, and in all the northern districts except St. Pancras and Hackney. Of the central and eastern districts there was decrease in all except the City; and of the southern districts there was increase in all except Wandsworth, Camberwell, Lewisham and Woolwich; the greatest increase was manifested in Southwark, and Bermondsey had the highest case-rate in the year. Scarlet Fever and Elementary Schools. The summer holiday of the London County Council schools began in 1906 on Thursday, the 26th July, i.e., the latter part of the 30th week, and the schools re-opened on Monday, the 27th August, i.e., at the beginning of the 35th week. If the number of cases notified in the four weeks 1 See footnote (1) page 8. 2 See footnote (2) page 7. 32 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—1906. Period. Notified cases—Age-periods. 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) 184 1,330 233 — Four weeks of holiday influence (32nd to 35th) 195 947 208 + 6.0 -28.8 -10.7 Four weeks following weeks of holiday influence (36th to 39th) 182 1,471 309 -6.7 +55.3 +48.6 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 1906. It will be seen that the case-rate, death-rate and fatality were all higher among males than among females at "all ages." In the age groups adopted for the purposes of this table, the greatest incidence of attack was upon both males and females of four years of age. The greatest incidence of death was upon males of three and females of two years of age. The fatality, it will be observed, was highest among both males and females of one year of age. Scarlet Fever1—1906. 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 9,627 296 3.1 432 13 10,702 247 2.3 429 10 0— 129 8 6.2 225 14 90 7 7.8 158 12 ]— 364 40 110 718 79 353 35 9.9 696 69 2— 667 46 6.9 1,302 90 667 45 6.7 1,307 88 3— 962 64 6.7 1,927 128 899 38 4.2 1,780 75 4— 1,041 39 3.7 2,131 80 1,071 25 2.3 2,203 51 5— 3,978 68 1.7 1,735 30 4,497 62 1.4 1,943 27 10 1,503 16 1.1 695 7 1,741 20 1.1 790 9 15— 468 7 1.5 215 3 537 6 1.1 222 2 20— 256 6 2.3 113 3 391 4 1.0 144 1 25— 194 1 0.5 50 0 353 4 1.1 77 1 35— 50 1 2.0 17 0 80 1 1.2 25 0 45— 10 — — 5 — 19 — — 8 — 55 & upwards 5 — — 2 — 4 — — 2 - Compared with the case-rates of 1905 there was decrease in 1906 at each age under five years and increase at the ages of five years and upwards. This was especially manifest at the age of ten. In the reports of several medical officers of health reference is made to the association of prevalence of scarlet fever and school attendance, and such relation was observed in Paddington in the Queen's Park and Harrow wards, in Westminster in connection with a group of schools on both sides of Vauxhall Bridge-road at its lower end, in Hampstead in connection with the Broomsleigh-street School, and in Lambeth where nine schools had to be disinfected. In St. Pancras, cases occurred among the scholars of Park Chapel Schools, Arlington-road, where some nineteen children were attacked, possibly from playing out of school with a child who had probably suffered from scarlatina, but whose illness had been supposed to be measles. Of 422 cases in Finsbury in which the cause of infection could be traced, it was found to be due in 95 instances to infection in the family, in 119 to cases in the same house or building, and in 46 cases to infection in the school. In Bermondsey, where similar observation was made in 118 cases, 72 cases were infected in the house or family, 19 cases were infected in neighbouring houses, and 15 cases were infected in school. In the report of Dr. Kerr (see Appendix II) it is stated that 36 classrooms and 6 departments were closed during the year on account of scarlet fever prevalence among the scholars. 1 In the preparation 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. DiagramXI Diphtheria. Diagram XII Admissions to Hospitals of the Metropolitan Asylums Board per cent of total cases notified in London. 1890-1906. 33 In the annual reports relating to Paddington and Westminster the number of instances in which multiple cases occurred in houses is stated thus— Paddington, Westminster, total cases 717. total cases 537. Houses with two cases 77 43 „ three „ 23 7 „ four „ 7 11 „ five „ 4 — The number of "return cases" is shown in some of the reports thus—in Fulham, 12 ; Chelsea, 1; Westminster, 1 or 2 ; Holborn, 6; Finsbury, 8; Shoreditch, 14; Bermondsey, 10; Battersea, 34, Woolwich, 13. In connection with the treatment of cases of scarlet fever at home, Dr Davies states that in 117 cases so treated in Woolwich subsequent cases occurred in the same house in 12 instances, the secondary cases numbering 15. 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 1906 than in any preceding year. Diphtheria. The cases of diphtheria (including membranous croup) notified in the Administrative County of London in 1906 (52 weeks) numbered 8,045, compared with 6,482 in 1905. The number of deaths registered from this cause was 691 in 1906 (52 weeks), compared with 546 in 1905. The diphtheria case-rates, death-rates, and case-mortality in 1906, and preceding periods, are shown in the following table :— Diphtheria. Period. Death-rate per 1,000 persons living. Case-rate per 1,000 persons living. Case-mortality per cent. 1861-70 0.18 1 1 1871-80 0.12 l _1 1881-90 0.26 1 1 1891-1900 0.492 2.6 19.0 1901 0.292 2.7 10.9 1902 0.252 2.3 10.8 1903 0.162 1.7 9.6 1904 0162 1.6 10.0 1905 0.122 1.4 8.4 1906 0.152 1.7 8.6 The death-rate in each year since 1858 in relation to the mean death-rate of the period 18591906 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 1891-1906 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 1896-1905 the London rate exceeded the rates of all these towns except Leeds, Sheffield, West Ham, Salford and Leicester, while in 1906 it was lower than the rates of any except Leicester. Diphtheria—Death-rates per 1,000 persons living. Town. 1896-1905. 1906. Town. 1896-1905. 1906. London 0.323 0.153 West Ham 0.50 0.29 Liverpool 0.25 0.20 Bradford 0.19 0.21 Manchester 0.18 0.19 Newcastle on-Tyne 0.16 0.24 Birmingham 0.26 0.18 Hull 0.20 0.52 Leeds 0.32 0.18 Nottingham 0.15 0.16 Sheffield 0.43 0.19 Salford 0.35 0.39 Bristol 0.26 0.21 Leicester 0.48 0.13 The following table shows that the London diphtheria death-rate was in the decennium 1896-1905 higher than that of any of the undermentioned foreign towns, except Stockholm, St. Petersburg, and New York, and in 1906 was exceeded by the rates of St. Petersburg, Berlin, Vienna, and New York :— 1 The Infectious Disease (Notification) Act came into force in 1889. - See footnote (2) page 7. 3 See footnote (1) page 8. 14911 E 34 Diphtheria—Death-rates per 1,000 persons living. Town. 1896-1905. 1906. Town. 1896-1905. 1906. London 0.321 0.151 St. Petersburg 0.82 0.85 Paris 0.15 0.06 Berlin 0.24 0.17 Brussels 0.11 0.10 Vienna 0.27 0.24 Amsterdam 0.14 0.13 Rome 0.09 0.08 Copenhagen 0.15 0.05 New York 0.54 0.46 Stockholm 0.38 0.14 The following table shows the diphtheria cases, deaths, case-rates, and death-rates for the year 1906, the case-rates for the decennium 1896-1905, and the death-rates for the period 1901-5, in the several sanitary districts:— Diphtheria.—Case-rates and death-rates in sanitary areas. Sanitary area. Notified Cases, 1906. (52 weeks). Case-rate per 1,000 persons living. Deaths, 1906. (52 weeks). Death-rate per 1,000 persons living. 1896-1905. 1906. 1901-5. 1906. Paddington 183 1.7 1.2 1.5 0.16 0.10 Kensington 178 1.4 1.0 19 0.12 0.11 Hammersmith 278 1.8 2.3 27 0.21 0.22 Fulham 404 3.2 2.5 32 0.23 0.20 Chelsea 162 2.1 2.2 15 0.10 0.20 Westminster, City of 209 1.4 1.2 16 0.09 0.09 St. Marylebone 141 1.5 1.1 12 0.16 0.09 Hampstead 99 1.4 1.1 8 0.11 0.09 St. Pancras 279 2.3 1.2 23 0.27 0.08 Islington 439 2.0 1.3 30 0.20 0.09 Stoke Newington 47 1.8 0.9 4 0.15 0.08 Hackney 389 3.1 1.7 20 0.25 0.09 Holborn 66 2.0 1.2 6 0.14 0.11 Finsbury 198 2.9 2.0 23 0.22 0.24 London, City of 18 2.1 0.8 2 0.19 0.09 Shoreditch 144 2.4 1.2 15 0.19 0.13 Bethnal Green 252 31 1.9 20 0.31 0.15 Stepney 604 3.0 2.0 61 0.24 0.20 Poplar 249 3.5 1.5 28 0.38 0.16 Southwark 401 3.0 1.9 31 0.20 0.15 Bermondsey 336 2.7 2.6 34 0.18 0.26 Lambeth 422 2.1 1.3 51 0.13 0.16 Battersea 275 2.4 1.5 18 0.11 0.10 Wandsworth 556 2.1 2.0 49 0.18 0.18 Camberwell 355 3.0 1.3 40 0.20 0.15 Deptford 305 2.9 2.6 20 0.23 0.17 Greenwich 409 2.4 3.9 29 0.18 0.28 Lewisham 261 24 1.8 21 0.16 0.14 Woolwich 386 2.2 3.0 22 0.17 0.17 Port of London — — — London 8,045 2.4 1.7 691 0.202 0.152 It will be seen from the foregoing table that in the period 1901-5 the diphtheria death-rate was highest in Poplar (0.38), and lowest in the City of Westminster (0.09); in the year 1906 Greenwich (0.28) had the highest death-rate, and Stoke Newington (0.08) the lowest. The diphtheria deathrates in each of the four quarters of the year were as follows: first quarter, 0.16; second quarter, 0.12; third quarter, 0.13; and fourth quarter, 0.18 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 1891-1906 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 — 1 See footnote (1) page 8. 2 See footnote (2) page 7. Diagram XIII Diphtheria. 35 Diphtheria. Sanitary areas.—Comparative case rates (London taken as 100). Sanitary area. Comparative case-rate (London case-rate taken as 100). 1891. 1892. 1893. 1894. 1895. 1896. 1897. 1898. 1899. 1900. 1901. 1902. 1903. 1904. 1905. 1906. Paddington 104 77 73 117 74 66 91 98 68 44 89 65 59 63 50 71 Kensington 78 60 68 63 86 70 67 49 51 74 52 43 59 63 50 59 Hammersmith 195 164 87 72 77 67 49 58 58 85 74 70 82 106 143 135 Fulham 61 58 78 126 139 99 109 145 135 178 174 126 118 125 129 147 Chelsea 138 110 83 107 143 184 107 79 61 74 56 78 76 50 50 129 Westminster,Cityof 58 91 57 53 61 53 59 67 50 59 52 70 59 50 50 71 St. Marylebone 70 81 88 78 64 66 53 64 47 59 74 78 100 56 71 65 Hampstead 105 96 73 53 61 84 47 65 48 74 70 52 59 44 57 65 St. Pancras 89 95 103 83 90 64 76 78 79 93 148 152 129 94 86 71 Islington 152 119 86 103 70 106 73 60 68 70 100 113 82 63 71 76 Stoke Newington.. 83 113 97 77 70 70 52 59 34 111 104 83 47 75 107 53 Hackney 131 147 135 108 93 89 122 152 106 107 167 139 141 156 121 100 Holborn 52 89 79 61 66 61 104 102 46 70 i04 87 53 50 57 71 Finsbury 118 82 130 81 86 112 170 163 93 74 107 100 76 94 100 118 City of London 59 130 60 49 51 74 71 60 68 89 96 161 65 106 50 47 Shoreditch 124 89 131 95 80 97 103 80 103 111 104 83 76 100 114 71 Bethnal Green 154 230 181 168 143 114 144 100 89 115 133 104 112 206 164 112 Stepney 106 132 112 123 157 150 128 93 89 107 104 113 106 169 150 118 Poplar 191 148 214 159 179 133 141 105 83 141 137 117 147 250 207 88 Southwark 71 72 116 113 86 106 102 151 207 141 100 113 100 87 107 112 Bermondsey 68 60 84 126 80 99 97 90 177 133 93 91 76 94 93 153 Lambeth 88 97 91 83 88 74 83 103 121 104 63 70 65 69 100 76 Battersea 144 123 132 122 97 81 125 178 116 70 59 74 106 81 79 88 Wandsworth 74 83 84 79 60 51 100 114 99 74 74 135 124 100 93 118 Camberwell 69 65 67 112 140 180 154 102 156 130 122 113 82 63 64 76 Deptford 72 68 86 153 225 113 141 132 121 111 144 104 241 106 93 153 Greenwich 60 43 84 85 137 189 82 105 122 89 74 78 124 94 100 229 Lewisham 48 74 82 70 57 122 85 127 170 126 85 130 118 56 79 106 Woolwich 32 68 66 66 81 96 91 86 100 115 67 91 88 81 157 176 London 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 Diphtheria and Elementary Schools. 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 26th July, i.e., the latter part of the 30th week, and the schools re-opened on Monday, the 27th August, i.e., at the beginning of the 35th week. If the number of cases in the four weeks preceding and the four weeks subsequent to the weeks most subject to holiday influence be compared, the following results are obtained for the age periods of 0—3, 3—13, and 13 years and upwards. It will be observed that the decrease in the number of cases notified during the period of holiday influence is most marked at the school age. Diphtheria—Notified cases—1906. Period. Notified cases—Age periods. 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) 116 425 105 — • — Four weeks of holiday influence (32nd to 35th) 100 322 88 —13.8 -24.2 —16.2 Four weeks following weeks of holiday influence (36th to 39th) 108 379 133 + 8.0 + 17.7 + 51.1 14911 E 2 36 Account is given in the annual reports of the occurrence of outbreaks of diphtheria among school children, and in all such instances the Klebs Loeffler bacillus was detected in some of the children. Thus, Dr. Jackson gives account of such occurrences in the Hugon-road school, the Clancarty school, the St. Dunstan's school, and a private school, all in Fulham. In all these schools either cases of clinically recognisable diphtheria or children harbouring the diphtheria bacillus were subsequently discovered. Only in the case of the last school was closure resorted to. In Chelsea, cases of diphtheria occurred among the scholars of the Walton-street school. Dr. Parkes writes that the school was eventually closed on the 5th April until after the Easter recess, but on the reassembling of the children other cases occurred among them. On November 14th, 115 of 550 of the boys in the Duke of York's school were found to be harbouring the diphtheria bacillus. Sore throat in an epidemic form had been prevalent among the boys since soon after the summer vacation, and definite cases of diphtheria were discovered on the 4th November, leading to bacteriological examination on the 14th. The boys harbouring the bacillus were each injected with 1,000 units of antitoxic serum, and later the remaining boys, 435 in number, were injected with half this amount. Of the 115 boys, 10 subsequently developed diphtheria, and of the 435 boys one was subsequently attacked. Subsequent examinations were made of material from the throats of the 115 boys. On the 28th November, 24 were still harbouring the bacillus, and subsequent examinations showed that the number thus affected fell to 7, 7, 5, 3, and 1. In Westminster a number of cases of sore throat occurred among the children attending the French Protestant school in Noel-street. Dr. Allan gives an interesting account of the outbreak, showing the number of cases which could be attributed to infection from person to person. The result of bacteriological examination was to show that the Klebs Loeffler bacillus was harboured by one child, and the Hoffmann bacillus by another. In Lewisham the infant department of the Plassy-road school was closed for a few days on account of diphtheria. In Woolwich a number of cases occurred among the children attending the Wood-street and Gordon schools. In the former exclusion of children on bacteriological grounds was resorted to. In the latter, the same course was adopted, but eventually the whole school was closed for two weeks and the infant department for four weeks. In the reports relating to other districts, similar accounts are given of the occurrence of cases of diphtheria among children attending particular schools. In Holborn, the infant department of the Rosebery-avenue school was affected. In Lambeth the Upper Kennington-lane school suffered, and after attempt to deal with the outbreak by exclusion of particular scholars, the school was closed; prevalence of diphtheria among the children of the St. Mary's infant school was dealt with by exclusion. In Wandsworth diphtheria was prevalent among the children of the Brandlehow-road school, and the school had eventually to be closed There was also prevalence of diphtheria in the children of the Hambro' Orphanage, and the St. Anne's-hill Home, Wandsworth, both residential institutions. Dr. Caldwell Smith gives an interesting account of the persistence of the disease in the Hambro" Orphanage. In connection with the outbreak, among the children of the Brandlehow-road school, Dr. Caldwell Smith states that " a review of the whole of the circumstances in connection with this outbreak only emphasizes the fact which has been previously noted, that carrier cases, or cases attending school with the diphtheria bacillus present, with very few clinical symptoms, invariably cause a serious outbreak of the disease, more especially it the carrier case or cases attend infants' departments of public schools. One feature of this outbreak. which has also been previously observed, is the association of the true bacillus and Hoffmann's bacillus. All the facts which have been observed in this outbreak appear to point to a distinct relationship between these two bacilli, either they are of the same species, or the Hoffmann bacillus renders the affected individual more liable to infection by the true bacillus." He thinks, moreover, that the children were rendered susceptible to infection by a specific germ through the flooding of the basement of the school, the result of a stoppage of the main drain. Bacteriological examination of " contacts " is discussed in a few of the reports. Thus, Dr. Brown has continued in Bermondsey the system which he instituted some years ago. Dr. Davies states that no " contact " in Woolwich is allowed in return to school except after bacteriological examination, and Dr. Annis shows in a number of instances in Greenwich the relation of bacillus carriers to certified cases of diphtheria. In this connection the London County Council in July adopted the following report and resolution submitted by their Education Committee :— " Our attention has been drawn to the difficulties which have arisen in districts where diphtheria " has been prevalent, consequent upon children who have been excluded from school being certified as " free from disease by medical practitioners. With a view, therefore, to dealing more thoroughly with " the disease, the various medical officers of health were asked to adopt the temporary arrangements " being carried out in Greenwich in the event of there being an outbreak of diphtheria in their respective " districts. These arrangements involve that any children excluded from school on account of " diphtheria or sore throat during the prevalence of the disease, should not be re-admitted without a " certificate from the medical officer of health that they were free from infection. " As a result of a conference of medical officers of health held on 27th April, 1906, the under" mentioned resolutions were passed—" That in the opinion of this branch (Incorporated Society of " Medical Officers) it is not possible in the absence of a bacteriological examination to decide that a child " is free from the infection of diphtheria. 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." " We are of opinion that it would greatly strengthen the hands of the various medical officers, " and do much to reduce the present risks of infection, if authority were given for the refusal, during " the presence of diphtheria in any district, of the re-admission of children excluded from school as 37 " suffering from diphtheria or sore throat until they have obtained a medical certificate of freedom from " infection, based on a bacteriological examination. We are informed that such certificate can be given " either by general practitioners or by the medical officer of health, and would be free from the dan" gerous errors of medical certificates given merely on the inspection of the children. We recommend— " 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." 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. 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 1906. The incidence of attack at " all ages " was, as in preceding years, greater on females than on males, while both the incidence of death and the fatality was higher among the latter. In the age groups adopted for the purpose of this table the greatest incidence of attack was upon males of three and upon females of four years of age ; the greatest incidence of death was upon males of one and upon females of three years of age. The fatality was greatest among males of under one and among females of age 55 and upwards. Diphtheria1—1906. Age-period. Males. Females. Notified Cases. Deaths. Case mortality per cent. Rates per 100,00 living. Notified Cases. Deaths. Case mortality per cent. Rates per 100, 000 living. Cases. Deaths. Cases. Deaths. All Ages 3,721 357 9 6 167 16 4,324 361 83 174 14 0— 100 40 40.0 175 70 85 27 31.8 149 47 1— 320 67 20.9 631 132 251 55 21.9 495 108 2— 354 55 15.5 691 107 300 53 17.7 588 104 3— 444 62 14.0 890 124 405 60 14.8 802 119 4— 400 40 10.0 819 82 487 49 10.1 1,002 101 5— 1,205 74 6.1 526 32 1,545 97 6.3 668 42 10— 402 11 2.7 186 5 510 6 1.2 231 3 15— 159 2 1.3 73 1 201 2 1.0 83 1 20— 108 2 1.9 48 1 184 1 0.5 68 0 25— 133 2 1.5 34 1 235 7 3.0 52 2 35— 68 2 2.9 23 1 83 2 2.4 26 1 45— 19 — — 9 — 33 — — 15 55 & upwards 9 — — 4 — 5 2 40.0 2 1 ' - Whooping-cough. The deaths from whooping-cough in the Administrative County of London in the year 1906 (52 weeks) numbered 1,226, as compared with 1,487 in 1905. The death-rates from this disease in 1906 and preceding periods have been as follows :— Whooping-cough. Period. Death rate per 1,000 persons living Period. Death rate per 1,000 persons living 1841-50 0.87 1901 0.35 2 1851-60 0.88 1902 0.40 2 1861-70 0.88 1903 0.35 2 1871-80 0.81 1904 0.32 2 1881-90 0.69 1905 0.32 2 1891-1900 0.502 1906 0.26 2 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:— 1 See footnote (1) page 32. 2 See footnote (2) page 7. 38 Whooping-cough—Mortality among children at ages 0-5. Period. Death-rate per 1,000 children living at ages 0-5 Period. Death-rate per 1,000 children living at ages 0-5. 1851-60 6.56 1902 3.561 1861-70 6.53 1903 3.161 1871-80 6.02 1904 2.911 1881-90 5.34 1905 2.881 1891-1900 4.211 1906 2.321 1901 3.131 The death-rate in each year since 1840 in relation to the mean of the period 1841-1906 is shown in diagram XIV., while the deaths in each month since 1890 in relation to the mean monthly deaths of the period 1891-1906 are shown in diagram VII., page 26. It will be seen from the following table that in the decennium 1896-1905 the London whoopingcough death-rate was exceeded by the death-rates of Liverpool, Manchester, Birmingham, West Ham, Newcastle-on-Tyne and Salford, and in 1906 was lower than the death-rate of any of the undermentioned large English towns, except Sheffield, West Ham, Bradford, Newcastle-on-Tyne, Nottingham and Salford. Whooping-cough—Death-rates per 1,000 persons living. Town. 1896-1905. 1906. Town. 1896-1905. 1906. London 0.411 0.261 West Ham 0.50 0.26 Liverpool 0.47 0.48 Bradford 0.27 0.13 Manchester 0.47 0.31 Newcastle-on-Tyne 0.43 0.22 Birmingham 0.48 0.45 Hull 0.37 0.28 Leeds 0.38 0.32 Nottingham 0.34 0.16 Sheffield 0.40 0.24 Salford 0.55 0.23 Bristol 0.35 0.28 Leicester 0.29 0.49 The following table shows that in the decennium 1896-1905 the London whooping-cough deathrate exceeded the death-rates of all the undermentioned foreign towns, and in 1906 was higher than that of any except Copenhagen. Whooping-cough—Death-rates per 1,000 persons living. Town. 1896-1905. 1906. Towu. 1896-1905. 1906. London 0.411 0.261 St. Petersburg 0.21 0.20 Paris 0.12 0.09 Berlin 0.28 0.17 Brussels 0.12 0.18 Vienna 0.09 0.09 Amsterdam 0.26 0.20 Rome 0.07 0.15 Copenhagen 0.31 0.29 New York 0.13 0.09 Stockholm 0.21 0.19 The following table shows the whooping-cough deaths and death-rates for the year 1906 and the death-rates for the period 1901-5 in the several metropolitan sanitary districts :— 1 See footnote (1) page 8. Diagram XIV Whooping Cough. Diagram XV Typhus. 39 Whooping-cough—Death-rates in sanitary areas. Sanitary area. Deaths, 1906 (52 weeks). Death-rate per 1,000 persons living. 1901-5. 1906. Paddington 12 0.27 0.08 Kensington 20 0.28 0.11 Hammersmith 19 0.40 0.16 Fulham 31 0.45 0.19 Chelsea 17 0.32 0.23 Westminster, City of 23 0.18 0.13 St. Marylebone 11 0.24 0.09 Hampstead 2 0.18 0.02 St. Pancras 70 0.39 0.30 Islington 74 0.35 0.22 Stoke Newington 17 0.24 0.32 Hackney 39 0.29 0.27 Holborn 10 0.28 0.18 Finsbury 54 0.45 0.56 London, City of 4 0.16 0.19 Shoreditch 61 0.56 0.53 Bethnal Green 63 0.52 0.48 Stepney 104 0.44 0.34 Poplar 52 0.49 0.31 Southwark 54 0.46 0.26 Bermondsey 51 0.42 0.40 Lambeth 71 0.36 0.23 Battersea 78 0.39 0.44 Wandsworth 60 0.27 0.22 Camberwell 77 0.32 0.28 Deptford 62 0.36 0.54 Greenwich 42 0.33 0.40 Lewisham 27 0.24 0.18 Woolwich 21 0.28 0.17 London 1,226 0.35 0.261 It will be seen from the foregoing table that in the period 1901-5 the whooping-cough death-rate was highest in Shoreditch (0'56) and lowest in the City of London (0'16); in the year 1906 Finsbury (0.56) had the highest death-rate and Hampstead (0.02) the lowest. The whooping-cough death-rates in each of the four quarters of the year 1906 were as follows: first quarter, 0.39; second quarter, 0.34; third quarter, 0.16; and fourth quarter, 0.15 per 1,000 persons living. All the districts show a lower mortality from whooping-cough in 1906 as compared with 1905 except the districts of Stoke Newington, Finsbury, the City of London, Bethnal Green, Bermondsey, Battersea, Camberwell, Deptford, Greenwich, and Woolwich, which had increased death-rates from this disease, and Lewisham, which had the same death-rate as in 1905. The increase was especially marked in Stoke Newington, Finsbury, the City of London, and in Deptford and Greenwich. Several medical officers of health comment on the extent to which the infectious nature of whooping-cough is ignored by parents, and the medical officer of health of Stoke Newington states that the disease was largely spread by school attendance, despite the precautions taken. Typhus. There were no deaths from typhus registered in the Administrative County of London during the year 1906. The death-rates from this disease in successive periods have been as follows:— Typhus. Period. Death-rate per 1,000 persons living. 1871-80 .055 1881-90 •008 1891-1900 •0011 1901 •0011 1902 •0011 1903 •0011 1904 1 1905 1 1906 1 — In this table .000 indicates that the deaths were too few to give a rate of .0005; where — is inserted no death occurred. 1 See footnote (2) page 7. 40 The death-rate in each period since 1868 in relation to the mean death-rate of the period 1869-1906 is shown in diagram XV. During the year 1906 seven persons were certified to be suffering from typhus, three resident in Islington, one in Hackney, one in Stepney, and two in Bermondsey. After removal to hospital there was revision of the diagnosis of these cases, and the number of persons known to be actually suffering from typhus in 1905 was four, this number including one who was sent to hospital on a certificate that he was suffering from enteric fever. The first of the four cases was that of a telegraph messenger, who was removed to hospital from Islington in January; it was thought that he must have contracted his disease in Peterborough. The second was that of a man aged 45, employed as an engraver, who was removed in March to hospital from Hackney, where he had resided for six months; there was no evidence as to how he became infected. The third case was that of a man aged 43, who superintended the removal of manure, including rags, in the Willow-walk depot of the London, Brighton and South-Coast Railway; he was removed to hospital in the beginning of March from Bermondsey ; and the source of his infection could not be discovered. The fourth case was that of a furrier, aged 33, who was removed to hospital from Whitechapel in June. In none of the above cases was there evidence of destitution. Enteric Fever. The number of cases of enteric fever notified in the Administrative County of London during 1906 (52 weeks) was 1,600, compared with 1,552 in 1905. The deaths from this disease numbered 260 in 1906 (52 weeks), compared with 234 in 1905. The case-rate and death-rates per 1,000 persons living and the case-mortality per cent, in 1906 and preceding periods were as follows :— Enteric lever. 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 0.112 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 1906 0.062 0.3 16.2 The death-rate in each year since 1868 in relation to the mean death-rate of the period 1869-1906 is shown on diagram XVI. The notified cases in each week of 1906 may be compared with the average weekly notifications of the period 1890-1906 on reference to diagram XVII. The diagram shows exceptional behaviour of the disease in the month of June ; increase of cases occurred during this month in more than one London district coincident with an increase in the cases notified in the Borough of West Ham, which increase was attributed by the medical officer of the Borough to the consumption of infected cockles from Leigh Creek. Further reference to this matter will be found on page 42. The monthly case-rate and case-mortality in each of the years 1891-1906 in relation to the mean of the whole period is shown in diagram XVITI. The following table shows the enteric fever cases, deaths, case-rates, and death-rates for the year 1906, the case-rates for the decennium 1896-1905, and the death-rates for the period 1901-5 in the several sanitary districts— 1 The Infectious Disease (Notification) Act came into force in 1889. 2 See footnote (2) page 7. Diagram XVI Enteric Fever. Diagram XVII Enteric Fever. Diagram XVII Enteric Fever. 41 Enteric fever—Case rates and death rates in sanitary areas. Sanitary area. Notified cases, 1906 (52 weeks). Case-rate per 1,000 persons living. Deaths, 1906 (52 weeks). Death-rate per 1,000 persons living. 1896-1905. 1906. 1901-5. 1906. Paddington 34 0.5 0.2 7 0.07 0.05 Kensington 39 0.5 0.2 5 0.06 0.03 Hammersmith 33 0.6 0.3 8 0.08 0.07 Fulham 45 0.5 0.3 13 0.08 0.08 Chelsea 17 0.5 0.2 – 0.06 – Westminster, City of 47 0.5 0.3 5 0.08 0.03 St. Marylebone 48 0.6 0.4 3 0.07 0.02 Hampstead 21 0.5 0.2 3 0.06 0.03 St. Pancras 95 0.8 0.4 15 0.09 0.06 Islington 146 0.7 0.4 20 0.09 0.06 Stoke Newington 10 0.5 0.2 – 0.07 – Hackney 93 0.9 0.4 14 0.13 0.06 Holborn 15 0.7 0.3 1 0.11 0.02 Finsbury 45 0.8 0.5 14 0.10 0.14 London, City of 10 0.9 0.5 1 0.06 0.05 Shoreditch 37 0.8 0.3 5 0.09 0.04 Bethnal Green 55 0.9 0.4 14 0.09 0.11 Stepney 124 0.9 0.4 26 0.10 0.08 Poplar 86 1.0 0.5 11 0.11 0.06 Southwark 111 0.7 0.5 12 0.09 0.06 Bermondsey 41 0.9 0.3 4 0.11 0.03 Lambeth 90 0.6 0.3 22 0.07 0.07 Battersea 45 0.6 0.3 8 0.08 0.04 Wandsworth 96 0.5 0.4 15 0.07 0.06 Camberwell 59 0.5 0.2 13 0.07 0.05 Deptford 41 0.6 0.4 6 0.06 0.05 Greenwich 43 0.7 0.4 5 0.07 0.05 Lewisham 25 0.4 0.2 1 0.06 0.01 Woolwich 41 0.4 0.3 9 0.07 0.07 Port of London 8 – – – London 1,600 0.7 0.3 260 0.081 0.061 It will be seen from the foregoing table that among the several sanitary districts in the period 1901-5, the enteric fever death-rate was highest in Hackney (0.13); the lowest death-rate for this period was 0.06, and this obtained in the districts of Kensington, Chelsea, Hampstead, the City of London, Deptford and Lewisham. In the year 1906 Finsbury (0.14) had the highest enteric fever death-rate and Chelsea and Stoke Newington, where no deaths were registered, the lowest. The death-rates from enteric fever in London in each of the four quarters of the year were as follows:—first quarter, 0.04; second quarter, 0.04; third quarter, 0.06; and fourth quarter, 0.09 per 1,000 persons living. 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 1900. The case-rate, the deathrate, and the fatality were at "all ages" higher among males than among females. In the age groups adopted for the purposes of this table the greatest incidence of attack was upon both males and females aged 10-15; the greatest incidence of death was upon males aged 25-35 and upon females aged 10-15 and aged 35-45. The fatality was greatest among males of 55 and upwards and among females aged 35-45. 14911 1 See footnote (2), page 7. F 42 Enteric Fever1— 1906. Age-period. Males. Females. Notified Cases. Deaths. Casemor tality per cent. Rates per 100,000 living. Notified Cases. Deaths. Casemor tality per cent. Rates per 100,000 living. Cases. Deaths. Cases. Deaths. All Ages 867 155 17.9 39 7 733 123 16.8 29 5 0– 1 – 12.9 12 2 1 – 21.1 7 2 1– – – 1 1 2– 9 1 4 – 3– 5 1 7 2 4– 16 2 6 1 5– 112 8 7.1 49 3 87 8 9.2 38 3 10– 131 9 6.9 61 4 130 17 13.1 59 8 15– 126 17 13.5 58 8 100 14 14.0 41 6 20– 102 23 22.5 45 10 99 12 12.1 37 4 25– 175 47 26.9 45 12 155 27 17.4 34 6 35– 113 26 23.0 39 9 80 25 31.2 25 8 45– 52 13 25.0 26 6 48 13 27.1 21 6 55 & upwards 25 8 32.0 12 4 15 3 20.0 6 1 Of the 1,600 cases of enteric fever notified during 1906, a proportion was found, after inquiry by the Medical Officers of Health, to be incorrectly diagnosed. With respect to those which were accepted as being actual cases of enteric fever, effort was made by Medical Officers of Health to discover the cause of the illness. As might be expected, it was found that a considerable number received their infection outside the district in which their illness was notified, some of them being infected on the Continent, where they had gone for their summer holiday. The annual reports relating to Westminster and Hampstead both mention cases which were infected abroad. The reports continue to show the occurrence of attacks following the consumption of particular articles of food—oysters, other shell fish, fried fish, and watercress. Cockles are still frequently mentioned as a possible cause of infection, and Southend and Leigh-on-Sea are still referred to as the source of some of these cockles. An outbreak of 52 cases of enteric fever occurred during the year in West Ham, and a number of the persons attacked were found by Dr. Sanders, medical officer of health of that borough, to have eaten cockles a short time before the onset of their disease. Dr. Sanders discusses in his annual report the probability of the outbreak being due to this cause or to fried fish, which was also largely consumed by the sufferers, deciding in favour of the former view. In the majority of these cases the cockles were said to have been purchased in Billingsgate Market, their original source being Leigh-on-Sea. Dr. Collingridge obtained a report from Dr. Klein concerning cockles from this source. The concluding paragraph of this report is as follows : " From the above analyses it follows that none of the six samples have been sufficiently heated, and are therefore unsafe, inasmuch as the interior of the cockles contained abundance of microbes in a living state, which, like B. typhosus are killed by temperatures far below the temperature of boiling water." Dr. Priestley alto found Colon bacilli of intestinal type in cockles sold in Lambeth, his attention having been directed to the matter by the occurrence of 19 cases of enteric fever in June and July apparently connected with cockle consumption. Dr. Collingridge refers to the risk of laying cockles in the Leigh Creek, and adds, " The Leigh fishermen are now fully aware that if they persist, as heretofore, in relaying cockles in the Creek that receives the town sewage effluent, they will lose their means of livelihood. Provided they entirely abandon this practice and cook the cockles properly there can be no objection to the fish being sold. The Rector of the parish and one other resident having been appointed to exercise supervision for ensuring that the directions and instructions of the Fishmongers Company were carried out, no further action was taken." Whatever view is taken as to the sufficiency of the evidence incriminating the cockles in these outbreaks, the fact remains that the risk of consumption of cockles which have been laid in the Leigh Creek is now well recognised and any further evidence of injury to London inhabitants from this source must necessarily raise question as to the steps which should be taken in dealing with this matter, by public authorities of the localities whose inhabitants suffer in this manner. In the majority of the reports the number of cases is stated in which shell fish was eaten at a time before the illness which suggests that this might have been the cause; in a few cases additional evidence is supplied. Thus in Fulham a servant girl ate cockles at Deal and subsequently brought some home; only one other member of the family ate them, a sister, who was afterwards attacked. In Finsbury a group of 14 cases occurred in June. The dates of onset, Dr. Newman writes, indicate a common source of infection; all had eaten fried fish, and 13 out of 14 had eaten cockles, at or about the critical period. Dr. Newman adds that it is possible that this outbreak was part of the larger outbreak which occurred at the same time in West Ham. In connection with the frequent statement that fried fish had been 1ee footnote (1), page 32. 43 eaten shortly antecedent to attack, Dr. Davies mentions the following cases occurring in Woolwich: " A fishmonger supplied two of the cases attributed to fried fish; he had recently had enteric fever; two persons outside the borough who bought fried fish from him had enteric about the same time." Infection from person to person is frequently mentioned in the annual reports as the cause of the disease. Dr. Warry gives the particulars of five groups of such cases occurring in Hackney, and adds that in the case of all of these groups the more usual sources of infection could be excluded. Dr. Millson had reason for thinking some 20 per cent. of the cases in Southwark could be thus explained. There is no reason for doubting that such infection frequently occurs, especially in houses occupied by poor persons, where the accommodation is limited and where conditions of cleanliness are not maintained. A suggestion of exceptional behaviour of the disease in this respect needs, however, close examination. The annual report of Dr. R. Dudfield gives account of a small outbreak of enteric fever in connection with the Paddington Green Children's Hospital, which, as he says, will be of interest in connection with the question of spread of the disease by personal contact. On the hypothesis which Dr. Dudfield constructs, he finds explanation for the infection directly or indirectly by a particular patient, A. F., of at least 25 persons, as follows:— (i) In the Willesden district there were reported to the Medical Officer of Health, Dr. Butler, 9 cases, to which, says Dr. Dudfield, "a suspicion of connection with A. F. more or less intimate attached." Here were, in addition, four other persons intimately associated with A. F., whose serum was found to give a Widal reaction. These four persons had not been ill. (ii) In the surgical ward, at the Paddington Green Children's Hospital, during September and early October, a probationer nurse and four patients were attacked. Here A. F. had from August 21st to September 1st been in bed No. 6; two of the patients occupied adjacent beds,Nos. 7 and 5; another patient occupied a bed, No. 8, next but one to that of A. F., and the probationer nurse who was attacked was in charge of the side of the ward on which the beds of these patients were placed. The remaining patient M.S. cannot be assumed to have been infected by A. F. in this ward ; for M. S. was at the Convalescent Home, at Slough, from July 30th until September 25th. This patient was brought into contact with A. F., however, at the Convalescent Home. (iii) At the Convalescent Home 8 cases, or including the patient last named, nine cases, occurred. (iv) Finally two cases occurred among patients discharged from the Hospital. Dr. Dudfield found that the child A. F., sot 3, had the following history:— Until July 31st, 1906, she was living with her mother and brother in Canning Town. The said mother "is reported to have been fond of shellfish and frequently bought fried fish for supper," and in June she suffered from an acute illness, which proved fatal on June 20th. A considerable outbreak of enteric fever had occurred in West Ham (of which district Canning Town forms' part). Dr. Sanders, Medical Officer of Health of West Ham, informed Dr. Dudfield that the whole history of Mrs. F.'s case was highly suggestive of the view "that the pneumonia and heart failure (the certified causes of death) from which she died were complications of an ambulatory form of enteric fever." On July 31st A. F. and her brother S. F. were brought to St. Vincent's Home, Paddington, and were on the same day handed over to Mrs. B., foster mother, living in Willesden. A. F. was "ailing" during the two or three weeks she lived in Willesden, and on August 14th and 21st was taken to the out-patients' department of the Paddington Green Children's Hospital; on the latter date A. F. was admitted as an in-patient suffering from pneumonia. Between August 21st and September 1st A. F. was in the surgical ward of the Paddington Green Children's Hospital. From September 1st to 5th A. F. was in the medical ward of the above hospital. From September 5th to 20th A. F. was at the Convalescent Home at Slough. On September 20th she was "readmitted," (apparently) to the Paddington Green Children's Hospital. Dr. Dudfield, on reviewing A. F.'s history, writes: "This information tended to confirm the suspicion that A. F.'s case was really one of enteric fever, a suspicion which was converted to a certainty by the Widal test on October 5th." Dr. Dudfield concludes that the child A. F. was originally infected in Canning Town in June, and "was capable of spreading infection from July 31st or thereabouts until October 2nd, when full precautions were put into operation." Even on the assumption that the Widal test is final, and that A. F. was on October 5th convalescent from enteric fever, it by no means follows that she was capable of spreading infection from July 31st onwards to October 2nd. Thus, taking first the Willesden group of cases, it will be found that the evidence here is of an ambiguous character. Dr. Butler discusses, in his third quarterly report for 1906, the possible influence of the polluted water of a canal "feeder" in causing the outbreak in his district. Furthermore, Dr. Dudfield refers to the fact that one of the Willesden patients was employed at the Kensington disinfection station and had there "handled bedding, etc., infected with enteric fever." Again, while Dr. Dudfield, in alluding to the Willesden cases, speaks of "more or less intimate" connection with A. F., Dr. Butler writes, with regard to three of the cases (occurring in two houses), "it must be admitted that no communication (between them and A. F.) can be traced." On turning, however, to the second group of cases, those occurring in the Paddington Green Hospital, the facts recorded are strongly suggestive of personal infection, though here again it is by no means certain that A. F. was at fault; there is, indeed, of course, a possibility that she was herself infected in the hospital and not the original source of introduction of infection into that institution; 14911 E 2 44 the circumstances of her "recrudescence of fever" on September 19th at Slough, suggest, however, a more probable hypothesis than this. At the Convalescent Home the first five cases sickened between September 17th and 26th. These cases might not unnaturally have been grouped with that of A. F. herself, who had a "recrudescence of fever" when at the Home on September 19th, and with that of M. S., who had a "recrudescence of fever" on September 24th at the Home, but who was readmitted to the institution (to the surgical ward already referred to) on the following day. The dates of onset of this group of seven cases are distinctly suggestive of some food infection, and if A. F. had enteric fever at all it is quite possible that this so-called " recrudescence of fever " really constituted her original attack. The one piece of evidence concerning A. F.'s relation to enteric fever (apart from the information gleaned in October from her friends) was the discovery, on October 5th, that her serum gave a positive Widal reaction, and this phenomenon might, of course, not unnaturally find explanation in occurrence of an attack of enteric fever commencing on September 19th, when A. F. was in the Convalescent Home. A food infection hypothesis of the seven children in the Home, as opposed to the hypothesis of the infection of six of them by A. F., finds, moreover, support in the fact that none of the children originally attacked at the Home were in the same ward as A. F., though two patients in the Home attacked later (September 30th and Octobcr 14th) were in that ward. The curious inter-relationships of the patients and nurse attacked in the surgical ward at Paddington Green Children's Hospital are, as noted already, suggestive of personal infection, but there remains the fact that while these inter-relationships fit in with the view that A. F. when in that ward was an unrecognised source of mischief, this theory does not accord so well with the subsequent occurrence of A. F.'s "recrudescence of fever" at the Home on September 19th, or with the almost simultaneous (September 24th) attack of the child M. S., then at the Home, and only subsequently sent to occupy the ward occupied by A. F. at the hospital in Paddington. The circumstances of these cases are well deserving of study, but they cannot be held to conclusively establish the infectivity of the child A. F. from July 31st to October 2nd. Diarrhœa. The deaths in the Administrative County of London attributed to epidemic diarrhoea and infective enteritis during 1906 (52 weeks) numbered 2,872, while 1,635 deaths were attributed to diarrhoea and dysentery. The figures for 1905 were 2,125 and 1,285 respectively. The age-distribution of these deaths was as follows:— Diarrhœa—Deaths1 at the several age-periods—1906. Disease. Under 1 year. 1-5. 5-20. 20-40. 40-60. 60-80. 80 and upwards All ages. Epidemic diarrhœa (infective enteritis) 2,289 519 18 5 15 20 6 2,872 Diarrhœa and dysentery 1,153 222 10 36 45 133 36 1,635 Total 3,442 741 28 41 60 153 42 4,507 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 diarrhœa combined, in relation to the mean death-rate of the period 1841-1903 in each year since 1840. The following table shows that the London diarrhoea death-rate was in the decennium 1896-1905 lower than the death-rate of any of the undermentioned large English towns except Bristol, Bradford and Newcastle-on-Tyne, and in 1903 was lower than that of any except Bristol and Bradford. Diarrhœa—Death-rates per 1,000 persons living. Town. 1896-1905. 1906. Town. 1896-1905. 1906. London 0.81 0.94l West Ham 1.45 1.88 Liverpool 1.55 1.79 Bradford 0.73 0.93 Manchester 1.36 1.53 Newcastle-on-Tyne 0.74 1.03 Birmingham 1.34 1.58 Hull 1.50 1.61 Leeds 1.01 0.97 Nottingham 1.17 1.52 Sheffield 1.46 1.71 Salford 1.55 1.44 Bristol 0.60 0.54 Leicester 1.25 1.13 1 See footnote (1) page 8. Diagram XIX Diarrhœa, Dysentery & Cholera. 45 The deaths and death-rates from diarrhœa for the year 1906, and the death-rates for the period 1901-5 in each of the sanitary areas of London, are shown in the following table:— Diarrhœa—Death-rates in sanitary areas. Sanitary area. Deaths, 1906 (52 weeks). Death-rate per 1,000 persons living. 1901-5. 1906. Paddington 125 0.64 0.84 Kensington 144 0.60 0.80 Hammersmith 131 0.82 1.09 Fulham 241 1.23 1.49 Chelsea 52 0.50 0.70 Westminster, City of 69 0.35 0.40 St. Marylebone 77 0.60 0.60 Hampstead 23 0.19 0.26 St. Pancras 155 0.58 0.64 Islington 201 0.50 0.58 Stoke Newington 25 0.46 0.47 Hackney 203 0.77 0.88 Holborn 35 0.53 0.63 Finsbury 120 0.98 1.23 London, City of 6 0.24 0.28 Shoreditch 187 1.31 1.62 Bethnal Green 154 0.89 1.18 Stepney 437 1.07 1.43 Poplar 291 1.15 1.71 Southwark 225 1.01 1.08 Bermondsey 165 1.03 1.29 Lambeth 282 0.78 0.90 Battersea 158 0.84 0.88 Wandsworth 226 0.60 0.83 Camberwell 247 0.67 0.90 Deptford 138 0.80 1.20 Greenwich 72 0.75 0.69 Lewisham 130 0.56 0.88 Woolwich 105 0.73 0.83 London 4,424 0.751 0.941 It will be seen from the foregoing table that the diarrhoea death-rate was in the period 1901-5 highest in Shoreditch (1.31) and lowest in Hampstead (0.19); in the year 1906, Poplar (1.71) had the highest death-rate, the lowest again obtaining in Hampstead (0'26). The diarrhoea death-rates in London in each of the four quarters of the year 1906 were as follows:—first quarter, 0.14; second quarter, 0.17; third quarter, 2.96; and fourth quarter, 0.49 per 1,000 persons living. The mean temperature of the air during the summer quarter in 1906 was 2'8 degrees above the average, that during the summer quarter of 1905 having been 1.3 degrees above the average. The London death-rate from diarrhoea which, as will be seen, was governed in the main by deaths under one year of age, was higher than in 1905, being 0.94 in 1906, and having been 0.72 in 1905. This higher death-rate was manifested in each of the sanitary areas except those of Stoke Newington, Hackney, the City and Greenwich. The annual reports show that by far the greater number of deaths occurred among infants who were hand-fed. Thus, in Finsbury 77 per cent. of infants under one year who died from epidemic diarrhoea were fed on cow's milk; in Bermondsey, of 415 children of this age dying from diarrhoea only 63 were breast-fed, 309 were otherwise fed, and 43 were fed by both methods. The condition of the homes in which deaths occurred is stated in some of the reports to be not open in the majority of cases to especial criticism, but in a few reports mention is made of the absence of proper larder accommodation for the storage of milk. Thus Dr. Dudfield, writing of infant deaths from diarrhoea in Kensington, says : ' In 30 of 65 hand-fed cases the milk used had been kept in the rooms occupied by the family; in 7 cases in a passage or wash-house—and had been usually uncovered and exposed to contamination by dirt, flies, etc." The experience of the year in Finsbury led Dr. Newman to the conclusion that the fact of mothers going out to work had little or nothing to do with the deaths, and that antecedent weakness or ill-health did not predispose the infant to attack. The system instituted in Woolwich in 1905, of voluntary notification of the first case of diarrhoea occuring in a family in July, August and September, was continued in 1906, and 366 cases were thus notified, of which 46 died, or 13 per cent. Dr. Davies compares the death-rate of Woolwich with that of London in the periods 1901-4 and 1905-6, and shows that in the former period (without notification) the Woolwich death-rate was 2.30 and the London death-rate was 2.27, whereas in the latter period (with notification in Woolwich but not in London) the Woolwich death-rate was only 2.13 and that of London 2.64. Erysipelas. The deaths from erysipelas in the Administrative County of London registered during 1906 (52 weeks) numbered 245. 1 See footnote (2), page 7. 46 The age-distribution of these deaths was as follows:— Erysipelas—Deaths at the several age-periods—1906. Under 1 Year. 1-5. 5-20. 20-40. 40-60. 60-80. 80 and upwards. All ages. 61 6 6 37 58 69 8 245 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 Death-rate per 1,000 persons living. 1891 4,764 1.13 214 0.05 1892 6,934 1.63 292 0.07 1893 9,700 2.26 424 0.10 1894 6,080 1.40 221 0.05 1895 5,660 1.30 179 0.04 1896 6,436 1.43 207 0.05 1897 5,794 1.31 184 0.04 1898 5,169 1.16 165 0.04 1899 5,606 1.25 213 0.05 1900 4,762 1.06 182 0.04 1901 4,604 1.02 171 0.04 1902 5,536 1.19 183 0.04 1903 4,372 0.95 183 0.04 1904 4,943 1.08 232 0.05 1905 4,972 1.06 226 0.05 1906 5,019 1.07 245 0.05 The number of cases of erysipelas notified and the case-rate for the year 1906, together with the case-rate in the decennium 1896-1905, in the several sanitary areas are shown in the following table:— Erysipelas.—Case-rates in sanitary areas. Sanitary area. Notified Cases, 1908 (52 weeks). Case-rate per 1,000 persons living. 1896-1905. 1906. Paddington 139 1.0 0.9 Kensington 148 1.1 0.8 Hammersmith 125 1 1.0 Fulham 140 1.0 0.9 Chelsea 60 0.8 0.8 Westminster, City of 127 0.8 0.7 St. Marylebone 148 1.5 1.2 Hampstead 51 0.6 0.6 St. Pancras 235 1.2 1.0 Islington 277 0.9 0.8 Stoke Newington 47 0.8 0.9 Hackney 301 1.3 1.3 Holborn 57 1.6 1.0 Finsbury 139 1.4 1.4 London, City of 18 0.8 0.8 Shoreditch 150 1.6 1.3 Bethnal Green 245 2.1 1.9 Stepney 415 1.6 1.4 Poplar 206 1.3 1.2 Southwark 332 1.4 1.6 Bermondsey 195 1.4 1.5 Lambeth 273 1.0 0.9 Battersea 161 1.1 0.9 Wandsworth 269 1.1 1.0 Camberwell 305 1.1 1.1 Deptford 158 1.3 1.4 Greenwich 100 1.1 1.0 Lewisham 97 0.7 0.7 Woolwich 97 0.8 0.8 Port of London 4 London 5,019 1.2 1.1 1 See footnote (1), page 8. 47 The following table shows the age and sex distribution of the notified cases of erysipelas in 1906— Age-period. All Ages. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75 and upwards. Males 2,188 212 78 99 89 107 328 417 407 261 148 42 Females 2,831 209 104 150 176 180 379 480 477 338 246 92 Persons 5,019 421 182 249 265 287 707 897 884 599 394 134 The table shows, so far as the figures relating to notified cases of this disease can be trusted in this connection, that the number of females attacked exceeds the number of males attacked. The question whether the notification of cases of erysipelas should be discontinued was considered by the London sanitary authorities at the instance of the Stepney Borough Council, but by a considerable majority the suggestion was not approved. The metropolitan branch of the Society of Medical Officers of Health also considered the subject, and was of a like opinion that the requirement of notification should be continued. In his annual report Dr. Allan gives an interesting summary of the cases notified in the City of Westminster during the last five years, viz., 630 in all. Of twenty-nine houses in which cases had been notified thirty-one cases subsequently occurred; twelve were second attacks and two third attacks of the same person. In seventeen instances the attacks were in different persons. " Puerperal fever occurred in two houses in which there had been erysipelas. In one case the child had erysipelas on the 16th February, and the mother died of puerperal fever on the 19th February; in the second, a case of erysipelas occurred on the 27th January, and a woman died of puerperal fever on the 2nd March of the same year. The reverse occurred in one instance, puerperal fever in January, erysipelas in the following May." From classification of the cases in connection with occupation it did not appear that there was any particular incidence on any occupation except that of the group headed labourers, costermongers, etc. Puerperal Fever. The deaths in the Administrative County of London during the year 1906 (52 weeks) attributed to puerperal fever1 numbered 187, compared with 183 in 1905. The number of cases notified and the number of deaths registered from this cause since the year 1890 have been as follows— Puerperal Fever.—Cases notified and deaths. Year. Notified cases. Deaths. 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 1906 298 187 If these cases and deaths are considered in relation to the total population and total births the following rates are obtained— Puerperal fever.—Case-rates and death-rates. Year. Case-rate per 1,000 living. Case-rate per 1,000 births. Death-rate2 per 1,000 living. Death-rate2 per 1,000 births. 1891 0.05 1.64 0.05 1.65 1892 0.08 2.55 0.07 2.37 1893 0.09 2.98 0.08 2.65 1894 0.06 1.92 0.05 1.60 1895 0.05 1.76 0.05 1.56 1896 0.06 2.04 0.05 1.66 1897 0.06 1.98 0.05 1.01 1898 0.05 1.86 0.04 1.39 1899 0.07 2.45 0.05 1.57 1900 0.05 1.81 0.04 1.29 1901 0.06 1.93 0.04 1.40 1902 0.07 2.34 0.04 1.51 1903 0.05 1.78 0.04 1.30 1904 0.06 2.11 0.04 1.53 1905 0.06 2.31 0.04 1.45 1906 0.06 2.39 0.04 1.50 Including deaths from puerperal septicaemia and puerperal pyæmia. * See footnote (1) page 8. 48 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 on pp. 87 and 88. Influenza, Bronchitis and Pneumonia. The deaths attributed to influenza, which in 1905 numbered 689 rose to 895 in 1906. The deaths from bronchitis numbered 5,373 in 1906, compared with 6,019 in 1905. In 1906 there were 6,586 deaths attributed to pneumonia, a decrease of 379 over the number occurring from the same cause in 1905. The deaths from these diseases sincc 1889 have been as follows:— Influenza, Bronchitis and Pneumonia. Year. Deaths1 from Influenza. Deaths1 from Bronchitis. Deaths1 from Pneumonia. 1890 652 12,448 6,224 1891 2,336 13,136 6,915 1892 2,264 11,183 6,164 1893 1,526 10,413 7,198 1894 750 7,816 5,321 1895 2,156 10,633 5,989 1896 496 7,558 5,537 1897 671 7,408 5,053 1898 1,283 7,779 5,440 1899 1,817 9,195 6,666 1900 1,950 8,699 7,189 1901 664 7,317 6,121 1902 1,073 7,901 6,788 1903 644 5,240 5,826 1904 709 6,373 6,609 1905 689 6,049 6,965 1906 895 5,373 6,586 The distribution of deaths from influenza throughout the year for each of the years 1890 to 1906 is shown in the following table:— Influenza—Deaths registered in London in four-weekly periods—1890 -1906. Number of weeks. 1890. 1891. 1892. 1893. 1891. 1895. 1896. 1897. 1898. 1899. 1900. 1901. 1902. 1903. 1904. 1905. 1906. 1—4 303 9 1,308 52 272 59 37 40 244 66 1,016 57 77 141 67 94 56 5—8 167 7 637 96 96 164 58 55 368 259 298 75 224 103 62 119 44 9—12 75 8 119 162 69 1,343 61 94 193 430 130 134 298 89 74 119 98 13—16 39 29 42 180 56 257 50 121 140 302 172 102 89 54 62 75 129 17—20 13 770 33 125 32 106 50 96 61 121 105 81 58 46 40 56 105 21—24 5 1,044 22 72 27 35 33 54 51 82 57 30 35 37 21 38 40 25—28 6 242 15 49 19 28 17 26 25 42 16 21 20 25 17 16 21 29—32 6 51 7 23 17 14 15 18 27 27 12 18 7 18 5 4 20 33—36 3 32 9 23 20 17 10 13 10 11 11 11 16 6 9 11 15 37—40 6 13 6 18 14 15 12 19 17 19 15 12 13 17 24 22 18 41—44 5 15 20 28 29 22 27 29 46 55 17 23 35 13 92 39 35 45—48 13 35 18 152 41 47 56 35 49 61 55 44 65 44 98 44 86 49—52- 6 81 28 546 58 49 56 71 52 342 46 56 99 51 138 52 228 Phthisis. The deaths from phthisis in the administrative County of London during 1906 (52 weeks) numbered 6,775 as compared with 6,622 in the year 1905. The death-rates from this disease in successive periods have been as follows:— Phthisis. Period. Death rate per 1,000 persons living. Period. Death rate per 1,000 persons living. 1851-60 2.86 1902 1.603 1861-70 2.84 1903 1.553 1871-80 2.51 1904 1.623 1881-90 2.09 1905 1.423 1891-1900 1.84 1906 1.443 1901 1.663 The phthisis death-rate since 1850 (corrected for differences in the age constitution of the population) in relation to the mean death-rate of the period 1851-1906 (males and females) is shown in diagram XX. 1 See footnote (1), page 8. 2 The deaths occurring in the 53rd week of the years 1890, 1896 and 1902 are excluded from these figures. 3 See footnote (3), page 7. Diagram XX Phthisis (Mortality). (The death-rates upon which this diagram is based have been corrected for differences in the age and sex constitution of the population.) 49 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:— Phthisis—Crude and corrected death-rates1 per 1,000 persons living, in the County of London and the several sanitary districts. Sanitary area. Standard death rate.2 Factor for correction for age and sex distritribution. Crude death-rate. Corrected death-rate. Comparative mortality figure. (London 1,000.) 1901-5. 1906. 1901-5. 1906. 1901-5. 1906. London 1.74 1.00000 1.57 1.44 1.57 1.44 1,000 1,000 Paddington 1.80 0.96659 1.07 1.12 1.03 1.08 656 750 Kensington 1.78 0.97419 1.30 1.27 1.27 1.24 809 861 Hammersmith 1.74 0.99600 1.37 1.25 1.36 1.24 866 861 Fulham 1.69 1.02786 1.36 1.13 1.40 1.16 892 806 Chelsea 1.83 0.95018 1.61 1.57 1.53 1.49 975 1,035 Westminster, City of 1.95 0.89205 1.68 1.39 1.50 1.24 955 861 St. Marylebone 1.85 0.93836 1.76 1.56 1.65 1.46 1,051 1,014 Hampstead 1.75 0.98862 0.83 0.67 0.82 0.66 522 458 St. Pancras 1.80 0.96551 1.79 1.81 1.73 1.75 1,102 1,215 Islington 1.75 0.99145 1.44 1.23 1.43 1.22 911 847 Stoke Newington 1.77 0.97914 1.38 1.04 1.35 1.02 860 708 Hackney 1.68 1.02969 1.35 1.30 1.39 1.34 885 931 Holborn 1.97 0.87894 2.93 2.37 2.58 2.08 1,643 1,444 Finsbury 1.72 1.01050 2.23 2.18 2.25 2.20 1,433 1,528 City of London 1.89 0.91946 1.70 1.74 1.56 1.60 994 1,111 Shoreditch 1.66 1.04206 2.10 2.01 2.19 2.09 1,395 1,451 Bethnal Green 1.59 1.08984 2.09 2.25 2.28 2.45 1,452 1,701 Stepney 1.65 1.05281 1.99 1.72 2.10 1.81 1,338 1,257 Poplar 1.66 1.04772 1.70 1.55 1.78 1.62 1,134 1,125 Southwark 1.74 0.99829 2.40 2.06 2.40 2.06 1,529 1,431 Bermondsey 1.65 1.05026 1.86 2.01 1.95 2.11 1,242 1,465 Lambeth 1.75 0.99258 1.52 1.37 1.51 1.36 962 944 Battersea 1.69 1.02483 1.36 1.28 1.39 1.31 885 910 Wandsworth 1.72 1.01050 1.03 1.01 1.04 1.02 662 708 Camberwell 1.68 1.03522 1.36 1.26 1.41 1.30 898 903 Deptford 1.69 1.02969 1.26 1.28 1.30 1.32 828 917 Greenwich 1.67 1.04143 1.21 1.19 1.26 1.24 803 861 Lewisham 1.69 1.02543 0.91 0.82 0.93 0.84 592 583 Woolwich 1.70 1.01881 1.58 1.33 1.61 1.36 1,025 944 It will be seen from the foregoing table (comparing the corrected death.rates) that among the several sanitary areas in the period 1901-5, Holborn (2.58) had the highest phthisis death-rate, and Hampstead (0.82) the lowest. In the year 1906 Bethual Green (2.45) had the highest death-rate and Hampstead (0.66) the lowest. The death-rates from phthisis in each of the four quarters of the year 1906 were as follows:—first quarter, 1.51; second quarter, 1.42; third quarter, 1.23, and fourth quarter, 1-59 per 1,000 persons living. The following table shows the number of deaths1 from phthisis at several age-periods in each of the sanitary areas. Phthisis—Deaths at the several age-periods in sanitary areas.—1906 (365 days). Age-period. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 anc! upwards All Ages Paddington 4 2 – 7 14 31 39 36 27 8 2 – 170 Kensington 9 2 – 4 15 51 69 50 20 14 – – 234 Hammersmith 7 1 5 7 10 26 46 23 15 9 1 – 150 Fulham 5 – 2 9 29 37 47 35 12 7 – – 183 Chelsea 3 – – 4 6 28 33 24 14 4 1 – 117 Westminster, City of 4 – 2 6 8 48 63 51 34 21 4 – 241 St. Marylebone 4 4 1 10 10 41 60 41 18 12 1 – 202 Hampstead 2 – – 3 6 10 15 13 7 2 1 – 59 St. Pancras 26 9 4 21 29 75 105 99 44 15 2 1 430 Islington 26 2 2 19 46 100 92 82 36 12 3 – 420 Stoke Newington – 1 – 4 3 13 13 11 7 – – – 52 Hackney 7 3 5 25 35 63 68 59 22 13 2 – 302 Holborn 2 1 – 4 8 14 50 29 19 6 – 1 134 (Continued on next page.) 1 See footnote (2), page 7. 2 The standard death rate used in the calculation of the "factors for correction" has been calculated to moro than the two places of decimals shown in the table. 14911 G 50 Age-period. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 and upwards. All ages. Finsbury 6 1 2 17 9 41 44 43 35 8 3 – 209 London, City of – – 1 1 1 8 9 9 7 3 – – 39 Shoreditch 13 3 3 9 18 41 73 56 17 4 1 – 238 Bethnal Green 19 4 3 11 14 72 59 61 32 15 2 – 292 Stepney 18 11 6 26 38 126 133 101 50 14 5 – 528 Poplar 7 2 9 19 25 47 76 57 15 8 – – 265 Southwark 14 4 4 26 28 84 131 91 34 14 3 – 433 Bermondsey 13 5 5 18 21 54 75 36 19 8 2 – 256 Lambeth 13 4 7 13 25 95 103 81 58 20 10 – 429 Battersea 8 2 1 14 29 54 48 37 28 6 2 – 229 Wandsworth 7 2 6 15 27 70 53 52 28 12 2 – 274 Camberwell 8 8 2 27 36 76 74 73 30 6 2 – 342 Deptford 9 1 2 8 16 30 40 24 14 3 – – 147 Greenwich 3 1 5 7 20 19 31 27 8 5 – 1 127 Lewisham 3 – 1 9 17 34 26 15 16 3 – – 124 Woolwich 2 1 4 8 19 42 26 46 9 14 – – 171 London 242 74 82 351 562 1430 1701 1362 675 266 49 3 6797 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 of less than five rooms. London, 1901-6. Phthisis death-rates in relation to overcrowding.1 Percentage of overcrowding in each group of sanitary areas. Crude phthisis death-rate per 1,000 persons living. Standard deathrate.2 Factor for correction for age and sex distribution. Corrected deathrate per 1,001) persons living. Corrected death-rate (London, 1,000). Under 7.5 per cent. 1.086 1.718 1.00991 1.097 711 7.5 to 12.5 per cent. 1.359 1.705 1.01761 1.383 897 12.5 to 20 per cent. 1.478 1.771 0.97969 1.448 939 20.0 to 27.5 per cent. 2.046 1.805 0.96124 1.967 1,276 Over 27.5 per cent. 2.047 1.651 1.05090 2.151 1,395 London 1.542 1.735 1.00000 1.542 1,000 The annual reports show increase of effort to limit the prevalence of tuberculous phthisis by applying to cases of this disease the methods usually adopted for the limitation of acute infectious diseases. A system of voluntary notification of cases of phthisis has been adopted in a number of London sanitary districts, and the number of cases notified in the several areas in 1906 was as follows:— Kensington 252 Hammersmith 105 Fulham 148 Chelsea 22 Westminster 78 St. Marylebone 248 Hampstead 35 St. Pancras 207 Islington 64 Stoke Newington 25 Hackney (6 months) 44 Holborn 191 Finsbury 217 Southwark 399 Bermondsey 170 Lambeth 322 Wandsworth 74 Greenwich 112 Lewisham (5 months) 76 Woolwich 176 Notification is followed in the large majority of cases by visits to the home and advice as to the precautions which should be taken by the sufferer. Disinfection is usually carried out after removal or death. The demand for larger measures for dealing with the disease is undoubtedly growing, and the compulsory notification of cases of the disease is more widely advocated. The desire for such notification, which is based on the fact that but a small proportion of the cases occurring are brought to the knowledge of the sanitary authorities, is manifested in a number of the annual reports, and was the subject of a resolution passed in favour of this requirement by the Metropolitan Branch of the Society of Medical Officers of Health. With the desire for compulsory notification of phthisis is the further desire for opportunity for the treatment of phthisical patients in sanatoria, and for the removal from their homes of persons who are in an advanced stage of the disease. In one instance the Medical Officer of Health writes : " Arrangements should also be made for the isolation or segregation in sanatoria of all advanced cases, which are a source of such danger to others living in the same rooms. This isolation might, with advantage, be made compulsory by new legislation." The view here expressed is no doubt more advanced than that which is usually held, but it is the view of a responsible 1 See footnote (1), page 17. 2 See footnote (2), page 49. 51 officer, and it is impossible not to recognise a trend of opinion in the direction of regarding the phthisical person as a public danger. It becomes, therefore, very necessary to examine the grounds upon which a demand is made which, if fully acted upon, would have the effect of depriving many thousands of persons in London of their liberty. These grounds consist in the main of observed instances of association of the sufferer with houses previously invaded or with other persons known to be suffering from the malady. The number of such instances is sufficiently large to create the impression that the association of the sufferer with such houses or persons has been the cause of his illness. It should, however, be borne in mind that this number would necessarily be large, even if infection played no part in the matter, and the question needs to be considered whether the number greatly differs from the number which would obtain if chance alone determined the observed association. A table contained in one of the annual reports shows that of 232 deaths from phthisis occurring in 190(5 in the district, 70, or 30.1 per cent., occurred in houses in which one or more deaths from the same disease had occurred in the preceding ten years. There is no information as to the length of time during which the persons dying in 1906 had resided in the houses in question, or whether, in fact, they had taken up their residence before or after their fatal illness first manifested itself, and the assumption must be that this point was not unconsidered, and that the 70 persons had resided in these houses sufficiently long to warrant the opinion that the disease had its origin in the houses in which they subsequently died or from which they were removed to institutions where they died. The question, therefore, which needs consideration is, in what proportion, as a matter of arithmetical probability, would the deaths of 1906 occur in houses in which previous deaths from this disease had occurred in the preceding ten years. The annual average number of deaths in those years may be taken as 224 and the number of houses in the district may be taken as 8,500. The result arrived at on purely arithmetical grounds is that 54 deaths out of the 232 recorded in 1906, or 23.3 per cent., is the most probable number which would have occurred in houses in which one or more deaths took place in the ten years 1896-1905. This is a near approach to the 30 per cent. actually recorded, and, indeed, the difference between the two percentages is within the range of "probable erro" owing to the smallness of the figures on which the calculation is based. Further, it must be recollected that if malnutrition, overcrowding, ill-ventilation and similar concomitants of poverty play an important part in the causation of phthisis it might be expected that quite apart from the question of the infectivity of the disease more deaths would occur in houses occupied by poor persons than in houses occupied by persons who are well to do, and that if it had been possible to make allowance for this the proportion of deaths occurring in houses previously invaded would have been still less conspicuous. Examination of the figures certainly suffices to negative the view that in themselves they afford any reliable evidence of the infectivity of the disease. Another method of investigation which is frequently adopted in connection with endeavours to throw light on the question of infectivity of phthisis is to inquire of a phthisical person in what way he has been associated with other cases of phthisis, and having found such association, before his illness was conspicuous, to assume that the disease was thus contracted. The inference is that but for this association the phthisical person in question would have remained free from his disease, and in this way a foundation is being laid for the claim to isolate persons suffering from this malady. For precise inferences a comparison of the relative incidence of disease upon persons thus exposed and others not so exposed is necessary. In this connection Dr. G. B. Longstaff's paper published in the Collective Investigation Record of 1883 is of especial value. Dr. Longstaff calculated the probability of the accidental and fatal incidence of phthisis upon both husband and wife, and he found that during ten years 1871 -80, in England and Wales, assuming marriage to have no influence upon phthisis, by selection, infection, or otherwise, it would happen 4,363 times that both husband and wife would die of that disease, and that of 4,363 husbands dying in the ten years 829 wives would die within one year of the husband's death, 742 within one year and under two years, 654 within two years and under three years, and so on in diminishing proportions. There was no evidence that this number is actually exceeded. Again, Professor Karl Pearson has studied the subject. He had for his use the facts relating to 384 families in which cases of pulmonary tuberculosis had occurred. The records were supplied by Dr. W. C. Rivers from the Crossley Sanatorium, Frodsham, and the patients were almost wholly of the lower middle and working classes from Manchester and Liverpool. Professor Pearson found that the number of tuberculous married persons who had a tuberculous mate was not sufficiently great to require an appeal to infection to account for this number, but what he did find was that the condition which governed the liability to attack was heredity of the diathesis of pulmonary tuberculosis. "A theory of infection does not," he writes, "account for the facts. I am inclined to think that the risks run, especially under urban conditions, are for tuberculosis, as for a number of other infectious diseases, so great that the constitution or diathesis means almost everything for the individual whose life cannot be spent in self-protection;" and again, " I feel fairly certain that for the artisan class the inheritance factor is far more important than the infection factor, because in a very large proportion of cases it does not lie in the power of the individual to maintain in the stress of urban life a wholly safe environment." The acceptance of the view that under the conditions which exist in urban populations the susceptibility of the individual and not the exposure to known cases of phthisis governs the probability of attack does not itself negative the theory of the infectivity of tubercular phthisis. It does, however, raise serious question as to the practicability of reducing the death-rate of phthisis mortality by efforts to segregate persons suffering from this disease, even if the theory of infection from person to person is accepted as the common way in which susceptible persons are infected. However this may be, it may 14911 g 2 52 undoubtedly be stated that our knowledge of the subject at the present time is insufficient to justify the introduction into London of a system of compulsory segregation. The view that pulmonary phthisis is necessarily the result of inhalation of tubercle bacilli derived from the sputum of persons suffering from this disease was a natural inference from the frequency with which the lungs appeared to be primarily infected and from the finding of the bacillus in the sputum. In children, where the abdomen was the frequent site of the disease, it was recognised that the method of infection was in all probability by ingestion, but the relative infrequency of local lesions of the intestine led to the opinion that this method was comparatively rare. There is now much reason for re-casting the views which previously prevailed on these questions, and for recognising that the lungs may be infected by ingested bacilli without the occurrence of local lesions of the intestine. There is no doubt that the relative frequency with which the disease invades the lungs of adults has also had its influence in determining the view that pulmonary phthisis is necessarily of human origin. Indeed, in his address in London in 1901, Professor Koch said: "In far the majority of cases of tuberculosis the disease has its seat in the lungs and has also begun there. From this fact it is justly concluded that the germs must have got into the lungs by inhalation." A further reason which had led to the conclusion that tuberculosis in man was almost entirely derived from human sources has been the difference observed between the tubercle bacilli of man and of the lower animals, diSerences which are morphological and cultural, and differences in the ability with which they can be inoculated into other animals. It is upon this question, the amount of risk to man from bovine tuberculosis, upon which the Royal Commission on Tuberculosis throw light in their second interim report of January, 1907. The Royal Commission studied the nature of the tuberculous material obtained from 60 cases of the disease in man. They state that their results led them to divide these cases into two groups, very clearly distinguished from each other by the properties and characters of the bacillus found in each. Nearly all the cases fall readily into one or the other group, but a few presented exceptional features. Group 1 contained 14 cases, and the viruses were obtained from sputum, from tuberculous cervical glands, and from the lesions of cases of primary abdominal tuberculosis. These were found to produce in bovine animals, rabbits, and other animals, effects which appeared to be absolutely identical with the effects of the bacillus of bovine tuberculosis, and the Commission state that they have wholly failed to discover any essential differences between the one and the other; both are equally virulent, i.e., equally able to set up tuberculosis in bovine and other animals. Group II was made up of 40 cases and the material was derived from cervical, and mesenteric glands, from lungs, bronchial glands, tuberculous kidney, testis, joints and bones. The bacillus of this group produced eSects which presented a marked contrast to those produced by group I. It was much less virulent, and this lesser virulence manifested itself in a number of ways-, but, "in all its essential features the disease set up by the bacillus of bovine tuberculosis is identical with that set up by the bacillus of group II; such diSerences as are met with are differences of amount and phase only." The essential diSerences between Group I and Group II were that the former manifested more virulence and grew with greater difficulty in artificial media, and in this way resembled bacilli of bovine origin; the latter manifested less virulence and less difficulty in growing in artificial media, and in this way resembled bacilli of human origin. A third group, however, Group III, diSered from those in the other groups, and interest in the future will chiefly centre in the bacilli of this group, for they behaved diSerently from those in the other groups in certain important particulars. In the cases included in this Group, and in cases of feeding with human sputum, the Commission say they met with— (a) Bacilli of a character intermediate between Group I and Group II. (b) Replacement of a eugonic* bacillus of low virulence by a dysgonic* bacillus of high virulence. (c) Indications of instability in virulence and cultural characters and want of accordance between virulence and cultural characters. The Commission say that the results may be explained on the supposition that there was a mixture of viruses, of a virus from a human source and a virus from a bovine source, each possessing stable characters, but they say they have met with no direct evidence of the simultaneous presence of bacilli of Groups I and II; on the other hand if it be assumed that the characters of the bacillus of tuberculosis (whether human or bovine) are not always absolutely stable the following alternative view may be adopted : "We may suppose that in the case of each of the passage experiments, the original "material contained only slightly virulent human bacilli, but that these were in a special condition "of instability; so that when subjected to certain influences they become modified in character, "and transformed into highly virulent dysgonic bovine bacilli, these influences being supplied by the "tissues of the bovine animals, through the bodies of which the bacilli were passed. Similarly, "we may suppose that highly virulent bacilli from a bovine source, lodged in the human body, "may, under certain conditions, manifest instability; may, under the influence of human tissues, "become modified in character, and so may be transformed into bacilli possessing all the features of "the bacilli of Group II." They point out that, "should it be proved that the cases in question were due to an admixture with the bacilli of human source of a few bacilli of bovine source, the two kinds always remaining * The Commission found it desirable to adopt the words dysgonic and eugonic to denote respectively that the bacillus grows with difficulty or with readiness on a medium or on several media. 53 tinct the one from the other and never becoming changed the one into the other, we should have no need to enlarge appreciably our conception of the extent to which the human body is subject to bovine tuberculosis. Such cases of admixture must be few and their effect slight; bovine tuberculosis in the human body would practically be limited to cases such as those which furnish Group I. Should, however, it be conclusively proved that a eugonic bacillus of low virulence may be modified under certain conditions into a dysgonic bacillus of high virulence and vice versa, our views as to the relation of human to bovine tuberculosis must be very different. Such a conclusion would lead to the following view. Bacilli from a bovine source entering a human body in scanty numbers may become lodged there without immediately provoking a generalised progressive tuberculosis. During their sojourn there they may become modified into eugonic bacilli of low virulence; and they may then give rise either to a limited tuberculosis only, or, under the influence of certain conditions, to a generalised progressive tuberculosis. For some time after the change they may remain unstable and capable of reverting to their bovine character under changed conditions, when subjected, for instance, to the influence of bovine tissues, as in the passage experiments. Or after a long stay in the human body their character may become so fixed that they cannot be distinguished from bacilli conveyed directly from man to man." The conclusions of the Commission are as follows:— There can be no doubt but that, in a certain number of cases, the tuberculosis occurring in the human subject, especially in children, is the direct result of the introduction into the human body of the bacillus of bovine tuberculosis, and there also can be no doubt that in the majority at least of these cases the bacillus is introduced through cows' milk. Cows' milk containing bovine tubercle bacilli is clearly a cause of tuberculosis and of fatal tuberculosis in man. Of the sixty cases of human tuberculosis investigated by us, fourteen of the viruses belonged to Group I., that is to say, contained the bovine bacillus. If, instead of taking all these sixty cases, we confine ourselves to cases of tuberculosis in which tho bacilli were apparently introduced into the body by way of the alimentary canal, the proportion of Group I. becomes very much larger. Of the total sixty cases investigated by us, twentyeight possessed clinical histories indicating that in them the bacillus was introduced through the alimentary canal. Of these, thirteen belong to Group I. Of the nine cases in which cervical glands were studied by us, three, and of the nineteen cases in which the lesions of abdominal tuberculosis were studied by us, ten belong to Group I. These facts indicate that a very large proportion of tuberculosis contracted by ingestion is due to tubercle bacilli of bovine source. A very considerable amount of disease and loss of life, especially among the young, must be attributed to the consumption of cows' milk containing tubercle bacilli. The presence of tubercle bacilli in cows' milk can be detected, though with some difficulty, if the proper means be adopted, and such milk ought never to be used as food. There is far less difficulty in recognising clinically that a cow is distinctly suffering from tuberculosis, in which case sho may be yielding tuberculous milk. The milk coming from such a cow ought not to form part of human food, and indeed ought not to be used as food at all. Our results clearly point to the necessity of measures, more stringent than those at present enforced, being taken to prevent tho sale or tho consumption of such milk, Cancer. The deaths from cancer in the Administrative County of London during 1906 (365 days) numbered 4,589. The death-rates from this disease in successive periods have been as follows Cancer. Period. Death-rate per 1,000 persons living. Period. Death-rate per 1,000 persons living. 1851-60 0.42 1902 0.931 1861-70 0.48 1903 0.961 1871-80 0.55 1904 0.921 1881-90 0.68 1905 0.931 1891-1900 0.851 1906 0.981 1901 0-881 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. 1 See footnote (2), page 7. 54 Cancer. Crude and corrected death-rates1 per 1,000 persons living in the County of London and the several sanitary districts. Sanitary area. Standard deathrate.2 Factor for correction for ago and sex distribution. Crude death-rate per 1,000 persons living. Corrected death-rate per 1,000 persons living. Comparative mortality figure (London 1,000). 1901-5 1906. 1901-5. 1906. 1901-5. 1906. London 0.87 1.00000 0.92 0.98 0.92 0.98 1,000 1,000 Paddington 0.98 0.89478 1.04 1.13 0.93 1.01 1,011 1,031 Kensington 1.02 0.85622 1.01 0.98 0.86 0.84 935 857 Hammersmith 0.90 0.96811 0.92 1.19 0.89 1.15 967 1,173 Fulham 0.77 1.13828 0.83 0.86 0.94 0.98 1,022 1,000 Chelsea 1.03 0.84874 1.09 1.16 0.93 0.98 1,011 1,000 Westminster, City of 0.96 0.91348 1.00 1.00 0.91 0.91 989 929 Marylebone 0.99 0.88571 1.18 1.06 1.05 0.94 1,141 959 Hampstead 0.92 0.94816 1.00 1.09 0.95 1.03 1,033 1,051 St. Pancras 0.92 0.95229 0.99 1.06 0.94 1.01 1,022 1,031 Islington 0.90 0.96704 0.99 1.09 0.96 1.05 1,043 1,071 Stoke Newington 0.98 0.89387 0.99 1.03 0.88 0.92 957 939 Hackney 0.88 0.99341 0.86 0.81 0.85 0.80 924 816 Holborn 0.95 0.91924 0.99 1.16 0.91 1.07 989 1,092 Finsbury 0.84 1.04071 0.81 0.86 0.84 0.90 913 918 London, City of 1.06 0.82316 1.34 1.36 1.10 1.12 1,196 1,143 Shoreditch 0.79 1.10518 0.87 0.72 0.96 0.80 1,043 816 Bethnal Green 0.78 1.12077 0.84 0.97 0.94 1.09 1,022 1,112 Stepney 0.74 1.17976 0.73 0.93 0.86 1.10 935 1,122 Poplar 0.81 1.08327 0.79 0.76 0.86 0.82 935 837 Southwark 0.82 1.06350 0.92 0.88 0.98 0.94 1,065 959 Bermondsey 0.81 1.08462 0.81 0.97 0.88 1.05 957 1,071 Lambeth 0.92 0.95333 1.02 1.00 0.97 0.95 1,054 969 Battersea 0.79 1.10798 0.89 0.96 0.99 1.06 1,076 1,082 Wandsworth 0.88 0.99116 0.94 0.98 0.93 0.97 1,011 990 Camberwell 0.87 1.00483 0.90 0.98 0.90 0.98 978 1,000 Deptford 0.81 1.07396 0.91 0.96 0.98 1.03 1,065 1,051 Greenwich 0.87 1.01064 0.83 0.76 0.84 0.77 913 786 Lewisham 0.92 0.95333 0.91 0.95 0.87 0.91 946 929 Woolwich 0.78 1.11933 0.77 0.93 0.86 1.04 935 1,061 It will be seen from the foregoing table (comparing the corrected death-rates) that in the period 1901-5, the City of London (1.10) had the highest cancer death-rate, the lowest death-rates obtaining in Finsbury and Greenwich (0.84). In the year 1906 Hammersmith (1.15) had the highest death-rate and Greenwich (0.77) the lowest. The following tables (a), (b), and (c) show the deaths during 1906 (365 days) 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) Sarcoma.—Deaths at the several age-periods in sanitary areas.—1906 (365 days). Age-period. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 60 4111(1 upwards All Ages. Paddington 1 1 2 – – – 3 – – 3 – – 10 Kensington 1 1 – – 1 – 2 3 – 1 2 – 11 Hammersmith – – – – – 3 3 2 1 1 – – 10 Fulham – – 1 – 1 – 2 – 2 1 – – 7 Chelsea 1 – – – – 1 – 1 3 – – 1 7 Westminster, City of – – – – 1 1 2 3 3 – – – 10 St. Marylebone – – – – 2 1 – 3 – – – – 6 Hampstead – – – 1 – – 4 4 1 – 1 – 11 St. Pancras 1 – – – 3 1 1 5 2 2 – – 15 Islington 1 – 2 1 1 2 2 4 6 3 1 – 23 Stoke Newington 1 – – – – – – – 1 1 2 – 5 Hackney 1 1 1 1 – 3 3 1 – 1 – – 12 Holborn – – – – – – 2 2 Finsbury – – – – – 1 – 1 – 2 – – 4 London, City of – – – – – – – – – – – – – Shoreditch – 1 – 1 – 1 1 – – – – – 4 Bethnal Green 1 – – 1 2 – 2 3 2 1 1 – 13 Stepney 3 1 1 2 – 7 3 3 4 4 – – 28 Poplar – – 1 – 1 – 1 1 2 – 1 – 7 Southwark 1 – – – – 1 2 1 – 1 1 – 7 Bermondsey 2 1 – – 1 3 1 1 4 2 – – 15 Lambeth – 2 1 – 3 3 2 4 4 5 2 – 26 Battersea 2 – – 2 – – 1 2 3 – – – 10 Wandsworth 1 – – – – – 2 3 3 1 1 – 11 Camberwell 1 – – 1 3 1 – 5 6 2 1 – 20 Deptford 1 1 – 1 – 1 3 1 1 2 – – 11 Greenwich 1 – – – – – 1 1 2 1 – 1 7 Lewisham 2 1 – 1 – – 1 1 2 3 – 1 12 Woolwich – 1 1 – – 1 – 1 1 – – – 5 London 22 11 10 12 19 31 44 54 53 37 13 3 309 1 See footnote (2), page 7. 2 See footnote (2), page 49. 55 (b) Carcinoma.–Deaths1 at the several age-periods in sanitary areas.—1906 (365 days). Age-period. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 and upwards All Ages. Paddington – – – – – 4 11 33 21 19 14 2 104 Kensington – – – – – – 16 19 31 24 12 – 102 Hammersmith – – – – – 3 11 19 31 13 5 2 84 Fulham – – – – 1 3 10 22 27 15 10 1 89 Chelsea – – – – – – 8 15 14 11 6 – 54 Westminster, City of – – – – – 3 10 27 30 23 15 – 108 St. Marylebone – – – – – 1 12 S 25 10 5 2 63 Hampstead – – – – – 1 4 6 15 25 8 1 60 St. Pancras – – – 1 1 5 17 29 43 35 15 5 151 Islington – – – – – 3 16 50 52 36 22 1 180 Stoke Newington – – – 1 – 1 – 7 8 9 3 2 31 Hackney – – – – – 2 7 17 30 25 9 2 92 Holborn – – – – – 2 1 12 7 10 3 1 36 Finsbury – – – – 1 1 6 9 17 13 7 – 54 London, City of – – – – – – 6 3 3 5 2 1 20 Shoreditch – – – – 1 2 5 20 13 12 2 – 55 Bethnal Green – – – – – 2 6 12 22 21 6 – 69 Stepney – – – – – 2 15 47 52 41 17 3 177 Poplar – – – – – – 11 22 25 18 7 – 83 Southwark – – – – – 1 15 38 30 29 11 – 124 Bermondsey – – – 1 – 4 5 21 19 24 5 1 80 Lambeth – – – – – 5 13 41 63 60 27 4 213 Battersea – – – – – 1 8 21 31 21 6 – 88 Wandsworth – – – – – 1 19 25 45 29 13 6 138 Camberwell – – – – 1 8 12 25 53 33 10 2 144 Deptford – – – – – 2 2 13 23 21 9 1 71 Greenwich – – – – – 5 4 12 14 9 3 – 47 Lewisham – – – – – 2 9 17 32 21 6 2 89 Woolwich – – – – 1 4 9 11 16 23 4 1 69 London – – – 3 6 68 268 601 792 635 262 40 2675 (c) Cancer (otherwise undistinguished).— Deaths1 at the several age-periods in sanitary areas. 1906 (365 days). Age-period. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 and upwards All Ages. Paddington – – – – – 1 6 10 17 12 6 2 54 Kensington – – – – – 2 7 9 18 16 13 – 65 Hammersmith – – – – – – 3 14 11 20 – 1 49 Fulham – – – – – – 2 14 8 13 5 2 44 Chelsea – – – – – – 2 8 7 5 4 – 26 Westminster, City of – – – – – 4 5 11 18 13 4 1 56 St. Marylebone – – 1 1 – 2 4 13 23 15 8 – 67 Hampstead – – – – – – – 4 13 5 5 – 27 St. Pancras – 1 – 1 – 3 9 19 24 17 10 2 86 Islington – – – – 1 2 21 37 57 38 17 1 174 Stoke Newington – – – – – – – 4 5 6 4 – 19 Hackney – – – 2 – 2 6 17 26 21 9 – 83 Holborn – – – – – – 2 6 10 6 2 – 26 Finsbury – – – – – 1 2 3 12 7 1 – 26 London, City of – – – – – – – 3 2 1 1 2 9 Shoreditch – – – – – 1 1 8 8 6 2 – 26 Bethnal Green – – – – – – 5 7 10 13 9 – 44 Stepney – 1 – – – 2 12 15 27 17 7 – 81 Poplar – – – – – – 8 9 13 10 – – 40 Southwark – – 1 – – 4 4 9 17 16 3 – 54 Bermondsey – – – – – – 2 5 10 9 3 1 30 Lambeth – – – – – 3 6 16 27 19 8 1 80 Battersea – – – – 1 1 6 12 34 11 7 2 74 Wandsworth – – – – 2 5 8 21 40 25 17 3 121 Camberwell – – – – – 2 10 25 27 28 12 1 105 Deptford – – – – – – 2 7 9 8 3 – 29 Greenwich – – – – – 1 2 3 11 5 2 1 25 Lewisham – 1 – – – 1 1 5 14 12 6 – 40 Woolwich – – – – – 1 4 8 14 14 3 1 45 London – 3 2 4 4 38 140 322 512 388 171 21 1605 1 See footnote (2), page 7. 56 The following table shows the proportional age-distribution of the deaths in London classified under the three headings— Deaths at each age-period per 1,000 deaths at All Ages. Age-period. All ages. Under 35. 35- 45- 55- 65- 75- 85 and upwards. Sarcoma 1,000 340 142 175 171 120 42 10 Carcinoma 1,000 29 100 225 296 237 98 15 Cancer 1,000 32 87 201 319 242 106 13 Total 1,000 51 98 213 296 231 97 14 In the report for the year 1905, a table was included showing the cancer death-rates in the period 1901-5 in areas presenting different degrees of overcrowding,1 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 1901-6:— London, 1901-6. Cancer death-rates in relation to overcrowding} Percentage of overcrowding in each group of sanitary areas. Crude cancer death-rate per 1,000 persons living. Standard deathrate.2 Factor for correction for age and sex distribution. Corrected death-rate per 1,000 persons living. Corrected death rate (London, 1,000). Under 7.5 per cent. 0.926 0.883 0.99003 0.917 986 7.5 to 12.5 per cent. 0.922 0.864 1.01180 0.933 1,003 12.5 to 20 per cent. 0.968 0.921 0.94919 0.919 988 20.0 to 27.5 per cent. 1.006 0.904 0.96704 0.973 1,046 Over 27.5 per cent. 0.809 0.774 1.12946 0.914 983 London 0.930 0.874 1.00000 0.930 1,000 Cerebro-spinal Fever. Only four deaths attributed to cerebro-spinal fever were registered during the year. Of these one was the death of a n adult aged twenty-four, occurring in March. There was, in addition, the death of a medical man whose illness was characterised by the appearance of a hæmorrhagic eruption and whose spinal fluid contained abundance of the meningococci of Weichselbaum. Anthrax. There were four deaths due to anthrax registered during the year. One was that of the wife of a carman, the others were those of three men employed respectively as a horsehair dresser, a skin importer's warehouseman, and a stevedore who had been engaged in unloading foreign hides. Four other cases attended by recovery occurred in persons employed in Bermondsey. The first was a man who had been handling foreign hides; the second a woman the source of whose infection was unknown; the third a man who had been handling hides, but the hides were tanned; the fourth a man who had been carting bristles. A further case occurred in Poplar, that of a man who had been employed in carrying hides in the St. Katharine Docks. 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 1906 was 50.7 deg. Fahrenheit, or 1.2 deg. Fahrenheit above the average of the preceding 50 years. The rainfall during the year amounted to 24.72 inches, an increase of 0.18 inch on the average of the preceding 50 years. The temperature and rainfall in each month of the year 1906 are shown in the following table:— Temperature and Rainfall—1906. Month. Temperature of the air. Departure of mean monthly temperature from average of 50 years, 1856-1905. Sain. Absolute maximum. Absolute minimum. Mean for month. Number of days it fell. Amount collected. deg. F. deg. F. deg. F. deg. F. Inches. January 53.2 25.8 42.2 +3.7 18 3.71 February 50.7 26.1 38.9 —0.6 18 1.80 March 65.0 27.4 42.2 +0.5 18 1.09 April 73.2 28.1 46.2 —1.0 9 0.67 May 76.2 31.6 53.4 +0.3 12 1.57 June 82.0 37.6 58.8 —0.6 7 2.80 July 86.2 45.1 64.4 +2.0 7 0.41 August 94.3 44.1 65.7 +4.1 8 1.39 September 93.5 37.1 59.5 +2.3 11 1.97 October 71.8 32.1 54.4 + 4.4 17 3.04 November 60.3 28.5 45.9 +2.7 17 4.11 December 54.3 19.8 37.2 —2.5 19 2.16 1 See footnote (1), page 17. 2 See footnote (2), page 49. 57 PART II. Dairies, Cowsheds and Milkshops. The County Council received during the year 244 applications for cowhouse licences, of which 240 were granted. The number of applications for licences received during the last thirteen 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 qranted. 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 55* 1906 244 240 In 1903 effort was made, in conjunction with the medical officers of health of London istricts. 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 1906. Number of notices 1906. Number of prosecutions 1906. On register at end of 1905. Added in 1900. Removed in 1906. On register at end of 1906. Paddington 1 – – 1 3 – Kensington 1 – – 1 37 – Fulham 3 – 1 2 20 1 Chelsea 4 – 1 3 61 – Westminster, City of 2 – – 2 68 – – St. Marylebone 6 – – 6 12 – – St. Pancras 10 – 1 9 – – Islington 9 – – 9 114 – – Stoke Newington 2 – – 2 2 – – Hackney 23 – 1 22 250 4 – Holborn 1 – – 1 50 1 – Finsbury 6 – 1 5 24 1 – Shoreditch 7 – – 7 20 – – Bethnal Green 15 – – 15 109 3 – Stepney 40 – 2 38 60 1 Poplar 16 – 1 15 89 – – Southwark 5 – – 5 66 2 – Bermondsey 7 – – 7 127 1 – Lambeth 15 – 1 14 30 4 – Battersea 3 – – 3 11 3 – Wandsworth 14 1 – 15 62 – – Camberwell 20 – 3 17 292 – – Deptford 6 – 1 5 41 4 – Greenwich 4 – – 4 14 12 – Lewisham 15 – – 15 133 7 – Woolwich 18 – 1 17 95 8 – Tuberculosis of the udder in cows. London County Council (General Powers) Act, 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 (a) mixed with other milk, or (b) sold or used for human food, or (c) sold or used for the food of swine without having first been boiled. * In two instances two licences were issued in respect of separate sheds on the same premises. 14911 g 58 It had been found in several instances 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 1906, 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 1906. Details of Examination. 1st period, loth Dec. (1905)—17th March (1906). 2nd period, 18th March— 12 th June (1906). 3rd period, 13th June— 12th Sept. (1906). 4th period, 13 th Sept.— 12th Dec. (1906). Total number of cows examined 4,026 4,333 3,773 3,908 Affected with disease or defects of the udder 239 265 253 238 Clinically affected with tubercular disease of the udder 1 1 – – Suspected cases of tubercular disease of the udder 2 1 2 2 Subjects of acute mastitis 21 31 20 19 Affected with chronic induration of the udder 6 3 9 4 Atrophy of one or more quarters 155 156 160 163 Injuries, abscesses, simple eruptions, strictures and obliterations of milk ducts 25 19 23 13 Hypertrophied udders without induration 2 7 3 – Giving milk of poor quality, dried-off cows 25 48 27 30 Presenting symptoms of tuberculosis – – – 1 Suffering from chronic diarrhœa – – – – Mr. Shaw's reports also show the action taken for the elimination of tuberculous cows from the London cowsheds, thus :— First 'period.—One cow, affected with tubercular disease of the udder, was seized under the London County Council (General Powers) Act, 1904, and slaughtered, the carcase being destroyed. A bacteriological examination of the milk from two cows suspected of having tubercular disease of the udder was made by Sir J. McFadyean, who, in each case, reported the milk to be free from tubercle bacilli. The number of cases of mastitis and atrophy of one or more quarters of the udder was slightly less than on the occasion of the previous inspection. Two cows affected with general tuberculosis were ordered by the owner to be slaughtered. Second period.—A sample of milk was taken from one cow, the udder of which presented lesions of a suspicious character,and submitted for examination, the result of which proved the milk to contain tubercle bacilli. The animal was seized under the London County Council (General Powers) Act, and slaughtered, the carcase being destroyed and the owner compensated. Third period.—Samples of milk were taken from two cows and submitted for examination. Tubercle bacilli were found to be present in one of them. The cow from which this sample was taken died during the period the milk was under examination, the carcase being cut up, boiled and given to pigs. Mr. Shaw, in his report, particularly directs attention to the fact that at the time the sample was taken the cow's udder appeared to be perfectly healthy, although the cow presented symptoms of tuberculosis. Fourth period.—Samples of milk were taken from two cows suspected to be affected with tubercular disease of the udder, and in both cases Sir J. McFadyean reported that they contained tubercle bacilli. One of the animals in question, before the result of the examination was known, was sent by the owner to the Islington Cattle Market to be slaughtered. In the other instance, the animal was seized and slaughtered under the Council's General Powers Act. Upon post-mortem examination, Mr. Shaw found the carcase showed evidence of the presence of tuberculous disease of the udder. The carcase, offal and hide were destroyed. A further sample of milk was taken from a cow affected with tuberculosis of the lungs, but which presented no clinical symptoms of tubercular disease of the udder. The inoculation test showed that tubercle bacilli were present in the sample. Prior to the result being obtained, however, the animal was sent by the owner to the knackers to be slaughtered. Upon post-mortem examination, Mr. Shaw found that the lungs were tuberculous, but was unable to examine the udder, as it had been already disposed of. Milkshop premises. The following table shows the number of milkshop premises on the register of the sanitary authorities at the end of 1906, the number of inspections made of such premises, the number 59 of notices served, and the number of prosecutions. The table has been compiled from information contained in the annual reports of medical officers of health or subsequently supplied by them. Milkshops. Sanitary area. Number of premises. Number of inspections, 1906. Number of notices, 1906. Number of prosecutions, 1906. On register at end of 1905. Added in 1906. Removed in 1906. On register at end of 1906. Paddington 172 9 3 178 218 7 – Kensington 304 12 17 299 1,122 59 – Hammersmith 284 39 9 314 1,256 67 – Fulham 320 292 1,020 30 – Chelsea 130 19 21 128 168 25 1 Westminster, City of 299 34 1 332 1,029 40 – St. Marylebon e 343 253 276 – – Hampstead 113 5 6 112 426 6 – St. Pancras Islington 727 36 145 618 2,239 84 – Stoke Newington 51 – – 51 51 3 – Hackney 362 30 24 368 981 6 5 Holborn 180 27 20 187 881 18 – Finsbury 262 21 27 256 283 56 – London, City of 567 14 – 581 Shoreditch 289 19 20 288 3,651 7 1 Bethnal Green 373 67 Stepney 945 114 43 1,016 2,151 10 12 Poplar 364 12 16 360 1,776 6 – Southwark 368 54 15 407 468 4 – Bermondsey 263 20 28 255 782 67 1 Lambeth 480 490 490 – Battersea 254 56 46 264 528 58 – Wandsworth 302 73 23 352 805 35 3 Camber well 602 38 42 598 1,277 – – Deptford 193 57 52 198 504 9 – Greenwich 215 19 14 220 243 22 – Lewisham 163 54 57 160 299 23 – Woolwich 186 21 57 150 300 – – In several of the annual reports the desire is expressed for greater power of control over the condition of premises in which milk is sold. At a conference of the Public Health Committee of theWandsworth Borough Council with dairymen and keepers of milkshops in that district, a resolution was adopted in favour of the annual licensing of milk premises. The London County Council has, moreover, been invited to seek powers authorising sanitary authorities to refuse to register premises which are unfit for use in connection with the business of a milk vendor. Dr. Newman states that there has been considerable improvement in Finsbury in the care taken to protect milk from pollution, but that much still requires remedy in the numerous general shops in which milk is sold. Milk coming from the country was in twenty-five instances examined by Dr. Klein for the City Corporation, and Dr. Collingridge states that of the twenty-five samples, twenty were reported as clean and pure, two as tuberculous, and three as unsatisfactory. On one of the two farms from which tuberculous milk was received a cow was found suffering from tuberculous disease of the udder. From the other farm five cows had been "turned away" on account of induration of the udder, and the remainder were found to be healthy. Examination of thirty samples of nursery milk supplied in St. Pancras led, Dr. Sykes states, to two of them being found to be tuberculous. Both these samples came from the country. These facts point to the need for systematic veterinary inspection of milch cows throughout the country. Dr. Davies reports that the general condition of the cows in Woolwich in respect of grooming and cleanliness is much better than those in Wiltshire, which he visited for the purpose of ascertaining the conditions under which milk is produced in that county. As showing the infrequency with which milk is received direct from the farmer by local vendors it is interesting to note that Dr. Lennane made inquiry in Battersea as to the sources of milk supply to local vendors, and found that 16 received milk direct from the farmer, 136 from wholesale vendors, 101 from retail shops in the borough, and 11 from retail shops outside the borough. Offensive Businesses. In the year 1906 the County Council received 310 applications for licences for slaughter-houses and granted 308. The following table shows the number of applications received and the number of slaughter-houses licensed in recent years:— 14911 H 2 60 Year. No. of applications received. No. of premises for which licences were granted. Year. No. of applications received. No. of premises for which licences were granted. 1892 543 537 1900 405 393 1893 538 529 1901 384 381 1894 518 506 1902 371 362 1895 497 485 1903 350 346 1896 478 470 1904 338 333 1897 460 460 1905 322 318 1898 442 429 1906 310 308 1899 419 411 The number of slaughter-houses in each of the London sanitary areas and the frequency with which these slaughter-houses, in some of the districts, were inspected are shown in the following table :— Sanitary area. Number of slaughter-houses. No. of inspections, 1906. No. of notices, 1906. On Register at end of 1905. Removed in 1906. On Register at end of 1906. Paddington 8 – 8 631 – Kensington 12 – 12 151 2 Hammersmith 12 1 11 288 18 Fulham 4 – 4 24 – Chelsea 6 – 6 96 – Westminster, City of 1 – 1 52 – St. Marylebone 10 2 8 48 – Hampstead 5 – 5 131 – St. Pancras 21 – 21 Islington 39 – 39 2,245 – Stoke Newington 8 1 7 13 1 Hackney 25 – 25 392 2 Holborn 1 – 1 18 – Finsbury 3 – 3 75 – London, City of1 8 – 8 Shoreditch 12 3 9 42 – Bethnal Green 6 – 6 32 – Stepney 10 – 10 25 – Poplar 19 – 19 83 – Southwark 6 – 6 91 3 Bermondsey 2 – 2 68 – Lambeth 27 – 27 54 6 Battersea 6 – 6 22 4 Wandsworth 22 1 21 400 1 Camberwell 15 – 15 149 – Deptford 6 2 4 42 – Greenwich 5 – 5 23 – Lewisham 16 – 16 152 2 Woolwich 11 – 11 105 6 In one instance the Borough Council took proceedings for slaughtering pigs on unlicensed premises and a fine was imposed. The Council's inspector attended the hearing of the case, to give evidence in support of the prosecution. The only change in the number of offensive trade premises, other than slaughter-houses, in London is a reduction in the number of tripe boilers' premises, one of these businesses being abandoned in Holborn. The number of authorised offensive businesses other than that of slaughterer of cattle in London, except those under the iurisdiction of the Citv Corporation, was at the end of the vear as follows :— Fat melters 24 Tripe boilers 22 Glue and size manufacturers 5 Knackers 5 Fellmongers 6 Bone boilers 6 Manure manufacturers 3 Soap boilers 13 Tallow melters 10 Gut manufacturers 4 Gut scrapers 1 Animal charcoal manufacturers 1 100 1 The eight slaughter-houses in the City of London are not licensed by the London County Council. 61 In several instances more than one offensive business is carried on at 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 1906. No. of Inspections, 1906. Sanitary area. No. on Register * at end of 1906. No. of Inspections, 1906. Kensington 1 73 Poplar 10 44 Hammersmith 4 104 Southwark 7 85 St. Marylebone 2 16 Bermondsey 12 336 St. Pancras 2 Lambeth 4 6 Islington 7 133 Battersea 2 4 Hackney 2 15 W andsworth 7 177 Finsbury 1 — Camberwell 4 — Shoreditch 1 10 Deptford 5 81 Bethnal Green 1 6 Greenwich 2 26 Stepney 8 52 Woolwich 1 - During the year a tripe boiler was prosecuted three times, and a firm of knackers once. Dr. Dudfield, of Kensington, reports, that, as a result of a previous prosecution, a fat melter gave an undertaking to discontinue the business during the current year. Nuisances. Smoke nuisances. Reference to action taken for the abatement of smoke nuisance, is made in nearly all the annual reports. in a few of these reports the statement is made that there was in 1906 less evidence of smoke nuisance than before. Dr. Collingridge is of opinion that much of the improvement noted in the case of premises in the City where motive power is required is due to the substitution of electricity for steam as a generating force; elsewhere, the substitution of the use of coke for coal in laundries is commented or. In his report relating to the Borough of Chelsea, Dr. Parkes gives account of unsuccessful proceedings in connection with the emission of black smoke from an electric generating station at Lots-road. Summonses were dismissed by the magistrate, to whom it was submitted in defence that the occasional emission of black smoke was not due to any want of reasonable precautions or care, and that the company's furnaces were constructed on the best-known plan for preventing smoke. Dr. Parkes writes that, "in support of the legal proposition that so long as the company is acting within its statutory powers, it is entitled to benefit by proof that these powers are carried on in the best possible practicable manner, there was put in evidence the analogous case of the Hammersmith Borough Council v. the Central London Railway, decided by the Divisional Court on the 6th June, 1901, in which Mr. Justice Bigham laid it down that all the company had to do was to show that it was carrying out the powers conferred by Parliament in the best possible practicable manner." The following table, compiled from information contained in the annual reports, shows the action taken by sanitary authorities in respect of smoke nuisance during the year. Smoke nuisances. Sanitary Area. Observations and inspections. Nuisances and complaints. Notices. Summonses. Paddington 239 5 Kensington Hammersmith 46 (premises) 20 Fulham 28 2 Chelsea 3 Westminster, City of 2,722 37 118 8 St. Marylebone 297 22 Hampstead 9 St. Pancras 840 (13 re-inspections) 6 Islington 783 (Continued on next page) * The business at some of these premises was discontinued during the year 1906: as, however, the statutory period of nine months had not elapsed at the end of the year the entries relating to these premises were not cancelled in the Council's register. 62 Sanitary Area. Observations and inspections. Nuisances and complaints. Notices. Summonses. Stoke Newington Hackney 802 81 Holborn 51 15 Finsbury 144 61 23 8 London, City of 595 Shoreditch 12 Bethnal Green 599 (premises) 27 31 Stepney 120 Poplar 119 124 4 Southwark 105 6 Bermondsey 265 90 5 Lambeth 560 72 Battersea 215 70 76 1 Wandsworth 128 8 Camberwell 53 Deptford 133 17 17 1 Greenwich 290 8 Lewisham 538 20 1 Woolwich 79 12 12 Nuisance from stable manure. There are but few references to the subject of stable manure in the reports for the year 1906. It is probable that the reduction in the number of horses owing to the replacement of horse vehicles by motor vehicles is having some effect in reducing nuisances from this cause. Many of the reports state that notices are issued by the sanitary authorities requiring the removal of manure at frequent intervals, usually at periods not longer than forty-eight hours, and in some reports it is specifically stated that this course was adopted. Nuisance from the use of peat moss litter has been less frequent since the enforcement of the practice of depositing the litter directly in the vehicle in which it is to be removed at the moment it is taken from the floors of the stables. In proceedings instituted by the Lambeth Borough Council concerning nuisance from manure, the magistrate adjourned the hearing of the case with a view to this course being adopted. Removal of house refuse. The by-laws of the London County Council made under section 16 of the Public Health (London) Act require that the house refuse shall be removed from all premises not less frequently than once a week, and provision is also made for the institution of a daily collection in particular streets and areas after resolution by the sanitary authority. A system of weekly collection and removal of house refuse is now well established throughout London, and it is interesting to note that the number of complaints by householders to sanitary authorities that their refuse had not been removed has been greatly reduced ; thus in Islington this number has fallen from 10,138 in 1891 to 52 in 1906, and in Hackney the number of such complaints fell to 58 in 1906 ; on the other hand, the medical officer of health of Hackney states that in 5,207 instances house occupiers refused to allow their refuse to be removed when the dust collector called for that purpose. Refusal constitutes obstruction, for which a penalty could be obtained, and there is little doubt that if this penalty were applied for in a few instances the refusals would practically cease. Removal more frequently than once a week is by degrees being introduced into some districts, probably necessitated by the substitution of gas stoves in which combustible refuse cannot be burnt for those which are heated with coal, and also by the increasing number of houses built in flats, or as blocks of so-called model dwellings, where storage of large quantities of house refuse is especially undesirable. In Paddington a second collection in the week is now made in several streets. In Holbom a collection is made twice a week during the months of April to October, and there is, moreover, a daily collection in the main thoroughfares. In Westminster, where there is already a number of streets from which a daily collection is made, this system was in 1906 extended to four more streets. In Wandsworth there is a collection from flats twice a week. In Finsbury there is a daily collection in some of the main thoroughfares, and a collection twice a week from model dwellings. The medical officer of health of Westminster refers to difficulty experienced in that district in dealing under the Public Health Act with old fixed receptacles in bad positions, improperly constructed or defective. It was to meet this difficulty that the County Council in 1904 obtained the following provision in their General Powers Act of that year :— "Where any person shall have provided in connection with any building in any sanitary district a movable ashpit conforming with the requirements of any by-law or order made under any statutory power or authority in that behalf, it shall be lawful for the sanitary authority of that district, by notice in writing, to require the owner of such building to remove or fill up any fixed ashpit in or about such building and restore to a good and sanitary 63 condition the site of such ashpit within a reasonable period to be prescribed in such notice, and if such owner fails to comply therewith within the period so prescribed, he shall be liable on summary conviction to a fine not exceeding twenty shillings, and to a further fine not exceeding ten shillings for every day during which he makes default in complying with such notice after such conviction. " Provided that the sanitary authority may, if in the circumstances of any particular case they think fit, bear any reasonable cost and expense or part thereof incurred in executing work under this section." Removal of offensive matter. The removal of offensive trade refuse by the sanitary authorities of Woolwich, Finsbury, Wandsworth, and Greenwich has been referred to in the last annual report. In his annual report for 1906, Dr. Davies states that there are now 63 tradesmen in Woolwich whose refuse is thus removed. The charge made for removal of offensive refuse is at the rate of 3d. a receptacle, charged per quarter in advance, on the amount collected in the previous quarter, and a total of £91 4s. 3d. was thus received .n the year. In Finsbury a weekly charge is made of from Is. to 2s., depending on quantity, the Borough Council supplying tins for the purpose of removal, upon which a deposit of 8s. is made, which is returned when the business is given up. In Wandsworth Dr. Caldwell Smith says that the system is working satisfactorily, but some increase in the minimum charge of collection has been necessary. In Greenwich, too, the arrangement with a contractor, Dr. Annis reports, continues to work very satisfactorily, and has had the effect of leading other collectors to improve their methods. Dr. Collingridge reports that a new system of collecting and removing fish offal from markets and fishmongers' premises in the City was instituted during the year. He writes :— " Hitherto it had been the custom for the cleansing department, by an agreement with the Markets Committee, to remove such material in the ordinary way as trade refuse, but Messrs. F. S. Hempleman and Co., of West Ham, having offered to undertake this work under special conditions free of charge, a contract was entered into with that firm for this purpose on 21st May, 1900. The conditions of this contract are that the contractors shall for twelve months from the date of contract collect and remove, free of charge, between the hours of 7 p.m. and 9 a.m., all fish offal from the Corporation markets and fishmongers' premises in the City to the entire satisfaction of the iredieal officer of health. The contractor is to provide a proper number of specially constructed galvanised iron bins, of a pattern approved by the medical officer of health, and to thoroughly cleanse and disinfect such bins before returning them to the markets or shops. Provision is made in the contract for requiring that the offal collected shall not be used for human food or food for animals, and for entitling the contractor to convert it into manurial products. The contract also contains penalty clauses for ensuring its due performance. The above arrangements has been found a great improvement upon the former method, and has been of special advantage at Leadenhall Market, particularly during the prevalence of warm weather. The approved bin has two covers, one of which is fitted with an indiarubber ring inside, and can be so fastened down as^to form a hermetically sealed joint, thus preventing any smell emanating in course of removal. This form of bin has been found well suited for the purpose, and no complaints of nuisance have been received. The experiment has not only been a success, but the City Engineer has estimated that it will probably result in a considerable saving." Nuisance from sewers. Nuisance from sewers is referred to in the reports relating to Paddington, Kensington, Hampstead, Lambeth, Battersea, and Greenwich. The remedy usually adopted is to erect a ventilating shaft in connection with the sewer from which nuisance is experienced. Little reference is made in the annual reports to the subject of flooding from sewers. Nuisance from rivers and canals. Dr. Warry reports in reference to the River Lea, that there was no improvement in its condition in 1906. He writes : " During the hot months of last summer complaints, by persons frequenting the large open space adjacent to the river, were frequent." In reference to the condition of the Regent's Canal in St. Pancras, Dr. Sykes states that analysis of the water showed that it was sewage polluted, but that the contamination was not such as to cause a nuisance. No nuisance from this source was experienced in Paddington. Housing of the Working Classes Act, 1890. The proceedings which were taken in 1906 under the Housing of the Working Classes Act related in the main to the erection of houses'on the estates which had already been acquired under this Act The following is a summary of the action taken during the year. :— Proceedings under Part. I. of the Act. Aylesbury •'place, Clerkenwell, and Union-buildings, Holbom, scheme.—In February the Housing of the Working Classes Committee reported that the Works Committee were prepared to undertake the erection of working-class dwellings on this area, for which the Council had, in the preceding December, sanctioned an expenditure of £80,050. In July the Committee reported the completion of Mallory-buildings on the Aylesbury-place area. The buildings provide accommodation for 164 persons in 17 tenements of three rooms, 15 tenements of two rooms, and one tenement of one room. The Committee also reported that all the houses on the Union-place area were now demolished. Webber-row and Wellington-place and King's Bench-walk, Southwark, scheme.—In November the Housing of the Working Classes Committee reported the completion of Overy and Delarch-buildings on 64 the Webber-row area. Each of these buildings provide accommodation for 230 persons in 20 tenements of two rooms and 25 tenements of three rooms. In December the Committee reported the near completion of Algar-buildings and Dauncey-buildings on the Webber-row area, each providing for the same amount of accommodation as Overy and Delarch-buildings. Only one block remained to be finished, and on its completion accommodation would be provided for 1,130 persons. The number of persons of the working class displaced by the scheme was 997. Warner-street, Holbom, area.—This area had been represented in 1903 by the medical officer of health of Holbom under Part I. of the Act, but the Council, anticipating that much of the property on the area would be re-developed by the freeholders for commercial purposes, was unwilling to incur the expenditure which would be involved in dealing with the area by scheme. . As the result of representations by the Borough Council, the Local Government Board directed a local inquiry to be held as to the correctness of the representation and other matters in connection therewith. At the inquiry, which was held in June, 1906, a formal undertaking was given on behalf of the Chandos Land and Building Society, the freeholders of the greater portion of the property comprised in the area, to demolish forthwith the houses standing in the courts, and to carry out any other reasonable suggestions, with a view to minimising or removing the more objectionable features which now exist. The other owners also agreed to comply with requirements affecting their particular properties. The necessity for a scheme under the act was thus obviated. Proceedings under Part II. of the Act. Providence-place, Poplar, scheme.—Under this scheme the Council was under the obligation to provide accommodation for 400 persons of the working class, but, in view of the large amount of vacant property in the neighbourhood, decided to make application to the Local Government Board for an order authorising the modification of the scheme in order that the required accommodation should be provided on vacant land in the possession of the Council in connection with the Southwark scheme. A local inquiry was held, and the Local Government Board subsequently informed the Council that it was prepared to release the Council from the obligation to rehouse on the Providence-place area, that it would sanction the demolition of buildings on that area, and that it was not satisfied as to the need of the provision of accommodation on the Southwark area. Proceedings under Part III. of the Act. White Hart-lane estate.—In February the Council accepted a tender of £11,415 for the erection of 29 first-class and 23 third-class cottages and a further tender of £10,855 for the erection of 3 firstclass, 36 second-class, and 25 third-class cottages in the first part of the Tower-gardens section of this estate. Totterdown-fields, Tooting, estate.—The Housing of the Working Classes Committee reported in April the completion of 126 cottages on section B of this estate, and that 20 more cottages were nearly completed, making the accommodation on the estate sufficient for 3,462 persons in 464 tenements. In May the Council accepted a tender of £9,650 for the erection of 21 cottages and 2 shops on the estate. In June the Committee reported the near completion of 106 more cottages on section B, providing accommodation for 684 persons, making in all accommodation for 4,164 persons in 570 tenements, and in October the Council accepted a tender of £2,643 10s. for the erection of 12 cottages in Section A, each cottage to contain three rooms, and a scullery. Caledonian estate.—In October the Housing of the Working Classes Committee reported the completion of the Bruce-buildings' on this estate, providing accommodation for 356 persons in 6 tenements of one room, 34 tenements of two rooms, 28 tenements of three rooms, and 4 tenements of four rooms, raising the total accommodation on the estate to that for 1,388 persons. Brixton-hill estate.—The Committee also reported, at the same time, that the erection of Briscoebuildings, on this estate, was nearly completed. The buildings provide accommodation for 718 persons in 10 tenements of two rooms, 73 tenements of three rooms, and 30 tenements of four rooms. Provision for persons displaced by street improvements. New King's-road, Fulham.—In October the Committee reported the completion on this estate of Bearcroft-buildings, accommodating 220 persons, in 10 tenements of two rooms, and 30 tenements of three rooms. The provision was made for the accommodation of persons displaced by the widening of Fulham Palace-road and High-street. Proceedings by district councils. Ilampstead.—Dwellings erected in Lower Cross-road, under Part III. of the Act, were completed during the year. They provide accommodation for 248 persons in 12 tenements of two rooms, 20 tenements of three rooms, and 10 tenements of four rooms. Chelsea.—Pond House, containing 31 tenements, and provided under Part III. of the Act, was completed' in 1906. Kensington.—Concerning the steps taken for improving the condition of Kenley-street, Notting Dale locality, Dr. Dudfield reports as follows :—"With few exceptions, all of the houses in the street were acquired ; most of those on the north side, 26 in number, have been remodelled (two were rebuilt), and provision made for 58 self-contained suites, of two and three rooms, now occupied by persons of 65 the working classes in receipt of incomes not exceeding thirty shillings a week. The houses on the south side were demolished, and replaced by six blocks of residences of three storeys, each containing six suites of two rooms, which at the present time of writing are completed, and nearly ready for occupation. In Thames-street and Hesketh-place, moreover, two considerable blocks, containing 26 single-room tenements, have been erected which will prove a great boon and supply to some extent a much-felt want." Dr. Dudfield comments on the steps taken to provide accommodation for persons displaced by the widening of the Great Western Railway in North Kensington. The number of these persons is 1,038, mostly of the labouring class. The railway company proposed to provide for 670, and after a local inquiry the Local Government Board decided that accommodation should be made for 707. Westminster.—Dr. Allan reports that the City Council have added to the dwellings under their control a block of 20 tenements on a site in their possession in Marshall-street. 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 the district authorities concerning houses represented as unfit for human habitation, and in respect of which the Council has received copies of representations from 1st January to the 31st December, 1906 :— Sanitary area. Total number of houses concerning which the Council has received information that representations have been made from the 1/1/0; to the 31/12/06 Number of houses dealt with by owners, without Magisterial intervention. Number of houses for which closing orders were granted. Number of houses for which closing orders were refused. Number of houses represented but subsequently dealt with under Publie Health (London) Acl, 1891. Still closed. Demolished. Improved. Total. Still closed. Demolished. Improved. Total, Battersea — — — — — — — — — — — Bermondsey — — — — — — — — — — — Bethnal Green — — — — — — — — — — — Camberwell — — — — — — — — — — — Chelsea — — — — — — — — — — — Deptford — — — — — — — — — — — Finsbury — — — — — — — — — — — Fulham — — — — — — — — — — — Greenwich — — — — — — — — — — — Hackney- — — — — — — — — — — — Hammersmith — — — — — — — — — — — Hampstead — — — — — — — — — — — Holborn — — — — — — — — — — — Islington — — — — — — — — — — — Kensington — — — — — — — — — — — Lambeth — — — — — — — — — — — Lewisham 5 — — 5 5 — — — — — — Paddington — — — — — — — — — — — Poplar — — — — — — — — — — — St. Marylebone — — — — — — — — — — — St; Pancras *6 — — 6 — — — — — — — Shoreditch — — — — — — — — — — — Southwark — — — — — — — — — — — Stepney — — — — — — — — — — — Stoke Newington — — — — — — — — — — — Wandsworth — — — — — — — — — — — Westminster, City of — — — — — — — — — — — Woolwich 14 — 6 8 14 — — — — — — Total 25 — 6 19 25 — — — — — — 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 1906. The population thus dealt with comprised 21,256 persons, and the death-rate at "all ages" after correction for age and sex distribution was 137 per 1,000 living compared with 15.1 for London. * Summonses were taken out in respect to these premises, but were subsequently withdrawn, the owner paying £5 5s. costs. 14911 H 66 Death-rales of persons resident in the County Council's dwellings-1906. Cause of death. Death rate per 1000 living. Council's dwellings. London. All Causes—All Ages 13.7 15.1 „ „ age 0—5 49.1 48.3 ,, ,, ,, 5-20 3.5 2.6 „ ,, ,, 20 and upwards 10.0 15.2 Diarrhoea 1.2 0.9 Principal Epidemic Diseases (excluding Diarrhoea) 1.5 1.0 Phthisis 1.2 1.4 Tuberculous diseases other than Phthisis 0.9 0.5 Bronchitis 1.1 1.1 Pneumonia 1.5 1.4 Common Lodging Houses. The administration of the Common Lodging Houses Acts devolved upon the Council in 1894. By the passing of the London County Council (General Powers) Act, 1902, the Council obtained powers to license common lodging houses annually. 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, the authorised number of ledgers, and the number of convictions, with the penalties inflicted, and other particulars during each year since 1894:— Year. No. of houses on register. Authorised number of lodgers. No. of day visits by inspectors. No. of night visits. No. of prosecutions. No. of convictions. Penalties and costs. £. s. d. No. of deaths, † No. of cases of infectious disease. 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 2,13.3 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 27,571 ½* 28.158 1.565 21 16 77 3 0 53 14 1906 402 28,063½* 30,028 2,349 4 4 11 1 0 65 22 In the year 1906, proceedings before the magistrate were instituted in 4 instances, resulting in 4 convictions, the penalties amounting to £5 12s., with costs amounting to £5 9s. The number of cases of notifiable infectious disease reported in common lodging houses were as follows Erysipelas, 8 ; scarlet fever, 6 ; enteric fever, 5 ; diphtheria, 3 ; total, 22. The following table shows the total number of 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 of London, on 31st December, 1906 :— * One child. † The number of deaths stated in the above table includes only those deaths brought to the knowledge of the inspectors as actually occurriug in the houses, and not those occurring in infirmaries and other institutions to which the lodgers were removed when attacked with fatal illness. 67 Sanitary district. 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 6 537 — — 5.37 Chelsea 9 337 52 — 389 Deptford 8 1,194 49 — 1,243 Finsbury 8 543 — 543 Fulham 2 60 — — 60 Greenwich 4 157 — — 157 Hackney 6 401 — — 401 Hammersmith 9 460 — 4 474 Hampstead — — — — — Holbom 30 1,797 162 — 1,959 Islington 42 1,178 217 18 1,431 Kensington 24 439 272 — 711 Lambeth 7 702 — — 702 Lewisham 1 30 — — 30 Paddington 7 195 40 — 235 Poplar 10 1,198 — — 1,198 St. Marylebone 17 1,321 84 — 1,405 St. Pancras 10 707 112 — 879 Shoreditch 11 731 — — 731 Southwark 43 3,171 492 — 3,663 StepDey 67 5,634 754 180 6,748 Stoke Newington 1 37 — 37 Wandsworth 9 170 5½* 20 221½* Westminster, City of 19 1,759 75 — 1,834 Woolwich 24 548 44 — 592 London—excluding the City of London 402 25,137 2,436½ * 245 28,063½* 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 in common lodging houses, the corresponding figures for London being shown for comparative purposes. Common lodging houses. Table I. Death-rates per 1,000 males living at fire age periods from certain causes in London (1905) and in licensed common lodging houses 1905 and 1906. Cause of Death. Age 25 to 35. Age 36 to 45. Age 45 to 55. Age 55 to t5. Age G5 and upwards. London, 1905. C.L.H 1905. C.L.H 1906 London, 1905. C.L.H. 1905. C.L.H. 1906. London, 1905. C L H 1800. C.L.H 1900. London, 1905. C.LH. 1905. C.L.H. 1906. London, 1905. C.L.H. 1905. C.L.H. 1906. Phthisis 2.30 6.72 5.42 3.28 10.02 11.37 4.46 18.84 13.60 4.27 19.83 16.92 2.43 21.10 14.86 Other tub r, ulcus disea es 0.10 0.42 0.24 0.18 0.55 0.33 0.22 0.45 0.21 0.24 — 0.63 0.16 - 0.75 Alcoholism (including cirrhosis of the liver) 0.12 0.21 0.24 0.42 0.55 1.14 0.75 1.12 1.2 1.19 1.14 0.94 1.06 2.23 2.23 Urinary diseases 0.21 0.42 0.24 0.57 0.91 1.51 1.41 1.12 2.72 3.13 3.05 3.45 7.51 13.36 7.43 Violence 0.55 0.42 0.71 0.83 — 0.19 1.24 0.90 0.63 1.69 1.53 1.57 2.27 3.34 2.97 Cancer 0.18 0.63 0.24 0.57 0.18 0.38 2.31 2.24 1.26 5.06 8.39 3.13 8.07 17.82 10.40 Circulatory dissascs 057 1.89 1.89 1.38 3.28 1.89 3.19 5.38 5.23 8.20 8.39 9.40 21.77 26.73 23.03 Nervous diseases 0.21 — 0.24 0.37 — 0.76 0.77 0.45 1.05 1.30 1.91 1.25 3.61 6.68 2.97 Bronchitis 0.10 0.84 0.71 0.31 1.28 0.70 1.04 4.25 2.72 3.20 9.53 4.70 15.45 50.12 30.46 Pn umonia 0.46 0.42 0.71 1.24 1.28 2.08 1.86 2.92 3.98 2.96 6.48 6.27 5.97 12.25 13.37 Other can. es 0.90 0.42 1.41 1.43 0.91 1.14 219 1.35 0.84 4.56 4.20 4 70 22.88 35.64 26.00 Total (all causes) 5.76 12.39 12.05 10.58 18.96 2100 19.44 39.02 33.50 35.80 61.45 52.90 91.18 189.33 134.47 *½ = one child. 1491) 12 68 Table II Table showing the number of deaths of males at five age periods from certain causes per 1,000 deaths from all causes in London (1905) and licensed common lodging houses 1905 and 1906. Cause of death. Age 25 to 35. Age 35 to 45. Age 45 to 55. Age 55 to 65. Age 65 ami upwards. London 1905. C.L.H. 1905. C.L.H. 1906. London 1905. C.L.H. 1905. C.L.H. 1906. London 1905. C.L.H. 1905. C.L.H. 1906: London, 1905 C.L.H. 1905 C.L.H, 1906. London, 1900. C.L.H. 1905. C.L.H, 1906. Phthisis 399 543 450 310 529 526 230 483 400 119 308 320 27 112 110 Other tubercular diseases 27 34 20 16 29 18 11 11 6 7 — 12 2 — 6 Alcoholism (including cirrhosis of the liver) 22 17 20 40 29 53 38 29 38 33 18 18 12 12 17 Urinary diseases 37 34 20 54 48 70 73 29 81 88 47 65 82 70 55 Violence 95 34 59 79 — 9 64 23 19 47 24 30 25 18 22 Cancer 31 51 20 54 10 18 119 58 18 141 130 59 88 94 77 Circulatory diseases 99 152 156 131 173 87 164 138 156 229 130 177 239 141 171 Nervous diseases 36 — 20 35 — 35 40 11 31 37 30 23 40 35 22 Bronchitis 18 67 59 29 67 35 54 109 81 89 148 89 169 265 227 Pneumonia 80 34 59 117 67 96 95 75 119 83 100 118 65 65 99 Other causes 156 34 117 135 48 53 112 34 25 127 65 89 251 188 194 Total (all causes) 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 Seamen's lodging houses. Under the provisions of section 214 of the Merchant Shipping Act, 1894, the Council has made by-laws for the regulation of houses accommodating Seamen. These by-laws came into force on the 1st October, 1901. On the 31st December, 1900, the total number of seamen's lodging houses under supervision was 84, situated in the following metropolitan boroughs :— Metropolitan Borough. Houses. I.odgers. Poplar 20 371 Stepney 63 1,154 Woolwich 1 26 Total. 84 1,551 During the year 1,431 day and 38 night 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 9 instances, resulting in 8 convictions, the fines amounting to £34 3s., with costs amounting to £9 4s. Only two cases of notifiable infectious disease were reported in seamen's lodging houses during the year, viz., smallpox 1, enteric fever 1. One case of beri-beri was reported. During February an inmate of a Chinese seamen's lodging house in Limehouse-causeway was found to be suffering from this disease. From enquiries made it was ascertained that the patient, a Chinese seaman aged 24, eighty-one days out of Hong-Kong, had been in hospital in Sweden, and, on slight recovery, had been allowed to travel to London for the purpose of being sent back to China by the shipping company. Arrangements were made for his removal to the branch seamen's hospital, Albert Docks. Aliens Act, 1905. The need for better accommodation for transmigrants in London was under the consideration of the Public Health Committee during the year. This accommodation was found to be unsatisfactory, whether the aliens were taken directly from the ship to the railway station by which they left London or whether they were temporarily housed in London pending the time at which they could be re-shipped to their destination. In July and December of 1906, the Committee presented to the Council the following reports on this subject:— 31st July, 1906. We have had under consideration the provisions of the Aliens Act, 1905, so far as they relate to the service of public health. Section 5 of the Act requires certain returns to be made as to aliens landing or embarking at any port in the United Kingdom, and we are in communication with the Home Secretary with a view to obtaining information, if possible, which would be of service to the Council in connection with precautionary measures taken by it, from time to time, for the prevention of the spread of such diseases as cholera and plague. 69 We are also in communication with the Home Office concerning the need of adequate and proper accommodation for transmigrants during their stay in London, as the Council's inspectors have found that in a great number of instances the persons who receive such transmigrants provide accommodation at houses totally unfitted for the purpose, both as regards the sleeping arrangements and sanitary conveniences. We are also directing our attention to the character of the temporary arrangements made for transmigrants when taken across London from the place of landing to the railway station, and in this connection we find that in a recent case 176 transmigrants from Libau were landed at a wharf on the Thames at about 1 o'clock p.m., and were temporarily accommodated in a shed under conditions of overcrowding. The shed was badly lighted and ventilated, and no sanitary appliances were provided, while the only water for drinking purposes was inadequate in quantity, and was supplied in two very dirty pails. About 5| hours after landing, during which time they received no food, the transmigrants were transferred to one of the large railway termini in London, where, until the departure at 12.20 a.m. of the train, they were housed in a waiting-room, where inadequate arrangements were made for gaining access to water supply or for the use of sanitary conveniences leading to gross nuisance. We have notified the above facts to the sanitary authorities in whose districts the wharf and railway station are situated with a view to their taking action to remedy the conditions referred to. 18th December, 1906. On 31st July, 1906 (p. 602), we reported on the inadequate sanitary arrangements made at one of the large railway termini in London for the accommodation of transmigrants pending their departure by train to their port of embarkation. We have been in communication with the sanitary authority of the district in which the terminus in question is situate, and are glad to be able to report that the railway company contemplate the provision of special waiting rooms in which to accommodate transmigrants, and that these waiting rooms will be constructed with due regard to the needs of the transmigrants as regards sanitary conveniences and cooking facilities. An inspection of the station was recently made, when it was found that the accommodation for the transmigrants was materially improved. Houses let in Lodgings. In previous reports I have referred to the fact that in certain districts new by-laws relating to houses let in lodgings have been made, amendment of previous by-laws having become necessary owing to the decision of the High Court on 3rd February, 1904, in the cases of Stiles v. Galinski, and Nokes and Nokes v. the Mayor, Aldermen, and Councillors of Islington. In these two cases, which were the result of actions taken under the by-laws against landlords of lodging houses, for not causing every part of the lodging house premises to be cleansed in the first week of April, the Lord Chief Justice decided that the by-laws were bad, inasmuch as they did not provide that the persons who were responsible for seeing that such cleansing was done should receive the necessary notice. Since my last report the Council has instituted further inquiry as to the extent to which new by-laws have been made, and the following table shows the districts in which this has been done, and the date of approval of the new by-laws by the Local Government Board :— Battersea Dec., 1905. Islington Aug., 1906. Bermondsey Jan., 1905. Kensington, Aug., 1905. Camberwell Jan., 1905. Paddington Feb., 1905. City of London Jan., 1905. Poplar Sept., 1904. Deptford Sept., 1904. St. Marylebone June, 1907. Finsbury July, 1904. Southwark Jan., 1906. Fulham Mar., 1906. Stepney Jan., 1905. Greenwich Mar., 1905. Stoke Newington May, 1905. Hackney Oct., 1906. Wandsworth Oct., 1905. Hammersmith Oct., 1905. Westminster Dec., 1904. With regard to the other districts the facts may be thus stated:—Hampstead, an additional by-law to cover the points in question was approved in June, 1905 ; Shoreditch, the by-laws were amended in August, 1905; Bethnal Green and Holbom, the existing by-laws, confirmed in January, 1895, and August, 1903, respectively, are stated not to be affected by the decision; Chelsea, no action has been taken, though the existing by-laws date from October, 1868; Lambeth, the by-laws were confirmed in May, 1897, and I am informed that there is no suggestion as to their amendment at present. St. Pancras and Woolwich, the question of framing new by-laws in place of those confirmed in November, 1893, and November, 1895, respectively, was under consideration ; Lewisham, it was proposed to draft new by-laws in 1904, but I understand that the by-laws of 1895 are still in force, and that there is no present intention of replacing them by new by-laws. The number of houses on the register of the several sanitary authorities at the end of 1906 and other particulars are shown in the following table :— 70 Registered houses let in lodgings. Sanitary area. Number of places. No. of Inspections, 1906. No. of Notices, 1906. No. of Prosecutions, 1906. On register at end of 1905. Added in 1906. Removed in in 1906. On register at end of 1906. Paddington 1,150 140 18 1,272 7,474 * 28 * † 4,422 † 13 Kensington 2,107 — 126 1,981 8,354 * 52 *- † 1,145 † 1 Hammersmith 2,577 275 329 2,523 231 Fulham 329 114 350 56 - Chelsea 602 — — 602 195 — - Westminster, City of 1,641 7 46 1,602 1,905 * 10 * - † 240 † - St. Marylebone 758 — — 758 Hampstead 199 40 — 239 189 58 - St. Pancras 2,192 151 47 2,296 Islington 891 — — 891 12,187 * 45 * † 1,199 † 2 Stoke Newington 259 53 66 246 246 Hackney 388 — 463 456 3/1 Holborn 759 1 70 690 1,397 881 - Finsbury 1,169 111 26 1,251 11,184 * 78 * - † 2,337 † 4 London, City of 315 374 Shoreditch 283 20 37 266 418 49 2 Bethnal Green 455 65 19 501 2,231 25 * 1 Stepney 2,672 165 25 2,812 2,451 * 375 * 10 † 1,232 † 16 Poplar 877 83 — 960 2,968 459 Southwark 1,241 12 5 1,248 4,298 3,021 10 Bermondsey 221 3 — 224 684 * 12 — † 140 — Lambeth 372 — — 372 372 48 — Battersea 121 2 — 123 386 118 — Wandsworth 218 — — 218 438 * 10 † 406 14 Camberwell 217 — - 217 621 * 4 * 1 — † 137 † - Deptford 269 — — 269 Greenwich 3 — — 3 — — — Lewisham 15 — — 15 180 * 9 — † 20 — Woolwich 265 48 6 307 520 * 46 * 4 † 270 † 4 The question of sufficiency of staff for the purpose of regulation of houses let in lodgings is mentioned in two of the reports. The medical officer of health of Hampstead states that "The services of at least one additional inspector will be necessary before the Health Department will be in a position to register and inspect an adequate number of tenement houses under the by-laws, and so exercise that control of these houses which is, in my opinion, one of the chief sanitary needs of the borough at the present time," and the medical officer of health of Greenwich reports, " On account of the inadequacy of the staff the by-laws relating to this class of property still remain in abeyance." The London County Council has been in communication with the Greenwich Borough Council on this subject. The Public Health Committee had under consideration the question whether the proportion of tenements of less than five rooms, as stated in the census returns, afforded any indication of the number of tenements which would be subject to by-laws for houses let in lodgings, and in this connection it was pointed out that the figures contained in the census returns included tenements in block dwellings which are usually not within the meaning of the term " houses let in lodgings." The Committee gave instructions for inquiries to be made as to the number of rooms and rents of tenements in block dwellings in the several metropolitan areas. As the result of these inquiries, a tabular statement was prepared which will be found in the Appendix. (See Appendix I.) It will be seen from this statement that of 672,030 tenements of less than five rooms in London, as shown in the census return of 1901, 53,571 or 7.9 per cent, are in block dwellings. In the central districts of Westminster, Holbom, and Finsbury, the percentage is 21.4, 21.4, and 18.5, while in the outlying districts of Lewisham, Wandsworth, and Woolwich the percentages are 0.7, 0.2, and 0.3 * For overcrowding. † For other conditions. 71 respectively". A comparison of the numbers of tenements of 1, 2, 3, and 4 rooms in the block dwellings, with those in London generally, shows that 3.8, 11.6, 11.3 and 2.6 per cent, respectively are in block dwellings. Thus, over 11 per cent, of the tenements of 2 and 3 rooms are in the block dwellings, while a much smaller proportion of the 1 and 4 room tenements are in these dwellings. The large proportion of 2 and 3 room tenements in block dwellings, when compared with the proportion of such tenements in London generally, may be further seen on reference to the subjoined table, which shows the percentage of 1, 2, 3, and 4 room tenements in every 100 tenements of less than five rooms in London generally, and in block dwellings:— London. Block dwellings. per cent. per cent. One-room tenements 22.2 10.6 Two-rooin tenements 30.0 43.9 Three-room tenements 27.0 38.6 Four-room tenements 20.8 6.9 Total 100.0 | 100.0 The number of the population inhabiting block dwellings in London was not ascertained in the course of the inquiry, but, if it be assumed that the number of persons per room in each class of tenement in such dwellings is equal to that in similar tenements of less than five rooms in London as a whole, it will be found that some 189,855 persons are at present living in tenements of less than five rooms in block dwellings in the county. The rents of the tenements in block dwellings vary considerably in the several districts, but it will be seen from the statement that about 3s. per room is the average charge. Water sup-ply to tenement houses. Reference was made in my last annual report to a report by Dr. Young on the subject of the adaptation to use as tenement houses of houses originally constructed for one family in which attention was called to the inadequacy of the provision of water supply in the basement and ground floors to the inhabitants of the upper storeys of such houses. This matter was made the subject of a further report to the Public Health Committee during the year (see Appendix III.), and the Committee recommended that powers should be sought from Parliament to deal with the matter. These powers have since been obtained. Houses Infested With Vermin. Increased use has been made during the year 1906 of the powers contained in section 20 of the London County Council (General Powers) Act, 1904, for the cleansing of rooms infested with vermin. The number of premises cleansed under the provisions of the Act in the several sanitary distri was as follows :— Paddington 227 Shoreditch 103 Kensington 269 Bethnal Green — Hammersmith — Stepney 716 Fulham 63 Poplar 37 rooms. Chelsea 32 Southwark 546 rooms. Westminster 55 Bermondsey — St. Marylebone 2 Lambeth 45 Hampstead — Battersea 1 St. Pancras 126 Wandsworth 35 Islington 67 Camberwell 56 rooms. Stoke Newington 8 Deptford 10 Hackney — Greenwich 5 Holbom 50 Lewisham — Finsbury — Woolwich 156* rooms. London, City of 2 In commenting on the practice of putting a clean paper over old papers at the time of repapering a room, Dr. Reginald Dudfield refers to the opportunity it gives for vermin to breed, and he states that all landlords of houses in Paddington registered under the by-laws for houses let in lodgings have been formally notified that any rooms which are repapered without preliminary stripping will not be deemed to have been " cleansed " as required by the by-law. Revenue Act, 1903. 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 * Including looms dealt with as nuisanccs. 72 from inhabited house duty are inspected. In many instances alterations are required to be made and work to be done before the certificate is granted, while in some cases the certificate is refused. 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 :— Sanitary area. No. of houses for which applications for certificates wcro received during the year. No. of tenements comprised therein. No. of tenements for which certificates were Granted. Refused. Deferred. Paddington 18 148 90 20 38 Kensington 52 98 73 14 — Hammersmith 80 231 136 9 86 Fulham 46 147 79 46 22 Chelsea 9 144 129 15 18 Westminster, City of 14 144 79 3 62 St. Marylebone 5 7 3 4 — Hampstead 17 92 71 — 34 Islington 23 381 377 4 — Stoke Newington 8 82 82 — — Hackney 52 864 864 Holborn 10 48 — 5 5 Finsbury 72 708 700 — 8 Bethnal Green 3 50 20 30 — Stepney 8 64 60 4 — Poplar 2 4 — 4 — Southwark 372 429 429 — — Bermondsey 2 8 8 — Lambeth 69 279 155 124 — Battersea 8 14 11 3 — Wandsworth 169 264 246 18 — Camberwell 34 140 59 6 75 Deptford 6 12 6 Greenwich 6 28 — 28 — Lewisham 169 378 366 12 Underground Rooms. In some of the annual reports information is given as to the number of underground rooms which are illegally occupied. From this information the following table has been compiled. Concerning the underground rooms in St. Pancras the medical officer of health writes : " At the end of the year there were on the register 538 underground rooms which had been illegally occupied as dwellings . . . Time is allowed to the occupants of these rooms to find rooms elsewhere, and during the time allowed the illegally occupied rooms are kept under observation, and the number vacated or otherwise occupied ascertained and reported. The houses in which these dwellings are found are added to the register of registered tenement houses." Sanitary area. No. of underground rooms illegally occupied. No. of rooms closed. Sanitary area. No. of underground rooms illegally occupied. No. of rooms closed. Paddington 3 3 Finsbury 14 — Kensington 28 28 Shoreditch 4 Chelsea 1 1 Bethnal Green 7 7 Westminster 29 29 Stepney 66 66 St. Marylebone 2 Lambeth 12 12 Hampstead 5 3 Battersea 11 11 Islington 37— Camberwell 1 — Stoke Newington 1 — Greenwich 2 2 Hackney 2 2 Woolwich 2 2 Holbom2525 Overcrowding. While it is probable that the increase of facilities for cheap travelling is affecting the demand for house accommodation in London, there is no evidence, so far as the annual reports show, of any marked improvement in or reduction of the overcrowding of dwelling-rooms. Particulars of the actual circumstances of twenty-six families in Bermondsey who Were found to be occupying overcrowded rooms are 73 given in Dr. Brown's report on the subject. Many of these families were living under conditions of overcrowding from inability to pay for better accommodation owing to lack of employment or low earnings. Dr. Newman notes that the population in Finsbury, a district which borders on the City, is declining but the density per house is increasing. In the suburbs, moreover, overcrowding readily occurs unless controlled by the sanitary authorities. Thus Dr. Caldwell Smith writes : " There has been a decided increase in the number of cases [of overcrowding] dealt with in Tooting compared with previous years, due to the poverty of the people residing in one or two streets in that sub-district. In Wandsworth the overcrowding was chiefly confined to the Fairfield and Springfield wards. All these cases were remedied after service of preliminary notice with the exception of one in Clapham, where it was necessary to issue a summons." The Followmg table snows the number ol instances in 1906 in which overcrowding was found and dealt with:— Sanitary area. No. of dwellingrooms overcrowded. No. remedied. No. of prosecutions. Paddington 438 287 1 Kensington 41 41 — Hammersmith 17 17 — Fulham 64 64 — Chelsea 11 11 — Westminster, City of 69 69 — Hampstead 12 12 — St. Pancras 117 117 Islington 136 136 — Stoke Newington 4 4 Hackney 62 62 Holbom 60 60 — Finsbury 145 145 — Shoreditch 117 117 1 Bethnal Green 161 159 1 Stepney 805 805 10 Poplar 132 132 1 Southwark 540 1 Bermondsey 69 69 — Lambeth 65 65 2 Battersea 71 71 — Wandsworth 100 100 1 Camberwell 81 81 2 Deptford 22 22 — Greenwich 21 21 — Lewisham 29 29 — Woolwich 86 86 Factory and Workshop Act, 1901. Under the provisions of Section 132 of the Factory and Workshop Act, 1901, the medical officer of health of every district is required to report 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 was prepared for use of medical officers of health, and this table has since been amended in certain particulars. The following summary table has been prepared from those tables which are contained in the annual reports of medical officers of health. 14911 K 74 75 TABLE SHOWING PROCEEDINGS OF LONDON SANITARY AUTHORITIES UNDER THE FACTORY AND WORKSHOP ACT IN 1906. Premises, Particulars, Class, Ac. Paddinglon. Kensington. Hammersmith. Fnlham. Chelsea. City of Westminster. S*\ Marylebone. Hampstead. St. Pancras. Islington. Stoke Newington. Hackney. Holborn. FinBbury. City of London: Shoreditch. Bethnal Green. Stepney. Poplar; Southwark. Bermondsey. Lambeth. Battersea. Wandsworth. Camberwell Deptford Greenwich. Lewisham. Woolwich. 1. Inspections. Factories (including factory laundries) 480 128 549 125 5 128 41 204 123 329 16 15 197 810 1,708 71 110 16 54 08 328 9 500 058 503 68 86 150 22 Workshops (including workshop laundries) 1,082 3,417 1,405 370 493 3,204 1,234 1,318 1,075 1,977 163 2,191 880 1,891 3,481 3,711 4,250 2,994 1,489 1,534 292 ; 940 1,864 3,233 2,340 423 360 1,297 295 Workplaces (other than outworkers' premises( 447 388 208 149 64 843 220 1,842 194 257 10 " 1,821 532 1,159 623 958 1,370 2,180 545 t 2,065 1,863 466 388 89 523 " Total (Inspections) 2,009 3,933 2,162 644 562 4,175 1,495 3,364 1.392 5,5451 189 2,206 2,898 3,233 6,348 4,405 5,318 3,010 2,919 3,812 1,165 949 4,429 5,754 3,309 879 535 1,970 317 2. Defects Found. Nuisances* under the Public Health Acts. Want of cleanliness 80 298 130 68 18 246 18 71 137 414 46 225 136 114 818 470 469 857 418 747 162 295 158 189 68 265 67 192 30 Want of ventilation 3 51 6 1 115 2 5 2 6 31 5 25 310 0 8 91 — 14 6 13 6 6 1 1 5 5 13 Overcrowding 8 20 1 4 8 28 1 11 2 30 1 19 5 7 40 4 7 49 3 14 1 20 7 5 4 143 5 9 5 Want of drainage of floors 4 21 2 5 — 9 4 2 5 8 — 8 3 — — — 1 38 36 — 4 — 5 5 — 12 2 Other nuisances 59 152 95 32 5 70 4 236 10 386 84 149 142 586 1,306 39 410 92 260 792 215 475 201 218 52 17 68 54 12 Sanitary accommodation Insufficient 1 14 1 1 20 7 11 30 1 4 15 16 2 9 57 1 27 19 — 9 35 7 — 4 o i 7 Unsuitable 24 83 37 15 204 2 56 8 184 27 110 105 265 1,592 64 — — 9 18 69 479 138 84 56 — 18 63 ) Not separate for sexes 2 6 1 1 69 1 1 4 6 7 12 6 81 5 4 11 3 4 4 14 1 2 3 — 2 1 — Offences under the Factory & Workshop Act. Illegal occupation of underground bakehouse (s. 101) Breach of special sanitary requirements for bakehouses (ss. 97-100) — 6 105 8 — 1 — — 21 — 7 24 26 19 Other offences (excluding offences relating to outwork) 47 — 4 — — — 5 9 i — — 62 " ~~~~ - Total (defects found) 228 651 376 140 32 762 33 400 196 1,058 170 550 433 1,088 4,166 589 907 1,157 695 1,654 512 1,296 550 558 196 431 169 341 69 3. Homework. Outworkers' Lists (s. 107). Received twice in the year fromemployers ( Number of Lists.. 44 26 1 18 46 147 115 96 50 246 31 408 128 220 958 20 116 80 94 108 48 38 12 165 89 23 122 40 Number of outworkers corresponding thereto 311 267 8 72 571 3,720 1,383 299 303 1,878 224 3,596 737 5,539 13,372 462 2,574 2,400 1,888 1,050 611 ■ 269 113 1,856 513 166 236 1 J6 Received once in the year from employers f Number of Lists... 32 49 25 10 24 56 12 9 50 16 24 154 41 26 123 11 24 2 35 2 21 14 — — 58 8 Number of outworkers corresponding thereto 78 234 77 29 282 687 34 34 215 9J 214 1,201 514 258 1,116 19 124 5 < 309 4 89 51 92 103 Number of addresses of outworkers leceived from other Councils 254 262 142 212 54 384 798 28 593 1,857 387 3,082 205 449 32 1,999 1,883 4,119 908 832 683 632 247 173 1,195 424 138 126 93 Ni mber of addresses of outworkers forwarded to other Councils 262 369 64 18 443 1,635 833 280 190 1,106 122 1,785 186 5,297 14,376 716 1,345 934 899 681 284 175 69 122 680 336 86 96 9 Prosecutions Failing to keep lists or permit inspection - - - - - - - - - - - - - - - - - - 1 - - - - - - - - - - Failing to send lists - - - - - - - - - - - 2 - - 1 - - - - - - - - - - - - - - Outworkers' Premises. Number of inspec tions of outworkers' 649 293 322 177 45 1,200 356 73 443 1,435 454 1,431 166 487 221 2,034 3,370 950 2,156 628 729 181 346 243 917 380 223 261 630 premises Out work in unwholesome premises(s. 108) Instances - - - 24 2 - 8 - 2 26 - 1 — - — 128 — 47 — - 50 — 18 — — 1 29 — — Notices served - - - 24 1 - 8 - 2 26 - 1 — - — 128 — 47 — - 50 — 18 — — — 19 — — Prosecutions - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Instances 15 19 - 1 - 52 - - - 9 2 — — 6 - 86 10 14 51 4 5 — - 6 19 3 — — — Outwork in infected pr< mises (ss. 109, 110) Orders made (s. 110) — — — 1 — — — — — — 1 - - - - - - - - - - - - - - - - - - Prosecutions fas. 109. no1* — — - - - - - - - - - - - - - - - - - - - - - - - - - - - 4. Registered Workshops. Workshops on the Btgister at the end of 19' 6 (». 131). Bakehouses 69 95 59 69 40 97 83 35 178 260 29 113 34 61 33 73 92 174 105 112 104 207 86 161 170 75 73 99 59 Laundries 51 224 324 92 32 32 23 6 73 147 19 111 13 21 2 33 29 25 47 67 34 38 119 85 11 19 83 28 Other workshops 798 1,320 536 251 458 2,723 2,648 475 1,075 1,423 144 901 881 1,822 2,801 1,245 1,556 2,304 454 2,092 557 1337 435 1,439 961 183 151 901 128 i otal i number of workshops on the Register) 918 1,639 919 412 530 2,852 2,754 516 1,326 1,830 192 1,125 928 1,904 2,836 1,351 1,677 2,503 606 2,271 695 1,544 559 1,719 1,216 269 243 1,083 215 5. Other Matters. Matters notified to H.M. Inspectors of Factories. Failure to affix abstract of the Factory and Workshop Act (S. 133) 45 73 - - 32 211 26 30 17 165 2 68 15 38 38 - 76 - 53 22 - 27 50 66 30 6 2 21 3 Action taken in matters referred by H.M. Inspector as remediable under the Public Health Acts but not under the Factory and Wo kshopAct (s.6) Notified by H.M. Inspector 18 25 19 9 9 117 43 - 10 18 4 132 15 22 39 77 22 161 7 18 15 47 3 13 18 22 2 5 2 .Reports (of action taken) sent to H.M. Inspector 18 24 19 9 9 117 33 - 10 18 4 9 15 22 39 17 22 161 7 18 15 47 3 13 15 9 2 5 1 Other 5 7 15 - 4 4 2 7 - - - - — 24 2 3 1 - 4 19 1 — — — 2 13 — — - Underground Bakehouse* (s. 101). Certificates granted during 1906 - - - - - 3 - - 1 - - 1 - - - - - - - - - - - - - - - - 1 In use at the end of 1906 58 77 36 50 32 81 74 22 178 104 19 50 27 40 27 44 28 62 33 41 33 72 32 48 66 28 19 23 25 * Including those specified in sections 2, 3, 7 and 8 of the Factory and Workshop Act as remediable under the Public Health Acts. † Including 2,982 4' miscellaneous re-inspections." 14911 K 2 The statistics of work done in three successive years may be compared. The results obtained are as follows :— Number of workshops on register 1904. 1905. 1906. 34,488 35,187 36,632 Number of inspections 84,600 86,071 7'J,526 Total number of defects found 18,922 19,023 19,407 Want of cleanliness 5,752 6,522 7,206 Want of ventilation 799 828 736 Overcrowding 413 347 461 Sanitary accommodation Insufficient 403 284 296 Unsuitable or defective 3,645 3,411 3,717 Not separate for sexes 808 239 251 It thus appears that there has been in London but small increase in the number of workshops on the registers in 1906, as compared with the number in 1905, and that the number of inspections has decreased. This decrease is probably due to the fact that special inspection was needed in the first instance in connection with the entry of workshops on the register, measuring up of workrooms, and obtaining the necessary particulars for entry. The number of inspections in 1906 has averaged something more than two inspections for each workshop, but there has been considerable difference in this respect in the several sanitary districts. In two districts, viz., St. Marylebone and Lambeth, the number of inspections has been considerably less than the number of workshops, a matter to which the attention of the local authorities should be directed. The number of total " defects " found, want of cleanliness, overcrowding, etc., shows no decrease in 1906 upon the number in 1905. This may be due in part to the fact that the officers of the sanitary authorities, having in great measure completed the initial work of measuring up workrooms and other matters incidental to registration, are more able to deal with the routine work of maintaining the premises in wholesome condition. The need for greater efficiency in connection with the supervision of home-workers' premises led the secretary of State to issue to local authorities, in October, 1906, a circular letter calling attention to their powers and duties under the Factory Act, especially (a) as to the necessity of requiring employers to keep and supply lists of out-workers, (b) as to the need of the prevention of industrial work being carried on in dwellings under less wholesome conditions than are required by law in workshops, and (c) as to the preparation of the tables regarding the lists of out-workers and the number of out-workers. It would appear from the annual reports that difficulty is still experienced by local authorities in obtaining the lists of out-workers which employers are required to send them, and in a few reports it is stated that a circular letter is now sent to employers shortly before the lists are required. With respect to the form in which the lists are kept, Dr. Collingridge reports that in the City," the greatest difficulty experienced is in getting employers to keep the list of their out-workers at their premises in the prescribed form. A recent investigation into this question showed that out of a total of 105 firms visited only six kept the list as required, and a number have failed to send in any list at all." So far as the annual reports show only in one instance was there a prosecution in London for failure to keep or permit inspection of the lists, and in only three instances was there prosecution for omission to send in the lists. j The number of out-workers on the lists supplied by the occupiers of workshops, approximately amounted to 28,000, and 20,800 inspections were made of their premises. In 336 instances the premises were reported to be " unwholesome," and in 302 instances " infectious." No prosecutions are reported in connection with either of these two classes of premises. Inspection of Food. The need for more complete supervision of the food supplies to London has long been evident. In a report presented to the Public Health Committee in the beginning of 1907 it was stated (see Appendix IV.) that the total bulk of foodstuffs reaching London annually is approximately some 2½ or 3 million tons, of which about three-fifths are consumed in London, the remaining two-fifths merely passing through London in the course of transit. Of the total, about one million tons consists of meat, fish, milk, butter, lard and eggs, about half a million tons consists of fruit and vegetables (including preserved fruit and sugar), and about one million four hundred thousand tons consists of grain and flour (estimated as grain). Of this total about two-thirds arrive by water and one-third arrives by rail. Of the first class of foodstuffs (meat, fish, etc.) about equal proportions are conveyed by water and rail, while of the second class (fruit, vegetables, etc.) about seventy per cent, arrives by water and about thirty per cent, by rail; and again, about twice as much meat arrives by water as that which arrives by rail, while conversely about twice as much fish arrives by rail as that which arrives by water. It needs to be remembered that supplies of the first class of foodstuff are frequently never taken into any market where there is opportunity for inspection, but go directly into cold storage, or directly to retail dealers. Hence in the absence of any organised system of supervision a wide door is opened to the dishonest dealer who wishes to dispose of unwholesome food in London. The subject of food inspection was under the consideration of the Public Health Committee during the year and the following report was presented in July to the Council. On the reception of the report the Council resolved to proceed to the next business and the motion therefore was " dropped." "The Council has long been cognisant of the need for improved administration in London for the purposes of inspection of food entering London. Under the Public Health (London) Act, 1891, the medical officers of health and 76 77 sanitary inspectors of the saiitiry authorities in London are empowered to seize unwholesome food, but there is no adequate arrangement by which this food is brought under inspection. The present position is no doubt due in the main to the division of London into 23 areas under separate administrative control. It is always open to the vendor to romove his goods across the boundary of a district to escape the seizure which is the first step to a successful prosecution, and, if the local authority of one district is especially vigilant, to supply this food to some other district where the administration is less efficient. Hence, in the absence of a uniform and efficient administration over the total area of London, the opportunities for the sale of unsound food in London must be much greater than in towns which have but one administration over their whole area. These difficulties relate to the inspection, not only of meat, but of fish, vegetables, fruit, and preserved foods. " As regards inspection of meat, we presented, on 11th October, 1898 (pp. 1107-9) a report in which we recommended the establishment of stations to which would be brought meat entering London, so as to ensure that all such meat was subjected to inspection on arrival in the county. For the purposes of dealing with meat killed in the private slaughter-houses in London we proposed the substitution of public slaughter-houses, provided by the Council, for the private slaughter-houses then existing. We expressed the opinion that, if all meat entering London, or killed in the slaughter-houses referred to, were examined by competent officers, and the inspected carcases stamped, and if the same course were adopted in the slaughter-houses at Deptford and Islington owned by the City Corporation, the inhabitants of London would be as effectually safeguarded as was practicable. Foreign meat coming from abroad would, of course, need to be dealt with on similar lines. Dr. G. S. Buchanan has recently presented to the Local Government Board a report on administration in London with regard to meat of pigs affected by tuberculosis, and in that report he refers to the scheme for systematic meat inspection and the establishment of public slaughter-houses in London put forward by us in 1898, and states that opportunity for proper examination of pigs killed would be afforded by the establishment of such slaughter-houses, or if meat prepared at private-slaughter-houses in London were required to be submitted to examination at the inspecting stations or otherwise. In giving consideration to the situation of the inspecting stations for food, railway communication and market traffic will, of course, need to be carefully studied, so that the necessary examination may be conducted with as little interference as possible with food distribution. It appears to us that, in connection with these stations, control would properly be exercised over the quality of foods other than meat; in particular, we have in mind foodstuffs such as fish, shellfish, fresh fruit and vegetables, especially those habitually consumed in the uncooked state, and refrigerated and canned goods. We reported on 7th March, 1899 (pp. 291-2), on the risks of contamination to which certain foods are exposed, and the Council, in its General Powers Bill of 1904, sought authority to deal with the dangers referred to, but, in consequence of amendments made by a Committee of the House of Lords, whereby the authority of the Council to act under the clause was removed, a motion to omit the clause was made on behalf of the Council and passed. We have, moreover, in a report presented on 13th December, 1904 (pp. 3147-8), drawn attention to the great extension of the use of refrigerated produce of late years, and to the desirableness of supervision being exercised over cold stores. We think these matters need to be considered in connection with legislation as to more efficient inspection of food. '' In connection with the subject we have considered the petition referred to us on 29th May, 1906 (p. 1428), signed by 100 signatories, amongst whom were several of the leading members of the medical profession, urging the Council to take steps for the establishment of public slaughter-houses. " In submitting, at a later date, our detailed proposals for the inspection of food, it may be necessary to deal with the institution of a special class of food inspectors, possessing special veterinary and other qualifications ; on this point we are in communication with the Local Government Board. " We are not prepared at present with the details of schemes to give effect to our proposals, but we are satisfied as to the urgency of the matter, and are of opinion that legislation on the subject should be sought in the session of 1907 ; and in order that Standing Order No. A 161(1) may be complied with, we ask the Council now to approve our suggestions in principle, subject to the submission at a later date of the details. We shall shortly be in a position to submit such details, with an estimate of the liability involved. We have consulted the solicitor, in compliance with Standing Order No. A 163, and he is of opinion that the Council can promote the suggested legislation. We recommend— " That application be made to Parliament in the session of 1907 for authority (i.) to enable the Council to establish food inspection stations and public slaughter-houses in London, and (ii.) to provide for the inspection of food entering London ; and that, before the introduction into Parliament of any Bill on the subject, the Public Health Committee do report details upon which the provisions of such Bill shall be based; During 1906 inquiry was made by Dr. Hamer concerning the inspection of food by riparian sanitary authorities and as the result of his investigations it became evident that to ensure efficiency of supervision over London food supply it was necessary to establish a system of inspection at the various points of entry, and to deal with foodstuffs whether brought in by river, rail, or road. Further, the need was apparent for power to prevent food acknowledged by the owner to be unfit for human consumption subsequently finding its way to the consumer through other hands (see Appendix V.). The Public Health Committee thus reported in November on this subject, and the Council adopted a recommendation to communicate the report to the Local Government Board. In connection with our inquiries as to the necessity for improved administration for the purposes of inspection of food entering London, as to which we reported on 17th July, 1906 (p. 201), we directed the medical officer to enquire and report as to the inspection by riparian sanitary authorities of food entering the county. The medical officer has presented to us a report by Dr. Hamer on the subject, and we have ordered a copy of the report to be sent to each member of the Council. The report calls attention to the enormous quantity (some 1,500,000 tons) of food entering London by the Thames every year, and to the altered conditions as regards the food supply of the inhabitants of the county at the present time with those obtaining 50 years ago, the tendency being to transfer from London nearly every process of food preparation that can be carried on elsewhere. He states that, in many cases, the change has presumably been greatly to the Londoner's advantage as regards quality, as it undoubtedly has been as regards price, but points out that the removal of the place of origin or manufacture beyond any control London can directly exercise emphasises the importance of examination of the food when it enters London, and this importance increases yearly as the amount brought from without approximates more and more closely to the total quantity consumed within the county. In the report attention is drawn to the sanitary authorities having jurisdiction over the areas within which imported food stuffs are landed, the Port Sanitary Committee of the City Corporation exercising supervision over the waters of the port and the area within the dock gates, including wharves and buildings, while the riverside wharves and buildings are supervised by the several riparian sanitary authorities, those mainly concerned with landing of food stuffs being the sanitary authorities of the City of London, Bermondsey, Southwark, and Stepney, although Poplar and Lambeth receive food stuffs at one or two wharves, and quite exceptionally other river districts (Deptford, Greenwich and Woolwich, for example) furnish the place of entry for comparatively small consignments of food materials. The number of inspectors employed for the service of food inspection by these sanitary authorities, together with details 78 as to the methods of inspection adopted, are set out in the report, and attention is directed to the absence of systematic inspection by a sanitary authority of the fish brought in to London. We are of opinion that the staff at present engaged in food inspection is small, and in this connection we may state that we deemed it necessary in May, 1906, to call the attention of the Bermondsey Metropolitan Borough Council to the need for the appointment by them of a special food inspector. With regard to the actual inspection of food brought into the county, it needs to be clearly understood " that it is not possible, even if it were desirable, to inspect in detail all the food stuffs entering the port," and again the ideal aimed at must necessarily be that of providing an efficient detective agency, which will serve to bring to light the underhand methods of the dishonest trader, rather than that of establishing a scheme of inspection in detail. There are many obstacles in the way of efficient inspection under existing conditions. One of those, to which much importance was attached at a public local enquiry held by the Local Government Board, in 1903, was the difficulty of obtaining knowledge as to the arrival in the port of consignments of food—a difficulty not now experienced, however, in districts possessing special inspectors. The examination of goods in a ship's hold or during transference from the ship to lighters is practically an impossibility, and the right to examine food stuffs in transit appears to be open to dispute, and Dr. Hamer refers to the time unprofitably spent by inspectors in following goods from place to place and achieving by diplomacy that for which no legal right can be claimed, and points out that, given a place in which to inspect, there must then be made available the labour necessary for the manipulation, incidental to inspection, of packages of goods, and also provision to enable the inspector to purchase from the owner such articles as must inevitably be rendered unfit for consumption, e-g., tinned foods, as the result of being opened for examination, the use of public money for such a purpose as the last mentioned finding its parallel in the procedure under the Sale of Food and Drugs Acts. We are of opinion, however, that the experience gained during recent years in connection with food inspection conclusively demonstrates the need of supplementing and co-ordinating the existing local inspectorates, and " evolving a system of control which, while causing the least possible interference with trade in food stuffs generally, will deal effectively with the fraudulent trader." The present system constitutes posts of observation, it is true, but these are so isolated from one another that the dealer in unsound food readily learns how to avoid them, and it is indeed obvious that, as the fraudulent trader will not on his own initiative court inspection of his goods, there is need of a system which will bring the inspector to the goods of the fraudulent trader. In illustration of this need, attention is drawn to the proceedings with regard to a number of carcases damaged before reaching London, owing to a breakdown of refrigerating machinery, and which were not brought to Smithfield, as in the ordinary course, but taken direct from a London railway station to a cold store, and only seized quite by accident, as it were, in part at that cold store and part at a retail butcher's premises in Stepney, its ultimate destination. Dealing with the disposal of trade refuse, we note the facilities afforded to dishonest traders for obtaining, through contractors or otherwise, unsound food, which is subsequently disguised by tinning or potting, and ultimately sold for human consumption, and urge the adoption of the principle that condemned food should be destroyed by the sanitary authorities themselves. Another point dealt with in the report is the need for special supervision in the case of particular classes of premises used in connection with the storage or manipulation of food. The Council on 28th February, 1905 (p. 685), ordered a report prepared by the medical officer on cold storage in London to be sent to the Local Government Board with a request that the Board would consider the suggestions that such premises should be registered, and that a health authority should have power similar to that given by the existing Dairies and Cowsheds Orders, under which premises before being used, are required to be approved as being structurally fitted for the purposes contemplated, and should be subsequently subject to inspection. We hold that premises at which sausage-making, potted meat manufacture, and various preservation processes are carried on should be dealt with on the same lines. We are of opinion that the facts contained in these reports should be brought to the notice of the Local Government Board for their information in connection with the framing of any regulations to be made by the Board, and we recommend—- That a copy of the report on the inspection of food by riparian sanitary authorities be sent to the Local Government Board, and that the report be placed on sale. The Court of Common Council of the City of London has taken an important step in adopting certain resolutions on the recommendation of their Sanitary Committee. The resolutions are as follows : — (1) "The necessity of forthwith promoting legislation for the compulsory inspection, at the time of slaughter, of all animals (together with the viscera) intended for the food of man, as the only reliable system for the protection of the public and ensuring such inspection being made by a veterinary surgeon or other recognised expert. (2) That all meat found free from disease after such inspection shall be officially stamped. (3) That all foreign meat be required to comply with the same standard as that of homekilled meat, and that the Government should be responsible for the maintenance of such standard. (4) That, with regard to boxed and boned fresh meat, arrangements should be made for the exclusion from the United Kingdom of any class of meat which is packed in such a way as to prevent inspection or the possibility of the detection of disease, or which contravenes the recommendations of the Royal Commission on Tuberculosis; and (5) That the report of the Royal Commission on Tuberculosis should be issued at the earliest possible date." Dr. Collingridge reports moreover that " In support of their views the Corporation have recently decided to abolish the private slaughter houses at the market under their control at Islington, and are now erecting in their place a public abattoir on the most approved principle. This new departure offers a very favourable opportunity for the Corporation to institute a system of marking all meat slaughtered that is found by their inspectors to be wholesome, and is a step that would in all probability be followed by every municipality alive to modern requirements where the public health is concerned." In connection with supervision of the meat supply the condition most urgently needed is inspection at the time of slaughter and the institution of a system of marking meat so as to enable the consumer to distinguish between meat which has been inspected at that time, and that which has not been so inspected. In the last annual report it was pointed out that the Danish Government had provided for the marking of slightly salted bacon imported into this country, as evidence that it had complied with the requirements as to inspection. Dr. Collingridge states that So far as Denmark and Holland are concerned the 79 ties there have made regulations which are now in complete agreement with the recommendations of the English Commission [on tuberculosis], including those relating to pigs." Action such as that which Dr. Collingridge suggests to the City Corporation should be beneficial to the home producer whose meat has to compete with that from foreign countries. So long as an efficient system of meat inspection is maintained in Denmark and Holland there is a guarantee of freedom of this meat from disease, which is not as yet provided in respect of meat killed in this country, and this fact must eventually have its effect on the mind of the consumer to the prejudice of the purchase of home produced meat. The City Corporation will undoubtedly render useful service both to producer and consumer in England by instituting such a system as Dr. Collingridge suggests. The annual reports contain many references to the condition of preserved food, partly as the results of statements published as to the canned meat industry of Chicago, and partly as the result of the issue of a circular letter by Dr. G. S. Buchanan, the Local Government Board's Inspector of Foods, asking that the examination of preserved foods may be made the occasion of obtaining information as to the use of preservatives and colouring matter. The subject of the use of preservatives has already been investigated and reported on by a Departmental Committee, and such use should be brought under effectual control. The following resolutions relating to preserved foods were adopted by the Metropolitan branch of the Incorporated Society of Medical Officers of Health. That it is necessary, in order to secure better protection for the public in regard to tinned and preserved foods, that legislation should be passed embodying the following important reforms— 1. The name and address of the manufacturer and the date of the canning shall be impressed on the cans. 2. It shall be unlawful to sell for any purpose canned goods that are unfit for consumption, and it shall be the duty of any person in possession of unsound canned food to notify and surrender the same to the local authority, who shall destroy such unsound food free of charge. 3. A certain number of tins (say 1 per cent.) from each consignment shall be opened on importation and the contents examined under the supervision or instructions of the sanitary authority concerned, prior to such canned goods being placed on the market. 4. Tins which are known in the trade as " doubtfuls " shall be deemed to be unfit for human consumption. 5. Food intended for canning shall be inspected by independent officials, and all foods shall be canned under strictly hygienic conditions. 6. In the opinion of the Branch, the use of preservatives in canned foods is unnecessary, and should under no circumstances be permitted. The annual reports show the amount of food which was surrendered to the sanitary authorities or seized by their officers as unfit for human consumption, and subsequently condemned by a magistrate's order. The largest quantities were dealt with in the City, in which are situated the City markets. During the year nearly 1,918 tons of meat were condemned, and of this amount over 165 tons of meat were diseased, 47 tons of this meat being tuberculous. The fish condemned by the fish meters of the Fishmongers' Company weighed nearly 1,445 tons, and 193 tons of foodstuffs were seized on the City wharves. In Finsbury, where a large wholesale meat trade is carried on in the vicinity of the Farringdon Market, 121 tons of meat were confiscated, of which over 35 tons were diseased. A system of inspection of meat at the time of slaughter in private slaughter-houses has been instituted in Islington, and over 2 tons of foodstuffs, mostly meat, were seized during the year. In Hackney more than 17 cwt. of meat were seized and over 4 tons of fish. In Stepney over 209 tons of foodstuffs were seized, tinned food constituting a large proportion of this quantity. In Shoreditch 19,449 tons of preserved food were surrendered, and in Bermondsey 41 tons of foodstuffs were destroyed. In Southwark a large quantity of unwholesome food, including much tinned food, was destroyed. In the other districts the amounts were much smaller than in those mentioned above, but seizures are reported in every district of London except one. The Sale of Ice Cream. It would appear from the annual reports that considerable attention is being given to premises on which ice cream is prepared for sale, and in some reports improvement in their condition is stated to have resulted. Cases of infectious disease have occurred on some of these premises, but there is no evidence of the distribution of disease during the year by this article of food. The proceedings of local authorities are shown in the following table :— Ice cream premises. Sanitary area. Number of places. No. of inspections 1906. No. of notices 1906. No. of prosecutions 1906. On register at end of 1905. Added in 1906. Removed in 1906. On register at end of 1906. Paddington 137 10 1 146 72 — Kensington 164 — 18 146 275 30 — Hammersmith 175 205 755 26 — Fulham 112 105 215 15 — Chelsea 48 5 14 39 36 2 — Westminster, City of 108 10 2 116 180 2 — Hampstead 73 3 4 72 107 2 1 (Contiuued on next page). 80 Sanitary area. Number of placcs. No. of inspections 1906. No. of notices 1906. No. of prosecutions 1906. On register at end of 1905. Added in 1906. Removed in 1906. On register at end of 1906. Islington 230 - - 230 458 57 Stoke Newington 34 — — 34 34 — — Hackney 158 158 35 Holbom 67 1 26 42 139 8 1 Finsbury 103 1 6 98 139 21 1 London, City of 249 233 Shoreditch 72 7 10 69 113 14 — Bethnal Green 72 6 10 68 151 20 — Stepney 45 36 2 79 110 4 — Poplar 77 139 284 6 — Southwark 50 84 70 34 1 Bermondsey 69 1 — 70 328 34 — Battersea 110 19 25 104 350 29 — Wandsworth 223 32 26 229 368 32 — Camberwell 222 30 19 233 518 4 — Deptford 99 32 17 114 241 25 — Greenwich 107 14 15 106 142 21 — Woolwich 87 19 38 68 224 8 - Disinfection. Dr. Collingridge reports that the rebuilding of the disinfecting station in the City is completed, " new fumigating chambers have been fitted, the steam disinfecting apparatus has been reconstructed, and an incinerator for the cremation of infected articles has been added." In 1906 a disinfecting station was provided at Wood Lane by the Borough Council of Kensington. The station consists of an " infected room," a " disinfected room," a laundry, an air-tight chamber for the disinfection of cabs and other vehicles, three van sheds and a boiler and engine house. Dr. Dudfield's report contains the following particulars as to the disinfector and machinery, and of the process of disinfection :— " The type of disinfector is that known as the ' Alliott and Paton pattern;' The disinfecting chamber of each of the two machines is 7 ft. long, 6 ft. high, and 3 ft. 7 in. wide internally, and is fitted with a steel framed door at each end. The process consists of: firstly, extracting the air from the chamber and its contents ; secondly, replacing it with dry high pressure saturated steam ; lastly, after the goods have been subjected to the action of the steam at 20 lbs. pressure for a sufficient period to destroy all traces of organisms, the steam is allowed to escape and a second vacuum obtained, this being broken in its turn by hot pure air, so that when, subsequently, the goods are removed they are not only sterile but also dry and aired; Some articles which are wholly or partially made with leather, fur, or the like, naturally cannot be subjected to steam without damage. These are disinfected in the same machine, but are treated by formalin vapour introduced through special appliances provided for the purpose. Each disinfector is fitted with recording pressure gauge, by means of which a diagram of every operation is obtained as a record, and as evidence of the exact treatment that the goods have received. Stained articles, if introduced forthwith into the ordinary disinfector, would be removed after steaming, with the stains ineradicably fixed, or even intensified. A rotary steriliser has been fixed with the object of getting over this difficulty. Articles which are received stained or which for other reasons require to be washed as well as sterilised, will be placed in the steriliser and properly cleansed without handling of any sort. On removal from the rotary steriliser the washed articles can be taken into the laundry and placed in a hydro-extractor, and afterwards dried in a drying closet, and finished in a Decoudun ironer. There is also an airing closet in which articles may be stored after disinfection.- This is conveniently placed alongside the standing place for the return van, and is warmed by means of steam coils. Two vertical boilers are provided as a precaution against stoppages. Dr. Reginald Dudfield states that an offer of a freehold site for the provision of a disinfecting station was provisionally accepted by the Borough Council of Paddington. Plans and estimates were prepared and an application for sanction to a loan was made to the Local Government Board. The report of the medical officer of health of Poplar contains an interesting account of the institution in that Borough of a plant for the manufacture of an "electrolytic disinfectant," from a solution of sodium chloride and of magnesium chloride. Dr. Alexander reports favourably of the result both in respect of its value as a disinfectant and in respect of cost of production. Shelters. Alteration in methods of disinfection of rooms after the occurrence in them of cases of infectious disease is leading to the less frequent use of shelters provided for the accommodation of persons who are temporarily deprived of the use of their rooms during the process. The annual reports show that in some districts the shelters were not used during the year. Others of the reports show the number of persons who were accommodated, thus:— Persons accommodated. Persons accommodated. Fulham 4 Finsbury 98 Chelsea 120 London, City of 27 Westminster 1 Bethnal Green 41 St. Marylebone 21 Stepney 179 St. Pancras 16 Southwark 1,266 Islington 32 Bermondsey 84 Hackney 114 Battersea 31 81 Mortuaries. The majority of the annual reports show the large use which is now made of mortuaries for the temporary deposit of the dead. The mortuaries are scantily used for the reception of the bodies of persons who have died from infectious diseases, but in this connection it must be recollected that the majority of the deaths of poor persons dying from infectious disease take place in public institutions and not in dwelling-houses. in dwelling-houses. The following table, which has been compiled from the reports of medical officers of health who supply the necessary information, shows the number of bodies removed to mortuaries in the several districts :— Sanitary Area. Total number of bodies removed. Total number of infectious bodies removed. Sanitary Area. Total number of bodies removed. Total number of infectious bodies removed. Paddington 281 4 Shoreditch 405 5 Kensington 400 18 Bethnal Green 386 10 Hammersmith 216 Stepney 778 8 Fulham 188 1 Poplar 376 Chelsea 138 3 Southwark 599 7 Westminster, City of 345 8 Bermondsey 252 13 St. Marylebone 432 4 Lambeth 407 2 Hampstead 87 2 Battersea 244 5 St. Pancras Wandsworth 212 1 Islington 642 2 Camberwell 328 8 Stoke Newington 46 — Deptford 68 — Hackney 424 2 Greenwich 134 — Holborn 103 1 Lewisham 129 3 Finsbury 395 21 Woolwich 162 1 London, City of 236 — Cleansing of Persons Act, 1897. The last annual report contained a tabular statement showing the provision which had been made by sanitary authorities under the Cleansing of Persons Act in November, 1906. In many of the districts the accommodation consists of baths at the disinfecting station or arrangements have been made with the Boards of Guardians by which baths at the casual wards can be used. The annual reports supply very little information beyond that contained in the tabular statement referred to, but in a few reports the number of persons cleansed is stated. Thus in St. Marylebone 8,865 adults and 5,184 children were cleansed. In St. Pancras, 1,314 adults and 1,087 children were cleansed. In other districts the number of persons cleansed was—in Hackney, 330 persons ; in Holbom, 262; in Finsbury, 35; in Poplar, 856; in Southwark, 49; in Lambeth, 45; in Battersea, 141; and in Camberwell, 33 persons. In respect of the remaining districts there is either no information or the numbers were trivial. There is no doubt that the extent of use of the cleansing stations in a large degree depends upon the character of accommodation provided, and the publicity which is given to its existence. It is much to be desired that adequate and suitable provision should be made throughout London, and that every effort should be made to secure its use. There is no subject which is more deserving of the consideration of authorities than that of improvement of the population in respect of verminous conditions. water supply. The report of the Water Examiner, appointed under the Metropolitan Water Act, 1871, supplies information as to the filtration and storage of water supplied during 1906. From a table contained in that report the following particulars are extracted :— District. Capacity of subsidence reservoirs. Filters. Monthly rate of filtration per square foot per hour, 1906. Cubic contents. Number of lays' supply. Area. Area per million gallons of average daily supply. Monthly average. Maximum average. gallons. auras. acres. gallons. gallons. Eastern 2,405,000,000 58.4 34 .746 .97 1.24 New River 463,100,000 10.9 255/6 .503 2.52 2.73 Southern (Lambeth idvision) 408,500,000 14.4 14.34 .454 1.93 2.13 Southern (Southwark and Vauxhall division) 390,000.000 12.7 35.34 1.160 1.37 1.98 Western (Chelsea division) 190,100,000 15.2 8 .639 1.66 1.91 Western (Grand Junction Division) 58,500,000 3.3 241/4 1.375 .86 1.042 Western (West Middlesex division) 397,500,000 16.0 22½ .90 1.226 1-396 Staines reservoirs 3,338,000,000 - - - - - 14911 I. 82 The Water Examiner states that the Local Government Board are in communication with the Water Board as to the experiments which shall be undertaken under section 25 of the Metropolitan Water Act, 1902, with a view to determining whether the present system of purification cannot be still further improved, and it is expected that arrangements will shortly be made for carrying out these investigations. The need of adequate provision for storing water before running it on the filter beds is insisted upon in the report, and it is stated that " at present some of the districts which have large storage reservoirs take water direct from the river or merely run it through some of their smaller reservoirs before passing it on to the filter beds." The report points to the marked improvement in the quality of the water supplied to the Grand Junction district, since the bulk of the supply has been taken from the Staines reservoirs. The Water Examiner anticipates an equally marked improvement in the quality of water supplied to the Southwark and Vauxhall divisions of the Southern district when the new storage reservoirs at Walton, which were completed during the year, are brought into use. Dr. Houston, Director of Water Examinations, in his report to the Metropolitan Water Board for the 12 months ended March 31st, 1907, makes the following observations upon the importance of storing water before delivering it to the consumer. He distinguishes between passive storage (holding water in store for emergency) and active storage (habitually circulating new river water through the storage reservoirs), and he points out that great caution should be exercised in drawing conclusions in connection with figures as regards " number of days' storage." Thus he says :— " For example, a reservoir might hold 365 days' supply and yet the daily supply might be drawn direct from the river throughout the entire year, the water being simply held in store in case of exceptional drought. This is an extreme and suppositional case, but in lesser degree the same principle applies to some of the Board's works. For example, the nominal figures for the number of days storage capacity in connection with the Southwark and Vauxhall Works during 1906 was 12.7 days ; but in practice it appears to have been customary to draw on this stored water only when the river was in flood and to turn the raw unstored river water on to the filter beds at such times as the water appeared to be in good condition. In effect this means that during a proportion of the total number of days throughout the year 1906, the storage was nil, not 12.7 days. Apart from the necessity of having water in store to cover times of drought, or periods during which the rivers are in high flood, it is desirable to hold a clear conception of the value of storage from the point of view of epidemic disease, and conceptions as to " safety " should, as a counsel of perfection, be based on the minimum number of days any portion of the raw water may be assumed to take in travelling from the river to the consumer. There is a consensus of opinion among bacteriologists that pathogenic microbes do not multiply in storage reservoirs, but gradually lose their vitality. The time required to effect the destruction of these bacteria is matter for controversy, and although the American authorities consider a few days may suffice, most British bacteriologists place the limit at a much longer period; The essential point is that each day's storage makes for safety.'and that time arrives eventually when all the pathogenic bacteria have perished, and in such a case subsequent filtration alone is required to improve the chemical and physical qualities of the water already incapable in giving rise to epidemic disease. There i s indeed an intrinsic biological difference between storage and mere filtration which should not be overlooked The fact that there are almost insuperable difficulties in directly and practically proving the absolute benefit, as regards the elimination of pathogenic bacteria, resulting from adequate storage, does not destroy the value of the indirect and inferential proofs which have led both epidemiologists and bacteriologists to regard storage as of paramount importance. Until the safety limit has been determined—and it doubtless varies according to the quality of the water, and the season of the year—it is obviously desirable to store water for as long a time as is economically possible. In this connection it may be asked whether storage if too prolonged may not actually lead to deterioration in the quality of a water. Under certain conditions which do not lend themselves to accurate definition, a water may deteriorate on storage, as judged by its chemical and physical qualities, owing to the abnormal growth and subsequent decomposition of some species of Diatomacæ, Cyanophycete, and Protozoa. But there are means of combating these retrograde changes should they occur, and they are more likely to take place, in my opinion, under conditions passive than of active storage. Moreover, the outstanding fact remains that in relation to danger to health, over storage is believed to be impossible. It frequently happens that water istakeninfor storage purposes in high flood, when it is of very indifferent quality, and such water, even after passing through the storage reservoir, might yield to most available tests of purity worse results than the river water, which by this time had become clear and comparatively pure. But this only points to the desirability of judicious selection of raw water for storage purposes, and even modern tests are practically powerless to demonstrate the important changes which take place in a stored water as regards the elimination of disease producing bacteria. It is quite possible that the outlet water from a storage reservoir might, on a given day actually yield worse results as judged by original and analytical data, than the raw river water'of that day; yet the former water might bo quite innocuous, whereas the latter water might contain the specific germs of disease. Undoubtedly from the epidemiological point of view, apart from the questions of cost and pumping, the storage reservoirs should be so worked as to give each drop of river water abstracted for water works purposes the maximum number of days detention in store. For example, given a single reservoir holding 65 days' supply it would be undesirable on epidemiological grounds to use raw river water for 300 days of the year, and during the remaining 65 days' water which had been stored for periods varying from 300 to 365 days (passive storage).'- 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. 83 Every sum paid to a sanitary authority must be applied in defraying the expenses of the sanitary authority incurred under the Public Health (London) Act, 1891, and so far as not required for that purpose those incurred in respect of lighting, and so far as not required for that purpose those incurred in respect of streets, and where the sanitary district comprises two or more parishes the sum paid must be apportioned among such parishes in proportion to their population, and the amount apportioned to each parish credited to each parish in the reduction of the rate required from such parish towards the above-mentioned expenses. The sanitary authority is required to render annually to the Local Government Board a return showing the amount of the sum to be paid and the total expenses incurred in respect of the three subjects mentioned. If the Local Government Board, under section 101 of the Public Health (London) Act, are satisfied that the sanitary authority have been guilty of such default as in such section mentioned, and have made an order limiting a time for the performance of the duty of the authority, the London County Council shall, if directed by the Local Government Board, withhold the whole or any part of the payment of the sum due to such authority. The Act provides that for the purposes of the distribution of the fund an estimate of population on the 6th April in each year shall be made by the Registrar-General upon returns which the Local Government Board receive from the authority making the poor rate in each parish showing the total number of houses entered in the rate book of the parish. The following table shows the estimated population on the 6th April, 1906, and the amount o. excess of contribution over grant, or of grant over contribution in respect of each district for the yeai ended 31st March, 1907— Sanitary area. Estimated population, 6 th April, 1906. Equalisation charge, being excess of contribution over grant for year ended 31st March, 1907. Net grant, being excets of grant over contribution for year ended 31st March, 1907. £ S. d. £ s. d. Paddington 145,338 4,669 19 3 — Kensington 182,748 16,523 2 8 — Hammersmith 118,025 — 7,539 9 6 Fulham 154,6S2 — 13,931 11 5 Chelsea 70,907 5,695 18 5 — Westminster, City of 172,085 108,942 8 0 — St. Marylebone 129,215 17,861 11 1 — Hampstead 87,005 6,647 10 5 — St. Pancras 231,236 — 8,740 19 6 Islington 336,848 — 29,662 2 1 Stoke Newington 51,843 — 3,250 5 6 Hackney 222,399 — 21,440 15 9 Holborn 54,666 13,216 18 6 — Finsbury 102,651 1,661 3 10 — London, City of 24,769 127,238 - 7 — Shoreditch ll7,383 — 7,256 5 5 Bethnal-green 128,660 — 16,242 1 11 Stepney 290,770 — 30,047 15 11 Poplar 169,494 — 18,462 19 4 Southwark 197,859 — 13,546 10 11 Bermondsey 128,951 — 6,483 2 9 Lambeth 307,764 — 22,960 - 4 Battersea 172,329 — 13,701 10 1 Wandsworth 296,020 — 20,593 12 3 Camberwell 266,245 — 28,080 5 5 Deptford 113,051 — 10,426 8 5 Greenwich 101,922 — 7,655 13 4 Lewisham 158,381 — 11,118 6 4 Woolwich 134,825 — 12,263 4 1 Inner Temple 127 602 7 3 — Middle Temple 107 344 0 3 Midwives Act, 1902. The number of midwives giving addresses in London on the roll at the beginning of the year was 2,105 and to these 245 names were added during the year as the result of examinations held by the Central Midwives Board, bringing the total to 2,350. The classification of the midwives is as follows :— Possessing L.O.S.* Certificate 1,611 „ Hospital Certificates 213 Passed C.M.B.f Examination 342 Enrolled by virtue of having been in bona fide practice a year prior to the passing of the Act of 1902 184 2,350 14911 Obstetrical Society. † Central Midwivos Board. l 2 84 It will be seen from these figures that less than 8 per cent, of the enrolled midwives are "uncertificated," The proportion of these uncertificated midwives among practising midwives is however much larger, for it must be borne in mind that the vast majority of enrolled midwives are not practising; many of them act as monthly nurses and many more are on the nursing staffs of hospitals. During the year 490 midwives (or 21 per cent, of the number enrolled) gave notice of their intention to practise within the county and this number includes a large proportion of the 184 uncertificated midwives. Four midwives died, eight gave up practice, and forty-five removed from the county during the year. There have been many changes of address within the county, and instances of removal of midwives from one district to another, An uncertificated midwife on changing her address rarely leaves a district where she is known. Inspection.—All practising midwives are subject to inspection to ascertain whether they are observing the Rules of the Central Midwives Board as to cleanliness, the possession of the required apparatus and antiseptics, the keeping of case books and registers, and the sending of the required notices to the Local Supervising Authority. Miss V. E. M. Bennett, M.B., B.S., was appointed inspector for the purpose of the Act in 1905. There was found, subsequently, need for an additional inspector, and in October, 1906, Miss L. S. Greig, M.B., L.M., D.P.H., was appointed. In November Miss Bennett resigned her appointment and the vacancy thus caused was not filled until after the end of the year, when Miss Ida Shields, M.B., B.S., was appointed. In addition to the routine inspection the inspector has given assistance to midwives by instruction and advice on any difficulties arising in their practice. During the year 1,092 inspections were made ; in 626 cases satisfactory reports were made; in 210 cases the reports were unsatisfactory or some special question was raised; in 177 cases the midwife was away from home at the time of the inspector's visit, and 79 visits were paid to midwives who had removed or ceased to practise. Under the new rules of the Central Midwives Board it is the duty of a midwife to report to the Local Supervising Authority any change in her address, and by this means a number of fruitless visits will be saved. In most of the cases where unsatisfactory conditions were found the inspector drew the attention of the midwife to the matter and on a subsequent inspection was able to make a satisfactory report. In cases of persistent neglect to observe the rules the matter was reported to the Midwives Act Committee and a cautionary letter was sent. Some 59 letters of caution were sent by the Council, as follows :— Failing to call in medical aid when required by rules to do so 11 Appliances defective or absent 14 Register improperly kept 5 Going to a confinement without disinfection subsequent to attending a case of puerperal fever 1 Failing to send in notices 5 Want of cleanliness 6 Persistent neglect to observe rules 2 Calling in an unqualified man to attend a patient 1 Delay in sending notice of calling in medical aid 14 One woman was suspended from practice for not possessing the required antiseptics and apparatus and the suspension was removed when these had been obtained. Four women were summoned to attend before the Committee and were cautioned, and seven cases were reported to the Central Midwives Board as prima facie cases of negligence, malpractice or misconduct, as follows : Nature of charge. Action taken by Central Midwives Board. Refusing to send required notices » » )• >» ••• Placing out an infant to nurse before ten days old Malpractice and calling; in unqualified person as a medical practitioner Illegal operation ... Falsifying register of cases Want of cleanliness Midwife cautioned. )) >■ »» ii Name removed from Roll. No action. Patient refused to give evidenci Midwife cautioned. Name removed from Roll. In addition to these cases the conviction of a midwife on a charge of theft was reported to the Board in accordance with section 8 of the Act, and the midwife's name was removed from the roll. In the first of the cases in the above table where the name was removed from the roll, the midwife appealed to the High Court of Justice against the decision of the Board, and the decision of the Board was upheld. Ten midwives were reported to be more or less illiterate, but such midwives either keep notes of their cases themselves or make use of relations or friends to keep their register of cases. In three instances breaches of the rules were said to be due to the midwife not being able to read English, and in this connection it may be stated that some 25 Yiddish midwives practise in East London amongst the Yiddish population, and two Italians practise in the Hatton Garden district. Uncertified Women.—In addition to the 39 uncertified women practising as midwives and referred to in my report for 1905, 36 others were brought to notice during the year. In the majority of these 85 cases there appeared to be no infringement of the provisions of section 1 (1) of the Act. In one instance a woman who used the title of midwife was cautioned by letter and in another case legal proceedings were instituted and a fine of Is. and 2s. costs was imposed. One uncertified woman, an Italian, practising in the Italian quarter, had two fatal cases of puerperal fever in her practice, and there was good reason to believe that she carried infection from one case to the other. She was reported to be wanting in cleanliness. Another uncertified woman was concerned in a case in which it was alleged that an illegal operation had been performed. The patient died and as a result of the coroner's inquest this woman was brought before the magistrate on a charge of murder. The magistrate did not consider the evidence sufficient and dismissed the case. A considerable practice is carried on by these unregistered women and complaints are made from time to time by certified midwives as to their practice. Medical Aid Notices.—The rules of the Central Midwives Board prescribe that under certain circumstances, which are set out in detail, a midwife must decline to attend alone and must advise that a medical practitioner be called in. The rules also provide that whenever a medical man is called in the midwife must send to the Local Supervising Authority within 24 hours a notice stating the reason why medical help is required. The number of such notices received during the year was 2,320, or more than twice the number received in 1905. Three midwives called in medical aid 94, 79 and 71 times respectively. Each of 2 midwives sent 50-70 " medical aid notices." do. 2 „ 40.50 „ „ do. 5 „ 30.40 „ „ do. 13 „ 20.30 „ „ do. 34 „ 10.20 do. 236 „ less than 10 „ „ It will be seen from this statement that of the 490 midwives who gave notice of intention to practise during the year some 200 did not give notice of calling in medical aid; these were all women who do not practise regularly. It would appear from the notices received that on the average a midwife calls in medical aid to the mother or child in nearly eight per cent, of the cases she undertakes. The five midwives who sent for medical help more than 50 times are midwives with large practices. The great increase in the figures over those for 1905 is no doubt due to a fuller knowledge on the part of midwives of the rules requiring them to send in their notices. The following were the reasons which the midwife gave for calling in medical aid c— Pregnancy— Abortions, miscarriages .. 18 Deformed or contracted pelvis .. 53 Ante-partum haemorrhage .. 64 Abnormal condition of uterus or vagina .. 12 Other diseases or complaints prior to labour .. 90 237 Labour— Presentations— Abnormal vertex 54 Breech in primipara; .. 34 Complicated breech 16 Foot and knee 18 Transverse 38 Hand, arm, or shoulder 31 Funis 9 Placenta prsevia 21 Prolapse of cord 20 Unable to make out 10 251 Prolonged labour .. 315 Retained placenta .. 137 Adherent „ • • 79 Rupture of perineum or injury of soft parts .. 228 Flooding .. 25 Triplets • • 2 1,037 Lying-in- Abdominal swelling or tenderness 18 Offensive lochia 2 Rigor 2 Rise of temperature 124 Unusual swelling of breasts 5 Post-partum haemorrhage 71 White leg 4 Pyrexia 3 Convulsions or eclampsia 11 Collapse or faintness 39 Mania 2 Other abnormal conditions 57 338 86 Child — Injuries received during birth 12 Malformations or deformities 74 Dangerous feebleness in premature infants 355 Inflammation of the eyes 20 Malignant jaundice 23 Syphilitic skin 4 Inflammation of umbilicus 3 Convulsions 47 Asphyxia '7 Circumcision required 4 Still births 82 Death of child 16 Complaints not specified 53 700 No reason assigned 8 2,320 Still-births.—During the year 574 still-births were notified, 195 midwives reporting still-births in their practice. 2 midwives each had 16 still-births 32 1 midwife had 12 „ 12 1 „ „ 10 „ 10 3 midwives each had 9 „ 27 3,, ,, 8 ,, 24 3 ,, ,, 7 21 13 ,, ,, 6 ,, 78 l5 ,, ,, 5 ,, 75 11 ,, ,, 4 ,, 44 30 „ „ 3 „ 90 48 „ „ 2 „ 96 65 ,, ,, 1 ,, 65 195 574 If this number represents the total number of still-births attended by midwives it would mean that some 2 per cent, of the children delivered by midwives are still-born. As a matter of fact, with two exceptions, the midwives who had seven or more cases of still-birth in their practice had an incidence of still-births ranging from 2'3 to 44 per cent, of total births in their practice. There is reason to believe that all the cases are not notified, and by comparing the number of cases attended by those midwives who send in weekly lists of births with the still-births notified by the same midwives, over 3 per cent, of the cases would appear to be still-born. Out of 2,700 children delivered by midwives of the Royal Maternity Charity 80 were still-born, or nearly 3 per cent. Midwives notifying still-births were asked to supply information as to (a) the period of the gestation of the child, (b) whether it was macerated or not, (c) the presentation. Question (c) was added to the form during the year, so that particulars on this point are not obtained for the whole year. The sex of the child was given in 487 cases—264 were male children and 223 female. On question (a) information was received in 502 cases as follows :— Full term 212 Eight months . 80 Seven 84 Six „ 55 Under six months 19 Premature (number of months not stated) 52 502 To question (b) 465 replies were received. 283 were said to be more or less macerated. 182 „ „ not macerated. In 242 cases question (c) was answered. Ordinary vertex presentations 143 „ breech and footling 60 Complicated and other presentations 24 i No statement, as child was born before midwife's arrival ... 15 242 Of the 212 full-term children 112 were not macerated. The presentation in the not macerated full-term cases was not stated in 37 cases, but of the others 39 were vertex presentations and 36 breech or other presentations. In 12 cases the midwife attributed the death of the child to ante-partum 87 hæmorrhage of the mother. Two were stated to be born with a caul completely over the head, two were hydrocephalic, and three imperfectly developed. In one case of triplets all were still.born. Of 30 cases of twins, one child was alive in 18 instances, and both children were still.born in 12 instances. The form of questions has now been included by the Central Midwives Board in the new series of rules and fuller information on these points is likely to be obtained. Inquests.— Arrangements have been made with the coroners in London to notify any inquest that is to be held where a midwife has been in attendance on the deceased, and by the courtesy of the various coroners the Council's inspectors are permitted to be present at the inquest, and are referred to in many instances where question is raised as to compliance with the rules of the Central Midwives Board. In this manner many cases of uncertified women practising midwifery have been brought to notice, and additional information has been obtained as to the methods adopted by midwives in the course of their practice. During the year 84 inquests were attended by the inspectors, in seven of these an uncertified woman was concerned. The midwife or "woman in charge was censured in 11 cases and in 7 cases want of skill on the part of the attendant was alleged. The following table shows the distribution of cases:— Inquosts on mothers. Inquests on children. No blame. Censure on attendant for not calling a doctor. Lack of skill. No blame. Censure on attendant for not calling a doctor. Lack of skill. Attended by certified midwives 13 4 1 48 5 5 Attended by uncertified women 1 2 — 4 — 1 The causes of death in these cases were as follows:— Mothers. Children. Puerperal fever 4 Weakness from prematurity 13 Post.partum hæmorrhage 3 Atelectasis and asphyxia from Heart failure 2 complete aeration of lungs ... 29 Convulsions 1 Suffocation in bed 7 Difficulties in labour 4 Congenital defects 4 Other diseases at time of Broncho pneumonia 3 birth 1 Still.born 2 21 Jaundice 3 Convulsions 1 Accidental fall 1 63 Full reports on all these cases were made and the censure of the coroner for not calling in medical aid was followed by a letter of caution from the Council. One case has already been referred to where an uncertified woman was committed for trial on a charge of murder. Puerperal fever.—All cases of puerperal fever, where there was reason to believe that a midwife was in attendance on the patient, were investigated, and full details of the illness obtained. For this purpose early intimation of all notified cases of puerperal fever is received by telephone from the Metropolitan Asylums Board, and weekly lists of deaths from puerperal septic diseases are obtained from the Registrar General. The term puerperal septic disease is held by the Registrar General to include puerperal septicæmia, sapræmia, pyaemia, peritonitis and metritis, occurring in connection with parturition. This definition of puerperal fever is in accord with that of the Royal College of Physicians, but a more limited interpretation of the term appears to be often adopted for the purposes of notification. During 1906, 298 cases of puerperal fever were notified, and 187 deaths were registered in London. Of these deaths, 68 referred to cases not notified as puerperal fever, and it would appear therefore to be probable that many cases of puerperal fever in its wider sense which do not prove fatal are never officially notified. The cases classed as puerperal fever in the following table comprise all notified cases, together with the fatal unnotified cases mentioned in the Registrar General's weekly return:— These cases were distributed as follows:— Cases. Deaths. Delivered by certified midwives 90 38 Delivered by a medical practitioner with a midwife acting as nurse 11 4 Not attended by a midwife 255 135 Deaths in London of cases from outside 10 10 366 187 88 Of the 00 cases attended by certified midwives, each of 15 midwives had more than one case during the year, viz.:— Two midwives (A and B) had four cases each. (A) had two in January, one in April, one in July. These cases followed a case in December, 1905. As the result of enquiry there seemed to be no ground for attributing the septic infection to the midwife, and it was noted that three of the patients resided in mews. (B) had two cases in February, one in May, one in November. In the second of the cases in February the confinement took place before notification of the first case as septic. Three midwives (D, E, and F) had three cases each during the year.—(D) had two cases in January, one in November. In the second of the cases in January confinement took place before notification of the first case as septic. (E) had one case in February, two in August (one of which was said to be a case of eclampsia). (F) had one in May, a second in June, and a third in October. There was an interval of five weeks between the disinfection of the midwife after attending the first and the confinement of the second case. Ten midwives had two cases each during the year. The interval between the first and second cases was less than eight weeks in only two instances, and in these the midwife had been disinfected prior to delivering the second patient. There seems to be some doubt in both these instances whether the second case was actually one of puerperal fever. The following table shows the number of children previously borne by the puerperal fever patients :— Cases. . Deaths. Primipara 18 7 2 para 5 — 3 „ 7 1 4 „ 7 2 5 „ 7 5 6 „ 3 1 7 „ 4 3 10 para 1 1 11, 12 „ 3 — Multipara (but number not given) 10 5 No statement 25 13 90 38 In the 38 fatal cases of puerperal fever death was certified to be attributable to the following causes:— Septicæmia 24 Puerperal peritonitis 5 Pyæmia 2 j;. Puerperal fever 2 Eclampsia 2 Acute blood poisoning 1 Septic Parotitis I Puerperal septic absorption 1 38 Of 124 instances where medical aid was called in on account of a rise of temperature, 38 were subsequently notified as puerperal fever. In many cases medical aid had been called in for some other reason, and the following table shows that in 39 instances out of the 90 cases of puerperal fever which occurred in the practice of midwives the history of the puerperium showed the following abnormalities :— Condition. Non.Futal. Fatal. Total. Perineal rupture 6 4 10 Retained or adherent placenta 5 4 9 Ante partum hœmorrhage or previous illness of patient 8 3 11 Difficult labour, forceps used 4 5 9 The following table shows, with regard to the 00 cases of puerperal fever occurring in the practice of midwives the day on which (a) rise of temperature occurred, (b) a medical practitioner was called in, (c) the case was notified :— 89 1st day (day of confinement). 2nd. 3rd. 4th. 5th. 6th. 7th. 8th. 9th. 10th. After 10th day. Rise of temperature Recovery 47* 2 3 9 10 5 4 2 5 1 2 4 Fatal 32* 2 2 4 7 3 2 1 3 2 6 Medical aid called. Recovery 52 8 3 4 8 7 5 2 4 2 3 6 Fatal 38 7 3 5 9 2 1 1 2 — 2 6 Case notified— Recovery 52 — — 3 5 3 9 7 9 6 2 8 Fatal 31t — — 1 4 2 3 2 3 2 1 13 Of the 38 fatal cases 10 died during first week of confinement, 13 during second week, 6 during third week, 4 during fourth week, three during second month, two during third month or later. Lists of births.—Midwives practising within the County were asked to send in weekly lists of the cases attended by them, forms and stampe d envelopes being supplied for this purpose. The information thus supplied has been distributed to the several medical officers of health in London, with one exception where the information was not desired. The lists are received each week on Monday and Tuesday morning and the information is sent to the medical officers on the Friday, so that the mothers may be visited about 11 or 12 days after the birth of the child, i.e., at the time when the midwife ceases to be responsible for the case. Some 212 midwives supplied lists more or less regularly, and among these were most of the midwives with large practices. Lists were also received from 14 institutions employing midwives. By the courtesy of the authorities of six lying.in hospitals, lists of the addresses of mothers discharged from their hospitals and going to houses in London were also supplied. The following figures afford some information of the extent of the practice of midwives:. Each of 22 midwives recorded attendance on more than 300 cases in the year. 99 10 99 99 from 250.300 99 99 12 99 99 99 200.250 99 99 22 99 99 99 150.200 99 99 32 99 99 99 100.150 99 99 54 99 99 99 50.100 99 99 27 99 99 99 20.50 99 99 33 99 99 99 less than 20 99 212 The midwives of the fourteen institutions mentioned above recorded 5,380 cases attended in the patients' own homes. The total number of births recorded was 30,749 or about one quarter of the births in London— of these infants 1,074 were either still.born or died within a week of birth. Charges by midwives.—The fees charged by midwives vary in different localities from 5s. upwards, but as a general average a fee of 7s. 6d. (or 10s. if patient be a primipara) is expected, while some of the charities employing midwives pay them 5s. a case. It is apparent from the figures given that only a small proportion of midwives can depend solely upon their practice for their livelihood. Some of those midwives having an extensive practice are approved by the Central Midwives Board to give practical instruction to pupils, and in this way supplement their income. Lying.in hospitals, etc.—The lying.in hospitals in London take in some 5,000 women annually and provide for attendance on some 10,000 patients in their own homes. The poor.law infirmaries, it is estimated, receive 2,000 cases a year. Many charitable institutions also arrange for confinements to be attended either free or at a nominal fee. Scholarships.—A scheme was arranged in 1905 for granting scholarships of the value of £25 to pupil midwives. A condition is imposed to the effect that when qualified the scholar must practise for two years in London. Five scholarships were granted during the year. Classes for midwives.—The Education Committee has arranged classes for instruction in midwifery for the benefit of midwives whose training was deficient, or who were trained many years ago, and many uncertificated midwives have availed themselves of this instruction. Lying.in homes.—The question of the licensing of lying.in homes was under consideration during the year, and enquiry was made by Dr. Wanklyn into the accommodation and methods of a number of these homes. An Act passed in 1773 required all lying.in hospitals to be licensed. It was found that four such hospitals had been licensed, but that for over 80 years no application for a licence had been made. Sanitary Inspectors. A return showing the number of sanitary inspectors in the service of the several sanitary authorities is appended (see Appendix VI.). The total number of inspectors employed in London in 1906 shows an * No information was obtained with regard to the date of rise of temperature in the remaining eleven cases. ‡ The remaining seven fatal cases were not notified. 14911 M 90 increase of six over the number employed in the year 1904, viz., 319, as compared with 313. This increase is due to larger employment of female inspectors, the number of whom in 1904 was 28 and in 1906 was 38. At the time of the return women inspectors were employed in all the London districts except Bermondsey, Deptford, Greenwich, Hammersmith, Shoreditch, Stepney, and Stoke Newington. The Medical Inspection of School Children. The work of the Education Branch of the Public Health Department of the Council is detailed in the report of Dr. Kerr, which is appended. (See Appendix II.) The report shows that of 20,110 children submitted to the local assistant medical officers for examination during the year, the numbers urgently requiring treatment were 1,165 children in respect of vision, 1,201 in respect of hearing, and 594 in respect of speech, while 2,504 were reported as physically defective and 807 as mentally defective. Of 636 children reported as requiring transfer to special schools, 4 were so reported on account of defective vision, 13 on account of defective hearing, 3 on account of defective speech, 72 on account of physical and 544 on account of mental defects. Of children selected individually from their classes, 1,617 suffered from external disease of the eye, 2,725 from throat or nose affections, 990 from ear disease, 206 were excessively dirty and 1,484 suffered from other defects. The results of the medical inspection of infants and of pupils in secondary schools and training colleges are also shown. A number of schools were inspected with regard to their sanitary condition and reported on in respect of lighting, ventilation, heating, furniture, etc. A table on page 6 of Dr. Kerr's report shows the number of instances in which these conditions were found to be good, fair or bad. The report of the preceding year contained statistics of height and weight of children in three groups of schools. The present report contains figures, calculated by Dr. Shrubsall, showing arithmetical averages, probable error, standard deviations, and co.efficient of variation in respect both of the weight and height of children at each age then examined. The results show that the physique of children (judged by height and weight) in a group of schools (suburban) in better circumstanced districts is superior to that of children in two groups of poorer schools in London. The report states that at first sight it would appear as if environment were the cause of the differences noted, but Dr. Shrubsall points out that racial differences between different parts of London are very great and unless this question be regarded it is impossible to assert that environment is the factor which governs the differences observed. Sections of the report are devoted to a discussion of particular conditions affecting school attending children. Thus dental conditions, spinal curvature, pulmonary tuberculosis, condition of tonsils, adenoids, acuity of hearing, articulatory capacity for consonantal sounds, and fatigue are dealt with, while other sections are devoted to verminous conditions, ringworm and favus, for children suffering from the last of which a special school was opened in July of 1906. The result of examination of the teeth of children in the Michael Faraday School, voluntarily undertaken by Mr. C. Edward Wallis, is especially instructive in showing the extent of prevalence of caries, and the need for the institution of a system for preserving the teeth of children and the removal of septic conditions from their mouths. The procedure adopted for the limitation of the spread of infectious disease through school attendance is stated in the report, and the need for the re.institution of the epidemic grant is properly insisted upon. The question of the exodus of children from London during the summer holidays is considered in its relation to the decrease in the number of notified cases of infectious disease observed at that time. A tabular statement shows the number of known cases of scarlet fever and diphtheria occurring in each week of July, August and September. A fact of importance brought out by this table is that the number of cases of scarlet fever shows no decline until the second week of the holiday, suggesting that a diminished opportunity of infection has governed the behaviour of the figures in a greater degree than the exodus from London. Details are given of the conditions affecting children admitted on medical certificates to the 23 invalid schools provided in London. These schools were attended by some 1,800 children. The large proportion of physically defective school children suffering from tuberculous diseases is obvious from the fact that of 1,050 children examined in fifteen " physically defective centres " as many as 400 were suffering from tubercular disease of the spine, hip, knee, or other joint. Under the heading " Vision " tables are presented showing the number of children found to have defective vision, and the report shews that the number in need of treatment amounted to nearly 30,000. An interesting report on the artificial lighting of schools is contributed by Mr. Bishop Harman, This report discusses the best positions for the sources of light and the results obtained by the use of gas light and electric light with different shades and burners. Included in Dr. Kerr's report is a chapter giving account of a limited number of observations of the effect on the mental activity of children, of varying conditions of the atmosphere of schools. Shirley F. Murphy, Medical Officer of Health. December, 1907. To the London County Council. 91 Medical Officers of Health of London Sanitary Areas, in 1906. 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.D. Chelsea L. C. Parkes, M.D. City of London W. Collingridge, M.D. Deptford H. W. Roberts, M.R.C.S. Fins bury G. Newman, M.D. Fulham J. C. Jackson, L.R.C.P. Greenwich E. G. Annis, M.R.C.S. Hackney J. K. Warry, M.D. Hammersmith N. C. Collier, L.R.C.P. Hampstead G. F. MeCleary, M.D. Holborn W. A. Bond, M.D. Islington A. E. Harris, L.R.C.P. Kensington T. 0. Dudfield, M.D. Lambeth J. Priestley, M.D. Lewisham A. W. Harris, M.R.C.S. Paddington R. Dudfield, M.B. Poplar F. W. Alexander, L.R.C.P. St. Marylebone A. W. Blyth, M.R.C.S. St. Pancras J. F. J. Sykes, M.D. Shoreditch L. T. F. Bryett, M.D. Southwark G. Millson, L.R.C.P. Stepney D. L. Thomas, M.R.C.S. Stoke Newington H. R. Kenwood, M.B. Wandsworth P. C. Smith, M.D. Westminster, City of F. J. Allan, M.D. Woolwich S. Davies, M.D. APPENDIX I. J.T.S.—1,000—7.1.07. [8421 Table showing number of tenements of less than five rooms (Census, 1901) and the number of tenements in block dwellings within the City of London and the several metropolitan boroughs, and the rent paid in respect of such tenements. Tenements of less than 5 rooms in sanitary area (Census 1901). Tenements in block dwellings. Number of 1.4 room tenements in block dwellings per cent, of tenements of less than 5 rooms in sanitary area. Number of rooms in tenements of 1.4 rooms in block dwellings per cent. of rooms in 1.4 room tenements in sanitary ar.ea. Rents of tenements in block dwellings (highest and lowest). Sanitary area. No. of tenements of less than 5 rooms. 1 room. 2 rooms. 3 rooms. 4 rooms. Total rooms in 1.4 tenements. No. of tenements. 1 room. | 2 rooms. 3 rooms. 4 rooms. 5 or 6 rooms.+ Total rooms 1.4 tenements. Total rooms all tenements. 1 room. 2 rooms. 3 rooms. 4 rooms. Total tenements 1 room. 2 rooms. 3 rooms. 4 rooms. 5 or 6 rooma. Battersea 24,089 3,413 5,887 7,934 6,855 66,409 424 34 199 168 23 — 1,028 1,028 1.0 3.4 2.1 0.3 1.8 1.5 2/6 to 5/. 3/9 to 7/6 6/. to 9/. 7/6 to 9/. — Bermondsey .22,064 4,258 6,968 5,738 5,100 55,808 3,365 357 1,86.9 1,054 84 1 7,593 7,598 8.4 26.8 184 1.6 15.2 13.6 2/. to 5/. 3/. to 7/9 4/. to 10/. 5/9 to 12/6 No rent Bcthnal.gieen 23,732 5,378 7,264 6,746 4,344 57,520 3,351 251 1,206 1,559 287 48 (4) 8,488 8,732 4.7 16.6 23.1 6.6 13.9 14.8 1/9 to 5/. 4/3 to 8/. 6/. to 11/. 7/3 to 12/. 9/. to 13/. Camber well 31,926 4,906 7,766 9,899 9,355 87,555 991 19 459 396 114 3 2,581 2,596 0.4 5.9 4.0 1.2 3.1 2.9 2/. to 3/6 4/. to 8/3 5/6 to 10/. 8/6 to 12/. 10/6 to 12/. Chelsea 12,082 3,812 3,736 2.927 1,607 26,493 712 136 246 299 25 6 1,625 1,655 3.6 6.6 10.2 1.6 5.8 6.1 1/9 to 3/6 3/6 to 6/. 4/9 to 8/6 10/. 14/9J average Deptford 13,956 1,974 3,313 3,906 4,763 39,370 400 — 199 188 13 — 1,014 1,014 .. 6.0 4.8 0.3 2.9 2.6 . 3/. to 6/. 4/9 to 9/. 5/9 to 10/. . Finsbury 20,515 6,364 7,882 4,233 2,036 42,971 3,897 460 1,386 1,691 254 106 9,321 9,851 7.2 17.6 39.9 12.5 18.5 21.7 2/. to 5/9 4/. to 91. 5/. to 12/6 6/3 to 12/. 11/3 Falham 21,681 2,t60 4,360 8,309 6,552 62,315 514 6 61 307 140 — 1,609 1,609 0.2 1.4 3.7 2.1 2.4 2.6 4/6 3/. to 7/6 4/. to 9/. 8/6 to 12/. . Greenwich 10,877 1,375 2,552 2,990 3,960 31,289 244 — 70 146 28 — 690 690 . 2.7 4.9 0.7 2.2 2.2 . 2/6 to 6/6 3/6 to 8/. 5/. . Hackney 29,089 4,827 7,211 9,387 7,664 78,066 1,123 5 309 662 126 21 3,113 3,218 0.1 4.3 7.1 1.8 3.8 4.0 3/3 to 4/3 4/9 to 71. 6/. to 10/6 7/6 to 12/. 9/6 to 11/9 Hammersmith 15,505 2,698 4,389 4,919 3,499 40,229 625 81 268 238 37 1(1) 1,479 1,485 3.0 6.1 4.8 l.6 4.0 3.7 2/6 to 4/. 4/. to 7/6 5/3 to 12/6 6/3 to 9/. 8/ (6 rooms) Hampstead 7,178 1,096 2,331 2,331 1,420 18,431 211 27 41 92 51 — 589 589 2.5 1.8 3.9 3.6 2.9 3.2 3/. to 3/3 5/6 to 71. 71. to 12/6 71. to 12/6 . Holborn 10,772 3,725 3,834 2,224 989 22,021 2,304 415 1,191 640 56 2 (1) 4,941 4,952 11.1 31.1 28.8 5.7 21.4 22.4 1/9 to 6/. 4/6 to 10/. 5/. to 15/. 11/. to 13/4 . Islington 55,801 12,955 18,934 14,379 9,533 132,092 2,561 259 1,142 899 245 16 6,220 6,300 2.0 6.0 6.3 2.6 4.6 4.7 2/3 to 4/9 3/6 to 8/. 5/9 to 15/. HI. to 15/. 10/5 average Kensington 21,115 5,695 7,776 4,757 2,887 47,066 309 — 100 156 48 5(5) 860 890 . 1.3 3.3 1.7 1.4 1.8 . 3/6 to 8/. 5/. to 11/. 6/6 to 12/6 15/. Lambeth 44,495 10,058 12,311 12,120 10,006 111,064 3,168 291 1,507 1,145 210 15 7,580 7,655 2.9 12.2 9.4 2.1 7.1 6.8 2/3 to 5/6 3/9 to 8/6 5/. to 12/. 7/9 to 16/. 12/6 to 16/. Lewisham 8,561 970 1,720 2,490 3.381 25,404 60 5 18 17 20 — 172 172 0.5 1.0 0.7 0.6 0.7 0.7 2/. to 2/6 3/9 to 4/. 4/9 to 6/. 6/6 to 91. — Paddington 21,815 5,035 6,668 6,548 3,564 52,271 293 56 212 22 3 — 558 558 1.1 3.2 0.3 0.1 1.3 1.1 4/. to 4/6 5/6 to 9/. 6/6 to 10/6 7/6 — 1'oplar 26,216 3,935 6,450 8,270 7,561 71,889 1,290 173 580 515 22 — 2,966 2,966 4.4 9.0 6.2 0.3 4.9 4.1 2/6 to 4/3 3/6 to 7/3 5/. to 10/3 5/6 to 13/6 . St. Marylebone 22,947 8,312 8,246 4,185 2,204 46,175 3,044 281 1,447 1,043 201 72 (4) 7,108 7,472 3.4 17.5 24.9 9.1 13.0 15.4 1/6 to 5/6 4/. to 11/. 6/6 to 12/6 9/. to 17/. 11/6 to 18/. St. Pancras 45,023 13,417 16,827 9,410 5,369 96,777 2,148 225 942 801 180 — 5,232 5,232 1.7 5.6 8.5 3.4 48 5.4 2/. to 5/. 3/6 to 10/. 5/9 to 14/. 6/6 to 21/. — Shoreditch 22,940 6,705 7,509 5,102 3,624 51,525 1,876 71 800 754 237 14 4,881 4,951 1.1 10.7 14.8 6.5 8.1 9.5 2/3 to 6/. 3/6 to 91. 5/. to 12/. 8/. to 13/. 10/6 to 13/. Southwark 39,612 9,896 12,480 10,211 7,025 93,589 7,436 787 3,056 3,046 443 104 (8) 17,809 18,337 8.0 24.5 29.8 6.3 185 19.0. 1/9 to 5/6 3/. to 9/. 4/. to 12/6 5/6 to 14/. 9/9 to 14/. Stepney 49,182 13,282 15,690 11,926 8,284 113,576 6,607 1,130 3,316 1,977 174 10 14,389 14,439 8.5 21.1 16.6 2.1 134 12.7 2/. to 5/. 3/6 to 10/. 4/6 to 13/. 6/9 to 14/. — StokeNewington 5,813 894 1,600 1,885 1,434 15,485 346 — 166 140 30 10 872 922 . 10.4 7.4 2.1 5.8 5.6 . 6/. to 7/. 7/6 to 10/. 10/. to 12/. 11/6 to 13/6 Wandsworth 21,052 2,039 3,591 7,458 7,964 63,451 32 — 6 26 — — 90 90 .— 0.2 0.3 . 0.2 0.1 . 6/6 7/6 to 8/ . — . Westminster 26,668 7,546 9,635 6,279 3,208 58,485 5,764 482 2,211 2,413 592 66 14,511 14,841 6.4 22.9 38.4 18.5 21.4 24.8 2/. to 6/. 3/. to 12/. 4/3 to 17/. 6/6 to 16/. 8/6 to 14/3 Woolwich 14,017 1,724 3,378 4,094 4,821 40,046 37 — — 37 — — 111 111 . . 0.9 . 0.3 0.3 . . 6/. to 6/6 — . * City of London 3,307 775 1,123 885 524 7,772 439 72 306 57 4 — 871 871 9.3 27.2 6.4 0.8 13.3 11.2 Not stated Not stated Not stated Not stated — Totals 672,030 149,524 201,431 181,542 139,533 1,655,144 53,571 5,623 23,313 20,488 3,647 500 128,301 130,824 3.8 11.6 11.3 2.6 7.9 7.8 1/6 to 6/. 2/6 to 12/. 3/6 to 17/. 5/. to 21/. 81. to 18/. Shirley F. Murphy, Medical Officer of Health. APPENDIX II. Xonbon County Council REPORT OF THE MEDICAL OFFICER (EDUCATION) FOR THE YEAR ENDED 31st MARCH, 1907. The Fifth Annual Report on School Hygiene, under the Education Authority for London, finds this subject in a very different position from what it was five years ago. It is recognised in other countries than England as a highly specialised branch of Public Health, which the ordinary sanitarian cannot be expected to follow in its fulness, and which requires officers experienced in the technique and specially trained to, do justice to the children and to the public interests. The great success of the recent International Congress for School Hygiene has undoubtedly done something to stir us as a nation from the position into which we, owing to neglect, had slipped The work followed in London during the past year has been directed mainly to the still unsettled problems of the ordinary classroom. Enquiries have been begun among the older pupils, and also some test examinations made of infants at admission. The value of last year's physical measurements have been enhanced by the calculation of the limits of error, and by some theoretical explanations. The physically defective children have all been gone over ; the subject of artificial lighting dealt with ; and ventilation has been returned to, especially in its relation to fatigue ; on this some other experiments are also given. A point has now been reached, as to whether the greater part of the medical inspection shall remain fruitless, or whether the Council shall take steps which will justify their later interference to see that its younger dependents have a fair chance of properly benefiting by the education offered. Treatment as a public concern will have to be considered in respect to certain educational matters, such as visual troubles, discharging ears, ringworm, and the care of the teeth, in which neither the private practitioner nor the hospitals can give any hope of either providing sufficient or satisfactory relief for most of the cases requiring it. EXAMINATION OP CANDIDATES. Head, assistant and pupil teachers, training college students, scholarship candidates, instructors and schoolkeepers employed in the schools are medically examined in this department before commencing work. During the year nearly 8,000 medical examinations have taken place, viz.: —1,963 head and assistant teachers, 1,563 pupil teachers, 3,676 scholarship candidates, 670 training college students, 104 instructors and schoolkeepers. References.—In addition to the " First" examination 535 references have been dealt with ; these relate to the health of employees already in the service of the Council who have been absent through i lines?. Special Schools Cases.—823 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 ; cases referred by magistrates and committees are also seen here. Scholarship Candidates.—The examination of candidates for'scholarships^as resultedJn a few being absolutely rejected, but a large proportion were referred back for medical or other treatment, and ultimately passed. There is still a considerable number of children of very poor physique being passed as scholars. Candidates for junior scholarships examined were noted as follows :— Age. Number examined. Number of examinations. Fit. Vaccination. Referred back. Absolutely rejected. Unvaccinated. No marks. Want of cleanliness.- Tliroat. Teeth. Vision. Sundry. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. (i. 9 — — — — — — — — — — — 1 1 1 — — — — — — — — 10 114 125 93 12 1 2 1 10 7 1 1 1<J3 273 129 13 7 40 8 8 15 o 1 11 600 709 512 43 6 6 15 53 58 13 2 1,008 1,628 668 106 12 253 57 47 79 17 11 12 2 2 2 10 13 7 1 3 1 ___ 1 13 — — — — — — 1 1 1 — — — — — — Total B. 776 836 607 55 7 8 16 63 65 14 3 G. 1,276 1,916 806 120 19 296 65 55 95 19 13 Grand Total 2,052 2,752 1,413 175 26 304 81 118 160 33 16 14958 A •> 4 The junior scholars are aged about 11; they are the most promising pupils who have scholarships awarded, so that they may reap the advantages of the higher education, and will in any case remain at school till they are fourteen years of age ; the grounds of rejection must therefore be very decided. Several who would have been rejected as pupil teachers were passed. Three cases with a comparatively high degree of myopia were accepted. It may also be noted that several cases were seen with ciliary spasm, in one case wrong glasses, concave, as prescribed by the optician, instead of convex, being the cause. Sixty.six cases were seen more than twice before being passed. The cases rejected absolutely, numbered only sixteen. Six of these were girls who were verminous, and seen many times before rejection. Another had very high myopia, which made her unsuitable for schooling. One had nasal disease (ozcena) which was so offensive that she was unfit for attendance. One had advanced valvular disease of the heart. One had only one eye, and that of exceedingly defective vision (6/24). One was frequently suffering from throat troubles due to enlarged tonsils, which actually met, but her parents could not persuade her to submit to treatment. Probationer scholarships are awarded to enable candidates to ultimately become elementary school teachers. They were noted as follows :— Age. Number examined. Number of examinations. "Fit." Vaccination. Referred back. Absolutely rejected. Unvaccinated. No marks. Want of Cleanliness. Throat. Teeth. Vision. Heart. Sundry. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. 13 19 24 11 3 — — — 2 2 — 1 — 25 30 13 — — 4 1 4 3 1 1 14 195 252 126 11 — — 5 24 23 2 1 3 570 742 399 36 4 48 26 62 37 7 5 10 15 92 114 67 3 — — 1 11 7 1 1 1 345 471 210 22 1 34 7 63 31 G 5 13 10 — — — — — — — — — — — — 5 10 2 — — — — 1 2 — — — Total B. 306 390 204 17 — — 6 37 32 3 3 4 G. 945 1,259 624 58 5 86 34 130 73 14 10 24 Grand Total 1,251 1,649 828 75 5 86 44 167 105 17 13 28 This table does not, however, express to the full the amount of defects found, in the cases referred back only the chief defect is recorded, but of these 17 per cent. had two or more defects. In the case of probationer scholars the examination has to be somewhat stricter than with junior scholars. Articulation which is hopelessly bad was a cause of rejection. Defective vision in six cases, three representing high myopic conditions. One boy had aural suppuration. On the other hand several doubtful cases were passed after the parents had been made thoroughly alive as to the defects of their children, and the need of remedy ; for instance, a girl, aged 15.6, recorded as having " hypertrophied tonsils, speech of nasal character, teeth a few carious stumps, scars from gland operations, rounded shoulders (kyphosis), and very awkward gait; fit for the present" ; or again, a boy 149 heart exceedingly irregular in force and frequency, has recently done much running." The majority of the cases rejected, however, were recorded as " fit for a scholarship, but not as a teacher." These are cases where there are definite signs of organic valvular trouble which would constitute disqualification under the Superannuation Scheme of the Board of Education. Some of these cases must certainly be rejected as, for instance, a girl aged 15 4, who had had to give up a scholarship on account of rheumatism and chorea a year previously, and now had definite mitral regurgitation ; others with valvular insufficiency and actually dilated hearts, but the majority are healthy children, with no troubles whatever, who take part in all games, and are often without a history of any kind of illness. Two boys and sixteen girls were rejected for mitral regurgitation, but of these ten were recorded as fit for scholarship but not for teachers. Considering the nature of a teacher's employment, the absence of great physical efforts, the usual well ordered life of self.restraint, and the freedom from alcoholism or other vice imposed by the nature of their calling, it is probable that in the absence of a rheumatic history these cases have as good an expectation of life as the majority of the population. They should not therefore be cut off from the most suitable occupation, on the chance of their employment resulting in a greater call on the superannuation funds. Some very hard cases arise when pupil teachers have passed through their whole course and final examinations, to be ultimately refused their certificates although recognised as in every way fit for teaching and allowed to be employed in schools, their earning capacity is greatly and unjustly reduced, to protect the Government's superannuation funds against possible risks. Special scholarships include domestic economy, gardening, trade, technical, blind, deaf, cripple, and boy artificers for the Royal Navy. They were noted as follows ; 5 Age. Number examined. Number of exam ina. tions. Fit. Vaccination. Referred back; Absolutely rejected. Unvaccinated. No marks. Want of cleanliness. Throat. Teeth. Vision. Heart. Sundry. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. 13 9 13 5 1 — — — 3 1 — — — 1 1 1 — — — 14 .10 43 37 — — — 1 1 — — 1 — 72 107 37 3 — 10 5 11 3 — 6 —— 15 53 00 42 2 — — — 2 4 — 1 7 25 40 9 3 — 5 — 6 3 1 — 1 10 36 42 30 1 — — — 2 4 — — — 24 27 20 1 — — — 1 — 1 1 1 over 2 2 1 — — — — — 1 — — — 10 7 8 6 — — — — 1 — — — — Total B. 143 150 115 4 — — 1 8 10 — 2 7 G. 129 183 73 7 — 15 5 19 6 2 7 2 Grand Total 272 339 188 11 — 15 6 27 16 2 9 9 6 Children were also selected individually from their classes, and reported with defects as follows :— External diseases of the eye. Throat or nose affections. Ear disease. Excessive " dirt." defects. N..P. schools 374 508 201 50 209 Council schools 1,243 2,157 789 150 1,215 Total 1,617 2,725 990 200 1,484 Very many more children are, however, seen than are thus reported to the head office. Where any doubt about alterations or the sanitary condition had arisen in connection with the transfer of Non.Provided schools, complete sanitary reports were furnished, and during the early part of this year very much time had to be given to this work. Apart from such survey work complaints have come in and reports been furnished in the ordinary course. These complaints are much less numerous than in previous years, but they do not indicate that many conditions requiring relief and previously reported on are not still in existence. Lighting. Ventila Heating. Sanitation. Furniture, tion. Non.provided schools Good 25 11 14 12 15 Fair 18 15 10 12 12 Bad 41 30 13 9 42 Good 90 72 75 08 71 Fair 10 10 14 7 5 Bad 50 25 10 5 12 EXAMINATION OP INFANTS. The Medical Inspection of infants is likely soon to assume great importance. It is at thetse ages that slight defects or diseases have such a profoundly modifying influence on the future, and it is of especial importance to have children examined at the ages of three to five years, to detect the beginnings of diseases, such, for example, as tubercular bone and joint diseases, which if not caught early result often in producing permanent injury or crippling. In a previous report the importance in other respects of attendance of quite young children in town schools has been insisted upon to the reasons there given might be added medical superintendence of the young child's growth. With the staff at disposal detailed examination is almost impossible, but some attempt has been made by sampling to ascertain what medical inspection of infants really means and what it is likely to lead to. Dr. Niall took fourteen schools, varying from slum areas of Vauxhall and North Lambeth, through artisan areas of Lambeth and Kennington to the vastly different districts of Brixton and Norwood. The effect of environment is at once apparent in that the survivors of the slum children at the age of five are as a rule sturdier and quicker than the more carefully nurtured children, who have not been exposed to hard climatic conditions, and who on the other hand appear to present larger numbers with anaemia, nasal obstruction, glandular troubles, and of dull and backward children. Information as far as the teachers could furnish it, was taken regarding the district, parents, amount of female labour, and so on. Children were then examined as presented by the teachers and finally inspected for various defects—physique, anaemia, mouth breathing as they sat in their desks. Any presenting obvious defects were brought out; they were never stripped. This method will give results which are considerably understated. Of 5,340 children in attendance 14.9 per cent., nearly 1 in every 7, was selected as requiring detailed examination. Two neighbouring schools, Walnut Tree.walk (9.3 per cent.) and Lollard.street, presented the lowest and highest number defective. The school with the highest proportion (26'7 per cent.) defective was Lollard.street, a poor district abounding in fried.fish shops. Many of the mothers are wage. earners, returning home late at night, too tired to take any interest in the welfare of the child. Semi. starvation and home neglect are important factors in producing the unhealthy conditions found. The high percentage here, too, was due in great measure to the number below the average mental ability in Grade IIBb. This is a dullard's class, and contained 47 per cent. of children with some defect. It is for such a class more particularly that early medical inspection will do much as early discovery of defects permit of their correction and in many cases prevents irreparable damage being done; cases of corneal ulceration, marginal blepharitis, early cases of ophthalmia and otitis being detected, and Council Schools 7 presumably remedied. Walnut Tree.walk presented a much smaller class of this kind, and this was the case in several schools. By careful supervision from the head teachers, and co.operation of the class teachers, many parents had been informed of children's defects, and persuaded to have them remedied, and it appeared to be due to such supervision that the numbers had been brought so low in these particular schools. Dirt conditions are the most obvious and very harmful, especially to the eyes, nose and ears, ulceration of the surface of the cornea often leaving permanent damage. In many cases the parents will do nothing even when asked by the teachers. In one class were three children with vision less than due to phlyctenular inflammation, which had been existing for months in spite of the parents having been frequently asked to have the condition attended to. These dirt inflammations in children of debilitated condition are the chief disease conditions of the slum schools, and in many cases for remedy require removal to a different environment as in a residential country school. In the schools attended by children of the well.to.do artizan, the clerk, and small shop.keeper the children are often over.clothed coddled and pampered, and lymphatic conditions from want of exercise, enlarged tonsils, adenoids and anaemia are essentially the troubles of these better class schools. Of the children the percentages with obvious defects were :— Percentage of children in attendance; Percentage of all the children with defects having particular defect. Vision 2.9 19.8 Hearing 1.2 7.7 Physique 4.1 27.5 Speech defects 0.78 5.25 Mental defects 1.4 9.75 Tonsils and adenoids 4.7 31.5 Enlarged cervical glands 2.1 14.5 Discharge from ears 0.5 3.5 In five schools of Hammersmith and Fulham Miss Janet Campbell inspected the new admissions to the infants departments together with a few older children, and actually recommended 196 out of 909 examined to have some form of medical treatment. Of the 104 newly admitted infants at Campbell.street, Mr. Elmslie noted 46 as having defects requiring remedy. The age of new admissions varies much with the district, as pointed out by Dr. Marion Hunter, in reporting on six Wandsworth schools. She classified them as poor, medium and better class schools and worked out the average ages of the newly admitted children presented to her as 3 9/12, 4 5/12. and 5 years old. The methods of examination and making returns are shown from these enquiries to require some standardising. If it is decided to extend medical inspection to each child the best method will be to adopt a card system, having a card filled up at the time, or better, previous to admission to school. A definite but simple scheme of examination being followed under uniform conditions, investigating matters likely to in any way affect the child's school life and avoiding all matters, whether statistical or anthropometrical, which might be regarded as merely of scientific interest. It will probably be legal in London under the General Powers Act to inspect any child as to person or clothing. The value of the first examination varying from two to ten minutes for each child, would be much enhanced if the mother could be present, and give an account of the child's history, especially as regards infectious disease. It would save the admission to school of cases with dirty heads, impetigo, ringworm, pediculi, seriously enlarged tonsils, or adenoids, defective vision, or contagious eye disorders, also the deaf, blind or physically defective and reduce the bulk of after inspection and the necessary staff required. The attention of teachers would also be directed to children from the very outset, where special treatment was required on account of nervous or other disorders, so that friction, suffering and even some of the risks of school life would be diminished. The institution of a weekly clinic at the Head Office for the detailed examination, under manageable conditions, of the various difficult cases arising during the week in the special schools examinations has greatly simplified and relieved administrative treatment. From this experience it may be taken as a necessity for many cases that they should be completely examined in detail as regards eyes, ears and certain other matters. Probably such examinations will be best conducted at special centres where large numbers can be rapidly and effectively handled. The establishment of general medical inspection means sooner or later the establishment of school clinics for treatment in quite restricted and defined ways. This treatment would be of the common cases, for instance, of abnormal refraction of the eyes requiring retinoscopy to ascertain whether the help of spectacles was indicated, the fitting of such with spectacles, the cases with discharging ears, cases of skin diseases like ringworm, favus or verminous conditions and scabies ; cases requiring dental treatment. Without such treatment mere medical inspection is incomplete, and in the majority of cases time and trouble wasted. 8 Most of these cases, even when known, are neglected. Their hospital treatment is often a serious tax on the parents. A few are attended to at hospital, but generally this is unsatisfactory, and of late very many cases have been refused treatment. If individual medical inspection becomes general then probably for eyes and ears, as has been indicated for teeth, all the hospitals in London would not provide for one.tenth of the children who should be treated. The question of school clinics ought therefore to shortly become a subject of careful enquiry. It is essentially an educational matter, and should not be complicated by any other considerations whatever than the health of the children in relation to education. Such clinics, if established, would also be useful for the further examination of many cases referre d from the preliminary examinations in school. MEDICAL INSPECTION OF SECONDARY SCHOOLS AND TRAINING COLLEGES. In April, 190G, it was decided that arrangements should be made for periodical medical examination of pupils in the Council's secondary schools. The medical superintendence of the schools, hygiene of buildings and general matters, is done by the permanent office staff. As the majority of the pupils are girls in their 'teens, the individual handling of these girls is done by medical women, except in special cases where they desire further consultation. Each pupil is separately examined on entering the school, and a regular medical report form filled up. This is kept at the school in a " Doctor's Book," but it will be preferable later to have a card system. It adds considerably to the working capacity of the pupils, especially in the case of girls, and prevents illness, if they can have access to lay any matters which they desire before the medical officer. A regular consultation day is therefore arranged about once in six weeks, when any pupil may see the doctor in regard to any trouble affecting their work such as headaches, neuralgia, sore throat, sleeplessness, or overfatigue, which would otherwise generally be allowed to run on unrelieved. The parents were present in many cases, and appreciated the doctor's examination of their children. Head Teachers are quite unanimous in regard to the fundamental importance of this work in these schools where the physical condition of the children is considerably below the type of high school girl, to which most of them have been accustomed. They feel the great help of medical examinations. They have altered time tables, arranged special classes, and made individual arrangements to suit particular pupils according to the doctor's advice. Pupil teachers have to be certified for the Board of Education, and they must be passed only if it can reasonably be expected that they will eventually qualify as teachers in accord with the Teachers' Superannuation Rules, which last urgently require overhauling and exactly defining. The Council;has eight pupil Teacher Centres with 1,700 students and the system of medical supervision for secondary schools is also applied to these centres. For Training College students the Board of Education requires an entrance certificate of fitness and at the beginning of each year of study a certificate that the student is in such health as to be able to continue their course of study. But quite apart from these legal requirements, the experience already gained has demonstrated the value of medical superintendence. Dr. Brincker, who has been inspecting the boys during February and March, examined those at PaddingtonTechnical School, and some of those at Hackney Downs Secondary School. The schools themselves were quite sanitary. The general physique of the boys much better than those of the elementary schools. One or two poorly.clad children were found, showing signs of ill.nutrition, and in one case it appeared as if the education was too great a stress on the boy, that he was not able to benefit by it, and was suffering in health. The following are notes of special points concerning these boys :— Vision.—28 per cent, were defective, 10 per cent. already had glasses, but in nearly half these appeared unsuitable. The other boys had never had glasses. Many apart from failing to pass vision tests, showed signs of eyestrain, e.g., headaches, conjunctivitis, blinking or smarting of the eyes, or swollen eyelids. Hearing.—One or both ears were found defective in 7 per cent. boys and in nearly half of these there was aural discharge present. Cardiac and Pulmonary Signs.—Heart symptoms were present in 9 boys (7 per cent.), three of these having a rheumatic history, and four others showing rapid pulse and cardiac dilatation with hypertrophy of muscle, associated with irregular and rapid growth. Chronic bronchitis was present in three cases, and one case was apparently old and arrested phthisis without active symptoms. At the Day Training College at Offord Road, the premises at present are somewhat overcrowded. The men there are the three.year students under Dr. T. P. Nunn, and the two.year students under Mr. Dexter. The three.year students will remove this autumn to the new college at Southampton Row, which will relieve any overcrowding. The cases here are picked men and practically without defects of serious nature. A general ignorance of how to expand the thorax by deep inspiration was noticed in making measurements of the basal girth of the chest. The anthropometric records will become of value when comparisons can be made between different years and a greater number have been collected, when they will be published. 9 The following tabular statement is for boys and men only:— Name of Secondary School or College. Number of Visits to School. Number on Roll. Number examined. Two or more defective teeth. Defects of Vision. Throat or nose. Hearing. Discharging ears. Heart. Lungs. Anaemia. Physique. Clothing. Nutrition Want of Cleanliness. h. Suitable glasses. Unsuitable glasses. Signs of Eyestrain. Paddington Teohnical 6 63 61 33 1 2 13 9 1 — 4 1 4 3 1 — — 5 Hackney Downs (late Grocer's) 8 426 73 50 7 4 11 12 8 4 5 3 3 1 1 2 1 8 Total 14 489 134 83 8 6 24 21 9 4 9 4 7 4 2 2 1 13 Day Training College 16 121 91 33 24 12 6 3 1 — 10 — — — — — — — GIRLS.—Since September, 1906, Dr. Annie Gowdey and Miss Campbell have been engaged on the inspection of the girls in the secondary schools and training colleges. They made detailed reports of every girl seen; some 1350 girls passing through their hands. In the secondary schools 12 per cent. showed lack of cleanliness, either of skin or hair or both, quite apart from any neglect of teeth. This is too low an estimate of the average condition as notice had generally been given, and the children were specially prepared for medical examination. About 15 per cent. were below the average nutrition and 24 per cent. anaemic. Headaches were complained of by 20.5 per cent., in many cases without obvious cause, but in others anaemia, defective vision, stomach troubles, and reading late at night were frequently noted. Exaggerated movements, corrugated foreheads, insomnia and somnambulism were met with. Several cases of overstrain were specially reported. Similar conditions were found in the training colleges, but the standard of personal cleanliness, although not always quite satisfactory, was of course much higher, and the use of the toothbrush better understood. The prevalence of spinal curvature has been mentioned on page 18. With regard to general physique, this varied considerably in the colleges. The highest standard was observed in the Two.Year Department at OfEord Road, where the students showed a particularly good physique, and were above the average in height and weight. They are chiefly drawn from the country, and are those not attempting a university degree together with their training course, or are those who have failed to satisfy the requirements of more advanced colleges elsewhere. At Avery Hill and Greystoke Place, where the academic aims are more ambitious, the average physique was much lower in comparison. The most striking fact brought out by the medical inspection seems to be ignorance of the ordinary elementary rules of health. With these girls a course of hygiene should take a leading and prominent position in the school. The overloaded literary and academic nature of the curriculum will no doubt ere long be remedied, and more rational studies be substituted, especially in the preparation of future teachers. The average standard of physique is low. Cleanliness of the teeth, hands, nails, skin, and hair much neglected. The necessity for a frequent bath, that a daily wash should embrace more than the face and hands, and that the same undergarments should not be worn during the day and night has had to be frequently insisted on. Name of School or College. No. on Roll. Visits paid. No. completely e jammed. Defects requiring improvement in. Backs. Eyes. Throats. Hearts. Ears. Glands. Teeth. Lungs. Lack of cleanliness. General physique. Secondary schools— Eltham 67 5 46 24 8 1 — 2 2 16 — — 9 Fulham 225 12 135 51 22 18 1 8 3 32 — 8 9 Hackney 190 10 112 68 25 45 3 3 8 54 (?) 1 30 17 Kentish Town 237 10 100 47 20 25 7 1 — 39 — 4 14 Kingsland 185 7 64 51 18 26 7 2 2 24 (?) 1 15 21 Manor Mount 100 4 29 17 4 2 2 1 1 8 — — 17 Paddington 133 5 36 16 10 9 3 — 1 22 — 4 2 Peckham 233 12 83 34 18 4 — 6 4 28 — 20 8 Stockwell 228 7 87 40 10 7 2 9 6 30 — 5 7 Southwark 116 11 82 33 25 21 5 2 1 38 — 17 14 Sydenham 118 7 63 47 15 6 1 4 3 22 — 1 14 Total 1,932 90 837 428 175 144 31 38 31 313 (?) 2 104 132 Percentages — — — 5.0 20.9 1.7 3.7 4.5 3.7 37.4 12.4 15 Training colleges— Avery Hill 159 9 63 21 18 1 4 2 — 16 — — 13 Grays toke.place 147 14 98 38 26 1 3 2 — 35 — 1 23 Southampton.stree (a) 2 year 180 28 141 27 36 6 6 1 70 1 1 7 (6) 3 year 80 — 75 21 24 10 3 1 —— 42 1 — 6 Total 566 51 377 107 104 18 16 5 1 163 2 2 49 Percentage 28"4 27.6 4 7 4 1.3 — 43 2 — — 13 149588 10 In addition 13G students were incompletely examined. Of these 22 had defective teeth and 26 defective vision. STATISTICS OP GROWTH, Etc. In last year's Report the statures and weights of three groups of schools were given. Group A.—(English measures originally) chiefly poorer class schools.—Ackmar.road, Beaufort House, Glenister.road, Old Woolwich.road, and Columbia.road, including 3,038 boys and 3,084 girls. Group B.—(Measurements taken on the metric syBtem) in the Acland, Burghley.road, Gipsy. road, Bellenden.road, Dulwich Hamlet, Bell.street, Buckingham.street, Rosendale.road, Honeywell. road, Michael Faraday, and Salters Hill Schools. With two exceptions these might be described as suburban schools. The numbers dealt with were 4,677 boys and 4,174 girls. Group C.—(Measurements made in 1905) at Capland.street, Honeywell.road, Prospect.terrace, Victory.place, Leipsic.road, and the Michael Faraday, 1,861 boys and 1,612 girls. These groups were taken in statures and weights, with reference to the sex and age last birthday. The arithmetical averages, probable error, standard deviation and co.efficient of variation has been determined as given in the tables which have been calculated by Dr. Shrubsall. WEIGHTS OF LONDON CHILDREN. Age last birthday. Series A. Series B. Series C. Average weight in kilos. Probable error. ± Standard deviation. Co.efficient of Variation. Numbers examined. Average weight in kilos. Probable error. ± Standard deviation. Co.efficient of Variation. Numbers examined. Average weight in kilos. Probable error. ± Standard deviation. Co.efficient of Variation. rs examined. Boys: 6 20.22 .19 2.2136 10.95 58 7 22.18 .15 2.8193 12.31 159 22.00 .09 2.6683 12.13 417 21.31 .19 2.5981 12.19 86 8 23.76 .08 2.6364 11.10 460 23.85 .07 2.7622 11.58 674 22.73 .10 2.4433 10.75 251 9 25.49 .08 3.0028 11.78 563 25.77 .07 3.0232 11.73 760 24.27 12 3.0066 12.39 285 10 27.56 .11 3.4609 12.56 436 28.22 .08 3.2634 11 56 710 26.64 .12 3.3015 12.39 346 11 29.61 .11 3.4173 11.54 440 30.67 .10 3.6729 11.98 635 29.28 .14 4.0595 13.90 386 12 32.06 .12 4.0575 12.65 506 33.42 .10 4.0521 12.12 704 31.60 .14 3.9319 12.44 364 13 34.86 .16 4.9585 14.24 438 36.93 .14 5.4479 14.75 642 34.21 .20 5.3768 15.72 307 14 37.30 .54 5.0713 13.60 36 40.99 .37 6.5015 15.86 135 35.72 .41 5.9346 16.61 94 15 44.35 .10 7.0590 15.92 20 36.50 1.30 8.0913 22.17 18 Gib ls : 6 19.74 .16 1.9748 10.00 70 7 21.30 .13 2.6056 12.24 181 21.09 .09 2.3749 11.26 328 21.03 .32 2.8125 13.37 35 8 22.52 .08 2.6554 11.79 494 23.18 .08 2.9034 12.53 580 22.89 .19 3.0806 13.46 246 9 24.55 .08 2.8611 11.56 540 25.36 .08 3.2970 13.00 647 24.50 .13 3.0166 12.31 232 10 26.83 .09 3.1218 11.64 546 27.59 .09 3.4088 12.36 643 27.10 .17 4.0150 14.82 256 11 29.44 .13 4.2302 14.37 449 30.59 .11 4.1473 13.56 646 29.35 .16 3.9421 13.43 268 12 33.10 .17 5.2421 15.83 420 33.98 .15 5.5525 16.34 574 32.84 .23 5.5018 16.75 256 13 36.81 .20 5.9655 16.20 410 38.56 .18 6.6325 17.20 592 37.33 .26 6.2378 16.71 255 14 40.16 .70 6.5682 16. 36 43 42.48 .33 6.3592 14.97 166 40.91 .56 5.7131 13.96 46 15 44.56 .87 6.5246 14.64 25 42.59 1.10 6.7387 15.82 17 HEIGHTS OF LONDON CHILDREN. Age last birthday. Group A. Group B. Group C. Average height in centimetres. Probable error. ± Standard, deviation. Co.efficient of variation. Numbers measured. Average height Probable error. ± Standard deviation. Co.efficient of variation. Numbers measured. Average height. Probable error. ± Standard deviation. Co.efficient of variation. Number measured. Bo ys : 6 111.66 .52 6 .0017 5.37 58 7 115.8 .30 5.8040 5.09 159 116.27 .20 6.1384 5.28 417 114.81 .49 6.8425 5.96 86 8 119.5 .17 5.9250 5.04 460 121.72 '16 6.2024 5.09 674 118.95 .24 5.7463 4.83 251 e 124.7 .15 5.8750 4.79 563 126.29 '14 5.7559 4.56 760 123.09 ..26 6.5551 5.33 285 10 129.1 '20 6.1012 4.81 436 131.15 '16 6.3545 4.85 610 127.74 .23 6.5559 5.13 346 11 133.4 ..20 6.1500 4.69 440 135.82 '18 6.7268 4.95 635 132.54 .54 7.5352 5.69 386 12 137.3 .20 6.4281 4.75 506 140.47 .18 7.0434 5.01 704 137.03 .24 6.8731 5.02 364 13 141.9 ..22 7.0745 5.06 438 145.42 ..20 7.7846 5.35 642 140.96 .31 8.1449 5.78 307 14 144.6 .78 7.0750 4.92 36 152.54 .49 8.7017 5.70 135 144.49 .59 8.6157 5.96 94 15 157.15 1.31 8.6389 5.50 20 144.44 1.80 11.6187 8.04 18 GIRLS :. 111.36 .37 4.6292 4.15 70 7 115.7 .30 5.9500 5.22 181 115.31 .20 5.4360 4.71 328 116.0 .61 5.4562 4.70 35 8 119.2 .17 5.9112 5.03 494 121.22 .18 6..2626 5.17 580 120.53 .26 6.1221 5.08 246 9 123.5 .17 6.0749 4.99 540 125.83 .16 6.2522 4.97 647 124.49 .26 5.9034 4.74 232 10 128.8 .17 5.9498 4.68 546 130.89 .17 6.5772 5.02 643 129.52 29 6.9231 5.35 256 11 133.5 .22 7.0736 5.37 449 136.14 .20 7.5020 5.51 646 134.31 .27 6.5567 4.88 268 12 139.3 .25 7.8050 5.67 420 141.93 .22 7.9687 5.61 574 140.34 .34 8.2085 5.85 256 13 144.8 .27 7.9563 5. 65 410 147.82 .22 8.1185 5.49 592 146.17 .35 8.3313 5.70 255 14 148 .6 .70 6.8455 4.68 43 153.77 .37 7.1302 4.64 166 151.11 .75 7.2511 4.79 46 15 155.80 .81 6.1579 3.95 25 151.18 .94 5.8241 385 17 11 The standard deviation is the error of the mean square. It is ascertained by adding up the sum of the squares of the individual variations from the arithmetical average and after dividing by the total number of observations, taking the square root of the result. It is usually called σ The table shows how to set about this ; taking the II year old boys of Group B as regards heights. HEIGHTS OF 11 YEAR OLD BOYS OF GROUP B. Dimensions. Number of individuals in each group. Deviation from centre. Dimensions. Number of individuals forming group. Deviation from centre. Z. X. ZX. ZX2. Z. X. ZX2 ZX2 113 1 23 23 529 136 114 — 22 — — 137 34 1 34 34 115 — 21 — — 138 36 2 72 144 116 1 20 20 400 139 38 3 114 342 117 3 19 57 1,083 140 27 4 108 432 118 1 18 18 324 141 31 5 155 775 119 5 17 85 1,445 142 21 6 126 756 120 4 16 64 1,024 143 17 7 119 833 121 2 15 30 450 144 18 8 144 1,152 122 1 14 14 196 145 14 9 126 1,134 123 5 13 65 845 146 12 10 120 1,200 124 9 12 108 1,296 147 11 11 121 1,331 125 8 11 88 968 148 5 12 60 720 126 13 10 130 1,300 149 5 13 * 65 845 127 10 9 90 810 150 7 14 98 1,372 128 14 8 112 896 151 1 15 15 225 129 17 7 119 833 152 2 16 32 512 130 33 6 198 1,188 153 3 17 51 867 131 23 5 115 575 154 1 18 18 324 132 42 4 168 672 155 — 19 — — 133 31 3 93 279 156 — 20 — — 134 41 2 82 164 157 1 21 21 441 135 37 1 37 37 158 — — — 136 50 0 — — 159 — — — — - 1,716 635 + 1,599 28,753 The dimensions must first of all be set out in the form of a seriatim table, the numbers of individuals forming the group in each dimension must be recorded in Column Z. The average of this series can be ascertained from inspection to be about 136 centimetres. Regarding this as centre the other dimensions can be taken as units above, positive, or below, negative. This gives column X. Then the products of ZX are calculated and added up. In this case there are 1,716 negative and 1,599 positive units, giving a total sum of 117 negative unit6. This number divided by the total number of observations made, 635, gives a quotient .18, which has to be subtracted, because the negative units were in excess, from the arbitrarily chosen centre, to give the arithmetical average 136 —.18=135.82 centimetres as average height. The products ZX are then once more multiplied by X, the amount of deviation from the arbitrary centre, to obtain ZX2, all being now positive. The sum of this column ZX2 divided bv the number of observations N (the sum of column Z) gives As the deviation was from the arbitrarily chosen and not true average, to correct this the square of the difference between the arbitrary centre and the true average must be tracted. That is' the square of in this case So that 45*283 —•03 = 45*2511. This is the square of the standard deviation or σ2 and =45.2511 therefore <r = 6*7268 The probable error of the average is The significance of the difference between the averages of any two groups of similar character can be determined by the relation this bears to the value of the square root of the 6um of the squares of the standard deviation of each divided by the total number in each group, this is in symbols When the difference between the averages (A, A.) is just equal to this; that is A—A, = the odds are that the difference is due to chance. When the odds are 49 to 1 against chance or random selection, but with the difference A—A2 = the odds are 1,000 to 1 against, and with four times they rise to 333,000 to 1 against a chance selection being the explanation. 14968 B 2 Diagram I. For each group the odds are a thousand to one that any subsequent average taken from the same material will fall within the limits of the original average A + 3 σ/N, σ being the standard deviation and N the number of observations in the original group. For each group of schools and for each age and sex these limits have been calculated both for stature and weight. The ordinates represent statures in centimetres and the abscissae weights in kilograms. They are shown in the charts for the three groups, A, B, and C schools for each year of age, and for boys and girls separately. 12 Thus the average stature of boys of 11 years old was for 635 boys in the schools of Group B equal to 135'82 cm., ascertained as shown above, and for 386 boys in schools of Group C 132.54 cm. To test the significance of this difference. A2— A2. = 135.82 — 132.54 = 3.28 cm., and from the table and σ2 are found, then but the difference of the averages ( A2 — A2) is about seven times as great, i.e,.,3.28 /.4673 = 7.1, and the odds are many millions to 1 against random difference, so that some definite factor must be acting. So, too, with groups A and B. The difference between the averages is about six times as great, again meaning millions to one against chance or random sampling, but between groups A and C, it is found Group A. Average height A2 133 4 Number 440 σ =6.1500. Group C. Average height A2 13254 Number 386 σ=7.5352. Now .86/.48 = 1.8 so that the odds are only thirty to one against random selection, and this is not enough to establish a real difference between them, or allow any definite conclusion to be drawn from their difference. The probable error of a series of observations is that divergence from their mean on either side within which exactly half the observations lie. The co-efficient of variation is the figure obtained by dividing the standard deviation of a group, multiplied by one hundred, by the arithmetical mean. It gives a value for the variation of a series independent of the unit employed. Roughly speaking, the amount of variation in groups, in which a sufficiently large number of measurements has been made increases with age. These three groups will serve as standards with which any subsequent averages may be compared. The results may perhaps be more clearly shown graphically in diagrams I., II., III. 13 Thus the average stature of girls in the schools of Group B at the age of 8 last birthday was 121*2 cm., the number measured N = 580, and the standard deviation σ = 6"2626, the value of 3 σ/N is therefore therefore .8. The range of stature within which subsequent averages might be expected to fall is 1212 + .8, that is from 1204 to 122 cm. Similarly the range of weight will be 22.8 to 23.6 kilos. Taking the averages 1212 and 23-2 as the centre and the limits as the angles a rectangle has been plotted out which shows the area within which it is 1,000 to 1 all subsequent averages should fall. Similar rectangles are drawn for other ages and groups. When the edges of such a rectangle Diagram II. do not overlap those of another rectangle belonging to the same age group it may be definitely concluded that some cause other than chance has been responsible for the differences observed. When they do overlap chance is not definitely excluded, though this does not prove that no other explanation is possible. In the diagrams the dimensions of the children in the schools of group A are represented by rectangles with dotted outlines, group B with continuous lines and group C with dot and dash. When, as sometimes occurs, the rectangle of one age group overlaps that of another age group, the differences must not necessarily be taken as due to chance, since the material, that is children at different ages, 14 is not homogeneous, and comparison can only be made age for age. The diagrams show that children in the schools of group B (suburban) are at all ages above 7 superior in physique to those in Groups A or C. and that from eleven years of age upward in the case of boys the superiority is such that they catch up the children a year older in the other (poorer) schools. In the case of the girls the retardation in the other schools is not so marked. The differences in schools of groups A and C are less marked. Diagram III. At first sight it would appear as if environment was the cause of these great differences amounting to nearly a year's growth between schools of Group B and Schools of Groups A and C, but Dr. Shrubsall points out that the racial differences between different parts of London are very great and that the fair-haired elements of the population are generally of taller proportions than the dark individuals. He has himself observed that the centre districts of London present more dark elements, and unless this question is regarded it is impossible to ascribe the main factor to environment. This racial element showed up in the preponderance of fair-haired children submitted as debilitated and delicate in connection with the open-air school started since the above paragraphs were written. 15 An analysis of children aged 10 in relation to standard and height was made in the last Report, and illustrated by diagrams. Setting out the data derived from these the following table is obtained:— STANDARDS AND STATURE, 10 YEAR OLD CHILDREN. Standard Average Stature c.m. Probable Error σ Standard Deviation Numbers Observed. σ2/N Coefficient of Variation; Boys I. 128.27 ± '85 5.9942 22 1.6318 467 II. 126.25 ± .52 5.7061 53 .6143 4.47 III. 130.02 ± .30 6.1139 183 .2043 4.70 IV. 131.03 ± .24 6.0918 273 '1359 4.62 V. 133.29 ± .33 6.1302 153 .2456 4.60 VI. 135.53 ± .90 5.7532 19 1.7421 4.24 Girls I. 125.25 ±.111 7.4283 20 2.7591 5.93 n. 125.76 ± 6.9599 33 1.4375 5.52 in. 129 43 ± .28 6.3561 233 .1734 4.91 IV. 13170 ± 6.0216 250 .1450 4.57 v. 133.77 5.6754 94 .3427 4.24 VI. 135 08 ± 1.02 5.3132 12 2.3525 3 93 These show that the difference is a real one, and quite exclude the possibilities of random sampling. The co-efficients of correlation between stature and mental attainment as defined by standard obtained by the process given on pages 15 and 16 are very high. The result gives for boys r = .39 ± 0.02 and girls r= .52+0.20 CALCULATION OF CORRELATIONS. The method of calculating the correlation between two immeasurable quantities, for example, the relation between boys' vision and mental intelligence as measured by their school standard, is of some importance in testing conclusions otherwise attained. In the table given on page 33 of the Report for 1905 will be found the analysis and standard of 5,708 boys aged 10 last birthday. as to vision Vision. Good. Fair. Bad. Totals Standard I. 50 28 14 92 70.56 1475 6.69 20.56 13.25 731 422.71 175.56 53 44 „ II. 205 80 36 321 246.20 51 46 23.34 41 20 28 54 1266 1 697*44 81453 160.27 „ III. 1,634 398 157 2,189 1,678.94 350.90 15914 44 94 47.10 214 2,019 60 2,218.41 4.58 „ IV. 1,695 284 148 2,127 1,631.39 340.96 154 63 63.61 56.96 6'63 4,046.23 3,24444 43.96 16 Vision. Good. Fair. Bad. Totals. Standard V. 641 97 49 787 603.62 126.16 57.21 37 38 29.16 8.21 1,397'26 850.30 67.40 " VI. 134 26 11 171 13115 27.41 1243 2-85 1.41 1.43 812 1.99 204 " VII. 19 2 0 21 1611 3.37 1.53 2.89 1.37 1.53 8.35 1.88 2.34 4,378 915 415 5,708 Grand total. In this table is given against each standard the number of boys with good, fair, or bad vision. The columns are then added vertically and horizontally. The number that should fall in each group if the distribution were uniform, that is if the distribution were the same in each standard as it is in the total number, is then calculated by multiplying the sums of intersecting columns and dividing by the total number. The quotient is then placed under the original figure (the second set of figures in each square.) Thus the theoretical number for good vision in Standard I. is for fair vision in Standard I. Dr. Shrubsall, who has calculated the correlation between acuity of vision and intellectual attainment as measured for each standard from the data obtained in the Council schools (1905 Report, p. 33) finds this correlation (r) to be :— Boys. Girls. Ages last birthday r Probable error ± Ages last birthday. r. Probable error. ± 9 .120 .010 9 .159 .007 10 123 .007 10 .123 .009 11 113 .007 11 .130 .008 12 .133 .008 12 .120 .009 The co-efficient of correlation exceeds its probable error in each case to such an extent that it shows a definite relation to exist between acuity of vision and school attainments. DENTAL CONDITIONS. In the last two Reports attention was called at some length to the unsatisfactory dental condition of the elementary school children, and it was shown that the more carefully they were examined the greater the amount of destruction and disease found. Dental care is wanted at all ages. Dr, Marion Hunter, in reporting on infants at the time of admission to school, gives instances of the and so on. The difference of the theoretical and actual numbers in each division is written down (the third number in each square). The result is squared, so that all results are positive. Thus in Standard I 50 is the actual number of good vision, 70.56 the theoretical. The difference is 20.56 and the square of this 422.71. This is now divided by the theoretical number 70.56 and the quotient, expressed to at least two places of decimals, is written down in a column with the other similar results. The sum of these quotients then (x2) is found for this particular example to be X4 = 88'38. This divided by the number of observations that is The co-efficient of correlation And the probable error of this co-efficient is 17 dental conditions actually existing. Out of 700 only 20 had no obvious decay, 205 had two, 152 from three to five, and the rest more, teeth in a carious condition. The following are individual instances :— Boy, aged 5 1/12, had not one tooth, merely offensive stumps. ,, ,, 3 7/12, had 7 teeth out and 5 stumps remaining. ,, ,, 4 9/12, had 11 stumps. >, ,, 4 9/12, had 14 stumps. „ „ 4 8/12, had 17 stumps. Girl, aged 5 2/12, had only 2 teeth left With such dreadful oral conditions and the constant absorption of septic material the chances of healthy childhood are small for most of these infants, although the popular idea seems to be that milk teeth do not matter. During the year dental care has been instituted for children over 10 years of age in the schools for the deaf. This is a matter of especial educational importance in connection with the teaching of articulation. The teachers have to come into close contact with their pupils, and foul or septic conditions of the mouth are often intolerable. The attention confined to children over ten should, however, be extended to all ages. The observations made in the schools were carefully checked by Mr. C. Edward Wallis, who voluntarily examined many children at the Michael Faraday School, and who is able to compare them with the children of the Council's two industrial schools at Mayford and Feltham. The boys are younger at Mayford and the importance of beginning young is emphasised by the greater care these boys seem to take for their teeth. Surprise visits at both schools, however, show the teeth to be usually in most excellent condition. From the work at Feltham, where there are usually about 540 boys and about 125 annual admissions, some idea can be obtained of the amount of treatment required to keep mouths in order. The first step is the inspection of the mouths. A large number of necrosed teeth were found in situ, and as a result alveolar abscesses, gingivitis, inflamed tonsils, and enlarged glands were prevalent. Having selected those to be treated, from 15 to 20 were seen at each weekly visit, and all teeth so diseased as to be incapable of being rendered healthy and efficient for the purposes of mastication and maintaining the proper growth of the jaws were removed, to as speedily as possible improve the condition of their mouths and consequently the general health. At first the time was almost wholly given over to extractions. No anaesthetics were given or required. As far as possible all were removed at one sitting, and the boy then told that so long as he kept his mouth clean he would have no further teeth out. The removal of the septic teeth alone produced a great improvement in general health, from diminution of the cases of sore mouths or throats, tonsilitis and enlarged glands. The teeth requiring stopping were then taken in hand, and only 15 boyB, but often not more than 12, could be managed at a visit. Assuming that 15 to 20 are seen every morning and afternoon, from 75 to 100 children will, as a rule, be dealt with weekly, or 6,000 to 8,000 yearly, by a dentist working all the time. The secondary schools and training colleges show dental conditions among their pupils which, considering their age and status, are no better than the conditions of neglect and offensiveness found in the elementary schools. Of the 134 boys examined at Paddington Technical School and at Hackney Downs 62 per cent. had two or more decaying teeth. In many cases there were spongy gums, and two had suppurating conditions (pyorrhoea alveolaris). Among the men.students at Ofiord.road neglect of the mouth was general, and several cases had suppurating conditions, the foulness in some being almost as offensive as ozoena. Among the girls of the secondary schools, for aesthetic reasons, the conditions are somewhat better, but one.third (37 per cent.) required improvement. Some never used a tooth.brush, some once a month, or once a week, and so on, and few appeared to realise the importance of the hygiene of the mouth. In the training colleges, although 43 per cent. are returned with dental defects, the use of the tooth.brush and attention to oral hygiene is much better, although there is yet great room for improvement. Hitherto the futility of mere examinations without treatment in dental cases has made the employment of school dentists scarcely a matter of practical politics. The experience of the last three or four years in Germany has, however, altered this. Professor Jessen, of Strassburg, from his dental work in connection with the army, was led to turn his attention to preventative measures among the school children. He has worked out a scheme for school dental care which was taken up by the municipality, and is now being adopted as the pattern throughout central Europe. During a recent visit to Strassburg this work was shown and demonstrated, and the work conducted on somewhat similar lines in other towns was also seen and enquired into. It is obvious that dental caries is the most widespread affection among the population, and as a result the working capacity, and even earnings, of large numbers of the population is seriously affected. Dental hygiene must be taught in school, but the continental experience shows that examinations and teaching are useless, unless followed by the practical measures of inculcating and enforcing cleanliness among the children, and providing remedial treatment. Most of these children will be neglected if left to private enterprise. The affection is so insidious and so widespread that it should be met by public provision. There is no way of dealing with money in the interests of public health which will return so enormous a gain to the population for the small expense required as this matter of school dentistry. Dentists never touch this class of child, and there is here no competition between the private practitioner and the public servant. The children at Strassburg, as we saw when there, come gladly and come voluntarily. They bring each other to be relieved. At present there is not hospital accommodation in London for more than about 200 cases weekly, say, 10,000 annually, but at least ten times this accommodation would be required to relieve even a part of the children whom school dentists would select as requiring it. Probably dentistry would be best practised as part of the work of the school clinics which are suggested. The operations would be 14958 c 18 of the simplest nature, extractions or fillings, no regulation cases or special operations being undertaken. The limited variety in the nature of the work, and the class of officer required, almost demand that the dentists should be part time officers, rather than full time. An assistant medical officer who has also practical dental experience is highly desirable now to make observations and enquiries and prepare information for the Council when they come to consider this very important subject. SPINAL CURVATURE. Elementary Schools.—In the course of the investigation into tuberculosis Dr. Annie Gowdey noticed the condition of the backs in 410 young girls at Addison-gardens school. These were children of ages varying from 6-16. 262 (64 per cent.) showed some abnormality. Fifty-eight were cases with round backs, and 204 (50 per cent.) had the scapulae " growing out," with or without some lateral curvature. There are evidently causes during school life, which should be remediable, and which bring about this condition. The matter must be further enquired into, although there are difficulties in the way. Meanwhile the attention of the teachers, who take drill especially, might be directed to the many causes which have been assigned for this condition, such as school-room lighting, desks, ways of sitting crosslegged, of standing with the weight always on one leg, defective eyesight, nail-biting, and the custom of always carrying books in satchels on the same side, the importance of broad-soled, low-heeled shoes. The enormous prevalence of deformity of the back among girls as compared with boys, however, points to some specific cause, and probably there is a want of regular development of the trunk muscles, induced by various constrictions and supports in the way of binders and corsets, which may be one of the causes. The carrying of infants by young girls may possibly be a contributing cause. Secondary Schools.—In examining the girls of the secondary schools and training colleges Miss Campbell has gone into this question in regard to the general physique of the girls, and with more detail than was found possible in regard to the notes on the elementary school children. Out of 604 examined, 138 cases showed definite lateral curvature. This is a smaller percentage than has been reported by Continental observers. Definite osseous deformity, which did not admit of correction, was presented by seven of these girls. Their ages were about 12, 13, 15, 20 and 22. In all the other cases the deformity could be made to disappear by placing the patient in particular attitudes of body and limbs. In the majority one shoulder was noticeably higher, in half the cases this was the right. The angles of the scapulae were prominent and there was a double curve, the waist being higher on one side. In a few cases the whole spine was convex laterally. The girls are mostly drawn from the elementary schools, and their average standard of physique is not high. As they have all been previously examined medically many defects have already been remedied. The 138 girls with spinal curvature had 10 above, 91 average, and 37 below the average physique. Anaemia was present in 50 per cent. of the cases, and very pronounced in some, of whom 8 (6 per cent.) showed decided listlessness and want of energy. Seriously defective vision was noted in 8, and deafness or discharge from the ears in 6, enlarged tonsils and adenoids being present in 7. As regards corsets, common sense seems prevalent. The ordinary corsets were worn by 47, rational stays with a few or no bones by 75, whilst 16 did without any artificial supports. The numbers are too small to give a sufficient statement of the age incidence, but 12-13 seemed the most prevalent time. As suggested above, the condition is to a great extent a temporary trouble of growth, as the numbers do not markedly increase with age, and many cases improve. The chest development is poor in nearly all these girls. They require, in the secondary schools, special remedial exercises to strengthen the muscles of the back, develop the chest and improve the general physique. These exercises, to be valuable, should be carried out under the supervision of the drill mistress at least twice a week, and should be done regularly at home. The girls need individual attention and separate exercises, so that large classes are almost useless. In most of the schools remedial classes have been formed for the more urgent cases. At present the drill mistresses have not sufficient time to give to this side of the work. More time should be given, as it is required not only for girls with spinal curvatures, but for the large number with rounded shoulders, and narrow flat chests, predisposing to consumption, which are not included here. At Greystoke-place College more time is required for physical development. Most of the students play no games and have time for very little exercise. Only the drill necessary for teaching purposes is included in the course. GIRLS IN SECONDARY SCHOOLS AND TRAINING COLLEGES. Ages last birthday 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 31 Number examined 4 5 1 66 137 98 23 46 17 9 33 33 56 44 22 6 2 1 604 Curvature of spine 1 2 — 14 47 27 3 11 2 1 4 4 8 5 6 1 1 1 138 Anaemia 1 — — 7 21 12 2 6 1 1 1 1 2 2 4 1 1 — 62 Serious defect of vision — — — 2 4 — - 1 — — — 1 — 2 — — — — 8 Heart trouble - - - 1 - 2 - - - - - - - - - - - - 3 Deafness, etc. — — — 1 3 2 - - - - - - - - - - - - 6 Throat troubles — — — 3 2 2 - - - - - - - - - - - - 7 19 PULMONARY TUBERCULOSIS AMONG SCHOOL CHILDREN. In a paper published in " Tuberculosis" some half-dozen years ago reasons were given for supposing pulmonary tuberculosis at school ages to be quite insignificant in amount, but there have not been wanting alarmist reports as to the prevalence of this disease among children. It became a matter of serious importance not to obtain statistics, but to ascertain how far children at school ages were affected, and how far they might be a danger to others. Our rule for some years has been that where a child has been supposed to have consumption it must be excluded from school if it coughs or spits. Teachers in any way affected with pulmonary tuberculosis are excluded from school for at least twelve months. The risks of infection from cases obviously suffering are therefore small. Further, the invalid schools remove many tubercular children, with bone or joint diseases, and some doubtful cases of pulmonary disease. There are, however, undoubtedly many cases of tubercular children in the schools who are practically not infective, and not likely to become so. On the other hand, cases are met with in hospital out-patient rooms who have been out of school for periods measured by years, on account of " consumption " who have no sign of disease about them. And cases are sometimes reported to us and medical examinations requested by managers of children said to have consumption, but who are often found in good health. An enquiry has therefore been carried out during the past year in schools of Fulham, Hammersmith, Kensington and Marylebone by Dr. J. E. Squire and Dr. Annie Gowdey. An attempt was first made to ascertain how far children attending school were popularly supposed by their parents or the teachers to have consumption or other forms of tuberculosis. The returns gave :— Number of children. Phthisis. Spinal disease. Hip disease. LupuS. Other forms of tuberculosis; Tonsils or adenoids. 58,934 335 56 43 7 154 2,065 Percentages 0.55 0.095 0.072 — 0.26 3.5 0.44 In one district the enquiry was extended to get included the number of children on the roll but not in attendance. The figures were as follows :— Roll. Phthisis. Spinal disease. Hip disease. Lupus. Other forms of tuberculosis. Tonsils and adenoids. In school 5,679 50 22 3 4 7 138 Absent — 36 34 27 3 12 3 This preliminary enquiry was not expected to furnish other than a popular idea of the prevalence of disease. It was evident on dealing with the returns that they were unreliable. As a matter of fact, cases reported as having " consumption " were free from it, and in the cases where it was found it had not been suspected. In the case of hospital patients watched through a long period Dr. Squire notes that many with pathological enlargement of tonsils or adenoids often show indefinite signs in the lungs, patchy dulness, tubular breathing and crepitations, which suggest that they may be going to develop phthisis, but completely clear up after a time and are probably due to atelectasis. My own experience is that two out of every three cases of non-attendance where " consumption " is assigned as the cause are beat treated surgically, and the majority of such cases, even with coughs, treated assiduously with cod liver oil, and often swathed in flannels are flabby children, often of somewhat better class parents, suffering from adenoids. In this examination one child was found with eight, another with six flannel garments. Most of the cases classed here as doubtful appear to have been cases with evanescent pulmonary signs. The two schools selected for individual examinations were Latimer-road, the one returning the greatest number of consumption cases, and a neighbouring school where the children were of a somewhat better social type. Examination was in some cases refused, but in the case of Latimer-road Boys all but 2 of the 335 were examined. The children were weighed and measured ; the condition of clothing, cleanliness and nutrition noted ; the teeth, throat, neck, and ears examined, and the chest carefullv examined without clothing, a card being filled up for every child seen. Dr. Squire examined the boys, Miss Gowdey the girls, and all cases with any abnormality were seen by both the doctors. 14958 C 2 20 Roll. Consumption Spinal disease. Hip disease. Lupus. Other forms of tuberculosis. Marked tonsils and adenoids. Latimer-road. —Boys. Teacher's return 335 4 1 5 Medical reports 333 2 — — — 6 123 Girls. Teacher's return 357 2 1 2 5 Medical reports 313 0 — 1 — 4 146 Infants. Teacher's return 417 1 80 209 Medical reports 243 — — — — 12 137 Addison-gardens Mixed.— Teacher's return 826 — — 2 — — 4 Medioal reports 776 6 — — — 61* 334 Total. Teacher's return 1,935 6 2 4 81 223 Medical reports 1,670 8 — 1 — 83 740 * This includes ohildren with enlarged veins on the chest or fine downy hair down the spine. The general results as regards glandular and lymphatic conditions in these schools and lung conditions were :— School. Number examined. Glands. Tonsils and adenoids. Anaemic. Tubercle Lungs, Doubtful. Unhealthy nontuberculous. Addison-gardens.— Boys 366 343 118 101 6 11 9 Girls 410 192 216 127 0 3 7 Latimer-road. — Boys 333 261 123 114 2 0 12 Girls 318 239 146 101 0 0 12 Infants 243 196 137 54 0 0 8 Totals — 1,670 1,231 740 497 8 14 48 Percentages — 737 443 29.7 0.47 0.8 2.8 1.3% 4.19 % There were indirect results from this examination in that many children suffering from phySIcal defects, which either interfered with school progress or were likely to seriously influence their future life, had medical treatment recommended. Many cases of heart trouble, greatly enlarged tonsils or adenoids and carious teeth were thus advised and went for treatment. As to the actual returns in the table above, out of 1,670 children examined, signs in the lungs which would justify a diagnosis of tuberculosis, were only found in 8 cases, that is less than 05 per cent. In 14 other children slight signs—prolonged expiratory breath sounds, or dry fine crepitation at the margin of the lungs—which might possibly be due to tubercular infection were found. Even if these are included as actual cases of tubercular disease the percentage of possible pulmonary tuberculosis only reaches 1.3 per cent. There is a further small proportion in which enlarged veins on the chest suggest the possibility of bronchial gland enlargement due to tubercular changes, but without any evident lung infection. Nearly three-quarters of these children presented enlargement of the cervical lymphatic glands, and over 40 per cent. (43 per cent.) had enlarged tonsils. Childhood is the period of glandular activity, and the lymphatic glands of children are most sensitive re-agents to irritants and indicators of the sanitary state of their environment. It is noteworthy that anaemia is present in about one-third of them, and is just as common in the better class as in the poorer school. TONSILS AND ADENOIDS. There are many children suffering from a series of remote symptoms, even up to the just mentioned cases supposed to have consumption, increasing however in importance and variety with age, who begin their troubles in life as cases of “ tonsils or adenoids.” No teacher is fit to have charge of a class of young children who cannot give a pretty fair opinion as to whether a child is suffering seriously in this respect or not. Certain powers of destroying or digesting hurtful foreign elements, whether living 21 or dead, are possessed by nearly all the body cells. These powers are in comparative abeyance, however, in the specialised structures, but prominent in certain leucocytes or white corpuscles, and those especially found in lymphatic structures. The normal tissues about the surfaces of the nasal and mouth cavities are chieily exposed to noxious foreign elements, and the structures guarding the lymphatic drainage from these areas are often liable to chronic enlargement. In individuals of robust health the leucocytes have such vigorous power that these conditions of chronic inflammation do not show ; in others of less vigorous stock or constantly in depressing surroundings chronic inflammatory conditions present themselves. The tonsils on each side of the fauces are easily observed, but it is found that in their case probably nearly all direct damage done is an event of early life and for most cases determined by influences existing in infancy, as the proportion of children with tonsillar enlargement remains steady during school life. Associated conditions and sequelae are developed in the later years of childhood. Mr. Cecil Rowntree who, in reference to these points, specially examined 1,521 children, viz., 794 boys and 727 girls, aged 3-13, in average Islington schools, noted that these glands were scarcely noticeable in 58 per cent. They were distinctly enlarged in 29 per cent., and enlarged to a pathological extent which would justify operative treatment in 10 per cent., while 3 per cent. were in urgent need of operative treatment, and the glands met in the middle line during phonation. These results are tabulated in detail, giving percentages of children at different ages, with tonsillar enlargement:— 794 Boys. 727 Girls. Ages 3- 4- 5- 6- 7- 8- 9- 10- 11- 12- 13- 3- 4- 5- 6- 7- 8- 9- 10- l1- 12- 13 Numbers examined 54 45 63 94 53 74 92 102 90 63 64 37 44 67 75 56 82 73 79 68 64 82 I. Normal 70 64 54 61 60 65 67 67 54 68 69 59 52 46 53 45 50 45 51 60 52 65 II. Enlarged distinctly 17 16 38 26 23 24 25 23 36 22 19 30 41 34 32 35 38 48 30 25 28 24 III. Enlarged pathologically — 11 13 3 11 13 7 6 8 7 7 12 8 5 15 11 18 7 6 13 12 20 6 IV. Requiring urgent treatment 2 7 5 2 4 4 2 2 3 3 - 3 2 5 4 2 5 1 6 3 — 5 These tables can be summed in the following diagram :— Diagram IV. Further analysis of the cases with reference to caries of the teeth showed this to be somewhat more common among children with enlarged tonsils, and showed also that the children with enlarged tonsils had probably poorer nutrition than the others. The presence of such enlargement may from mere mechanical obstruction hinder correct articulation ; this is noticed even in the pupil teachers ; or the enlargement may cause increased efforts at breathing, resulting in mouth breathing. The accumulation of decomposing secretions on the surface and in the crypts of the tonsils often lead to production of offensive material, and the surface of the tonsil itself appears as a dangerous spot for the entrance of various organisms leading, for instance, to rheumatism, scarlatina, diphtherial or other blood infections. But it is rather as an indicator of other conditions in neighbouring tissues that enlarged tonsils are generally useful. The lymphatic masses which are present about the upper part of the pharynx, and the mucous tissues about the posterior ends especially of the turbinate bones, are liable to become greatly hypertrophied, and sometimes cause much trouble from chronic irritation, whether by substances in the air, or from want of proper drainage of the surfaces, from actual deformities in development of the upper jaw, or even from want of development, due to the habit of mouth breathing having become established at an early age. Mere catarrh is apt to set up mouth breathing. 22 and in mentally defective children is probably the chief cause in producing the excessive proportion of mouth breathers amounting to perhaps 50 per cent., a condition without other defects which is comparatively uncommon in the mentally normal children. This catarrhal condition often results in infection of the lymphatic tissues, and in children of low vitality the infection sets up chronic inflammation. Thickening of the soft palate leads to impaired tones in the nasal sounds. Discharges sometimes start pharyngitis, which gives the child the appearance of having nasal trouble, and an excoriated upper lip. A remote result not uncommon is persistent conjunctival troubles and blepharitis, which requires treatment at a throat rather than an eye hospital if a cure is to be hoped for. For some reason apart from the organs of the special senses, the existence of hypertrophied structures in this nasopharyngeal region, adenoids especially, is associated with a peculiar mental condition of great importance educationally, sometimes called aprosexia. Every teacher should be acquainted with this condition. Such children are often submitted for examination as mentally defective, and the condition has been classed as spurious mental defect. Apperception is greatly lowered and the attention cannot be maintained, The nutrition of the frontal areas of the brain seems affected, whether by interference with the lymphatic drainage, or in more subtle ways is not known, but these children are common. The condition is remarkable for variability ; they may be quite sharp and intelligent at times, and again dreamy, absent-minded and wool-gathering. The variations depend on the condition of the structures of the nasopharynx, being more obvious when these are swoollen from catarrh or humidity. The children are always mouth-breathers, and often have other sequelae of the adenoids from which they suffer, not the least important of which is said to be the development of a character which in later life is timid, fearful and doubting. The great change of importance, however, in most cases, is the chronic thickening started in the tissues about the eustachian tubes leading to the middle ears,often causing subsequent aural changes and very intractable deafness in later life. Sometimes during childhood the grosser form of suppuration of the ears takes place, and this is more likely to happen from scarlatina or measles in these children than in others. All the dangers of suppuration of the ears, blood-poisoning and meningitis are much more disposed to in mouth-breathers than in other children, and many lives are cut short from neglect of this condition. Even in the inspection of children sitting in their classes the majority of mouth-breathers are at once apparent. It is also obvious how they tend to gravitate to the bottom classes. Dr. Niall has compiled the following table from notes in thirteen infant schools in Lambeth and Norwood :— Obvious mouth-breathers with enlarged tonsils. Infant Schools. Numbers. M outhbreathers with enlarged tonsils.- Percentages; Glass. Standard L A 565 26 4.6 B. 456 43 9.6 Grade III. A. 815 29 3.6 B. 585 40 7.0 C 329 26 8.0 Grade lie A; 383 7 1.8 B. and G 751 27 3.6 Grade 1 818 6 0.7 Totals 4,902 204 4.2 % Similarly Mr. Elmslie, in examining the newly admitted infants at Campbell-street,found in 104 infants 13 mouth-breathers, 12 having adenoids ana 5 discharging ears. The breathing drills of the infant school which require the children to breathe both in and out through the nose should have some effect in calling attention to the condition when existing, and any teacher who notices the condition should make the parents aware of it. If, in addition, the child is noticed to snore much at night it may be confidently asserted that operation is required to clear the nasopharynx. Mr. Rowntree and Dr. Squire, who have reported on these conditions, insist on the necessity of children in the infant schools being taught to use their handkerchiefs as a means of diminishing the chronic catarrh. It is quite possible that constrained attitudes, especially in the attempts to do some of the fine work of the infant departments may aid the development of mouth-breathing habits. ACUITY OF HEARING. The testing of the hearing power in children is always a difficult matter. It is increased in them by the mental factor being very evident. The younger any group of children probably the better do they hear, but it is only at a comparatively late period, when they pass from the infant schools, that the mental reaction to hearing tests is reliable without much care and many precautions being taken. Any complicated method of testing will fail for school purposes, and further any simple test of a rigorous nature will probably depend on a few single sounds and the reaction of an individual often varies considerably to differing sounds. 23 The most useful method for school work is very rough but fairly reliable, giving what may be called the educational value of the hearing. The observer, after emptying the chest as much as possible, whispers as loudly as he can, using no voice, the “ forced whisper ” and repeating numbers between ten and a hundred. The child, especially if somewhat deaf, frequently lip-reads ; it must, therefore, after it has understood the method, again be tested with its back to the observer. With such methods of testing I have found that in the open air, in a comparatively quiet playground and still atmosphere, the normal hearing distance is 25 metres facing the examiner and 21 metres with the eyes covered. It is not merely the actual deafness which requires investigation but also allied conditions which later may cause deafness, and more particularly conditions indicating the presence of quiet catarrh in the middle ear. This would be work of great educational value, and requires to be done for sufficient numbers to make our statistics of value ; it also requires much experience on the part of the examiners to assess the exact conditions as seen under the circumstances necessary for school examinations. The results so far obtained show that defects in hearing, and all the associated troubles, are intimately related to neglect and ignorance in the care of childhood. Miss F. Ivens, M.S., has investigated the hearing powers of 1,000 children in East End schools, namely, at Myrdle-street (H.E.), Heckford-street, Cable-street (H.E.), Berner-street and Lower Chapmanstreet. These schools, however, are not representative of average conditions, as most of the children have foreign names. There were 439 boys and 567 girls, and partly to eliminate the mental factor and partly to save time unselected children were taken only in the higher standards, and aged 10 to 14. They were of poor class, except Myrdle-street, which is somewhat better, and where many gave an account of previous treatment and even of throat operations, All who heard the " forced whisper " at 20 feet were taken as " educationally " of normal hearing, although this is a trifle less than one-third the distance at which healthy children should hear. Only 6 per cent. of failures to this test occurred amongst the suburban children in Bradford, from whom the standard for hearing was determined, but Miss Ivens found five times this amount fail in the East End, which accords with the high percentage found some years ago in examinations of the Poor Law children at Hanwell. On the other hand, Miss Alice Johnson only notes 12 per cent. among 500 mentally defective English children in South London. One-third of the East End children are therefore not merely subnormal, but have a defect in hearing that may be expected to affect their educational capacity, and their efficiency in after life. The psychology of defective hearing in an uneducated child is very intricate. Such a one misses many details, possibly misinterprets others ; its pronunciation is seriously modified if very young and its understanding vague. The teachers note that deaf children often prefer to sit in a back row of a class and lip-read, rather than in front, especially during a dictation lesson. Here, as in all educational matters, so very much depends on mental capacity, but the partially deaf child always fails to attain the full level of its intellect, and usually has only moderate success in school, its failure being marked in the highest marks or classes. Some of the sharper children when deaf seem nervous almost to overstrain ; this is also noticeable in schools for the deaf; but in most of the 30 per cent. here noted defective attention was evident, and appeared to be associated with ill-nourished, possibly poorly fed children, many of whom indeed suffer from insufficiency of sleep. Each child had been recorded by the teacher as to its mental capacity in marks from 1 (lowest) to 5. This marking has been done carefully, many cards showing that the teacher's judgment had been revised. It is probably the best assessment of intellect that can be made at present, but is not entirely satisfactory and must not be accepted as more than an estimate of an immeasurable quality and possibly not as good as the standard of the child in school. Mental condition of 1,000 children as noted by the teachers :— Mental status as marks 1 to 5. Numbers. Percentages. Sufficient hearing. Insufficient hearing. Sufficient hearing. Insufficient hearing. 302 boys. 402 girls. 132 boys.- 165 girls. 704 children. 297 children. 1. (Bad) 0 23 1 11 3.6 4.5 2. (Poor) 11 59 7 19 9.9 8.7 3. (Fair) 84 116 48 52 28.5 33.7 4. (Good) 111 115 53 53 320 35.9 5. (Excellent) 96 89 23 30 26 0 17.0 This table shows the pulling down of intelligent children with aural defects from the excellent class to the merely fair or good. Careful records were made of each child. Testing by the watch was only occasionally used in special cases, as its unreliability as a general test is well known. Adenoids were inferred when not seen, from mouth-breathing, discharge and facies, actual palpation with the 24 finger being omitted. With enlarged tonsils or other morbid conditions the throat was inspected, a spatula and electric lamp being used. Each ear was also looked at with a speculum ; the drums being inspected and the conditions noted ; many interesting conditions being recorded which cannot be dealt with now. The following table gives a short statement of the number of individuals with the chief conditions seen:— 308 boys who had sufficient hearing to pass the test. 131 boys who failed in hearing test. 430 Boys Ages 9 10 11 12 13 14 9 10 11 12 13 14 176 mouth-breathers — 6 16 35 37 2 — 1 18 29 29 3 Cicatrices 1 1 2 3 - 3 13 5 1 Opacities, etc. — — — — 3 2 - — — 1 8 4 Perforations - - 2 - - - 6 3 Discharges — — — — 1 - — 1 3 8 5 Enlarged tonsils — 2 3 12 5 - — — 7 9 5 2 38 partial mouth-breathers — 1 10 8 5 - — 1 3 8 1 — Cicatrices 1 - - - 1 2 - Opacities, etc. — — — 1 — - — 1 — 2 Perforations - - - - - Discharges — — — — — - — - — 1 — Enlarged tonsils — — 1 — 1 - — - — 1 — — 226 normal breathers — 8 34 68 70 8 — 1 7 16 13 1 Cicatrices 1 2 2 4 - 2 6 1 1 Opacities, etc. — 1 3 3 3 — — — — 4 5 Perforations - - - - - - - - - Discharges — — — — 1 — — — — 3 — Enlarged tonsilS — 2 7 10 21 1 — 1 2 4 4 1 Totals — 15 60 111 112 10 — 3 28 53 43 4 399 girls who had sufficient hearing to pass the test. 168 girls with hearing insufficient to pass the test. 567 Girls Ages 9 10 11 12 13 14 9 10 11 12 13 14 184 mouth-breathers 3 8 22 40 28 3 3 6 14 23 31 3 Cicatrices 2 4 4 - _ 3 6 10 11 - Opacities, etc. — 2 1 4 1 — 1 — 2 4 — Perforations — 1 — 1 — — — 1 3 7 6 - Discharges — 1 — 5 3 — — 1 5 10 10 Enlarged tonsils 2 3 6 17 12 1 1 2 — 10 9 2 29 Partial mouth-breathers 1 1 6 8 1 1 — 1 3 2 5 — Cicatrices 1 1 1 - - Opacities — — — — — — — — — — - Perforations - - - Discharges — — — 1 — — — — — — 1 Enlarged tonsils — — 2 4 1 1 — 1 1 — 1 — 354 non-mouth-breathers 8 33 68 102 64 2 — 2 18 39 15 3 Cicatrices 1 3 5 1 1 1 7 15 5 - Opacities 1 — 1 1 1 — — — 3 7 3 - Perforations — — — 1 — — — — 2 6 1 - Discharges — — 1 — — — — — 1 9 1 Enlarged tonsils 2 5 17 26 11 — — — 3 8 9 — Totals 12 42 96 150 93 6 3 9 35 64 51 6 Of these 1,006 children 73 showed existing chronic suppuration. Many gave a history of discharges, but have not been included, as most would be recorded under cases with cicatrices or perforations of the membranes, and the histories are untrustworthy. Although many might easily be missed, cicatrices on the drums were recorded in 134 children, and 42 had perforations, apart from those with actual suppuration. This means, for instance, in regard to swimming or diving, that in 5 per cent. of these children there would be a risk of re-awakening old disease in the ears, 25 The relation of mouth-breathing and its accompanying conditions can be obtained from Miss Ivens's observations, as follows :— Actual numbers. Percentages. Children. Passed the test. Failed in the test. Existing Suppuration. Remains of old disease. Existing Suppuraation. Remains of old disease. Failed to pass the hearing test. There were of— Mouth-breathers 360 200 160 53 99 15.0 27.5 49 Partial mouthbreathers 66 42 24 4 8 6.0 12.0 36 Non-mouth- breathers 580 465 115 16 69 2.8 12.0 20 Totals 1,006 707 299 73 176 7-2 17-4 31 The percentages of children with more or less of the mouth-breathing habit may be represented in these various groups by the black portions of the diagrams. Diagram V. This enormous proportion of disease, existing or past, associated with mouth-breathing shows the importance this habit may have in determining whether an attack for instance of measles will leave permanent and serious damage. The condition of mouth-breathing is more apparent to teachers than even deafness and its educational influence so important that it is set out in relation to the marks awarded by teachers for mental capacity. To eliminate errors from selection of the children among the younger or older groups, they are omitted and a fairly homogeneous group of children, aged 11, 12 and 13 years last birthday, is taken. Hearing and mouth-breathing in relation to mental capactiy:— There were of the children in the groups below. Numbers. Percentages getting marks 1 to 5 for mental capacity. 1 2 3 4 5 Satisfactory Hearing f Boys 279 - 3 28 37 31 Girls 329 5 155 27 30 22.5 Unsatisfactory Hearing Boys 125 1 5 36 41 18 Girls 145 7 13 28 34.5 17 Not mouthbreathers Boys 207 4 28 33 35 Girls 311 6 13 28 31 22 Mouth- breathers Boys 153 1 6 26 45 22 Girls 170 5 22 26 30 176 14958 d 26 These figures shew the educational drag that the conditions accompanying mouth-breathing effect, but not wholly, for these children are from higher elementary schools and upper standards, and it would require a wider basis, to include the children kept down in the standards by ear disorder, to give full expression to the educational seriousness of this condition. Dr. Alice V. Johnson has similarly analysed the results she obtained with 514 children tested from five South London schools for the mentally defective. Roughly speaking, all defects were present about twice as often as among the normal children of the East End examined by Miss Ivens. Enlargement of glands and insufficient hearing were, however, less frequent. Boys. Mouthbreathers. 118 M.D, boys with sufficient hearing to pass the test. Mouthbreathers. 17 boys with insufficient hearing to pass the test. Ages. 10 11 12 13 14 10 11 12 13 14 Mouth-breathers 20 29 25 30 14 3 3 4 4 3 Cicatrices 1 4 2 2 _ 1 3 1 Opacities 2 5 3 6 3 — — — 1 j Perforations 6 6 6 3 1 1 1 — 1 1 Discharging ears 5 3 3 7 3 1 1 1 3 2 Enlarged tonsils 6 5 6 10 4 1 2 3 2 2 Adenoids 14 15 13 11 4 2 1 4 3 3 Enlarged glands 9 6 9 8 5 2 2 2 1 1 90 non-mouthbreathers. 4 non-mouthbreathers,- Non-mouthbreathers 20 15 28 17 10 1 1 1 1 Gicatrices 1 2 4 — — — — Opacities 6 1 3 3 2 — 1 — — Perforations — 2 4 1 — 1 — — 1 Discharging ears 2 3 5 — — 1 — — 1 Enlarged tonsils 7 8 11 6 1 — 1 1 — Adenoids 2 1 1 — — 1 — — Enlarged glands 5 1 6 5 3 — —■ 1 1 Girls 52 M.D. girls mouthbreathers with sufficient hearing to pass test. 15 mouthbreathers with insufficient hearing to pass the test. Ages. 10 11 12 13 14 10 11 12 13 14 Mouthbreathers 16 13 7 10 6 4 2 3 5 1 Oicatrices — 2 1 2 — — — — — — Opacities 4 2 — 1 3 1 1 — 2 — Perforations 1 — — 3 1 — — 1 2 1 Discharging ears 2 2 2 3 1 1 — — 3 — Enlarged tonsils 10 6 1 7 5 2 1 1 1 1 Adenoids 12 6 4 6 5 3 2 — 1 1 Enlarged glands 6 4 2 1 4 3 1 """" ~ 1 43 non-mouthbreathers.- 7 non-mouthbreathers; Non-mouthbreathers 14 6 8 11 4 1 1 2 2 1 Oicatrices 1 1 — 3 1 — — — — — Opacities 1 — 2 4 — — 1 — 1 — Perforations 1 — 1 1 — — — 1 1 1 Discharging ears 1 1 2 3 — — — — — —• Enlarged tonsils 9 1 2 8 2 1 — ■ 2 1 — Adenoids — — — — — — — 2 — — Enlarged glands 2 1 2 3 - - 1 - - 27 Summary of M.D. children of all ages :— Ages. Numbers. Discharging ears Mouth breathers Adenoids: Enlarged glands Residuar of disease in drums Failed to pass 20ft test Very deaf, nothing at 2½ft Wax B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. 7 13 4 0 9 5 6 3 6 6 6 3 2 1 1 — 8 8 8 36 5 3 24 11 19 9 19 9 16 7 2 3 1 1 12 8 9 45 27 7 3 26 13 22 10 14 12 18 10 5 5 - - 22 14 10 44 35 9 4 23 20 19 15 16 11 17 10 4 5 3 1 22 19 11 48 22 8 3 32 16 16 7 9 6 20 6 4 3 1 2 23 11 12 58 20 9 4 29 10 18 6 17 5 27 6 5 5 2 1 20 13 13 52 28 11 9 34 15 15 7 16 4 19 20 5 7 1 — 28 13 14 27 12 5 1 17 7 7 4 9 5 9 7 3 2 1 — 14 6 15 11 2 1 1 7 — 3 — 5 — 4 1 1 — 1 — 4 1 16 2 3 - 2 2 1 - - 1 1 — 2 - - 1 1 Totals 336 178 59 30 203 98 125 61 112 59 136 72 31 31 11 5 146 94 Percentages 514 14 16 60 55 37 34 33 33 40 40 9 17 3 28 44 52 DEVELOPMENT OP ARTICULATORY CAPACITY FOR CONSONANTAL SOUNDS. The development of speech in children is the evolution of one of the latest acquired faculties and one most liable to disturbance, and hence also most susceptible of education at the proper time. Series of cases have already been described in a previous report where certain speech faculties are rudimentary or wanting so that such children have been classed as imbecile; these are, however, comparatively gross and rare exceptions. The study of the development of the speech faculty at school ages should afford material of great value to the teacher as well as the physician. This study has been undertaken by Dr. Ernest Jones. The immense field to be covered necessitated restriction for the present to the development of the articulatory power for consonants. Difficulties of pronunciation (dyslalias) may arise :— i. From mechanical defects in the peripheral speech apparatus. ii. From lack of adequate education and practice or exercise (blesitas). Some 650 children were examined in the schools of the North Kensington district. They were selected so as to represent average samples and to eliminate such matters as social grade or great poverty as far as possible. Further, children are only dealt with who were selected by their teachers as having normal speech capacity. They, however, frequently choose children of better mental capacity, so that it is probable the children examined may have been generally somewhat above the average in mental capacity. The cases finally examined and now analysed number 450. There were 25 of each sex for each year of age during compulsory school attendance. The 200 with " defective speech " will be reported on later. Frequency.—The absolute frequency of blesitas is very great, the mispronunciation of vowels being most common. Only 2 of 3,000 children seen were noted as quite free from defect. As blesitas may be avoided entirely by training. its occurrence has an important bearing upon elementary education so far as it relates to the training of speech production. With regard to age and sex distribution, the incidence is only determined for the commonest defect, consonantal blesitas. Methods.—21 single, 75 double and 13 triple consonantal sounds were used. These sounds were given in suitable test words, in the three positions they can occupy, namely, commencing, ending, or in the middle of words. Marks from 0 to 3 were recorded for each sound ; 0 meant unintelligibility or another sound substituted, 1 just recognisable, 2 obvious defect, and 3 the correct sound given. The only criterion was intelligibility, and the full mark 3 might be recorded for a sound which had a gross accent, or would have seemed horribly uncouth to a purist. As some of the sounds do not occur in English in all the three positions, the total number used was not 3 x 109 = 327, but actually 227 only. The full number of marks was 1,266, as double consonants were given 6, and triple 9. For statistical purposes and in these records all marks are reduced to a total maximum of 1,000. The spontaneous speech of a child who only got 930 marks or less was practically unintelligible to a stranger. It is probable also that the standard adopted for the younger children was lower than the others, an unconscious bias, difficult to contend against, giving some leniency in marking the youngest. The method of obtaining the articulation was the most favourable possible, the children being asked to repeat the word as spoken to them, and even to watch the speaker's lips, and when necessary easier words were tried first, so that the utmost limit of articulatory capacity was evoked. The total number of tests made was 105,000. Sex Incidence.—The standard reached by the girls, 980.1 average marks, was higher than that reached by the boys, 974.9, chiefly owing to the preponderant number of boys who got very low marks. Age Incidence.—Dr. Jones has gone into a very detailed examination of the age incidence in the sexes, which can only be summarised here. 14958 D 2 28 Average marks per 1,000 gained in each age group :— Age 5-6 6-7 7-8 8-9 9-10 10-11 11-12 12-13 13-14 Totals, Bovs 945 932 960 984 987 993 992 988 993 9749 Girls 948 966 975 980 972 991 994 997 997 980 1 The progress made during school life is not uniform, but occurs at special ages, differing in the sexes. Amongst boys there was no improvement in the years 5 to 6, but a marked improvement shows itself at the age of 7, the average rising from 931.8 to 960.4, or 28.6 points. This rise in the average is due not only to the improvement in low mark boys, but to all round progress, and at this age for the first time children appear (16%) having marks above 990. At eight years a further great advance is made, the average rises to 983.6, that is 23.2 points, due to all round progress; 44 per cent, now obtain over 990, and 12 per cent. get 1,000 marks. After 8 only slight progress is made, in fact almost the only change in the last six years is an elimination of the lowly marked boys, that occurs between the ages of 9 and 10. Of boys aged 8-9, 10 per cent. are below 960 marks, whilst there are none below this in the group 10-13. Amongst girls there is already a decided improvement from 5 to 6, the average rising from 948.5 to 966'2, or 17.7 points due to all round improvement. At 7 the average rises from 966.2 to 974.6, due to the continued improvement of girls with high marks, but no improvement is made with girls with low marks, that is below 960. No further improvement takes place until the 10th year group is reached, and then the improvement is greater than at any other age among girls. The average is 198 higher than the 9 year-olds, but there are no cases in the group below 960 marks contrasted with 253 per cent. in the previous years, and there are 72 per cent. in the above 990 group contrasted with 32 per cent. In the last four years only slight changes take place, the most important being an increase in the high marked girls at 12. Summary of Development.—Improvement in boys is confined almost to the years 7 and 8, but those slow in speech development improve later at 10. In girls the first improvement is earlier (5 and 6) than boys, but the later improvement at 10 is more important in girls affecting both bright and dull children. The precocious speech development of the girls is very marked from 5 to 7, but by 8 the boys catch up, and it is only after 10 that the girls become permanently better in articulation than the boys. Percentage of children at different ages who enter into certain mark groups. Ages. Below, Below, Below, Below. Below. Above. Above Full marks. 910 930 950 960 970 980 990 1,000 Boys. 5 16 20 40 68 80 12 — — 6 28 32 44 64 88 8 — — 7 8 12 32 42 68 24 16 — 8 - 12 20 64 44 12 9 _ - 4 8 16 84 76 4 10 - 4 96 64 28 11 8 92 76 8 12 8 76 60 4 13 — — — — — 96 96 36 Girls. 5 8 16 36 68 72 16 8 — 6 4 4 4 24 52 28 — — 7 12 24 32 44 24 — 8 - 4 16 28 64 36 — 9 4 16 36 42 48 36 8 10 4 92 72 4 11 - - 4 96 80 32 12 - - - - - 100 96 32 13 — — — — — 100 96 32 In marking the separate sounds, boys fail most often with Th(730.3). The initial Th, 714.1, is the worst, Final Th gets 746'6. Ng, 829.6, is the next worst, and this almost entirely due to final, ng, 675.5. Various sibilants all run practically the same, 983-989, whilst P, M, W, L, Y were in all cases correctly given. The same holds generally for the girls except that the final " ng " takes an extremely low position, 459, and that they pronounce the Th sounds much better than boys, particularly at the beginning of a word. It is obvious that the work of which this is only a beginning will become of great interest when extended to children with marked defects, and of very high value indeed if the mental factors of speech can be investigated, as has already been exemplified by the word blind and word deaf children, but probably the following up of this enquiry will require finer methods than are applicable in an ordinary school visit. 29 FATIGUE. Fatigue is Nature's danger signal to prevent excessive wear and tear. It is almost certainly due to toxic action, to definite chemical products, accumulating locally and later becoming generalised in the blood. Recent experimenters have asserted what Erlich's theories would suggest, namely, the power of preparing antitoxin which prevents fatigue. The normal course of work indicates that Some such changes happen. There is a consciousness of working more effectively, so far as mental work is concerned, in the second or third hour of work than in the first. The results of the ventilation experiments given on page 63 tell the same story. Partly for this reason and partly because it is the natural way of development noticed in young animals, we have always maintained that the most educational form of any exercise for growing structures is in short, sharp, violent bursts with relapses to comparative quiet. The physical exercise of infants during evolution of their motor acquirements should tend to forms explosive in violence and duration. A healthy organism will not suffer from such exercise. Running, jumping, and simple, short and large movements are not only judicious in the infant department, but it is an educational crime to withhold them. Play can become a labour and organised games tedious weariness, just as drills or exercises may be done so slowly or carefully that they are a source of serious exhaustion and fatigue. It is therefore wrong not to have physical exercises of a simple nature and plenty of them in the infante' schools, but the teachers must learn to know almost instinctively what to avoid and what is useful. Dr. R. J. E. Hanson, who has been paying some attention to fatigue, points out that the early fatigue symptoms, quickened heart action and respiration, with flushed face and sharpened mental activity are the very results wanted by our scheme of exercises. But many out of school exercises, especially swimming lessons and contests, are more exacting, because respiration is impeded, and these sometimes become most exhausting exercises, breathlessness being especially noticeable among the young girls. In contests between older boys, particularly if of different racial stocks, there may be difficulties if they are matched age for age. The tendencies of development at each age must be respected. If at the proper time the particular educational tendency is neglected then the education is incomplete and defective in 6ome respects. The tendency of the girls to nurse dolls or of the boys to play soldiers is absolutely natural. The failure to exhibit these normal tastes may be held to indicate mental defect, and often that defect is elusive in being shown only by perverted moral traits. The educationalist will be wanting if he fails to turn this developmental stage to account. It may be made a most powerful influence for good at this particular age, which for most English boys is strongest about 12 or 14 years ; probably somewhat earlier among the East End aliens. In the City, Marylebone and Paddington divisions, Dr Hanson has established an organised sport (Art. 90, Sec. vii. of the Code) out of school hours, in the form of light rifle shooting. The boys are squadded under their own leaders in groups of 24 (three sections of 8), the leaders being captained by the leading schoolboy (school captain), and as each ultimate unit (section of eight) contains two senior boys, it results that the responsibility for discipline and range attendance is minutely detailed. Elementary military drill by a service instructor gives just that tinge of reality and " go " which is lacking in the Code of Physical Exercises, and which appeals to the instincts of an English boy in the way that no amateur instruction can do. There is no question that the moral effects in the way of self-restraint, obedience and alacrity are remarkable. There is the great element of interest, that each bit of practice or self-sacrifice demonstrably brings the boy nearer his goal of correct shooting. There is the additional element of a sporting chance. These two elements make up the chief pleasure of all our sports and games, and this is a sport for the town dweller that has the interest and chances of cricket or football. The boy of twelve is capable of learning accurate shooting as quickly as at any other age ; the only doubt is the possibility which has been urged of over-fatigue. It was important to trace the relation of fatigue to rifle shooting, and this Dr. Hanson has been able to do graphically, and thereby furnished also a complete demonstration of its value as a neuromuscular training of the highest value for boys. In order to prevent fatigue of the eyesight a large bull's-eye subtending an angle of ten minutes is used in the early days of training. It is gradually diminished with improved shooting till the standard size is reached. In light rifle shooting the necessity for free ventilation is as evident as in the work of the class-rooms. Fatigue quickly ensues if the air is used up and filled with bye-products whether from respiration or from spent cartridges. The emanations from damp and dirty clothes also appear to predispose to headache and inaccuracy. It generally takes some months to produce a consistent shot. This is due to the necessity of learning co-ordination of eye, hand, and respiration. The lads are taught in the prone position, Diagram VI. which is not fatiguing, on a definite system by which all accident has been avoided. The alignment of the rifle sights upon the bull's eye, together with the holding of the breath at the top of the normal 30 inspiration, and the gradual increase of the squeeze of the trigger finger and thumb are thus learned. This co-ordination is at first rapidly fatiguing, but it is rapidly learned, and the fatigue disappears. The above is a record of the movement of the rifle, which is obtained by attaching a quill to the muzzle, and making the quill scrape on a smoked paper, moving rapidly on a rotating drum. The small wavy indulations K-L represent unsteady oscillation of the rifle from anxiety and consequent fatigue, the large waves C D represent respiratory movements transmitted from the shoulder and chest to the rifle. Diagram VII. Passing out from the recruit stage the alignment and pull-off is correct in the next tracing, but the boy does not yet hold his breath at the right position; holding it here midway between expiration and inspiration. There are some tracings from boys who, being marksmen, had fired as many as thirty shots without showing a trace of unsteadiness or fatigue. Diagram VIII. Fatigue shows itself at once in the tracings here In a skilled boy minute oscillations show and at the pull-off there is an upward jerk of the rifle. Diagram IX. The amount of work done in firing seven rounds from a War Office pattern light rifle is probably some 120 poundals. There is a good deal of exercise in co-ordinating the various muscles. The rifle is supported by the left hand, forearm and elbow; these with the right arm and the butt against the chest form a steady tripod. To get the rifle to " present" about 8 foot poundals are necessary. To accommodate the rifle to the schoolboys, Dr. Hanson has had the butt cut down so that there is only a length of 12 inches instead of 14 inches between the trigger and heelplate. The work done by the trigger hand is on the average about equal to that in raising the rifle to present. Unless watched, a recruit in his early stages now and then perspires profusely and becomes breathless in his strained effort to let go at the proper moment, but without practice he is unable to co-ordinate alignment of the sights, breathing and pull-off. The amount of work is trivial compared with the out of school work of the boy carrying milk, or even fetching coals or water. The movements themselves of presenting and aiming are more highly specialised and educational than anything at present taught in school, meaning the training and co-ordination to very high perfection of a large number of nerve centres and muscular masses. The result of the shot ending in a bull's eye affords greater educational perfection and finish than in anything else that boys of 12 can be expected to do usefully. The effects of any excess lends itself to immediate demonstration. The result of even a single cigarette could no doubt be made evident at once in the tracing on the smoked paper. For these reasons as well as its highly moral influence, rifle shooting seems one of the best educational subjects for boys from the age of twelve and upwards, and is free from any unduly fatiguing effects. COUNTRY HOMES. One unknown factor in the estimation of vital statistics has been the extent of reduction in the child population from migration during the summer holiday. Reference to this movement of population has often been made, but its extent has been a matter of conjecture. To form a more accurate estimate a census was taken immediately after the summer holiday of 1906. This census was based on enquiry made by Dr. Thomas, the local medical officers and teachers. Particulars were obtained from all but the youngest children as to the time and locality in which holiday visits had been made. The number of agencies at work is considerable. The Children's Country 31 Holiday Fund, for instance, sent away 38,000 children. This fund does not extend its work all over London. Some districts like Finsbury and Holborn have separate organisations doing thorough work in their own areas. In addition to purely philanthropic agencies numerous religious organisations are active and in some schools as many as a dozen agencies are found to be in existence. In addition to charitable agencies many children go to relatives. The growth of London is so recent that population has come from far and wide and children were found who had been to the Orkney Islands, to the Scilly Islands, or to France, Germany or Switzerland. A considerable number had also gone with their parents to various popular watering-places. The enquiry extended to 320 school departments and only to children over five years of age. Out of 107,584 children in these departments 35,406 had spent from one to four weeks' holiday out of London. The total number of weeks so spent was 75,787. This represents a reduction of 17'6. per cent. in the child population of London during the holiday period. The departments were not selected, and this may be taken as applying to all children of 6 and upwards in the elementary schools. It has been suggested that girls being more useful and less troublesome at home than boys fewer girls will go from home. The enquiry does not bear this out, for of 52,305 boys, 17,256 or 32.9 per cent. had holidays amounting to 36,782 weeks, and equivalent to a 17.6 per cent. reduction of population, whilst of 52,162 girls, 17,449, or 33.4 per cent. had holidays amounting to 37,512 weeks, and representing 17.9 per cent. reduction in population. The feeling that children should be sent to the country whenever possible extends even to the Jewish population, although for centuries these have been town dwellers. Enquiries at the Jews' Free Schools in Whitechapel and Westminster showed a reduction of 13.2 per cent. in population from this cause. The percentage was considerably lower in the non-provided schools, including Jewish, owing to many of them being attended by the very poorest children. The percentage leaving London was stated as 28.4, corresponding to 146 per cent. reduction of population. Any vital statistics contrasting holiday months with the rest of the year must take this considerable reduction of population into account, especially when it is considered that in addition to the 750,000 children in elementary schools there are 150,000 who do not attend elementary schools, and who mostly 6pend the greater part of the holiday term out of London, and who would probably make the holiday reduction of population at least 20 per cent. The reduction in notification of infectious disease amongst children of the ages 5-15 during the summer holiday of 1906 is shown in Table I, where it is seen that at these ages the drop in the weeks of holiday influence, for instance in scarlet fever, amounts to 25 per cent., whilst the greatest number of cases still occurs at these ages. In Table II. the Boroughs are arranged in order of percentage reduction in notifications at all ages. It was found that in 14 boroughs in which the reduction of notifications of diphtheria and scarlet fever was over 25 per cent., 33,361 children spent 23,661 weeks in the country, giving a reduction in population of 17.7 per cent., whilst in 15 boroughs where the reduction in notification was under 25 per cent., 75,219 children spent 54,268 weeks or a drop in the population of 18 per cent.; this shows that the elementary school population all over London is about equally affected, but it is to be noted that those boroughs with the high reductions contain almost all those in which the classes reside whose children do not attend elementary schools and amongst whom the general reduction through leaving London would be greatest. Table I.—Effect of holiday influence on notifications 1906. E.S. holidays began July 27th. First week of influence, August 11th. Scarlatina. diphtheria. 1 0-5 5-15 15-0 0-5 5-15 15— July 14 128 255 44 61 74 30 „ 21 127 268 39 59 77 20 „ 28 135 253 43 72 76 15 Aug. 4 151 257 55 71 66 20 Total 541 1,033 181 263 293 85 Aug. 11 126 188 31 51 59 23 „ 15 120 168 41 63 56 20 „ 25 130 184 50 65 53 11 Sept. 1 105 171 32 37 51 21 Total 481 711 154 216 219 75 Sept. 8 141 287 38 68 67 36 15 131 270 41 65 61 30 22 118 331 69 42 69 21 ,, 29 136 339 62 67 76 19 Total 526 1,227 210 242 273 106 32 Table II.—From census of schools taken. Borough. Percentage Reduction of notifications (all ages). Number leaving London; Number of weeks spent out of London. Stoke Newington 68 Hampstead 59 2,824 2,492 Holborn 60 — Islington 42 4,743 3,895 Fulham 36 5,348 3,945 Westminster 38 Hammersmith 35 1,734 1,519 Chelsea 34 Bethnal Green 33 2,513 1,234 Hackney 32 953 258 Woolwich 31 999 409 Lambeth 29 7,426 3,705 Finsbury 28 5,538 4,301 Kensington 26 1,283 1,403 Total — 33,361 23,661 17.7 % Deptford 24 7,406 5,159 Greenwich 24 2,113 1,369 Lewisham 23 1,313 2,008 Stepney 21 4,377 2,817 WandB worth 18 10,771 5,901 Camberwell 16 11,323 8,937 Southwark 15 11,038 7,532 Shoreditch 11 3,122 1,790 Battersea 11 2,006 1,702 Poplar 6 — — St. Marylebone 2 3,201 3,347 Paddington 0 4,713 4,709 Bermondsey +9 7,404 4,360 Gity of London + 15 — — St. Pancras + 16 6,432 4,637 Total — 75,219 13,567 18 % CLASS HYSTERIA. In February, 1907, an anomalous case occurred in a school class in North-East London. It is worth record, as such outbreaks are extremely rare in English elementary schools. They may be seen occasionally as outbursts of hysteria in private boarding schools, but on the Continent they are more common. The teacher reported that a little girl in Standard II. suffering from infantile palsy of left arm, broke the right arm ; she was away some weeks and returned, and within a few days three children had lost the use of their left arms, and a fourth of a rheumatic disposition had such severe pains in her left arm that she held it to the side and could not be persuaded to use it. The diagnosis was clear. They were, however, examined by Dr. Hogarth. Two were of Polish extraction and all nervous children, one very ill-developed, one very affected in manner and speech, and another supposed to have heart disease. By suggestion, the children were got to move their arms freely, and the head mistress was instructed to see that they did not become paralysed again. The outbreak ended. THE CLEANSING SCHEME. Heads.—The number of unclean heads in the schools is steadily diminishing. During the past year in some schools there was so marked an improvement that the question of vermin could be practically ignored. Inspectors, managers, teachers and others speak in the highest praise of the good work being done by the nurses. The new superintendent of nurses has commenced duty, and the work will be more carefully regulated in future, but there is no doubt that the staff is still too few to fulfil the high expectations which their services are gradually raising in the minds of those who have the management of schools, and there are many complaints of insufficient attention to particular schools. The cleansing scheme has been earned out in 122 schools 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 22,190 21,290 900 624 182 91 49 Girls 24,860 16,888 7,972 7,039 3,454 1,864 1,117 Infants 27,769 23,294 4,475 3,985 1,744 905 591 Mixed 5,944 4,643 1,301 1,119 595 362 223 Special 866 625 241 208 115 62 47 Total 81,629 66,740 14,889 12,975 6,090 3,284 2,027 33 The parents of 277 children have been prosecuted and fines imposed varying from 1s. 6d. to 18s. 0d. and 2s. Od. costs. The magistrates have on several occasions expressed strong views in regard to the shocking neglect on the part of parents in these matters. Bodies and Clothing.—The cleansing of the heads was first instituted because here the cause of offence was evident and demonstrable, and its prevention easy. The carrying out of the scheme was at once educational and of benefit to the children, and could be insisted on. In regard to the children who are bodily unclean the difficulties were greater. Reports were constantly being received in regard to children who were verminous as regards the bodies or clothing. Some results of a scheme tried in Saint Marylebone in co-operation with the Borough Council were given in the last report. The nurse examined the children, and in the case of those with bodies or clothing so verminous that they were unfit to be in school the names and addresses were sent to the Medical Officer of Health, whose Sanitary Inspector delivered cards stating that the children could have a warm bath and their clothes sterilised free of cost at certain hours on specified dates. The scheme worked so satisfactorily that it was decided to extend the scheme and work it into the regular cleansing scheme by co-operating with the Borough Councils in those districts where arrangements for personal cleansing were already in force. Seventeen Borough Councils agreed to assist. In most of the boroughs, however, the cleansing station was only open during school hours, and it is obvious that daylight hours are the only proper times for any treatment of children away from their homes. Here a difficulty, threatening to wreck the scheme, was raised by an inspector, and application was made to the Board of Education for the recognition of the child at a cleansing station as an attendance under Art. 44 of the Code of Regulations. Difficulties were at once raised by the Board of Education which would have destroyed the scheme, but the Council wisely determined that arrangements should be made so that verminous children could be enabled to attend the cleansing stations during school hours without regard to the Board of Education grants. Meanwhile, in view of the new powers to be obtained in the L.C.C. (General Powers) Act, 1907, this part of the cleansing work has not been pushed forward. Since most of this report was written the Act has been passed. The powers obtained are contained in Clauses 36, 38 and 39 : (1.) The Medical Officer or any person provided with and, if required, exhibiting the authority in writing of the Medical Officer may, in any school within the County provided or maintained by the Council as the Local Education Authority, examine the person and clothing of any child attending such school, and if on examination the Medical Officer or any such authorised person as aforesaid shall be of opinion that the person or clothing of any such child is infested with vermin or is in a foul or filthy condition, the Medical Officer may give notice in writing to the parent or guardian or other person who is liable to maintain or has the actual custody of such child, requiring such parent, guardian, or other person to cleanse properly the person and clothing of such child within twenty-four hours after the receipt of such notice. (2.) If the person to whom such notice as aforesaid is given fail to comply therewith within the prescribed time the Medical Officer or some person provided with and, if required, exhibiting the authority in writing of the Medical Officer may remove the child referred to in such notice from any such school and may cause the person and clothing of such child to be properly cleansed in suitable premises and with suitable appliances and, if necessary, for that purpose may without any warrant other than this Act convey to such premises and there detain such child until such cleansing is effected. 38. The Council and the Sanitary Authority may make and carry into effect agreements and arrangements for or with respect to the cleansing of the person or clothing of any person under this part of this Act and for the use by the Council for the purpose of effecting such cleansing of any premises or appliances adapted for such purpose and belonging to or used by such Sanitary Authority. 39. The examination or cleansing of females under this part of this Act shall only be effected either by a person duly qualified as a medical practitioner or by a female person duly authorised as hereinbefore provided. RINGWORM. Attention has been drawn in previous years to the necessity of providing public means of treating the various forms of ringworm. The infectious nature of this disease does not seem to be fully recognised ; its clinical appearance is very frequently mistaken even by medical men. This is most common when it has become chronic, and yet remains infectious. There is only one test on which we rely, if the fungus and its spores are recognisable in hairs examined by the microscope then the case is to be excluded from school as infectious. It is quite absurd to say that a nurse cannot recognise ringworm. This is a matter of experience, and we find the nurse's judgment quite reliable. When they have any doubt stumps are removed from the affected head, and submitted for examination at the office. The number of such doubtful cases during the year was :— Number of specimens examined. Found to be forms of ringworm. Found to be favus. No fungus found. Insufficient material for judgment. 1,578 1,094 84 336 64 In 140 of these cases medical certificates to the effect that the children had no disease or were free from ringworm, or recovered, had been submitted by parents at the time or shortly after, but the cases were so doubtful that the nurses forwarded stumps, and in 129 of these 140 cases ringworm was found to be still present, favus in 5 cases, and only in 6 cases was no fungus found. In several cases this judgment has been disputed during the past year, but the only decision which could reasonably be contested would be a statement that a child had not ringworm. When we can actually see the fungus in every case referred to the office before a diagnosis is sent out, it is futile to contest it. A week or two at the most would decide any doubtful case. Only twice during the past year has personal examination of 14958 x 34 children failed to detect ringworm, where it had been found microscopically within a week or two previously. In one case repeatedly examined microscopically the doctor several times refused to accept this decision, and on a summons being issued went into Court and contradicted the evidence offered on behalf of the Council. The case was adjourned for the evidence of a specialist, and Dr. Sequeira, the dermatologist of the London Hospital, examined the boy and certified it to be a case of chronic small spore ringworm, upon which the defendant agreed to accept the Council's decision, and placed the boy under treatment. In another case where ringworm was found, and the case contested owing to the allegation that a mistake had been made, and the nurse failing to send up stumps when asked, a small sum was actually paid in compensation for loss of time, etc., and within a week or two there was no doubt about the correctness of the first decision. Another case, where the Committee actually saw a deputation of managers later, was where two children had been suffering since September, 1906, from ringworm, but returned to school in the spring with a card from Hospital stating that they were suffering from a non-contagious disease. Stumps sent up by the nurse were shewn to have ringworm, and the children were excluded, but re-admitted a week later on the written authority of a manager. As permission to take further stumps was refused, and no medical evidence submitted, the children had to be excluded. Every opportunity was given to the parents to show that the children were free from disease, and they remained out of school until after the summer holidays, when they were re-admitted on a medical certificate. We have had a good many Hospital cards and certificates of freedom from ringworm, but under the circumstances of the Hospital out-patient room this is quite to be expected. Quite apart from the serious irritation set up by the exclusion of these children there is just as much trouble to people who want to get their children cured. Many parents, trying to do their best, have enquired how a chronic case is to be relieved and cured. They have attended doctors and hospitals till the doctors are tired of seeing them. Some cases are exceedingly chronic, and for even respectable and better class people there may be no available means of cure, save attendance at one of the two or three hospitals where Rontgen-ray apparatus has been installed and where only a few patients have a chance of treatment. Apart from the duty of the Public Authority, quite apart from charity, to help those whose means do not allow of their benefiting by such apparatus as recent developments have made available, and as the only efficient means in many cases, it will be an economic gain merely from the school attendance point of view. Twelve schools taken at random in various parts of London lost 26,766 attendances from ringworm in twelve months. On this basis, which is quite reasonable, the loss of attendance in the whole of London is 1,179,934. Taking the minimum number of sessions in one year required by the Board of Education to be 400, the number of lost attendances is equal to 2,950 children in average attendance. or a loss of grant amounting to £5,654 per annum. Evidently there is a financial profit on the treatment of ringworm besides the increased time gained in education. The Metropolitan Asylums Board used to have ringworm schools at Banstead Downs and Witham. The average stay of the first hundred children was 1 year 7 months ; 28 per cent. stayed over 2 years, and 15 per cent. over three years. In May, 1905, the X-ray treatment was introduced, and at the following Easter the Witham school could be closed as there was no further use for it, The average period of detention of the first hundred children being 5¾ months, or 4½ months from the date of the application of the rays. In 1906 over 400 children were discharged cured by X-rays only. Dr. Critchley, who is on our staff, has been applying X-rays to the cases of ringworm at Croydon, and finds that they are cured in a few weeks ; a child who had been under treatment for two years] was rendered fit to return to school five weeks after the use of the rays, and numerous cases given a clean bill of health within the month. At first the number treated was small, because parents were not over-anxious to submit their children, but latterly their anxiety to be treated has increased beyond his means of satisfying it. There is no doubt that the installation of this treatment will be one of the duties to be attended to in the proposed school clinics, and probably the formation of special ringworm classes will not be required. FAVUS SCHOOL. First Year's Working.—The method of treatment of the cases of Favus which occur chiefly among the children of the alien population in the East End has been to exclude such children from the ordinary school and require their attendance at a school for favus cases only. The school was opened on July 8th, 1906, with 61 children. Between then and 31st March, 1907, 29 more children were admitted and 9 left. There were, therefore, 81 on the books at that date. Of those who left 3 were cured, 3 had attained the age limit, 2 had removed from London, and 1 was taken off the books as the boy was forbidden to attend by the authorities of the hospital where he was being treated. Dr. Bertram Abrahams has kept all the cases under close supervision, and has attempted to follow up the modes of dissemination of the disease. Of the 90 children under his observation 8 had never previously attended school. Fourteen came from the Jews' Free school, 13 from Myrdle-street school, 5 from Baker-street school, 4 each from Chicksand-street, Quaker-street, and Old Castle-street schools, and smaller numbers from 23 other schools in the immediate neighbourhood. The residences of the cases were noted and analysed, but no local incidence could be detected. There is considerable difficulty in finding whether other members of the family are affected ; the details given by children or relatives untrustworthy; even home visits have not given satisfactory results. 35 Dr. Abrahams shewed last year that the infectivity of favus was not great. Dust collected from various parts of the school failed to give any favus cultures, thus shewing that the risk of re-infection in the school is not great. Treatment has been beyond the scope of the work, but Dr. Abrahams has supervised sanitary arrangements which prevent the dissemination of the fungus, and he also sees that any treatment ordered by doctors or hospitals is regularly carried out. On the child's admission, the consent of its parents being obtained, the hair is cropped short, and this is repeated weekly. This has been done in all but three cases. The children who use applications under medical advice bring their ointments or lotions to school, where the nurse takes charge and applies them at the stated times. Each child has its own head-cloth, and these are washed by the nurse. In many cases when admitted the head is covered with a thick mass of crusts, and the cleansing by poulticing is often a tedious process of many weeks or even months duration. A considerable number of the children have no treatment; some have given up attendance at hospital, having seen no benefit; others have been discharged "cured," or " further treatment unnecessary," others again are neglected through the ignorance or stupidity of relatives. In these cases the following sanitary measure has been adopted as a hygienic routine, not in the hope of cure, but as a means of preventing infection:—The head is kept shaved or closecropped and is washed twice a week with 1 in 1,000 solution of perchloride of mercury. Every morning and evening the affected parts are well rubbed. Notes have been kept of the course of cases. Thirteen of the children were submitted to a change of treatment during the year, so that the cases appear below as 103 instead of 90. The records are the course of cases up till March 31st. They are not intended in any way as criticism, merely as a statement of facts. Cases recorded as cured are those in which repeated microscopic examinations failed to detect the fungus. Ten cases untreated. In three the parents refused to allow the hair to be cut; in others the process of cleansing was still incomplete. Thirty cases treated at the London Hospital, without the use of X-rays, but with various lotions or ointments. Twenty-eight cases treated at the London Hospital with X-rays. Epilation usually resulted, but was hardly ever complete. The affected hairs appeared to be the most resistent. The fungus was more than once found in the fine down returning after epilation. The epilation produced a temporary appearance of improvement, but the figures shew the ultimate result. Thirteen cases simply undergoing the hygienic routine of the school, most of them had had previous treatment; some showed improvement in a month, some were unchanged after six months. Four cases treated at Goulston-street Dispensary. Three cases treated by Milofsky's depilatories and leeches. Two cases treated by light at Guy's Hospital improved at first, but subsequently relapsed and became worse. Thirteen cases treated by various institutions or practitioners. Totals. Cured.- Improved. Unchanged. Worse. Untreated cases 10 - - 8 2 London Hospital— Medical treatment 30 1 - 16 11 X-ray treatment 28 2 6 16 4 School routine ... 13 4 4 5 — Goulston-Btreet dispensary 4 — — 3 1 JJilofsky's plasters, etc 3 1 — 2 — Guy's Hospital, light treatment 2 — — — 2 Various practitioners 13 1 1 8 2 Percentages 10 10 54 25 These statistics bear out the plea put forward last year that to render the Favus school efficient as a means of stamping out the disease regular treatment must be undertaken there. It has now been resolved to do this, and the formal certificate of the Board of Education for recognition as a special school under the Act of 1899 is only awaited, when the Council will have powers to treat the children at the school. Having had considerable experience of the actual treatment of favus no medical treatment shewing such successful results as the school routine has accomplished, has hitherto been known to me. Meanwhile Dr. Abrahams reports that he is beginning to feel that in all but the most inveterate cases the routine instituted—hair-cropping, repeated washing with solution of perchloride and mercurial inunction really affords a reasonable hope of cure. For the worst cases, and as an accelerator to the others, the X-ray treatment is required, and must be repeated until effectual. INFECTIOUS DISEASES. Notifications.—Diagrams X. and XI. are given to indicate the weekly rise and fall throughout the year of Scarlet Fever and Diphtheria, among (a) all persons, (b) children attending public elementary schools. The figures obtained for the formation of the curve shewing the latter class have been compiled from the teachers' notifications allocated in the various weeks according to the date of the children's last attendances at school, assuming this to be the date of the premonitory symptoms. During the holiday periods a mean has been struck, owing to the fact that teachers notify all cases occurring during the holidays on their return to school. In addition to curves, the rise and fall is indicated in the form of a percentage above and below the mean, Diagrams XII. and XIII. The Measles Diagram XIV. shows a comparison of this year's curve with that of last year. 14958 E 2 36 The following is a tabulation of the numbers of cases of Scarlet Fever, Diphtheria and Measles that have been notified during the past year as compared with those of 1906, from which the weekly mean is deduced, in each case :— Total number notified. Weekly mean. Disease. Year. All ages. Children attending public elementary schools. All ages. Children attending public elementary school. 1905-6 19,892 7.400 382 142 Scarlet fever 1906-7 20,741 8,716 399 168 1905-6 6,553 1,977 126 38 Diphtheria 1906-7 7,987 2,645 153 51 1905-6 Not notifiable 22,157 — 426 Measles 1906-7 Not notifiable 19,065 — 367 The above table shews that there has been a considerable increase in the number of cases of Scarlet Fever and Diphtheria this year and a great diminution in the number of Measles cases. There is some fear that this may be the upward wave of an epidemic prevalence beginning. One particular feature also to be noted is the extreme mildness of both scarlatina and diphtheria in the present forms. The following table shews the average number per week of children attending public elementary schools suffering from Scarlet Fever and Diphtheria in relation to the average number of all persons, expressed as a percentage. The numbers of school children for the first three years represent those attending Provided schools ; the numbers for the last two years indicate all children attending public elementary schools (Provided and Non-provided):— 1902-3. 1903-4. 1904-5. 1905-6. 1906-7. Average per week. Average per week. Average per week. Average per week. Average per week. Disease. All Persons. Board School Children. Per cent. All Persons. Board School Children. Per cent. All Persons. Provided School Children. Per cent. All Persons. Provided and XonProvided School Children. Per cent. All Persons. Provided and NonProvided School Children. Per cent. Scarlet fever 326 100 31 228 64 29 278 76 27 382 142 37 399 168 421 Diphtheria 193 51 26 135 37 27 137 31 23 126 38 30 153 51 33 School Closure.—School closure is adopted principally in measles outbreaks. When a classroom is closed on account of measles, a card, M.O. 19, is given to each child excluded on that account cautioning the parents, in the event of their children showing symptoms of the disease, to keep them from contact with other children and from exposure in public places. Closure is also resorted to in cases of scarlet fever, but only when the infection can be definitely traced to school influence or when the disease becomes threatening. The usual course followed in scarlet fever outbreaks is to send a Medical Inspectogh investigation into all the circumstances in connection with the outbreak and to examine the children with a view to the exclusion of suspicious cases of a post-scarlatinal nature or those exhibiting symptoms. By means of the Medical Inspector's report, the Medical Officer (Education) is able to decide as to whether or not school influence has contributed to case recurrence. Diphtheria is under special treatment, whereby closure is rarely necessary. School closure is rarely resorted to in cases of mumps, whooping-cough or chicken-pox, since there is an absence of evidence to demonstrate its utility. The numbers of schools under observation throughout the year for the three most dangerous diseases affecting school children are as follow :— Diphtheria—Provided 94) , Non-provided 20) 114 Scarlet Fever—Provided 248 340 Non-provided 92 Measles—Provided 356) 506 Non-provided 150 37 The following table shows the number of closures during the year and also the number of departments under observation for the various diseases :— Department. DISEASE. Diphtheria. Scarlet Fever. Measles. Humps. Chicken Pox. Small Pox. Number unde Observation. Classrooms Closed. Departments Closed. Number Under Observation. Classrooms Closed. Departments Closed. Number Under Observation. Classrooms Closed Departments Closed. Classrooms Closed. Departments Closed. Classrooms Closed. Departments Closed Clasrooms Closed. Departments Closed. Boys' Provided 15 — — 48 5 - - - - - - - - - 1 Non-provided 4 - - 13 - - - - - - - - - - - Girls'. Provided 20 — — 81 12 - - - - - - - - - 1 Non-provided 4 — - 22 3 1 - - - - - - - - - Mixed. Provided 13 — 1 19 — 1 — — — — — — — — — Non-provided 1 - - 13 - - - - - - - - - - - Infants' Provided 86 — 1 198 16 2 356 40 6 - — - - - 1 Non-provided 13 - 1 68 — 2 150 12 9 — 1 1 — — — Thirteen of the above closures were carried out by order of the Local Sanitary Authorities (including the three departments for diphtheria), viz.:—Lewisham, 9 ; Chelsea, 3; Westminster, 1. In the case of measles, the disease for which most frequent class closure is required, the numbers of classrooms and departments closed in infants' schools were distributed through the year as follows:— Month. 1906. 1907. Apl. May June July Aug. Sept. Oct. Nov. Dec. Jan. Feb. Mar. Classrooms. P 1 6 12 5 — — 1 1 - 3 6 5 N-P 1 4 3 1 — — 1 1 - — — 1 Departments. P 2 1 - 1 - - - - - 1 1 — N-P. 2 3 - 2 — — 1 — — — — 1 Schools affected. P 3 6 12 5 — — 1 1 — 4 7 5 N-P. 3 7 3 3 — — 2 1 — — — 2 Miscellaneous Closures.—Br oomsleigh-street School (Hampstead) was closed three days before the summer holidays at the urgent request of the Medical Officer of Health for the district on account of the prevalence of scarlet fever. Christ Church School (Southwark).—Infants' department. Closed by the Managers, on the advice of the Medical Officer of Health for the district, for three days before the summer holidays on account of the prevalence of scarlet fever. St. Marys and Christ Church Schools (Lewisham).—Closed by order of the Medical Officer of Health for the district on account of the unhealthy conditions of the drains. " Wanile " School. Wandsworth.—Closed for a few days before the Easter holidays owing to the basement being water-logged and the consequent ill-health of the children and teachers. Closure for Disinfection.—The following closures were carried out for the purpose of disinfection only, but in no case did closure extend beyond four days. Scarlet Fewer.—One classroom in Girls' department; two classrooms in Infants' department ; one Girls' department. Scarlet Fever and Diphtheria.—Two classrooms in Infants' department. Epidemic Grant.—The omitted epidemic grant still remains a blot on the history of our Educational administration. It is of such serious importance that the warnings of previous reports written in vain are worth repeating. " 1903, p. 9." Abolition of Grant. Unfortunately the Elementary Education Code has recently been modified and no further grants are to be paid under Art. 101*. This announcement came upon everyone interested in epidemic disease as a perfectly incomprehensible decision for which the reasons assigned were quite inadequate. 38 A generous interpretation of this Article, in accordance with the doctrines put forward in the Memorandum of the Local Government Board on School Closure and Infectious Disease, made it one of the most powerful factors for promoting good health among the children. Any inducement to officials or teachers to increase attendance at the risk of health was removed. It is, therefore, advisable to treat the provisions for registration, calculation of average attendance, the grading of schools and remuneration of teachers in accordance with scale, as if the epidemic grant still remained in force. Diagram X. “ 1905, p. 24.” It is to be noted that one of the conscquences of the abolition of the Article marked 101*, in the late code of the Board of Education, is that not only is the grant for absentees lost, but, in cases of severe epidemics, authorities are actually fined for keeping schools open, and it would be almost worth while defining what percentage attendance is required to prevent loss of grant arising from keeping a school open and marking the registers. The reinstatement of this Article 101* has been urged on the Board of Education by many educational and sanitary authorities in the country, but their entreaties are made to those whose 39 ^Diaqram XI. 40 training has not been such that they can appreciate the enormous importance of keeping infectious and convalescent children out of school without penalising teachers and school authorities. The value of the regulation is so great that efforts should be continued to have it re-enacted. " 1906. p. 30." 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 the Imperial 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 SCARLET FEVER. Diagram XII. 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 re-open this question, and to press on the Board of Education the necessity of allowing the epidemic grant as a national insurance against the school diffusion of disease, and a means of allowing sufficient prolongation of the convalescent period where children have been suffering from zymotic diseases." Time accentuates these remarks, but still the blot remains which has blacked out this valuable provision, the grant against disease. SCARLET FEVER. The mildness of many cases of scarlatina and the considerable proportion of apparently immune individuals make the study of scarlatinal diffusion very difficult. School infection must play a part, and it is justifiable to take measures based on the assumption that the statistical proof of school 41 influence is correct, yet it is by no means satisfactory, or free from considerable risks of error and the preponderating influence of school dissemination is certainly not yet beyond doubt. The usual course of a scarlatinal outbreak in a school is not a class outbreak, but for the first half a dozen cases to occur in probably five different classes, a mode of onset which is distinctly suggestive of other influence than school infection as the chief factor. The importance of the subject, however, would justify much time and trouble to discover the mystery of its diffusion, which really still eludes explanation. Even the extent of its prevalence is unknown. It is given roughly by returns of notified cases, but if we could compare it with diphtheria there may be very many more missed cases than is usually supposed. All estimates of prevalence necessarily omit a considerable number of children protected by mild and unrecognised attacks. Dr. Stevenson has attempted to calculate the proportions of children known to be immunised by previous attack. The method employed is first to calculate the attack and death rates for each year of life up to the age of fourteen. The differences between these rates yield protection rates, showing the proportion of children per 100,000 living in each year of life, and in each calendar year Diagram diphtheria. Diagram XIII. who acquire immunity by surviving an attack. It is then assumed that this immunity is permanent in all cases, and that the subsequent general death rate of " protected " children equals that of children unprotected from scarlet fever. On this latter assumption the proportion of children protected by attack during any year of life will be maintained as regards attack in that year by their survivors at all subsequent ages. To ascertain, therefore, the proportion of children aged 5-6, say at the end of 1905, who were protected by previous attack, it is only necessary to add together the protection rates of age 0-1 in 1900, 1-2 in 1901, 2-3 in 1902, 3-4 in 1903, 4-5 in 1904 and 5-6 in 1905. By this means the proportion of London boys, protected by previous attack at the end of 1905, has been shown to vary from 2 per cent., at the age of 3, to 14½ per cent. at the age of 13, beyond which the data at present available do not suffice to carry the calculation, so that at present in London about 2 per cent. of the boys are immunised at the age of 3 by previous attack, and about 15 per cent. by the age for leaving school. This is approximately verified by finding that 17 per cent. of the boys examined in the secondary schools knew of a previous attack of scarlet fever—a rate which might have almost been calculated by this method. 14958 F 42 In studying scarlatina it is evident that little account need be taken of school children's ages with regard to the numbers protected by previous attack—a striking contrast to ; measles where this factor is so very important. An enquiry into the method of propagation was pursued by Dr. Stevenson, 132 cases altogether, chiefly but not exclusively the school children of five schools being investigated both at school and at the child's house. In addition to these a considerable number of outbreaks were inquired into at the school only. Incubation period.—Amongst the 132 cases thirty occurred of secondary cases in households, under circumstances pointing with some probability to infection from the primary 1905 6 MEASLES. 1906-7 Diagram XIV. case. Certainty in any individual caae is unattainable, but the general teaching of a considerable number, if it points strongly to any particular period, cannot well mislead. If all the cases were coincidences, there would be as many secondary cases in the third week after the primary case as in the first. Of the thirty cases, however, 21 pointed to a period of five days or less and only two to a minimum of over a week. The conclusion seems inevitable that, in most of the 30 instances, the secondary was certainly infected by the primary case, with an incubation period commonly of five days or less. Infectivity and Susceptibility.—In nearly all of these instances the primary must have infected the secondary case, within the first day or two of illness. It was the removal to hospital of the primary case, and disinfection of the premises, which enabled a minimum limit to be 43 assigned in certain cases to the incubatory period. In London, where most cases notified receive hospital treatment (87 per cent.) in 1905, the bulk of the infection for which they are responsible must be at the very commencement of their illness, and a large proportion of the total infection must be at this period. It is probable, however, that a considerable proportion of infection is by missed cases, and, as regards these, the period of greatest infectivity becomes a matter of practical moment. Included amongst the 132 cases were eight which were missed, but afterwards established. In each case susceptible children were exposed to infection in the house, and in six cases infection occurred, during the first week of the infecting case in two instances, and during the second in four. These cases seem to point to the second week as more infectious than the first, but not conclusively, for resistance may be lowered by continued exposure. It is likely that moBt unprotected children would succumb to sufficiently prolonged and close exposure. The families of the eight cases just mentioned contained 20 other children under 14 unprotected by previous attack ; 11 of these, or (55 per cent.), caught the infection, as against 19 out of 134 unprotected children in 71 families where the first case was promptly isolated. But some children are protected by a previous undetected attack, and some appear to be proof against any exposure. Origin.—Most cases of which the origin can be traced are infected during the first day or two of illness of the infecting case. A few are " return " cases. There was strong evidence for this origin in two, and less strong in four more, of the 132 . Imperfect isolation can originate cases, but where the great proportion are sent to hospital this must be a comparatively unimportant factor. One such was met with. Indirect infection seemed possible in seven, two pointing to infection by fomites after imperfect disinfection, and five to transference of infection by a child not ill at the time. Three of these five possible " carriers " became infected later themselves, and two are not known to have done so. These two may either have been healthy "carriers" or very mild missed cases. There can be no sharp line of demarcation. Another possibility is infection by a missed (or concealed) case, and the number of these is so large that they must account for a considerable proportion of the total infection. Eight undoubted cases were met with, eleven others in which the evidence was very strong, and six more in which the possibility was suggested. Nearly all of these were brought to light by the onset of a second case in the family,so that the chance of a case permanently escaping detection must be greatly increased where the family is small. The case which remains undetected has probably not propagated the disease at home, but has every opportunity of doing so in school, consequently the present day decrease in the size of the family must tend to diminish home infection and increase infection in the school and street. It may well be that the majority of those infected in the school and street are due to missed cases. For these are very numerous, and have many of them prolonged opportunity of conveying infection, whereas the case diagnosed at the ordinary time has little opportunity of doing so outside its own home. Most children before scarlet fever are perfectly well on the last occasion of school attendance. Excluding a number of doubtful cases 70 of the children dealt with were not ill in school at all, and 21 were ill mostly at one school session only. It may be taken roughly that ten ordinary cases make five attendances after the onset of symptoms. But ten missed cases, assuming an average infective period of three weeks, would make whilst infectious no less than 300 attendances. Thus the missed case has fifty or sixty times as long an opportunity of conveying infection as the other. Many missed cases are also found in the peeling stage who have been continuously attending school, although not in this series, where no other case can be traced to them. The possibility of infection by a previous known case in school was established in only a small proportion of the school cases, namely, eight out of the whole number, which followed in the same class within a week of the last attendance of the 21 cases above referred to. Others, of course, may probably have been infected in hall or playground. There is some evidence, however, that these 21 did cause a certain amount of infection. The day of last attendance of the 70 cases not ill was followed within a week by a subsequent case in the same class in 16 instances against 8 in the case of the 21 children who were ill. The proportionate number for 70 children would be 27 as against 16. The difference, and the numbers dealt with are too small to admit of any definite conclusion. The subsequent history of a number of classes also in other schools from which cases of vomiting were feported shows little evidence of infection from these cases. The initial vomiting was reported from school in 47 cases, but there were only 10 cases followed in these rooms within a week, whereas in 40 cases where there was no vomiting and the child appeared well on the occasion of its last attendance there were 23 cases followed within a week. Eighteen cases where the child vomited in the class room were followed by four other cases within the week. Little evidence has been obtained that the disease is spread in school to any material extent by cases recognised and isolated at the usual time. On the other hand, the circumstances of many school outbreaks admit of little doubt as to the reality of a school spread from some source. In about twenty school outbreaks about one-third showed evidence of school infection. If this is a reality, and not due to any great extent to cases coming to light at the usual time, it might be due largely to missed cases which are so often found on investigation, or possibly even to mere carrier cases. Without some bacteriological means it is difficult to see how these cases are not to be missed. There was no evidence of undue want of care on the part of teachers or parents, although one or two parents seemed to have been lax, the atypical nature of the disease being mostly to blame in such cases. Such atypical cases were often recognised from subsequent cases occurring in the house, or from sequelae developing. This enquiry must be continued particularly in the direction of studying cases only recognised in their later stages. 14958 f 2 44 DIPHTHERIA. The method of dealing with diphtheria when there is any reason to suspect danger of school spread has been modified. Formerly no notice was taken in general by teachers of cases of illness other than those formally notified as diphtheria by medical practitioners. It has now come to be recognised that during the prevalence of diphtheria there are very many slight cases which escape detection and return to school in an infectious condition or continue in attendance throughout the attack. It is these cases which are responsible for school outbreaks. In accordance with the resolution of the Council, whenever diphtheria appears in a department, the head teacher is communicated with and is now instructed that no case of sore throat or suspicious illness, however mild, is to be re-admitted to school after absence without a medical certificate based upon bacteriological examination. This prevents the admission into school, between the visits of the school doctor, of children who otherwise would return in an infectious condition, and for a while disseminate the disease. In addition the medical officer of health of the district obtains early information of all such cases from the school, and the grip of the health authorities upon diphtheria is tightened. Many of the local authorities who provide for such bacteriological examination have welcomed the arrangement; a few have raised endless difficulties and necessitated unnecessary expense to the public by reason of the extended absence of the children, under suspicion, which has been required, in addition to conducing to the out-of-school spread of the disease. As has been pointed out repeatedly we have been fortunately, of late years, on the waning slope of a wave of diphtheria incidence covering many years ; there are not wanting indications that we have reached the trough between two such periodic waves, and it is necessary to consolidate our forces with a view of being prepared for the recrudescence which epidemiological experience warns us to expect. Like scarlatina, diphtheria has been more prevalent during the past year, 7,987 cases occurring at all ages, and 2,645 occurring amongst elementary school children, compared with 6,553 and 1,977 respectively during the preceding year. It has seemed more widely diffused rather than in definite outbreaks. This is possibly the commencement of a period of increasing susceptibility to the disease generally ; there is no evidence of increased school prevalence, the proportionate rise amongst the general population and the school population being practically the same. The number of schools during the year in which the rule with regard to non-admission of sore throats during diphtheria prevalence were applied was 39 (94 departments). The number of schools to which special visits for swabbing purposes were made was 32, the number of cultures taken 803, and the number of carrier cases detected 68. MEASLES. During 1905-6 measles was not very prevalent in Woolwich, but in 1906-7 an outbreak took place which this time commenced in the most easterly district (Bostall Lane) and spread westwards. The results in 16 schools are shown in the following table :— Number of Children. Had measles previously. Not had measles. Percentage unprotected. Number of cases in this outbreak. After the outbreak. Percentage left unprotected. Had measles. Not had measles. Non-closing schools— Eglinton-road 453 257 196 43 106 348 105 23 Wood-street 367 187 180 49 84 266 101 27 Plum-lane 257 135 122 47.5 94 223 34 13 Mulgrave-place 215 111 104 48 45 153 62 29 Bloomfield-road 630 396 234 37 121 512 118 18.6 Union-street 259 143 116 45 41 184 75 28 Totals 2,181 1,229 952 44 491 1,686 495 2.27 Closing schools— Earl-street 359 266 93 26 55 315 44 12 Vicarage-road 328 209 119 36 57 260 68 20.7 Conway-road 446 278 168 37.6 91 361 85 19 Ancona-road 415 241 174 42 103 342 73 17.5 Church Manor-way 338 183 155 46 96 272 66 19.5 Purrett-road 249 151 98 39 46 189 60 24 The Slade 265 171 94 35 69 237 38 14 Tim bercroft-road 273 148 125 45.8 58 200 73 26.7 High-street 401 217 184 46 110 301 100 25 Bostall-lane 324 213 111 34 69 277 47 14.5 Totals 3,398 2,077 1,321 38.5 754 2,754 654 16.3 Here it is seen at the expiry of four years from the beginning of the experiment in 10 schools in the closing area 38.5 per cent. were unprotected by a previous attack, while in 6 schools in the non-closing area 44 per cent. were unprotected. Measles attacked 22 per cent. of the children in both districts, and 22 per cent. of the children in the non-closing area were left unprotected, as against 16.3 per cent. in the closing district. Further, with regard to babies admitted since the 45 outbreak, of 213 in the closing division 162, or 76 per cent., have already suffered, while in the nonclosing district of 99 children, 76 have suffered, exactly the same percentage. It is therefore clear that, in the long run, closing has had little effect upon the spread of measles. Bostall Lane School is an interesting example; at the end of the year 1904-5, although measles had appeared several times, outbreaks were cut short by class closure and 42 per cent. of the children were left who had not had measles ; this seemed to be a signal success, but the sequel was 16 separate class closures, owing to as many outbreaks in 1906-7. No control was obtained over the disease, and at present this school stands among the schools with the lowest proportion of children who have not had measles. Our experience shows the usual official sanitary idea of results in measles prevention by school or class closure is mere imagination, and that closure applied in the only successful manner, at the occurrence of a first case, postpones measles for such a short time that the interference with school work except under special conditions is hardly justified and that for any effective results trained teachers capable of detecting the first case of measles are an absolute necessity. Whilst the incidence of measles has not been diminished, but appears to have been if anything rather increased, by closure in Woolwich, there has been a considerable effect on the death-rate due probably to better warning of parents and education by the cards issued from the schools ; by the instructions of teachers and visits of sanitary inspectors. It is to be noted, too, that the teachers who at first were disposed to be hostile, have now also become educated and carry out the routine required intelligently and accurately. The time has now come when the details carried out in Woolwich can be remitted, and the registration of measles immunity be required in a special column of the attendance register in every infant school. SPECIAL SCHOOLS. There is no fresh departure to chronicle in connection with the Special Schools. New provisions and new work is being more or less held over until the Report of the Royal Commission appears. The numbers of children examined for admission were :— Number of examinations. Numbers Examined. Passed for Mentally defective. Physically detective. Mentally and physically defective. Blind. Deaf. Residential Ischool. Industrial school. Elementary school. Imbecile. Invalids and Epileptics . April 26 433 147 65 - 1 10 _ _ 130 6 74 May 49 692 262 75 - 7 14 1 1 207 18 107 June 44 607 202 98 1 3 13 - 1 145 20 124 July 45 618 204 85 - 1 5 1 4 175 16 127 September 46 604 169 101 - 7 19 6 1 158 16 127 October 48 772 192 151 - 5 15 4 1 194 16 194 November 49 739 195 121 - 11 12 - 3 200 22 175 December 32 452 118 53 - 2 5 1 3 135 9 126 January 42 534 135 83 - 1 8 7 2 179 20 99 February 45 592 132 95 2 6 20 2 - 162 22 151 March 38 530 112 90 - 7 8 3 2 145 16 147 Total 464 6,573 1,868 1,017 3 51 129 25 18 1,830 181 1,451 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 1906-7 464 6,573 1,868 1,017 3 51 129 25 18 1,830 181 1,451 Last year + or — + 49 + 1,019 + 30 + 198 + 3 — 6 + 15 + 25 + 18 +326 + 18 +392 The examination of all difficult cases at the Head Office has already been referred to. There have been 823 cases examined during the year. Excluding cases seen in connection with transfers to or from residential schools, they were disposed of as follows :— Deaf. Blind. Mentally Defective. Imbecile and Blind. Elementary School. Invalids and Epileptics. Mentally defective Physically defective. Imbecile. High Myopia. Industrial Schools. Deaf. Blind. Boys 62 31 3 2 - 80 52 30 9 10 12 Girls 69 27 - - - 135 91 12 5 6 20 7 Total 131 61 3 2 - 215 143 42 0 15 30 19 During the winter, for political reasons apparently, an attempt was made to discredit the Special school work of the Council on its medical side. The details of the attack are not worth recounting. Such an attack from the first was perfectly hopeless. The method by which the cases are examined and recorded make the decisions on the particular class of case selected as subjects for the demonstration as accurate as practical clinical specialist knowledge can make them, so that the Council can be prepared to stand by these decisions fearlessly before any honest tribunal. 46 There has been some difficulty with the Board of Education in the meaning which they attach to the word " Deaf." This, it appears, is to be restricted to the very narrowest possible definition, and the class of borderland cases who, if young, will become speechless, or who from want of particular and localized brain defect should have a probationary trial, to see whether speech cannot be developed by kinaesthetic methods, are to be excluded. These, however, are highly technical questions, and only affect a comparatively limited class of child. The question of special classes for hard of hearing children has, however, been brought under consideration. Such classes are practically deaf classes, and can only be treated and considered as such, and should have the special grant for the deaf paid. PHYSICALLY DEFECTIVE CHILDREN. There are now 23 invalid schools with approximately 1,802 children on the roll ; 35 ambulance carriages and 11 omnibuses take these children daily to and from school, and 24 nurses attend to their conveyance and care in school. The admission of an invalid or crippled child to such a school is only permitted after a medical examination in accordance with the provisions of the Elementary Education (D. and E.) Act, 1899. In most cases the decision as to whether a child is fit for the special school or not is a comparatively easy matter. For the benefit of the child itself, however, a much more careful examination by an expert surgeon is of advantage. The future chances of the child must be estimated. Some children should be made to work; others should be treated very lightly. Each case requires a separate and careful judgment apart from the mere question of fitness or unfitness for the special school, and this work has been undertaken during the past year by Mr. R. C. Elmslie. The introduction of a card system of keeping these records has enabled him to analyse the results, and thus give a more comprehensive survey of physical defect in childhood than hitherto has ever been possible. Children in fifteen " Physical Defective " centres have been examined. In 1,050 cases details have been noted of the nature of the disease or defect, the presence of active disease or deformity, and the efficiency of any treatment adopted. Great difficulty was experienced in getting sufficient or accurate histories, the details noted in the family history books being often extremely meagre. The Medical Officers at the admission sessions appear to be too fully occupied to take details of history, and there is no power to oblige parents to visit the school subsequently in order that the facts may be ascertained. The histories taken by the teachers, who are of course without medical knowledge, often omit most important matters. The time taken up in these re-examinations was 53 school sessions, of not less than two hours each. So that about 20 children are examined and noted in a school session. Further examinations, when the cards are to hand, giving the results of previous examinations, could probably be done at nearly double this rate. Boys. Girls Total. Classification of P.D. children— 1. Tuberculous disease of spine 106 80 186 2. „ of hip 100 + (5)* 95 + (3) 203 3 „ of knee 46 + (2) 34 + (1) 83 4 „ „ of other parts 8+ (5) 11 + (4) 28 5. Various deformities (rickets, septic, congenital, etc) 66 + (3) 71 + (1) 141 6. Infantile paralyses 57 57 + (1) 115 7; Spastic hemplegia, paraplegia, diplegia 27 37 64 8. Progessive paralyses 8 1 9 9. Heart d'sorders 61 + (1) 59 + (3) 124 10. Var ous other diseases (chorea, phthisis, etc.) 22 32 54 11. Defects of eye or ear only 9 8 17 12. Delicate children, without present disease 26 30 56 536 514 1,050 Age of onset of tuberculous disease where there was a definite history. Age. Tuberculous Disease of Spine. Hip. Knee. Other parts. Total; 0— 1 14 9 4 2 29 1— 2 27 17 5 2 51 2— 3 28 35 8 3 74 3— 4 26 28 10 4 68 4— 5 24 25 8 4 61 5— 6 8 28 10 2 48 6— 7 7 11 6 2 26 7— 8 6 13 6 2 27 8— 9 4 8 6 4 22 9—10 1 4 2 — 7 10—11 1 1 2 — 4 11—12 - 2 2 - 4 * The numbers enclosed in parenthesis refer to children who, having two or more defects, have been included in one of the previous classes. 47 Remarks.—80 per cent. of these cases began below 7 and 67 per cent. below 5; of the spine cases 72 per cent. below 5 ; hip cases 64 per cent. between 2 and 6; of the others there was fairly even distribution over the first nine years of life. (1) Tuberculous Disease of the Spine. In the large majority of these cases the onset of the disease was quite early in life ; in 72 per cent. between the second and fifth year. It is not possible to ascertain with accuracy the presence or absence of active disease without watching the child for several weeks, and hence no good estimate of the proportion with active disease could be made; probably it is, however, not more than 10 per cent. to 15 per cent. There is a great tendency to recrudescence in cases of caries of the spine which may for a long time have been quite quiet, and many of the children have other foci of tubercular disease. In 186 children there were 8 with hip disease, 7 with lung disease, and 8 with other tubercular disorders in joints, skin, or glands. Excluding 4 cases in which there was no sign of disease, past or present, and 2 in which the diagnosis was extremely doubtful, the classification of the 180 remaining cases, as regards deformity or complications, was :— Slight angular deformity 35 Moderate angular deformity 41 Severe angular deformity 104 History of past paraplegia 19 Present or past abscess 50 The severity of the deformity depends (i.) on the portion of spine affected ; the upper dorsal region is far more likely to be the seat of severe deformity than are the lumbar or the cervical regions ; (ii.) the efficacy of the early treatment; if all the cases could be diagnosed early and the children kept fixed in a recumbent position for a sufficient length of time, amongst good hygienic surroundings, the cases with severe deformity would practically disappear. Paraplegic cases are not as a rule admitted to the schools. Of the 19 cases of paraplegia, 16 had completely recovered, and three had partially recovered and were still improving, the only case seen of a spinal paraplegia which was still complete, had resulted from a fracture of the spine and not from caries. These cases seem to illustrate the very good prognosis of paraplegia in spinal caries in children, prolonged treatment in recumbency leading almost certainly to complete cure. In only one ca6e had laminectomy been done, and in this, gradual recovery had resulted some months later, the result of rest rather than operation. (2) Tuberculous Disease of the Hip-joint. Tubercular hip disease is evident at a slightly later age than spinal caries, but 64 per cent. of the cases appeared between the third and sixth years. Allowing for seven bilateral cases, a total of 210 affected hip-joints could be classified as follows ;— Quiescent, with good mobile hip 14 Good functional result with ankylosis 22 „ „ „ with some mobility 20 Moderate functional result 34 Bad functional result (including 25 excisions) 71 Active disease 36 Amputations 6 7 cases could not be fully examined owing to the mode of fixation in splints or plaster. The separation into good, moderate, or bad functional result was made by noting the degree of fixed flexion and adduction deformity, and the amount of apparent shortening, i.e., the preventible deformity, as distinct from the real shortening, which is due to destruction of bone and is not preventible. Thus a hip which was ankylosed in a good position with two inches of real shortening would be classed as a good result, whereas one in which there was only one inch of real shortening, but 30 deg.each of fixed adduction and flexion, leading to an additional apparent shortening of 2½ inches, would be classed as a bad result. Most of these bad results might have been avoided had it been possible to keep the child recumbent for a long period, with an extension applied to the hip in the adducted position. Many of them might still be improved by active surgical treatment, by weight extension, or by osteotomy ; in only ten cases out of the 210 was there evidence that an ostectomy had been performed. The 25 cases in which excision of the hip had apparently been carried out were all classed as bad functional results. In none of them was the disease still active. Excision of the hip is a severe operation which seems to mend or end the disease. It invariably results in a dorsal dislocation of the stump of the neck of the femur, and by thus removing pressure from the acetabulum enables any remaining disease there to undergo cure. A child, on whom an excision of the hip has been performed, seems, when lying on the couch, to have a remarkably good joint left, with excellent mobility in all directions, but directly he stands the dorsal dislocation appears, and he walks most laboriously, the whole body dropping over with, each step taken upon the weakened limb. He would be much better off with a firmly ankylosed joint in even a fair position. Evidences of past suppuration were present in 61 per cent, of the cases, and in two cases unopened abscesses were found. Associated tuberculous disease was present in 12 cases, in 8 of them the spine being the other site of disease. (3) Tuberculous Disease of the Knee Joint.—The distribution of the age of onset over the first nine years of life was much more even than in the two previous diseases. f the 83 cases two were bilateral, giving a total of 85 knees, in 27 of which the disease was active, in 54 inactive, whilst 48 The results as regards deformity following different methods of treatment were :— Excision performed. Other operation. No operation. Flexion deformity 19 (9 over 40°) 6 (2 over 40°) — Genu varum 8 Genu valgum (3 very severe) 2 2 - " Triple displacement" - — 9 (1 severe) Shortening 1—2 in 6 — — „ 2—3 in. 8 1 - „ 3—4 in. 4 - — 5 in. 2 ,, (not measurable owing to other deformity) 6 — — Little or no deformity 6 6 17 Disease still active 5 4 12 Total Amputations—7. 34 14 26 The striking fact in this table is the frequency of severe deformity after excision of the knee, and remembering, that all these children have still years of growth left, it will be seen that the deformity, particularly the shortening, is certain to increase. In 9 of the 34 cases re-excision has already been carried out, and will be required in many of the others. A German surgeon (Hofmeister) pointed out some years ago that excision of the knee was not a justifiable operation before the age of nine, owing to the great liability to subsequent deformity. English surgeons do not yet seem to have realised this. No fewer than 25 of the excisions were done before this age and some were done as early as the fourth year. Associated tuberculous disease was present in 8 cases, including 3 in the spine and 5 in the elbow. (4) Tuberculous Disease of other Bones and Joints.—These cases were distributed as follows :— Ankle 13 (5 cases amputated) Tarsus and metatarsus 4 Elbow 7 Shoulder 1 Wrist and forearm 2 Head of tibia1 Upper end of femur1 Sternum 1 The numbers are too small to justify deductions. In 11 cases the disease was present in more than one region. General Remarks on the Results of Tuberculous Bone Disease.— These 500 cases emphasise the proportion left with serious deformity. Their treatment should strive to (i.) cure the disease, (ii.) prevent deformity. Economically, failure in the second of these objects is more serious to the community than a high death rate from the disease, tending to leave a number of cured, but crippled, individuals handicapped by deformity in their struggle for livelihood, and having to be supported by other members of the community. It might be objected that only the worst cases, surgical failures, are collected in the physically defective centres, but this is not so. Last year, it was shewn that only 16 cases of tuberculous bone or joint disease had been noted in 14,098 children in the ordinary schools in Islington; disease of the spine, hip, or knee only occurring in 11 of them. Mr. Rowntree noted, too, that the disease was not active, but that the resulting deformities were very marked. Most of the children are treated as patients at the large general hospitals. There are Teasons, press of work, numbers waiting for admission, necessity for shewing results apparently economical in short stay of patients, which indirectly lead to the treatment of these cases being made as brief as possible, and often it is practically confined to taking them in when an abscess has to be opened, and sending them home when the wound is healed, or even earlier. At other times they are treated as out-patients, in some form of splint, or in plaster, and are seen at irregular intervals depending to a great extent on the pecuniary circumstances of their parents. The very bad results, following excision of joints such as the hip and knee, are almost to be regarded as due to hospital exigencies. The advantages of such operations are that they effect rapid cure by clearing out the disease, and shorten the necessary stay in hospital. The corresponding disadvantages to the child are so great that it is doubtful whether these operations should be done on children of school age. The usual hospital method of treating such cases can never be efficient. A prolonged period of rest to the diseased part, procured by absolute fixation in splints, and necessitating recumbency in most cases, is required for periods of months and even years. The best place for such children is the country recovery school, which has been often referred to before. The few special hospitals, which treat hip disease in this manner, shew very much better ultimate results than can be found among the patients of the large general hospitals. 49 This miscellaneous group were mostly inevitable deformities, but many might have been alleviated had good treatment been carried out earlier. The cases of rickets are not very numerous, only children in whom a severe deformity had arisen, or in whom the process had remained active later than usual being admitted to special schools. If these children were detected on admission to the Infants' departments at 3 or 4 years of age, and proper treatment enforced, they would be mostly cured by the age of 5. (6) Infantile Paralysis.—In 68 per cent, of these cases the paralysis had its onset in the first two years of life, and practically all the recovery that will take place has done so by the age of admission to school, so that examination of infants at entrance would at once weed out those requiring treatment in special schools. A large proportion of children shew neglect in treatment either as regards correction of deformity or provision of instruments. Of the last class 38 have abandoned treatment. These numbers refer to the lower limbs ; of the four other cases, three had had amputation, and in one the arm only was affected. Many slighter cases of infantile paralysis and of paralysis of the upper limbs remain in the ordinary schools, and the above numbers therefore give no indication of the relative proportion between slight and severe cases. These cases are particularly the victims of bone-setters, and cases were often seen in which treatment had been stopped, or instruments removed by those appearing at music halls or elsewhere. (7) Cases of Spastic Paralysis. Hemiplegia 22 Paraplegia 25 Diplegia 17 Most cases of paraplegia and diplegia (22 of 48) dated from birth, the hemiplegias (18 of 22) generally arose during childhood. There are other such cases in the ordinary schools or amongst the mentally defective children. From the damage to the brain the general intelligence is apt to be low, and 19 cases (3 hemiplegic, 9 paraplegic, and 7 diplegic) were judged to be mentally defective as well. (8) Cases of Progressive Paralysis. Pseudohypertrophic palsy 8 Friedreich's ataxia 1 (9) Heart Disease. Congenital heart malformations17 Acquired heart disease 107 Of the congenital heart cases 16 were " blue children " with pulmonary stenosis, and 1 had aortic stenosis—12 were boys, and only 5 girls. The acquired heart diseases were chronic valvular lesions as results of rheumatism or chorea (St. Vitus' dance), except 1 case of dilated heart, 1 of rapid heart and 7 in whom no valvular lesion could now be detected. Prognosis was attempted from the evidence in each case, and could only be said to be good in 33 out of 124 ; the congenital being all regarded as bad. The histories were insufficient to estimate age incidence. (5) Various other Deformities. Congenital dislocation of the hip Boys. Girls. 8 16 Coxa vara 1 7 Congenital talipes 11 4 Results of epiphysitis, etc. 13 10 Rickets 16 24 Scoliosis 4 6 Amputations (omitting those for tuberculous disease and paralyses) 15 3 Miscellaneous 4 6 72 76 148 Cases of infantile paralysis :— Requiring treatment. (i.) Slight lesions not preventing the limbs being good and useful 27 13 (ii.) Severe lesions which must permanently cripple, but which with proper treatment and support will permit walking 30 10 (iii.) Very severe, doubtful whether the child will ever do more than hobble without crutches 54 — 111 23 14958 o 50 (10) Various Diseases. boys. Girls. Slight or convalescent cases of chorea (excluding cases with cardiac lesions) 9 12 Epilepsy (petit mal and slight cases) 6 13 Phthisis 3 6 Hæmophilia, 2. Exophthalmic goitre, 1.- Fragilitas ossium and ventral hernia 4 1 (11) Defects of Eye and Ear only. There is a very small group of children whose defects are insufficient to necessitate classification as blind or deaf, but which are unfit for ordinary school. (12) Delicate Children without definite existing Disease. Some anæmic, some with adenoids, some delicate after past illness. Every elementary school contains such children, and the few, in the physically defective centres, have only been admitted temporarily for observation. They, undoubtedly, improve rapidly both physically and educationally in these classes. Frequency of various other defects amongst 1,050 children in physically defective schools:— Boys; Girls; Notes; Phthisis 8 8 Only 7 with active signs; Chronic bronchitis 6 7 Eye defects 9 21 Nebulae. 10 Interstitial keratitis, 5, Congenital cataract, 4. Squint, 5. High Myopia. 2; Nystagmus, 2. Ptosis, 1. One eye lost, 2; Ear defects 9 13 Otorrhæa, 18 (4 with adenoids).; Old otorrhæa, 1. Deafness from adenoids, 3. Adenoids, etc. 12 11 Only 3 operated on. Tuberculous glands - 5 3 had had glands operated on. Anaemia 6 6 Skin defects 2 3 Lupus, 4.- Chronic eczema, 1; Various 7 3 Cleft palate, 4. Hernia, 3; Fistula, 1; Incontinence, 2. 59 in 56 77 in 66 boys. girls. Except for the cases of phthisis, and any defects of eye or ear previously quoted, these were all secondary defects. Backwardness of Children in P.D. Schools. A large proportion of children are several years behind their educational level. This was more marked in children with long illness from tuberculous disease than among the rest. Educational Status. Up to proper standard Behind proper standard. 1 year 2 years i years 4 years 5 years 6 years Total Abilities Exceptionally low Number Percentage. 1. Tuberculous disease of the spine 9 42 49 46 23 11 6 186 36 19.3 2. „ „ hip 10 19 56 58 37 15 8 203 40 19.7 3. „ „ knee 4 12 22 15 14 12 4 83 19 22.9 4. „ „ Other bones or 2 4 10 8 2 1 1 28 2 7.1 joints 5. Various deformities 19 36 30 28 23 3 2 141 28 19.8 6. Infantile paralysis 22 35 30 15 37 5 1 115 20 17.4 7. Spastic paralysis 1 7 13 9 13 12 9 64 33 51.5 8. Progressive paralysis 0 3 2 2 2 0 0 9 3 33.3 9. Morbus cordis 11 26 36 29 14 8 0 124 19 15.3 10. Various diseases 8 10 12 15 6 1 2 54 11 20.4 11. Defects of eye or ear only 0 0 5 3 5 1 3 17 9 52.9 12. Delicate (without definite disease) 4 8 16 11 10 7 0 56 19 33.9 Grand Total 90 202 281 239 156 76 36 1,080 In children with spastic or progressive paralyses the accompanying mental defect is well recognised. In the last two groups, those with only eye and ear defects and delicate children, the degree of backwardness is great and the proportion with low ability considerable. These children are only a 51 selected few of the great group of semi-blind, semi-deaf, nervous and debilitated, which exists in the elementary schools. Their admission to P.D. schools would be unnecessary if simpler schools existed. With the enormous amount of child material handled in the London schools there are greater opportunities of selection and classification than exist anywhere else, and there should be corresponding provision, as suggested at p. 48 of last year's Report. Ability of P.D. Children to Earn their own Living. An effort was made to estimate how many of these children would be able to earn their own living or to contribute to their own support. The proportion with each class of disease had to be considered, the probability of their growing up, and the chances of escaping without considerable deformity or delicacy to impair their powers; educational backwardness, the poor mental capacity of many of the children, and the long period of apprenticeship probably necessary for any skilled work were, however, left out of reckoning. The general conclusions arrived at were :— Able to work at ordinary occupations and probably to earn their living 20% Able to work at special occupations if taught, to contribute to their own support, and possible in some cases to earn their living 50% Not likely to live, or likely to be so severely crippled as to be incapable of work 30% With co-operation of teachers and managers an attempt was made to find how past experience would tally with this estimate. The children who could be traced were mostly traced by after-care committees, and many were still learning and earning very little, many were lost sight of, and others who would come into the first two classes had gone to ordinary schools. The enquiry seemed to indicate that the above theoretical estimate was too optimistic, and that a larger proportion than 30 per cent. drops out or fails to make a livelihood. Considering the conditions seriatim of the children with tuberculous disease, a certain proportion die of the disease, or other tubercular infection, meningitis, etc. Some others become so crippled or delicate as to be useless as workers. These account for 15 to 20 per cent. Of those who will subsequently be able to work, most are cured of the actual disease during the school years. They are often transferred to the ordinary schools, and in any case should be able at 14 or 16 to commence attendance at technical schools. This applies also to other deformities or paralyses. Those incapable of getting to such schools should be provided for in homes where possibly they could contribute something by work to their own support. The heart cases in these schools mostly die before adult life. Nearly half the deaths among P.D. pupils are from heart disease, and it is even more fatal in the years immediately succeeding school life. They miss the regular surveillance of school, and are often put to work that breaks down the balance of their heart compensation. Such children in these classes as are to be expected to earn their own living should be capable of attending technical centres or undergoing apprenticeship in trades which are suitable to their condition. VISION, Routine vision testing is regularly carried out in all the elementary schools as well as in the secondary schools and training colleges. The ordinary school examinations are necessarily superficial, and beyond the school comparatively little use is yet made of the knowledge of existing defects thus brought to light. The affected children are followed up in school each year, and the teachers show increased appreciation of the help which these examinations give them, as indeed they do of nearly all the medical inspections carried out in the schools. The provision of treatment, particularly by spectacles, is still unsatisfactory. The Voluntary Association for providing spectacles for school children has done much good, although the demand on its resources in the way of organised service has been very great and at times the supply of glasses slow. This Association has, however, practically brought glasses within the reach of all by reducing the unreasonably high prices hitherto charged. Attention being drawn to these prices many of the hospitals have made arrangements for their patients to obtain spectacles at prices which they can afford, and which this Association was the means of first obtaining for the school children. Results of the Vision Testing:— Standard Dept. Provided Schools. Non-Provided Schools. Number on Registers Returned as Bad Vision by the Advice Cards given. Number on Registers Returned as Bad Vision by the Advice Cards given. Teachers. Oculists. Ordinary Green. Urgent Red. Teachers Oculists, Ordinary Green Urgent Red. I. Boys 15,400 1,457 1,046 644 329 6,950 739 565 345 180 Girls 15,357 1,607 1,133 657 359 6,319 788 567 333 194 Mixed 6,385 553 441 286 117 2,361 268 187 136 44 II. Boys 24,752 1,792 1,408 890 433 7,573 780 590 373 191 Girls 25,065 2,469 1,814 1,035 616 7,824 904 682 407 241 Mixed 9,032 729 600 336 172 2,655 293 236 155 75 III. Boys 24,974 1,794 1,405 807 468 7,569 728 567 332 208 Girls 25,644 2,349 1,806 1,066 588 7,955 895 726 399 284 Mixed 6,403 521 367 206 117 2,269 215 172 114 62 11958 G 2 52 Standard Dept. Provided Schools. Non-Provided Schools. Number on Registers Returned as bad Vision by the Advice Cards given. Number on Registers Returned as Bad Vision by the Advice Cards given. Teachers Oculists. Ordinary Green. Urgent Red. Teachers Oculists Ordinary Green. Urgent Red. Boys 24,174 1,697 1,414 783 401 7,196 680 522 320 168 IV. Girls 24,111 2,231 1,657 921 534 7,524 858 676 429 206 Mixed 5,346 372 285 157 82 2,099 174 143 97 42 Boys 21,705 2,480 1,829 1,187 369 6,228 1,155 772 555 177 V. Girls 20,931 3,555 2,362 1,523 494 6,212 1,444 971 675 215 Mixed 4,620 544 404 248 82 1,703 288 226 151 61 Boys 15,101 1,635 1,130 717 222 4,420 794 536 374 135 VI. Girls 14,619 2,154 1,416 859 269 4,196 892 601 419 147 Mixed 3,487 417 291 161 41 1,176 191 134 92 26 Boys 11,068 1,026 726 422 145 3,113 472 295 193 70 VII. Girls 10,269 1,318 876 503 155 2,504 435 278 171 63 Mixed 2,884 306 203 112 35 821 140 90 59 26 Boys 137,174 11,881 8,958 5,450 2,367 43,049 5,348 3,847 2,482 1,139 Totals Girls 135,996 15,683 11,064 6,564 3,015 42,534 6,216 4,501 2,833 1,350 Mixed 38,157 3,442 2,591 1,506 646 13,084 1,569 1,188 805 335 By totalling these results an idea of the numbers who require some attention can be obtained. It is to be remembered that children are only returned as defective in vision whose education is likely to be seriously hampered by their defect and many are not given advice cards where permanent damage (opacities, scarring, etc.) has already occurred. Children below Standard V. are only included if the visual acuity is 6-18th or worse, and over Standard V. for 6-12th or worse. Further, many cases would be benefited by treatment which escape our net in school. The totals obtained are :— Provided Schools. Non-provided Schools. Totals. Percentages. Number on registers 311,327 98,667 409,944 100.0 Returned as defective by the Teachers 31,006 13,133 44,139 10.7 Oculists 22,613 9,536 32,149 7.8 Advice Cards given. Ordinary green 13,520 6,120 19,640 4.8 Urgent red 6,028 2,824 8,852 2.2 Total cards 19,548 8,944 28,492 6.9 As a result of the vision testing treatment was recommended for nearly 30,000 children during the past year, and towards this some of the hospitals with ophthalmic outpatient days once or twice a week have such pressure of more urgent cases that they are only prepared to admit 14 to 20 school children on any one day* To cope with this great work as a public service the Council would require half a dozen school clinics open daily for at least half the day. The rest of the time would soon be required for other work. Each centre by hard work could manage about 150 new cases weekly and thus just meet the demand. THE ARTIFICIAL LIGHTING OF SCHOOLROOMS. Schoolrooms are artificially lighted by gas or by electricity. Electric lighting has advantages of cleanliness, absence of heat, and freedom from deterioration of the air. The rapid deterioration of the atmospheric condition from gas lighting has been stated incidentally in previous reports on ventilation. The drawback to electric lighting is its cost, which, based on estimates derived from a dozen schools during 1905, amounted, in the case of electric lighting, to 1.7 that of gas. Quite apart from this question of relative cost, the illumination of the classrooms required investigation. Mr. Bishop Harman undertook an enquiry, and has furnished the following report as to the best positions of the sources of light, and the best distribution of the light, and what simple improvements could be suggested. His experimental observations were done in schoolrooms and in his own laboratory. Photometry. The simple photometric methods of the physical laboratory, by the comparison of shadows, or by Bunsen's grease spot method, fail in this work, and an instrument has to be * No further reference need now be made to the question of hospital service in relation to tho schools. I may be taken as sub judice having been referred to a Hybrid Committee for enquiry. 53 used which is quite simple and portable. Wingen's photometer has been used for several years in London schools. It consists of a metal box, 8 in. by 6.5 in. by 4 in., within which, near one end, is placed a benzine lamp, the wick of which can be raised or lowered at pleasure. Outside the box is a small shelf covered with a white card upon which falls the rays of light to be examined. Inside the box is a similar white card lighted by the benzine lamp. The two white cards are viewed simultaneously at the bottom of a tube glazed with red glass, whilst the wick of the benzine lamp is adjusted till the cards appear equally brilliant. The value of the illumination is read off by looking through a small slit in the side of the box, a mark on the glass covering this slit is taken as a " backsight," the top of the flame as a " foresight," and the figure on the scale fixed on the side of the box beyond the flame, in a line with the " back " and " fore " sights gives the value of the illumination in " metre-candles." That is a light equal to that which would be given by so many standard candles at a distance of one metre from the spot, where the examination is being made. This instrument was carefully examined by Mr. Harman and tested by himself and by the expert in charge of one of the L.C.C. gas testing stations, against the standard pentane lamp used there. It was found to be correct for the purposes required, and the calibration, which extends from 10 to 50 metre candles, was further extended down to 1 metre candle. Minimum Desk Illumination. The possibility of distinguishing one object from another by sight depends primarily on the illumination of the objects. A finger mark on a sheet of white paper is easily recognisable in good daylight, but not easy of recognition by candle light. The same principle holds good for distinguishing print on paper. The possibility of distinguishing any given object depends upon the familiarity of the examiner with the object examined. A normal sighted person of middle age will distinguish characters on paper in a poor light with greater readiness than a small child, because the characters are more familiar to the adult, and so much more easily recognised. Conversely a child requires a better light to learn to read than does an adult to whom reading is second nature. From a large number of experiments the least illumination permissible on the school desk of a child has been found to be equal to 10 m.c. This may seem a large amount of light if ten wax candles fixed in a chandelier and their effect in a room is considered, but it is not large when compared with ordinary daylight in a fairly lighted room. To-day is cloudy, the sky dull, and there is not a ray of sunshine, but the light on the paper is equal to 60 m.c., and the desk is fourteen feet from the window, and even at a distance of twenty-four feet the illumination is equal to 30 m.c. So that 10 m.c. is a modest demand for the minimum illumination on each desk in a schoolroom. Variety of Illuminants. Gas and electricity were the only illuminants used in this enquiry, and then only as used in rooms of moderate dimensions. Most of the Council schools are lighted by gas, burned directly as an illuminant at the jets of fishtail or batswing burners, or used as a source of heat to render Welsbach mantles incandescent. The use of naked gas jets is still the rule especially in the non-provided schools, but the Welsbach fittings are supplanting them rapidly with excellent results. The value of naked gas jets as a direct illuminant as compared with the superior value of the use of the same or a less quantity of gas with the Welsbach mantle cannot better be shown than by giving the result of the comparative examination of one room fitted with these two varieties of burners. A convenient infant classroom hung with four points of gas was fitted first with the most approved form of naked gas burner, Bray's No. 4 with No. 6 regulator, that is a good pattern well-made fishtail burner of No. 4 size with another No. 6 size slipped over it. The effect of this double burner is to reduce excessive gas pressure or " flaring " and give a steady flat flame of high illuminating power. The desk lighting was then examined. Then these burners were replaced by Welsbach " C" burners and mantles with " Calypso " shades. Although the gas consamed with the Welsbach burners was no greater, perhaps less than that burned by the fishtail burners, the desk illumination was increased nearly threefold over the whole room. With the naked gas jets the minimal desk illumination was obtained over only a very small part of the room. The desk area A, B, C, D of the room is 179 square feet and the patch of fair illumination 26 square feet, and this only when no obstruction such as the bodies and hands of the children come between the lights and the desks. On the other hand, with the Welsbach the illumination never falls below 10 m.c.,whilst in most parts of the room there is an ample margin for the interference which bodies or hands will make with 54 the light. This room is not quoted as shewing how a room should be lighted, on the contrary, it is an example of bad lighting. It is bad when lighted by naked gas jets, because the light is insufficient, and still bad when lighted by Welsbach light, because the lights are badly placed. For schoolrooms with the usual company's gas, naked gas jets afford a poor and wasteful illuminant. In such a room as quoted, at least four more burners would be required to obtain the minimal desk illumination. The cost, the heat, the consumption of air, and production of fumes and soot, would all thereby be doubled. Again the sootiness of these jets prevents the use of suitable reflectors, and a great part of the light is wasted. Even given the minimal illumination, the light is yellow and unsteady. The colour does not give the best contrast and the flicker is very objectionable and fatiguing. Incandescent Gas Light.—The preceding example is enough to shew the advantage of this means of lighting. The examination resolved itself into a determination of what form of burner, shade, and pendant, is most useful for classrooms, and the position of the lights in the room. The three burners examined were " C," " Kern," and " Simplex." The last is the latest pattern produced and seems to be the best of the three as regards the light given. The light given by it, and the mantle provided, is better than that with the others. It has the advantage of being 2½ inches shorter than the " Kern." It has a good air regulator, which, although theoretically unnecessary, with a constant gas pressure, is practically a most important part of the burner, and a device by which it is possible to considerably improve the light. The burner might be improved in some details. The makers have now, accordingly, supplied a pattern burner without the unnecessary brasswork obstructing the downward path of the light rays, which is an improvement. With a good burner and mantle a proper shade is the most important part of the gas fitment. For deskwork a Welsbach light without a shade is rather worse than a naked jet, because the brasswork of the burner casts a black shadow beneath the light; by reflection from a shade, the light can be so distributed as to be practically perfect. Such a lamp shade for school use should in the first place be cheap and durable. It should reflect the light so that there is no shadow beneath the burner. It should also so reflect the light that the lamp at a given distance will efficiently cover a given area. The shade should also protect the teacher's eyes from the direct glare of an exposed mantle. Four varieties of shades were submitted for examination— "Squat," " Calypso," " New No. 3," and " Reflex." Most of the shades or globes on the market are adaptations of the old globes around naked gas jets, and variously altered or contorted to suit the fancy or aesthetic ideals of the makers. Diagram XVII. The inadequacy of such a form as the "Squat" is obvious. The sides subtend an angle of 45 deg. to 50 deg. and do not reflect the light past the massive brass burner. In the "Calypso," with something of a parabolic reflector in its shape, the opaque mass of the burner is particularly effective in stopping the rays. " New No. 3 " differs only from the " Calypso " in the shape of the lower clear glass portion, which is immaterial. The " Reflex " is an attempt in the right direction, but its details have been carelessly arranged, so that in classrooms it may be very objectionable to the teachers. Effi- 55 cient reflection can only be obtained from a Welsbach burner when the opal sides of the shade subtend an angle of about 90 deg. The opal upper portion of the "Reflex," 2¾ in. vertical is shaped on this plan and, consequently, the shadow beneath the burner is less than with any of the other shades. The lower part of the shade, 2¾ in. perpendicular, is of clear glass so that two-thirds or more of the incandescent mantle is directly exposed to the teacher's eyes ; the effect being intolerably dazzling. For this reason the " Reflex " is quite unfitted for the classroom. This effect is easily remedied by extending the sides of the " Reflex " with a simple paper shade figured as the 90 deg. shade globe. The relative values of these shades from the point of efficient lighting can be shewn by the figures from the following experiment in which the metre candle value of the illumination was measured on the desks immediately below the burner and then at intervals of a yard along the horizontal desk tops, which were five feet vertically below the burner. All the shades were examined in this way. The results found for the " Squat," " Calypso," and " New No. 3 " were alike, and 1 m.c. less than the " Reflex," below the burner: they are therefore omitted from the table. The experiments were made consecutively with the same burner and mantle. Table of results with " Simplex " burner and " C " mantle in metre candles :— Shade. Perpendicularly below burner. 1 yard. 2 yards. 3 yards. 4 yards. 5 yards. None <1 2 2 1 + 1 1 " Reflex " globe 8 8 5 2 1 1 90 deg. shade globe 22 15 7 2 1 1 The improvement on the unreflected light by the use of the " Reflex " shade is great, but the results to be obtained by increasing the depth of the shade are most striking. The gain is obtained by reflecting the rays that would otherwise be dissipated upon the upper part of the walls of the room, and the teacher's eyes are screened from the dazzling of the naked mantle by the depth of the shade. The general wall illumination of the room does not suffer; it is quite as good as when the " Squat " is used, 56 and although not so bright as with the " Reflex," yet, owing to the absence of the dazzling effect of the exposed mantle, it appears better. The shadow beneath the burner can be estimated by the simple test of holding a large sheet of white paper below the burner. When no shade is used, a sheet of paper held a yard below the burner shews a deep shadow more than a yard in diameter ; with the " Squat" or " New No. 3," deep circular shadows about 2 feet diameter are cast. The " Calypso " throws a small central blot with a secondary outer ring of darkness. With the 90 deg. shade globe, as devised, no shade could be detected, even when the screen was held up to within a few inches of the burner. This 90 deg. shade globe fulfils all the four conditions required for a school globe, and could be made without any difliculty or any material increase in cost as compared with those now in use. The spread of the shade, about eleven inches, would not permit of its use with the loop pendants now issued to the schools ; but as these pendants leave much to be desired, they could be altered to suit a more efficient globe shade. Two kinds of pendants are now in use, a "two light" and a " harp shaped." The former is the ordinary ┴ shaped pendant, with a light at the extremity of each arm. The " harp shaped " is a single light pendant, formed by a perpendicular length of tube suspending an elongated elliptical shaped loop. Since all rooms are not the same size, the two-armed pendant is not fitted for general use. With a properly devised "harp-shape," the lights can be placed individually where most wanted. For such a pendant there is the usual ceiling plate, ball and socket joint, and a variable length of tubing to suit the height of the room. The loop is triangular in shape—one side carries the gas, the other side is merely a support to balance the shade. On the gas side is the stop-cock, which is on the bend and quite clear of the bottom tube. The burner is to screw clear on to the bottom tube, without any wasted room filled in with needless brasswork. Arrangement Of Lights. The position of the pendants in the existing classrooms is rather with a view to symmetry than good lighting. There is often waste of light in some parts, and poor light in other parts of the rooms. It is difficult to lay down definite rules, as each classroom has to be considered by itself. (i.) Each classroom should be considered as being made up of two portions, the children's area, and the teachers' area, and the lighting of these parts must be arranged independently. (ii.) Left hand lighting must be arranged for as far as possible, exactly as in the rules for window lighting. (iii.) In calculating the area over which the rays of a lamp will extend, we must only take into our valuation those rays which proceed from lamps in front of the class to the back of the class. Lamps in front of a class illuminate to some degree the desks of the back row, but lamps to the back of a class do not help to illuminate the front rows of desks when the children are in their places. (iv.) There must be a clearance of 6 feet 6 inches beneath pendants, and the luminous mantle must be as closely as possible approximated to this level, hence burners must be short and cocks or byepass fittings must be placed on one side of the pendant arms, and not between burner and pendant. From suggestions (ii) and (iii.) it will follow that the main desk lighting will be arranged to come from the left and somewhat in front of the child. The gasfitter should mark the position of the first lamp to be hung over the centre of the first dual desk on the child's left of the front row. Proceeding, lamp positions should be marked out along this front row at from 6 ft. to 9 ft. intervals, according to the height of the desks from the floor ; being closer in infants and further apart in the higher standards. The row of lamps thus marked out would give sufficient light for the front row and the second row of desks. A second row of lamps similarly spaced would light the third and fourth rows of desks. Since a lamp hung behind a child throws no light on the desk of that child, it follows that the space between the lamps from front to back of a room should be less than that between the lamps from side to side of the room. 57 In Diagram XX. the plan of a model room is given to accommodate 40 children. The children occupy two-thirds of the floor space and the lamps for this area may be hung so as to give efficient lighting in two ways, according as to whether infants or older scholars are to occupy the room. For infants the perpendicular distance from lamp to desk must be calculated as 5 feet. Three lamps will be required in the front row and three over the front row in positions marked A.A.A. For a room with well-grown children we need only reckon 4 feet as the perpendicular distance from lamp to desk, and with this shortened distance the power of the lamps is improved by one-third, so that two lamps over the first and two over the third rows of desks in positions marked B.B. would be sufficient. The illumination of the teachers' portion of the classroom must be taken separately. Here are hung maps, charts, and the blackboard. Blackboards or slates should be fixed against the wall with the right hand slightly tilted forward, as shewn in sketch. They should always occupy the right hand half of the wall behind the teacher. For illumination, when daylight fails, a pendant should be hung to the left of the teacher's desk in the portion marked X ; this light should be fitted with a chimney and a metal shell-shaped reflector, opaque to light, to project the light well on to the blackboard or master's desk as required, and to present a dark back to the children. Electric Lighting. Handiness, simplicity, and ease of distributing points of light, complete absence of shadows below the lamp, the possibility of perfect reflection, healthiness in freedom from consumption of air and production of fumes, and noiselessness, make lighting by the electric glow lamp the most perfect means now available for school use, the only drawback being its present greater cost, as already stated, this worked out in 1905 at about 17 times that of gas. The following experimental examination of the illumination given by a glow lamp under different shades will give an indication of the value of the light. A 16 c.p. lamp was used with 100 volts of the Strand supply. The lamp was hanging in a room chosen for its convenience and the measurements made in a plane 4 feet below the level of the lamp:— Shade. Below lamp. 1 yard. 2 yards. 3 yards. 4 yards. None 5 m.c. + 3 + 1 1 1 110 deg:. 3⅛ in. deep 20 9 5 3 1 80 deg.: 5 in. deep 30 9 5 2 1 Two sorts of opal shades are in use in the schools; one subtends 110 deg. in the sides, and has a vertical depth of 3⅛ in. This shade does not cover the lamp, and the incandescent filament is exposed to the teacher's eyes. The other shade has sides subtending an angle of 80 deg. and with a vertical depth of 5 in.; this shade completely screens the lamp from the teacher, and is the one to be preferred for classroom purposes, as the light below is also increased by one-third. These lamps throw an image of the filaments. If a sheet of white paper be held under the lamp at the distance of a yard, four bright stars, each with a bright tail outwards, will be seen marking the corners of a square of one foot side. At the distance of two yards the separation of the points is two feet. The better the reflector over the lamp, the less noticeable are these lines. Ground glass bulbs obscure the lines completely, but frosting the glass reduces the illumination by 25 to 30 per cent. The only suggestion to be made as to bulbs is that these should be as large as possible, and the filament twisted in as long a loop as possible. Mr. Harman has also examined the "Tantalum" and the " Nerst" lamps. The former appears very good, but the latter is unsuitable for schoolrooms. The distribution of the lamps should follow the lines indicated for the gas pendants. Beginning at the left hand of the children's portion of the classroom, a lamp should be hung over the centre of the first dual desk and from there across the breadth of the room at distances of not less than 6 ft. and not more than 9 ft. for 16 c.p. lamps with 90 deg. shades. With gas the fewest possible number of burners is desirable, for the more burners the worse the atmosphere; but with electricity, the points of light may with advantage be more generously disposed, and a cross room spacing of 6 ft. might be uniformly arranged. A second row of lamps should be hung in the same relation over the third row of desks. The lamps, as usually hung, err in being hung too far back; for instance, over a back row of desks, with the idea of their illuminating the desks in front, which they, however, fail to do when the children are present in their seats. The use of a front row of lamps with tilting shades, to light the blackboard in the teachers' section of the room, or desks in the children's portion, fails to serve both purposes in practice. It would be better to use a lamp to illuminate the desk and blackboard and completely shaded from the children's portion of the room. The most common complaint in electrically lighted schools is want of light owing to low pressure in the supply. Sudden and total failure also occurs occasionally. In installing electric light, it should be used in classrooms only. Staircases and passages should be lighted with gas, naked jets with wire frames. In one old school building, where communication was from classroom to classroom, and where passages had irregular floor surfaces, the evening classes are much attended by foreigners, and, in the event of failure of light, the difficulties of exit would probably have even puzzled the schoolkeeper. In addition to these ordinary means of illumination used in the schools, there are several other methods used in America, or on the Continent. The inverted gas burners with incandescence, recently much used in shop lighting, although they throw the light downwards, have drawbacks for school use. With an inverted Bunsen burner, the combustion is imperfect, and noxious fumes escape to a much greater 14958 H 58 extent than with erect burners. They are also very susceptible to variations in pressure, and at times give very poor light. They easily get out of order and require a great deal of attention. In some nonprovided schools they are found in very bad condition. Refraction and reflection in certain forms of shades have been much recommended in America for school use. The " Prismatic " and "Kalophane " globes were examined. The " Prismatic " globe has the outer surface of a glass bowl moulded into a series of prisms, running round the bowl and so placed as to throw light downwards. It is very effective, especially when a flattened opal shade closes the mouth of the bowl. The combination is costly and heavy, and an equally good effect can be obtained with the 90 deg. shade globe. Indirect illumination by reflection is now a very favourite method in the newer German schools. By this method, powerful lights, usually arc lamps, are hung from the ceiling with metal reflectors below them, the light is thrown on to the white ceiling or to special reflectors and reflected as a delightfully uniform and soft radiance over the whole room. The effect is not unlike daylight of modified brilliance, and it is most successfully employed in shops and showrooms, where the deep shadows of direct light would be destructive of the general effects of mass and colour required to be shewn. It is however, not good where continuous and detailed work at a desk is required. The system was adopted in the New Anatomical Laboratories of Cambridge University. but has had to be superseded by direct glow lamp illumination. With the increase of evening continuation schools, the lighting of the gateways and entrances of the schools becomes a matter of importance. At present the precincts of a school at night are generally the darkest part of a street, and the dark exterior is scarcely a fair indication of the light that shines within. VENTILATION. Since reporting in 1904 on experiments on the need for ventilation of certain classrooms, chiefly shewn by determinations of the deterioration of air by the carbonic acid gas present, attention has been directed to the almost inexplicable subjective feelings of languor and fatigue noticed in many mechanically as well as naturally ventilated schools. Some mechanically ventilated schools are almost museums of mistakes, most in London are failures from want of appreciation of the problems to be treated, but the failures are purely in matters of engineering. It only seems to be in schools with warmed air, where the air supply runs up to about 2,000 cubic feet per head per hour, that freedom from the easily induced exhaustion is found. Although every school room should be mechanically ventilated, yet the necessary arrangements with low pressure fans, otherwise desirable for school purposes, seem in London to be almost out of the question owing to cost in space and material. From Haldane's observations, the actual amount of respiratory carbon dioxide appears to have little to do with the production of unpleasant symptoms, and no evidence can be obtained of the existence of the anthropotoxin previously generally supposed to exist. He favours the idea that temperature and humidity, by interfering with the loss of heat from the body surface, disturb metabolism and induce unpleasant or even dangerous symptoms. These observations have been independently confirmed by various workers in the laboratories of Professor Fliigge at Breslau. It has therefore been attempted to supplement the previous observations on school air in London by observations on Fatigue and also on the relation of the atmosphere to the working capacity of the children. The Effect of Ventilation on School Fatigue. Dr. Thomas and Dr. Stevenson made a few observations during the year at St. George's Row School, Pimlico, a school ventilated on the plenum system, warmed and moistened air being driven in from the basement by a low pressure fan through large ducts to the classrooms. There was practically no interference with the school work. The tests used to determine the efiects of fatigue on the boys during the school session were the numbers of simple addition and subtraction sums of simple integers which the boys could do in five minutes at the beginning and end of their tasks. It was also attempted to use the estimation of an angle which was copied by eye from the blackboard, to assess the correct judgment of the boys. On the first two occasions the ventilation proceeded naturally. The carbonic acid gas present and the humidity were determined at regular intervals. The moisture was practically constant under normal ventilation both in July and February, only varying between 71.4 per cent. and 73 per cent. On these two occasions the temperature varied from 60 deg. F. to 72 deg. F., and the carbonic acid present from 6 to 12 per 10,000 volumes. The effect of teaching under these normal summer conditions was shewn by an increase in the quantity, but greater decrease in the quality of the work done in the time. The number of figures worked at the second test being 24'6 per cent. and 15.6 per cent. respectively in excess of the first, but the proportion of errors to figures being increased 63.3 per cent. and 86.4 per cent. On the third occasion, by blocking the inlet ducts, the ventilation was converted into an ordinary naturally ventilated system, with inadequate inlets, air entering by the upper valves of the outlet openings and leaving by the lower. The humidity during the session rose to 81.4 per cent. and the carbonic acid from 10 0 to 22'5 ; the temperature rising from 71'5 deg. F. to 74.5 deg. F. The increase in amount of work done on the previous days now fell to the insignificant amount of 2.3 per cent. whilst errors were increased by 135.9 per cent. The angle test, in which the boys were set to copy as accurately as they could angles of 67 deg. at the first test, and 22 deg. at the second, shewed a mean error of 5'82 deg. at the first and 6'14 deg. at the second test. On the fourth occasion the ventilation on entering the room was found hindered, and a stuffy smell existed, the caretaker's attention being drawn to this, considerable improvement was effected in this particular room. The first two readings of carbonic acid were 14 and 17 respectively; this fell and was maintained about 11 as on previous occasions. Temperature varied from 65 to 67, moisture 70.6 per cent. to 72.4 per cent. Under these favourable conditions, there was greatly improved work ; the quantity improved 26 per cent. the proportion of errors decreased 30.1 per cent. The mean error of angle drawn (45 deg.) fell from 7.62 deg. to 6.60 deg., a decrease of 13.4 per cent. The effect of improved ventilation more than counterbalancing the expected fatigue. On the last day of experimenting, there was fog and gaslight; the inlets were stopped, so that the air was allowed to deteriorate. The temperature fell from 72 deg. F. to 66 deg. F ; moisture rose from 71.8 to 100 per cent., and carbonic acid from 24 to 50 parts. Little inconvenience was felt in spite of these high figures being recorded, the teacher noticing for the first time at the close of the lesson that " something seemed wrong with the ventilation." The work done was anomalous, the output was 5.2 per cent. less, instead of the increase always noted before, but the quality was good, only 1.1 per cent increase in errors. before, but the quality was good, only 1.1 per cent increase in errors. With the angle test (31 deg. and 35 deg. set) there was, however, a great falling off, the mean error of estimation increasing from 5.40 deg. to 8'81 deg., an increase of 63.1 per cent. First Experiment. June 26, 1906. Second Experiment. July 3, 1906 Third Experiment. July 19. 1906. Fourth ExperimentFeb 21, 1907. Fifth Experiments Feb. 28, 1907; I. Test. II. Test. I. Test. II Test. I. Test II: Test. I. Test. II. Test I. Test. II; Test. Number of boys present 48 + 1 47 + 2 50 50 49 49 58 58 58 58 CO2 vols. per 10,000 8.5 10.5 9.0 22.5 17.0 11.0 24.0 49.5 Difference T°wet and dry bulb 5.5° 5.0° 5.5° 7.0° 6.0° 6.5° 6.0° 0.0° Average number of figures worked 10. 6 13.4 13.0 15.0 15.98 16.35 11.16 14.05 14.93 14.16 ,, mistakes 0.86 1.84 1.18 2.86 1.48 1.31 1.29 1.24 Mistakes per cent, of figures 8.6 14.3 6.6 12.3 7 .41 17.48 13.3 9.3 8.7 8.8 Percentage change in figuresworked + 26.4 + 15.6 +2.3 + 26.0 - 5.2 „ mistakes + 66.3 + 86.4 + 135.9 - 30.1 + 1.1 Angle set for copy 67° 22° 45° 45° 31° 35° Angles greater than copy 15 25 12 40 25 39 11 „ less „ 34 19 33 14 30 18 44 „ correct 1 5 4 4 3 1 3 Average error in excess 5.0 6.56 6.08 9.45 8.00 6.6 5.6 „ deficiency 6.85 6.37 6.91 4.57 6.10 3.0 10 2 Total excess or deficiency — 157 + 43 —155 + 314 + 17 + 205 - 387 Mean angle resulting 56.86° 67.9° 18.8° 39.6° 45.3° 34.5° 28.3° Mean error 5.92 5.82 6.14 7.62 6.60 5.40 8.81 Percentage (+) or (—) of mean error - + 5.5 13.4 + 63.1 These few observations tend to confirm the results of other observers, such as Burgerstein*, as to the effect of slight fatigue on improving the capacity for mental work. They strongly suggest that in any future observations on fatigue made on children in crowded rooms, the conditions of ventilation may constitute an all-important factor in the results. A curious point probably involving a psychological explanation dependent on ocular movements is that on each day there was a tendency to over-estimate the angle at the first test, and to underestimate it later. This reversal was complete on the days when bad ventilation was accompanied by deteriorated work, but with the good ventilation, although there was still overestimation at first, the number of under c6timations only just exceeded the over-estimations in the second test. Unfortunately, other work prevented this exceedingly important question of fatigue being followed up. A further extended series of observations on the effects of varying the atmospheric conditions on the school work has been made by Dr. Hogarth and Dr. Brincker. General Methods Of observation. The school work was allowed to take its ordinary course, the atmospheric conditions and variations being carefully noted, and after a time artificially altered in certain ways. The subjective and objective signs observable in children, teacher, and doctors were also noted, and, as in the enquiry just detailed, an attempt was also made to ascertain the veriations in the working capacity of the children. The Method of Recording Variations in the Capacity of the Children. After a considerable number of preliminary observations, subjective tests were rejected as of little value. Then algebraic and arithmetical problems were tried, and also memory tests, but finally simple arithmetical tests were adopted as most suitable for comparisons. A set of twenty multiplication sums of three figures was given, the figures being placed side by side in columnar form, to be done in five minutesThen an estimate was obtained of the number of sums done right, number wrong, and number omitted. The work was given out (Test I.) at the commencement of the school session, and the results collected in five minutes. A like process (Test II.) was repeated two and three quarter hours later. The Head * Burgerstein, Dr Leo, "The Working Curve of an Hour," Trans. VII:, Congress of Hygiene and Demography. London, IV., 87 14958 H 2 59 60 Master, Mr. Draper, and class teachers, Messrs. Campbell and Barber, gave great help, and materially aided the working out of the fatigue figures. At first the results of the tests were set out diagrammatically, marking off horizontally numbers to represent the numbers of sums done rightly by different groups of boys, and then marking vertically the number of boys in each group. Curves were got for each test, and on superimposing these curves displacement to the right or left indicated improvement or deterioration in the mental capacity of the boys. Diagram shewing deterioration of groups of boys getting fewer correct sums in the II. test. To express the gain or loss in figures the total number of sums multiplied by the number of boys working them correctly was averaged among the boys, and the gain or loss in the average taken. The later method was, however, always to give twenty simple multiplications of three integers and represent this multiplied by the number of boys as a rectangle, whose surface was equal to this number of squares, then the right, wrong, and omitted sums could be recorded by light lined or stippled squares on the rectangle, and the actual numbers taken in percentages gave a numerical estimate as shewn below. For instance, the records of observations on January 9th, 1907, were :- 26 boys and 20 sums = 520 1. Right 446 = 85.77% II. Right 406 = 76.15% Wrong 53 = 10.20% Wrong 52 = 10.00% Omitted 21 = 4.03% Omitted 62 = 13.85% 520 = 100.00% 520 = 100.00% 61 Result. Deterioration chiefly marked in work omitted. Test II. over I. Right = -9.62% Errors = + .20% Omissions = — 9.82% — 19.24% The same tests were at times given to a control class, working under other conditions, in a separate room, and it was evident that on the same day a class working under normal conditions could produce a much better second test than the class under conditions which were abnormal and productive of deterioration in the working capacity. The satisfactory nature of the results is confirmed by the fact that, in every case where boys were working under good conditions, the tests shewed a distinct improvement at the end of the session, whereas, when the conditions were acknowledged to be bad, the results were always inferior (at the end of the session). This made the comparison of results easy. The converse is true, namely, if the results of similar mental tests set before and after school session to a class of ordinarily honest and intelligent children, shew a falling off or even an absence of improvement in the mental alertness and accuracy, it is just to conclude that some deteriorating influence has been at work. By methods of exclusion this is shewn in these observations to be various atmospheric conditions. Actual Observations. During the summer of 1906 about 25 observations were made in both boys and girls classes, to get experience with the apparatus and general technique of the methods. The subjective symptoms of the teachers and children, working under various conditions, were also analysed, but owing to numerous errors and fallacies, none of these observations are included here. There was practically no disturbance of any of the school arrangements. Since October, 1906, numerous observations have been made in which the four chief factors of temperature, humidity, carbonic acid gas, and movement of the air have been associated in every combination, and their relation to fatigue indicated. The work was done at Cassland-road in a school ventilated on the plenum system, so that the temperature of the air could be regulated by means of a damper and the room kept at any temperature between 50 deg. F. to 80 deg. F. The records of carbon dioxide were made about every quarter hour, and always with Haldane's apparatus, each observer making estimations with his own apparatus, and thus checking the other. Samples of air elsewhere in different parts of the building, and outside were also examined. It was for instance determined that in one classroom, the ventilation was incomplete in the teachers' part of the room. On an early observation, when it was attempted to increase carbon dioxide by the action of dilute acid on marble in beakers, the particulate impurity, consisting of invisible droplets of acid fluid set free by effervescence, produced such coughing without much difference in the carbon dioxide, that this method had to be discontinued, and henceforth the carbonic acid content was varied by adding the gas from a cylinder This latter means was used to alter the carbon dioxide without interfering with the ventilation, but it was difficult to get any considerable concentration without also blocking the air ducts. The relative humidity was determined about every quarter hour, from the readings of a standardized wet and dry bulb hygrometer. This was always swung in the air a few seconds before a wet bulb reading was taken,so that a maximum evaporation would be produced ; this proceeding reduced the wet bulb readings by about from 1.2 deg. F. to 2 deg. F. . When local movement was produced by a fan* the hygrometer was always set near the fan. The hygrometric condition outside was also noted. To increase the humidity, evaporation of water by boiling kettles over spirit lamps was tried, but it was found impossible to attain any high humidity with temperatures of 70 deg. or over. This must be attempted again during hot wet summer weather. Movement of the air took place by the ordinary currents due to the pressure of the ventilation system, but was also varied when the ventilation currents were insufficient by means of an electric fan in the classroom. By this means, evaporation could be furthered when the air was hot and moist, and much improvement Subjectively could always be obtained. These observations required continual attention during the whole time. As an example of what was necessary, the record is given of an afternoon's work, No. 21 in the table, under normal school conditions. " January 30. A very fine cold crisp day, clear, with wind N.N.E. outside. Dry bulb, 43 deg. F. Wet bulb, 39 deg. F. Humidity, 71%. Carbon dioxide in outer air, 3.5. * A special 16 in. oscillating electric fan was kindly lent for these observations by Messrs. Marples, Leach & Co. 62 Time. Outside air temperature. Inside air temperature. Humidity. Outside C02 Inside. CO. Work done by boys. Number of persons. Remarks. Dry. Wet. Dry. Wet. 2 40.5°F 36°F. 56 48 56 4 5 Copy off board. 24 boys.- Boys do not feel cold and work well. 2.15 66 rel. =RH. hum. 57 48 53 7 History & geography 2 adults Attention good. 2.30 57 48 53 9 First test taken ,, ,, 2.45 40.5 36 57 49.5 59 4 9 History & geography ,, ,, 3 Singing. 3.15 57 49.5 59 9 ,, ,, ,, 3.30 39.5 35 57 48 53 9 Geometry. Interval 3.30 3.40. 3.45 7 ,, 4 57 48.5 55 3 5 8 ,, 4 15 39 34.5 9 ,, 4 30 57 48 9 ,, 4 45 57 48 9 Second test taken. ,, 5.0 57 48.5 9 Ave rages 57 48.5 55 8 \ Master's Remarks. Room cool-boys bright and very attentive. They worked well. Some very good work done by the boys without any great demand on the teacher's energy. Result of mental tests—20 simple multiplication sums thus, 8 x 7 x 6=336. Test I. Boys 18. Sums right 305. Sums wrong 29. Omitted 26. Test 11. Boys 18. Sums right 345. Sums wrong 15. Omitted 0. Summary of tests :- Sums omitted. Sums wrong. Sums right. 1 2 3 4 5 6 1 2 3 4 5 11 12 13 14 15 16 17 18 19 20 Test I.- Boys 2 2 — 2 — 2 7 2 3 1 1 1 — 1 1 1 2 3 3 5 1 Test II.- Boys - - - - - - 7 4 - - - - - - - - - - 4 7 7 Percentage Right 84.7 Wrong 8.05 Omitted 7.2 100 Right 95.9 Wrong 4.1 Omitted 0.0 100 An improvement in Rights 11.2 Wrongs 4.0 Omissions 7.2 Summary. Temperature, dry bulb 56-57. Average 57. Wet bulb 48-49.5. Average 48.5 Rel. Humidity 53-59. Average 55. CO2. content 5-9 vols. Average 8.0. No pollution of air. Normal ventilation. No fan used in room. Object to prevent pollution of air Keep a low air temperature, low relative humidity, usual ventilation. Results. 1. Subjective symptoms, nil. 2. Objective, nil. 3. No human or school smell. 4. Master's report boys bright all afternoon, good work done. 5. Result of tests. Improvement of Test II. over I=22.4 % Under normal conditions of atmosphere, the usual school fatigue at the end of two hours has improved the boys' mental capacity. The results of the various observations are summarized in tabular form. -See pages 64 and 65. 63 From these enquiries it seems that the London school child takes little notice of variations of temperature between 56 deg. F. and 64 deg. F., and apparently does its best work about 58 deg. F., but in this regard there are considerable individual differences. There seems to be no advantage whether the air at these temperatures is dry or saturated, or whether at rest or in gentle movement. A fall below 55 deg. gives rise to comment, and a rise above 65 deg. to unpleasant subjective symptoms in some persons. It is to be remembered that temperatures of 65 deg. to 70 deg. are almost habitual in America, and in continental lands where closed stoves are used, so that habit may establish tolerance. With high temperatures 65 deg. F. or more, whatever other factors may be present, high or low proportions of carbonic acid gas, moisture or not, movement of air or rest, the high temperature alone has an evil influence in determining deterioration in mental work in the children. On two occasions boys attributed headaches to the noise of the fan, but restlessness, inattention, and listless attitudes were noticeable. Above 70 deg. three or four children in the class got headaches, and others flushed faces, and this whether the carbon dioxide was in high or low quantity, or the air fresh, or unpleasantly stuffy from human exhalations. The only occasions with high temperature where no mental deterioration was determined was when, with high C02 and unpleasantly stuffy condition, the air was kept pleasantly moving by the fan, on occasions with 77 deg. dry and 74 deg. wet bulb readings, no subjective signs or mental deterioration was noticed when the fan in the room was thus kept working. It was found impossible under school conditions to obtain a high temperature, 70 deg. or more, with considerable humidity, that is over 60 per cent. Possibly this may be attained in suitable weather, and help to solve the question of what part humidity plays. Meanwhile, the conclusion seems justified that below 65 deg. F. relative humidity plays no important part in affecting mental work. But humidity appears intimately related to high temperature and loss of body heat from the surface. The nearer the wet bulb temperature comes to the body heat, the more important physiologically it seems to be, as the difficulty of getting rid of heat increases disturbance in the metabolism, probably setting up toxic symptoms, first in diminished working capacity, flushing and restlessness, and later by headache, sickness, and rapidly increasing and marked failure of working power. Carbonic acid gas in the usual concentration seems to exert no appreciable effect on mental capacity. Above 35 or 40 parts in 10,000, this may not be true. Dr. Brincker and Dr. Hogarth personally experienced subjective feelings as of a light band round the forehead and temples, and round the chest, and although no effect in change of atmosphere was apparent to teacher or scholars the test shewed, and the teacher actually noticed at the time, that after about an hour there was a remarkable collapse in the mental capacity of the children. They appeared exhausted mentally, whilst at the same time, there was entire absence of the headache oppression and nausea, or of the laziness, restlessness and irritability shewn in a hot close atmosphere alone. It yet remains to be determined whether there are not two trains of symptoms capable of disentanglement, due to different toxic causes, one from so-called " heat retention" (Warm Anstauung) the other an ultimate effect of carbon dioxide poisoning. Summary. Although many gaps remain to be filled ere these observations constitute a complete series, the following conclusions seem indicated. i. Mental alertness and accuracy is improved by two or three hours of school work, provided that the atmosphere is satisfactory. ii. Temperatures above 65 deg. F. give rise to definite subjective symptoms ; slackness and inattention in some, headaches in others. Although it is not easy to assert definite mental alteration till about 70 deg. F. iii. Symptoms do not appear at 65 deg. if the air is kept in gentle movement by a fan in the room. At higher temperatures the symptoms and mental conditions are ameliorated by such movement of the air. iv. With temperatures 70 deg. F. and above, other factors being normal, there are marked symptoms and very evident deterioration in mental alertness and accuracy. v. Relative humidity does not affect the mental capacity of children, at low temperatures. Increase of humidity appears to increase the effects of high temperature. vi. Carbonic acid gas in considerable excess, although not producing the symptoms found in a hot and close atmosphere, seems to produce, after a time, considerable fatigue in the performance of mental functions by the children. LECTURES ON HYGIENE. It has been decided to modify the scheme of teaching for the examinations in theory and practice of physical exercises. Unfortunately our suggestions have been only partially followed. As there are many opportunities open to teachers of obtaining instruction in hygiene, attendance at the lectures has not been made compulsory, or a necessary qualification for admission to the examinations. A word of warning should therefore be given. The lectures which are to be given are very simple, but quite out of the usual line of the elementary physiology book or introduction to hygiene and so specialized on points concerning school hygiene, and the knowledge that it is necessary teachers should have, that there is very little hope of any one doing even a fair paper, who has not attended the lectures, the material of which cannot be gathered from books alone. The course will be divided into the theoretical lectures, a series of 12 to 14 lectures by the doctors, and the practical demonstrations by the instructors in physical exercises. The syllabus,which has been abbreviated by leaving out the terms printed in italics, is the one which was used ten years ago for lectures to teachers in Bradford, and has since been slightly modified and approved by a committee of the Incorporated Society of Medical Officers of Health as suitable for medical men who may be required to lecture to teachers. 64 No, Data. External weather. Room T°, % Humidity. CO2 vols. in 10,000. CO2 limits. Increased movement of air. School smell. Number of children present. Dry. Wet. 1 Oct 2 Warm. muggy day, wind S.W. 64.5° 62.5° 87.5 5.3 3.5 0 + ?? 40 7.5 2 5 Warn: and close, wet bulb 61°, wind, S.W. 68.5° 64.5° 79.0 26.5 15 0 + + 40 35 3 „ 9 S. wind, warm, moist and cloudy. 67.0° 64.0° 82.0 23.0 12 0 + + 35 34 4 ,,12 S.E. wind, bright and cool. 67.0° 62.0° 76.0 24.0 14 Fan + + + 35 31 5 ,,15 Damp, fresh morning. 60.0° 56.5° 80.5 31.0 17 Fan + + + 37 44 6 ,,17 Fresh S.W. breeze, few clouds. 65.0° 63.0° 84.5 23.0 20 0 + + 28 + 4 kettles 35 7 ,, 23 Warm and cloudy, S.W. wind. 63.0° 60.5° 83.0 30.0 8 Fan + + + 36 +4 kettles 37 8 ,, 26 Morning foggy, cloudy day, N.E 61.0° 58.0° 82 34.5 30 Fan + 0 23 38 9 Nov. 13 Close, cold, foggy, no wind 71.0° 60.5° 53 17 10 0 0 38 22 10 ,, 29 Mild, S W. breezes and rain. 58.0° 56.5° 89 8 7.5 Fan + 0 35 95 11 Dec 4 Mild, fine drizzle. 58.0° 56.0° 86 7 5 0 o 35 7 12 ,, 11 Drizzling, not cold; 58.0° 55.0° 76 30 15 0 + + 36 +4 kettles 40 13 ,,14 Sunshiny and fresh. 57.0° 52.0° 72 26 18 0 + + 34 +2 kettles added 35 14 „ 17 Damp, muggy, no wind, slight fog. 73 0° 63.0° 54 8 6 0 0 36 9 15 Jan. 7 Windy and bracing. 74.5° 63.5° 54 7.5 5.5 0 0 25 14.0 16 ,, 9 Warm, cloudy. 73.0C 63.5° 56 64.5 10 Fan + 0 26 +4 kettles added 100 17 ,,16 Cloudy, close. 73.0° 60.0° 46 40 20 Fan + + ? 26 + 4 kettles added 60 18 „ 18 Dry day. 56.0° 52.5° 78 34 9 Fan + + ? 23 +4 kettles added 45 19 „ 23 Bright, frosty, keen dry wind. 55.0° 44.0° 44 60 50 Fan ++ 0 24 added 63 20 „ 25 Snow on ground, sunshine 56.0° 50.0° 70 60 11 Fan + + + 20 added 80 + 21 „ 30 Fine crisp day. 57.0° 48.5° 55 8 5 0 0 18 9 22 Feb, 6 Bracing sunny day. 60.0° 49.0" 47 6 4 0 0 23 7 65 Nature of lessons. Nature of test. Result of test at end of work. Symptoms noted. Remarks. Subjective. Objective. Geography, history, singing, arithmetic. 4 sums 85 mental efforts. +31.8 o Good work, room stuffy. Only excess of moisture. Geography, history, singing, arithmetic. 5 problems. — 4.5 Headaches o Flushing of face, 3. Inattention, restlessness, work badly done. Excess of temperature and carbonic acid. History, composition, grammar, arithmetic. Filling in 20 names and dates elided. —21.2 o Good work, no noticeable inattention. do. History, composition, grammar, arithmetic. * * * ... Headache 10, sick 1, one observer with headache. Not working well, restlessness. do. Geography, history, singing, algebra. 8 problems. — 9.8 Headache 10, sick 1, flushing, 1, observer too had headache. Lazy, marked drop at half time, inattention and inactivity. do. Chemistry, arithmetic. 5 problems. -15.0 Headache 1. Work well done, bright at end. Normal, save for excess of respiratory CO2, fans, aided this. History, algebra, arithmetic. 5 problems. -37.6 o Work well done till half time, then restless and wanting in concentration. do. Geography, writing, arithmetic. 8 problems. + 2.2 o Good work done. Movement by fan saved conditions in spite of great excess of respiratory C02; Geography, writing, arithmetic. 20 sums. — 5.0 o Work badly done, especially late in afternoon, no concentration. High temperature. History, composition, arithmetic. do. + 4.54 o Good work done.- Normal, save for moisture. Arithmetic, algebra. do. + 8.86 o Good work done. do Algebra, arithmetic. do. —14.46 Headaches 2, Well done at first, later marked deterioration. Moisture and carbonic acid in excess. Reading, arithmetic do. + 1.76 o Well done, but lazy at end. do. Arithmetic. geography, history do. — 5.0 Headaches 3, flushed faces all. Room oppressive and hct, good work at first but marked drop. High temperature only. Composition. grammar, arithmetic. do. — 1 6 Headaches 3, flushed 4. Slack, lolling about; teacher disinclined for work. do. History, arithmetic. do. —19.24 Headache 1. Well done at first, but exhausted at end of day. High temperature, moisture and excessive C02. Writing. singing, algebra, arithmetic. do. — 8.26 Headaches, all: oppression of chest and head 3. Work well done, oppression, marked drop at end. do. Notetaking in history and geography, then arithmetic. do —14.6 Headaches 3. Lazy, want of application and concentration.' do. History, algebra, arithmetic.- do. — 8.74 No headaches, but oppression of chest and head. Work well done, but mentally exhausted at end of day. Normal save great excess of added co2. History, geography, arithmetic. do. —110 Headaches, 8. Slackness and want of concentration. do. History, geography, singing, geometry do. +22.4 o Good work done Normal conditions. History, geography, singing, geometry do + 9.2 o Good work done Normal conditions. 66 These suggestions are neither systematically complete nor intended for scientific training, but they embody the principles underlying school-work. Proportion is preserved, there is no unnecessary detail, nothing which cannot easily be made plain, nothing which is not of great practical moment, as well as an essential part of the knowledge of every successful teacher. Summary. Life, its characteristics and requirements. Review of physiological systems of the body (with special reference to immaturity and instability of childhood).; Micro-organisms in their relation to health: Development of the nervous system and its education. Study of fatigue. Special senses. Hygiene of the eye, ear, and throat. The vocal organs. Brain culture. Nutrition. Environment. Personal hygiene. Sanitation of school buildings. School diseases. A. A short description of a lowly unspecialized organism like the amceba, illustrating vital functions in their simplest form. A similar description of a multicellular polyp, illustrating differentiation and specialization of function, the beginnings of a nervous system, sensitive cell, and muscular process. B. The essential elements of the highly differentiated nervous system of higher animals, reflex arc, sensitive termination, nerve cell, motor ending. Plan of the nervous system-its bony protection—complexity of system, sensory side, motor side, three levels: (1) Lower and most ancient reflexes; (2) Controlling brain cells and special sensory areas ; (3) Highest levels, association centres, etc. Description of muscular system. Blood stream in relation to nervous and muscular structures. Description of blood. Means of circulating it. Oxygen and aeration of blood. Animal warmth. Respiration. Dangers of want of aeration. Means of ventilation. Anaemia, proclivity to infection, want of reserve power. Exercise develops reserve. Removal of products of function. Fatigue a poisoning by toxin. Lymphatic system in relation to absorption of food and reception of infection. Effects of exercise on lymph circulation. Excretory organs, the skin. the bowels. C. Need of full vitality in all cells of body in order to resist micro-organisms or germs of disease; Description of typical germs. Germs both friends and foes. The role of leucocytes as defenders against micro-organisms and their toxins. Other toxins. Food poisoning. The most dangerous germs in daily life. Skin cocci, blood poisoning, tetanus. Drinking water and enteric fever. Infection by milk. Tubercle as a danger to teachers. D. Signs of ill-health. Personal hygiene. Regular habits and their necessity. Care of scalp and hair. The gross infections, lice and ringworm. Chilblains. Headaches and neuralgia. The prevention and preliminary treatment of external eye diseases. Stimulants. Dangers of stimulants— alcohol, tea. Diet in young and after middle life. Clothing, constituents, character, care, suitability Occupation, rest and recreation in their bearing upon health. The duties, rights and responsibilities of the individual in relation to the health of the community. Means of aiding resistance to germs—close rooms and open air, food in relation, importance of fats in infancy and youth. E. The development of the nervous system in the race and individual as a clue to processes in education. Its growth in the child. The appearance of function and its development by stimulus. The age of spontaneous performances and of imitation. Child's sensory receptivity in plastic period. Everything moulds its character. Inheritance and environment. Food and sleep. Play and work. Fatigue. Short lessons. Physical exercise and movement for children, for town dwellers. F. Recapitulation of means of nourishing nerve cells and of removing waste products. The growing cell, its nascent period and liability to fatigue, its full growth and old age. Causes of premature senility, hardening of arteries, etc. Education implies fatigue. Repair after fatigue. Sleep. Changes after work and rest. Fully grown nerve cell no longer educable. The means by which nervous action is produced—sensory organs, intellectual organs, motor organs. Vision, taste, smell, hearing. Common sensation (temperature, pressure, feeling, weight, muscular sense). Vision. Structure of eye and relation to brain. Mechanism of accommodation. The infant's eye. Eye-strain. Spectacles for children, young, adults and old age. Hygiene of the eye: large work for infants, distance for eye work, sewing, headaches from eye-strain. Smell and taste, hygiene of the ear and throat, eustachian tube. Significance of adenoids and of nasal breathing. Spurious feeble-mindedness. Night snoring. Night terrors. G. Intellectual concepts and their content. Speech written and spoken. Picture language, signs, alphabet (physiological alphabet). Muscular mechanism of speech. Respiration and breathing exercises. Production of voice. Clergyman's and teacher's sore throat. Cure of stuttering and stammering. The teeth as part of oral mechanism. Care of teeth, effect on general health. The mouth, nose and throat as area of invasion by germs. Protracted infection in scarlet fever and diphtheria. H. The school and its influence. The home.: Regular habits. Child not to be coerced but led. Caref ully divided work in the schoolroom and elsewhere an ideal. Schoolroom as an obiect lesson in health and cleanliness. The teacher as an object lesson in self-restraint, kindness, neatness, and artistic expression. The development of self-respect and character through cleanliness, and effective performance. The more important infective diseases; Means for their detection. Causes and methods of spread. Vehicles of infection. Infections through wounds of the skin. The prevention of consumption; The need of hygienic knowledge among the teachers has been already alluded to. It should be one of the chief subjects of instruction, to them it is much more important than a knowledge of say, music, needlework, or a foreign language. The requirements of the Board of Education will always determine the teachers actual knowledge, and in the above respects much alteration is needed. James Kerr, Medical Officer (Education). APPENDIX III. London County Council TENEMENT HOUSES. Further report by Medical Officer on the accommodation provided in houses used as tenement houses. (In continuation of report presented on the 24th March, 1904 (No. 8117).) (Ordered by the Public Health Committee to be printed, 4th October, 1906.) In the latter part of 1903 I presented to the Committee a report by Dr. Young, giving the result of his inspection of a number of streets of tenement houses in London. The general outcome of the inquiry, as the Committee remembers, was to show that the occupant of a tenement in a house not originally designed for use by members of more than one family is placed at a serious disadvantage in regard to such matters as water-closet accommodation, water supply, and ths provision made for the washing, cooking and storage of food. All these questions need to be considered in the light of the existing use of such houses by a number of families, but, unfortunately, the provision actually made is almost without exception merely designed for the requirements of a single household. As regards water-closet accommodation, the Council's by-law which requires in tenement houses one water-closet for every twelve persons has been, generally speaking, enforced throughout London, and considerable improvement has thus been brought about—though, as Dr. Young noted three years ago, the requirement of the by-law relates only to the proportion the water-closet accommodation provided bears to the number of residents, and does not apply to position. Turning now to the question of water supply, the case for legislation with a view to eflecting substantial improvement in the conditions at present existing is particularly strong. Dr. Young found, as a rule, that in the majority of the houses the only tap from which water was drawn was situated either in the back yard or in the wash-house on the ground or basement floor, though in some instances a tap was provided on a higher level, usually placed on the staircase landing over a sink, which could be made to serve as a scullery sink. The conditions existing in 1903 remain practically unchanged. The question has indeed arisen whether the provisions of sections 2 and 48 of the Public Health (London) Act, 1891, do not enable Sanitary Authorities to require a supply of water to the tenants of each floor in tenement houses. In the first instance, the Council decided (on 14th June, 1904) to promote legislation to remove the possibility of doubt on this subject, but the resolution to do this was subsequently rescinded (6th December, 1904), as the Parliamentary Committee reported that it was by no means clear that the present law was insufficient to meet the case. In December, 1904, the Woolwich Borough Council directed proceedings to be taken in respect to the water supply in a tenement house situated in High-street, Woolwich, and, in the result, the magistrate made an order to abate the nuisance at this house, and ordered the defendant to pay 5 guineas costs. The facts in this case, briefly summarised, arc as follows:— The house is a three-storey house ; a single man occupied the ground floor rooms ; a woman and a child occupied the first lloor front room; the first floor back was separately let; in the top floor front room there was a man, his wife and two children (one of the children, however, was not always at home), and in the top floor back there was a single man. The only appliance for supplying water for domestic use to the occupiers of these five sets of tenements was that situated in the back yard of the house. All water for cooking, drinking, personal ablution, washing clothes, and scrubbing floors had to be fetched from the yard ; there was no wash-house, and the copper in the yard was in a dilapidated condition. The tenants of the top floor stored water in a pail, which was kept on the landing at the top of the staircase ; this staircase was very dark and the pail was uncovered—the water stored in this manner being liable to become polluted. The conditions as regards cleanliness of the rooms and staircase were unsatisfactory. This was not surprising, having in view the need of carrying water from the yard all the way upstairs. A recent inspection made of these premises shows that there are now two water taps and sinks above the ground floor level in this house, and it appears from the annual report of the Medical Officer of Health of Woolwich that the precedent established in this instance has led to similar improvement being effected in the case of a few other houses in the borough. The London County Council called the attention of all the Borough Councils to the decision of the magistrate in this case, to the effect that the supply of water from the tap in a yard was not a " proper and sufficient supply " within the meaning of section 48 of the Public Health (London) Act, 1891, and the hope was expressed by the Council that the Borough Couucils would take all possible steps to secure the provision of a " proper and sufficient supply " of water for the tenants of every floor of tenement houses. The Council's letter led to careful consideration being given to the question of the supply of water in tenement houses by several Borough Councils, and in particular, it may be noted, that the Paddinglon Borough Council resolved that their Public Health Committee be authorised to secure 11393-1250-22.11.06 S.8./14512 2 the provision of a "proper and sufficient supply" of water for the tenants of every tenement house in the borough. In July, 1905, a circular letter was, accordingly, sent to the owners of certain houses in Clarendon, Cirencester and Woodchester-streets, in which the need for the provision of a "proper and sufficient supply" of water was particularly apparent. Owing to the special circumstances of the houses in these streets, the owners were required to provide a better supply and means were suggested for doing this. In some instances an additional supply was provided, in others nothing was done, and ultimately summonses were taken out against the owners of six houses. The first summons — against the owner of three houses in Cirencester-street—was heard by Mr. Plowden, on the 17th November, 1905, who dismissed the case with one guinea costs against the Borough Council, and, in doing so, stated that the words of the section of the Act as to the provision of a "proper and sufficient supply" of water referred to the source of supply and not to the provision of taps within the house. The magistrate did not think that the section was intended to deal with an instance in which the occupant would be put to inconvenience, as was alleged was the case in these houses. Inasmuch as the houses in this test case presented particularly striking instances of the need for the provision of that additional supply of water which the magistrate held could not be insisted upon in the existing state of the law, the Committee will no doubt like to have a detailed description of the conditions existing at these premises at the present time. The three houses are similar and consist of four storeys—basement, ground floor, first floor, and second floor— the only tap available for the supply of water to the inmates of each house is one which is placed over a sink in the back addition wash-house in the basement, and the two water closets provided at each house are situated in the yard. The approximate height of these houses is shown by the following sketch :— It will be noticed from the sketch that the tenants on the top floor have to carry all water for use in the tenements up three flights of stairs, consisting of 48 steps, and being a vertical height of about 30 feet, and all waste water has to be taken down a similar distance to the water closets or sinks in the yard. No. A, Cirencester-street. The basement front and back rooms are occupied by one family of two adults and four children, at a rental of 6s. per week. The ground floor front, back and back addition rooms are occupied by a family of seven persons, three being under 10 years of age, at a rental of 7s. per week. The first floor front room is occupied by a man, his wife and one child ; the rent of the room is 4s. 6d. per week. The water for use in the tenement is stored in a one-gallon can, which contained water and was under the bed at the time of inspection. This can is said to be filled about ten tines daily; thus necessitating a return journey to the basement ten times ; the basement floor is 31 steps and about 20 feet below the first floor, the labour involved being therefore equivalent to that required to lift 10 pounds weight of water to a height of 200 feet. The first floor back room is occupied by two persons at a rent of 2s. 9d. per week. Four gallons of water is said to be the average quantity required for U6e in the room, and a two-gallon jar is employed for storing the water in the living and sleeping apartment. 3 The second floor front room is rented at 4s. per week, and it is occupied for living and sleeping purposes by two adults and one child. An ordinary iron bucket is used for fetching the water from the tap in the basement, and water is stored in a large jug in the room. About six gallons of water are required each day, and this necessitates at least three journeys to the basement and the carrying of 60 pounds of water up three flights of stairs, to a height of about 30 feet. Almost a like quantity of waste water has to be taken to the basement, which contains the only fittings available for disposing of waste water. The second floor back room is let at a rental of 3s. per week to a man, wife and young child. About four gallons of water are used in this tenement, and a tucket is kept specially for the purpose of obtaining the water from the basement and storing it in the living and sleeping apartment. There are two water-closets for the use of the tenants, but both are in the yard at the basement level. The only sinks for waste water are at the basement level. Two of the single room tenements are without ovens in connection with the fire grates provided for the purpose of cooking food. There are cupboards at the side of the fireplaces in some of the rooms, but none are suitable for the storage of food, being without vontilation to the external air. no. B, clrencester-street. The front and back rooms on the basement floor are occupied by one family, consisting of a man, wife and four children, and are let at a rental of 6s. 6d. per week. The ground floor consists of a three-roomed tenement rented at 7s. 6d. per week, and occupied by a man, his wife and five children, two being over 10 years of age. The two rooms on the first floor are separately occupied for living and sleeping purposes by two families, each consisting of two adults and two children ; the rent of the front room is 4s. 6d. per week. The top floor front room is a single room tenement occupied by three adults at a rental of 4s. per W6ek. Water is stored in the living and sleeping apartment in a bucket; about six gallons are said to be required daily for use in the room, and this has to be brought from the tap at the basement level, necessitating at least three journeys up and down three flights of stairs—including the somewhat dark basement flight—numbering 51 steps, a vertical height of about 30 feet. The total weight of the water which is carried daily to this room is about 60 pounds. The top floor back room is separately occupied by a man, his wife and a boy 14 years of age ; the weekly rent of the room is 3s. About ten gallons of water are said to be used by the occupants, and this quantity has to be carried up 30 feet, as described in connection with the front room. no. c, clrencester-street. The front basement room is separately occupied for living and sleeping purposes by two adults and two children at a rental of 3s. 6d. per week. There are two cupboards in the room, but both are without ventilation to the external air. There is no oven provided for cooking food. The back basement room is also separately occupied. The ground floor rooms, three in number, are occupied by one family consisting of man, wife and four children, at a rental of 6s. 6d. per week. There are two single-room tenements on the first floor, the back room is occupied by a man, his wife and two children at a rental of 3s. per week. A small bucket is used for the storage of water in the room, about eight gallons are used daily, and four return journeys to the tap in the basement, in each instance down 20 feet, i.e. 32 steps, are needed to bring the water to the tenement. The front room is similarly occupied, and approximately the same conditions as to water supply obtain for that room. The top floor rooms are occupied by a family consisting of a man, wife and four children; about six gallons of water have to be brought from the basement, 30 feet below, for use in the tenement. The following diagram shows the height to which water has to be carried by the occupants of the various floors in a house of the type shown in the preceding diagram :— A bare recital of the weights of water used and the heights in feet through which they need to be carricd conveys but a meagre idea of the hardship inflicted upon the tenement population of London under existing couditions as to water supply. One of the most serious questions, from a health point of view, is the tendency to limitation of use of water which these conditions of necessity 4 foster. In standard works on hygiene, it is commonly stated that, excluding the water needed for use in water-closets and in general baths, about 12 gallons (weighing 120 pounds) per head/per day are required for domestic purposes. Dr. Parkes divided these 12 gallons as follows :— Cooking ¾ gallon Fluids as drink ¾ „ Ablution 5 gallons Share of utensil and house washing 3 „ Share of clothes, laundry washing 3 „ Inquiry in several London tenemented houses visited shows that only about one-sixth of this amount, i.e., some 2 gallons instead of 12, is the average quantity employed where the difficulties associated with carrying the water upstairs are specially experienced. With such small amounts of water, after deducting the quantity needed for maintaining life, there remains an absurdly inadequate supply for cleansing purposes. Personal ablution necessarily can be only imperfectly carried out, and for such purposes as floor washing, for example, the quantity of water used is too often only sufficient (as a local inspector observed) to "soak the dirt into the boards." The hardship entailed by the need for carrying everything up a lofty flight of stairs in London houses of a certain type was eloquently described by the late Dr. Poor:; in his book entitled " The Dwelling House." He calculated the amount of work performed by a footman in carrying coal upstairs at about four foot-tons per diem. When houses of the sort in question become converted into tenement houses, tLe hardship is vastly intensified, and even under conditions of parsimony as regards use of water such as have been described above, many thousands of foot-tons of work per annum need to be performed merely in conveying water upstairs. The criticism may be made that this entails expenditure of muscular energy which may not be altogether unbeneficial. But it needs to be remembered that the labour, which is poor enough exercise at the best, falls to be performed, as a rule, by the mother of the family, and that she has to carry it out day by day without intermission, and even at times when she is rendered, for one or another reason, unfit to perform hard work. In the Woolwich house, referred to above, the magistrate had before him the fact that the woman on the top floor was pregnant at the time when she was carrying pails of water upstairs ; and in one of the Paddington houses, the summons in regard to which was dismissed by Mr. Plowden, the r* cent inspection of the Council's officers elicited the fact that a woman was being confined in a top-floor room and that the disadvantages associated with want of a proper water supply were intensified by reason of that fact. The Council has been in communication with the Metropolitan Water Board on the subject of supply of water on upper floors, and that Board has expressed its willingness to co-operate as far as possible in the direction desired by the Council. The Board adds: " It is of course understood that proper arrangements would be made to prevent the lower floors taking away the pressure from the higher floors during the busy times of the day, and further that the Board would not contribute in any way towards the cost of providing the necessary pipes and fittings in the houses. It is of course desirable that the Chief Engineer of the Board should be communicated with in each case before arrangements for an improved supply are commenced, so that there may be no misapprehension as to the height at which the supply can be afforded." Further inquiry has been recently made by the Council's inspectors, and the general result of this is to show that the conditions found by Dr. Young as regards water supply some three years ago remain practically unaltered. Obviously, as matters at present stand, very little improvement is being effected in regard to the water supply on the upper floors of tenement houses, and, in face of the Paddington decision, it is not likely that any further action will be taken by the health authorities. The details obtained by the Council's inspectors in the recent inquiry show that in 86 per cent, of the houses the water supply was situated only on the basement or ground floors. It may be suggested that, admitting the case for the amendment of law is a very strong one, there remains some doubt as to the extent to which additional water supply taps on upper floors can be icasonably insisted upon. For instance, in a house of three storeys above the ground floor it might be argued that to require three additional water taps with additional sink wastes would be unreasonable. It appears to me that the difficulty would be met by accepting the principle that the provision of a waiter supply tap on the half landing next adjoining a tenement should be accepted as meeting the requirements of the family occupying that tenement. The following table contains information on a number of further points which were made the subject of inquiry by the Council's inspectors. Total number of houses inspected.. Number of tenements of Totel number of tenements. Total number of rooms. N» mbei of tenements without ovens for cooking food. Number of tenements without provision for lies ting water in connection with fire grate. Number of gas cooking stoves without ventilation fixed in living or .sleeping rooms. Number of houses without a tap or sink above the basement level. Numbei of houses without a tap or sink above the ground-floor level. Total number of houses without a tap or sink above the basement or ground floor level. One room. Two rooms. Three rooms. Four rooms or more. Houses with basement and two floors above. Houses with basement and three floors above. Houses with basement and four floors above. Houses with ground floor and two floors above. Houses with ground floor and i liree floors above. Houses with ground floor and foulfloors above. 274 414 377 101 63 | 1,055 1,843 321 1,041 107 24 67 29 106 10 0 236 5 It is only necessary to refer here to the question of the provision made of ovens for cooking food, and that made for heating water and for the storage of food. In 739 tenements visited in 1903 (including tenements of 1, 2, 3 and 4 rooms), one-third had no oven in which food could be baked by fire, the fire-grate being the same as that originally provided, or of the same kind, and not more adapted for cooking purposes than an ordinary bedroom grate. Some amount of improvement in this re3pect is being effected, though only very gradually, for recent inquiry shows that in place of 33.7 per cent, three years ago, 30.4 per cent, of the tenements are still unprovided with ovens. The need for further provision was especially manifested, both in 1903 and in the more recent inquiry, in tenements of one room. In such tenements, when an oven was found it was usually heated by a coal fire, but, in exceptional instances, it was associated with gas stoves ; in tenements of 2, 3 or 4 rooms, the number of gas stoves is larger in proportion than is the case in single tenements. The question of the need of making provision for carrying away all the products of combustion from gas stoves, commented on in my report to the Committee in 1903, is assuming increasing importance as years go on. From the recent inquiry it appears that many instances were noted of gas stoves in sleeping rooms. With regard to the supply of hot water, it was quite the exception to find any provision made. In most instances, food was stored in cupboards, but, save in exceptional cases, there were no means of ventilating the same other than through the cupboard-door opening into the room. Shirley F. Murphy, Medical Officer or Health. 11393 b APPENDIX IV. INSPECTION OF FOOD. Extracts from a Report to the Public Health Committee on the 24th January, 1907. With a view to determining the extent to which foodstuffs are brought into London by rail, and comparing the amounts so conveyed with the quantities coming in to the Port of London, I have had inquiries made by the Council's officers and have made use of various official returns and of an article on the " Food of London," in the Quarterly Review of 1899-1000. The result is to indicate as an estimate that the total bulk of foodstuffs reaching London annually is approximately between and 3 million tons, of which amount some three-fifths are consumed by the inhabitants of London, the remaining two-fifths merely passing through in the course of transit elsewhere. Of this total, 2| or 3 millions, rather more than two-thirds, arrive by water, and less than one-third by rail. The whole mass may be regarded as including three classes of foodstuffs . Tons. (1) Meat, fish, milk, butter, lard, eggs, etc., approximately 1,000,000 (2) Fruit and vegetables (including preserved fruit and sugar) 500,000 (3) Grain and flour (estimated as grain) 1,400,000 Very differing results are obtained on dividing these different classes of food up into the amounts which, respectively, are land and water borne. Thus, while more than 80 per cent, of the grain and flour are brought into the Port, and only 20 per cent, comes by land, and more than 70 per cent, of the fruit vegetables, preserved fruit and sugar, etc., is brought into the Port, and only 30 per cent, comes by land, the quantities of the first-class of foodstuffs conveyed by water and by rail are approximately equal. It transpires therefore that the railway traffic in these classes of foodstuffs, which specially need examination from the public health point of view, is practically equivalent in amount to the river traffic. Moreover, if the items making up the total sum of foodstuffs here in question be considered in a more detailed manner, it will be found that the amount of meat arriving by water is about twice that arriving by rail; the amount of fish.arriving by water is about one-third that arriving by rail; and again, it is deserving of note that the bulk of the milk arrives by rail. It should be observed that some of the foodstuffs arriving in the Port are doubtless included subsequently in totals returned from railway stations. It will, moreover, be of course recollected that the amounts given represent total inflow into London, and that a considerable percentage of this inflow is merely in transit, on its way to the population of Greater London, or to more distant destinations. A considerable portion of the total amount of food entering is taken to certain well-known markets, meat to Smithfield, fish to Billingsgate, vegetables and fruit to Covent Garden, and so on, but no insignificant amount is conveyed directly to the retailer. This last fact is not generally recognised, for there is a prevalent opinion that a complete system of market inspection is all that is necessary to protect the health of the public. It may be mentioned that the writer in the Quarterly Review, 1899, on "The Food of London, "stated as a fact that much food reaches the London consumer "without passing through a London market."This conclusion the inquiries of the Council's inspectors, made at the 26 chief railway depots in London, generally confirm ; but the information obtained by the Council s officers brings out very clearly two points which deserve to be specially considered. In the first place, meat, poultry, eggs, etc., even when consigned to market salesmen, are frequently taken to cold storage, or to a warehouse before being exposed for sale. In the second place, the foods which would appear to stand particularly in need of inspection constitute a considerable percentage of the material never taken to market at all. Thus the smaller consignments of meat and fish are in numerous instances sent direct to particular retail dealers, and these smaller consignments, in some instances, include boned meat, offal, cats' meat, etc., which have undergone no inspection when the animals were killed, and are certainly not destined to undergo inspection in any London market. From the notes made by the inspectors at particular stations, it appears, for example, that they found "pigs' heads," "offal and plucks consigned to potted meat makers," "brawn consigned to a shopkeeper," "very many private consignments of fish," "offal to cold storage or to private consignees," "loads of offal consigned direct to a contractor;" and the entry "cats' meat to various consignees in the East-end of London" is a continually recurring one. The question of the cats' meat industry indeed is one which merits careful consideration. About 1,000 tons of cats' meat, consigned as such, are received annually at London railway stations, and any attempted explanation of this large amount must also meet the fact that the bulk of the 1,000 tons is consigned to the East-end of London. The continental export of "Jacko" (chopped horse flesh) is said to have fallen off considerable of late years, though price lists are still sent from abroad to East-end sausage makers. There can, of course, be no doubt that much cats' meat is still eaten by human beings in London. It is largely sold in extremely poor neighbourhoods, and the women seen buying "fourpenny worth," or "fivepennyworth" are clearly not buying for cats. One vendor of cats' meat has stated that he had a customer whose practice it was to buy " greens " at the same time as the cats' meat. The Council's inspectors call attention to the facts concerning a particular cats' meat dealer "A," which throw some light on the dark side of the cats' meat trade. This dealer receives raw cow flesh, admittedly unfit for human food, and raw horse flesh, which, he states, he boils for cats" meat, but he has no boiling appliances on the premises, and, as a matter of fact, he has been found to slice the cow flesh and dress it with a preservative. The man who supplies "A" with raw cow flesh supplies a well-known cats' meat dealer "B" with boiled horse flesh, and "A" sends this same dealer "B" his raw horse flesh because he has no boiling apparatus. The question raised by the Council's inspectors is,"What becomes 2 of the raw cow flesh, which is generally received by the cats' meat dealer "A" in clean bags and wrappers ?" The slicing and dressing of cows' meat are quite out of keeping with the custom of the cats' meat trade. Cats' meat dealers like to buy the flesh in large lumps. The slicing, on the other hand, is consistent with the subsequent use of the meat for sausages or meat pies. "A's" firm, it seems, has been convicted for selling meat unfit for human consumption to sausage makers. In the absence of power to inspect foodstuffs in transit, men who carry on a trade of this kind are able to do so with comparative impunity, and there is need for the exercise of supervision, not only in respect of rail and water borne food, but also of that which enters London by road. As illustration, for example, it may be stated that near the London boundary there is carried on the business of a knacker, and also that of a slaughterer of cattle by one and the same person. The meat, in this instance, comes up to London by road. The inspectors further refer to their observations upon meat in sacks which "from the feel appears to have been boned out," and they say "such packages should always be open to suspicion and should be inspected." The need, moreover, for examining "small consignments of sausages and preserved meat" and "chopped meat in casks," which the inspectors note in some instances "is highly coloured and spiced and possibly contains a percentage of 'Jacko,' is only too apparent." In fact, the inspectors' observations abundantly prove, if indeed proof of the fact be needed, that foodstuffs open to suspicion are not as a rule taken to the open market to be disposed of, but find their way to the consumer by devious routes, which, in the absence of powers of inspection, it is only possible in rare instances to follow up. (Signed) Shirley F. Murphy, Medical Officer of Health. APPENDIX V. London County Council Report by the Medical Officer presenting a report by Dr. Hamer, Medical Officer (General Purposes), on the Inspection of Food by Riparian Sanitary Authorities. (Printed by order of the Public Health Committee, 12th July, 1006.) The Committee have caused inquiry to be made from time to time concerning the efficiency of the system of inspection of foodstuffs arriving in London via the Thames, and this subject was considered in 1903, when the Council, in conjunction with the Borough Councils concerned, successfully resisted a proposed extension of the Port Sanitary Authority's jurisdiction to warehouses and wharves outside the limits of the port of London. The methods of inspection in operation in 1903 were felt to be of a more or less tentative character, and I reported some six months ago that it was desirable further inquiry into the matter should be made by the Council, with the result that Dr. Hamer was directed to undertake this duty. In the course of his inspections it became clear that whilst useful work was being done in some districts, there was laxity of administration in others, and in particular the need for the appointment of a special food inspector in Bermondsey was, on my report, made the subject of a communication from the Council to the Borough Council in May of this year. Dr. Hamer, meantime, has completed his inquiries and has reported upon the subject of inspection of foodstuffs in the port generally. The main outcome of his investigation is to show that river inspection needs to be considered in relation to the inspection which should be practised at other portals of entry of foodstuffs into London, otherwise the devotion of special attention to one avenue of approach merely leads to the diversion of traffic in unsound foods to other avenues less subject to scrutiny. In fact, the work already done by the port and riparian authorities, while it has been hampered in many ways, e.g., by uncertainty as to the limits of the powers possessed by the authorities concerned and by the smallness of the staff engaged upon the duty, has at least made it quite obvious that one of the most important questions arising in connection with attempting to perfect the system of river inspection is the need of co-ordination of the methods of supervision exercised at the various points of entry, whether by river, rail or road, and indeed of the adoption of a general scheme of inspection of foodstuffs brought into London. It may be pointed out that in the case of meat the public health could, in a measure, be safeguarded, so far as relates to diseased conditions visible at the time of slaughter, by ensuring that proper inspection was carried out at that time, whether in foreign countries, at the various ports of this country, or in the country itself, but in addition to such original inspection, it is essential that the condition of the meat as to soundness at the time it enters London be made subject to investigation. The need for such frontier inspection on entering the County is equally necessary in the case of fish, and tinned and preserved foods, which for the most part have not undergone any examination with a view to guaranteeing fitness for consumption prior to being brought into London. A second point of considerable importance is the need for ensuring that food which has once been "surrendered," or "condemned," as unfit for human food, should not again find its way back into the market, either in its original form or more or less completely disguised. That the risk of such occurrence is, under existing conditions, a real one, is unfortunately too apparent. Unsound food is purchased from owners by contractors who "make what they can out of it," and again sanitary authorities are content to employ contractors and to hand over to them, in some instances after a preliminary process of " denaturing," meat, etc., judged to be unfit for consumption. Even in those cases in which the sanitary authority deals directly with condemned food it is customary to impose a charge for its removal arrd destruction, and this practice undoubtedly tends to discourage the voluntary surrender by owners of material which ought to be destroyed. An important means of safeguarding the public would be afforded if the ownership of foodstuffs originally intended for human consumption, but which have become unsound, were vested in the sanitary authority, who would effect the necessary removal and destruction without cost. Shirley F. Murphy, Medical Officer of Health. 4th October, 1906. 11757- 1,000—29.11.06 s.s./13946 2 Dr. Hamer's Report. The inspections and inquiries which form the subject of this report were commenced early in March last, the objects held in view being to ascertain the existing arrangements for inspection of food coming into London by river, and to earn the general outcome of recent experience of the practical working of the system of inspection now in operation. Vessels entering the port are unloaded in the docks, in the river, or at riverside wharves. The goods from a vessel which enters a dock may either be warehoused on the dock premises, or be conveyed out of the dock by lighters to a wharf or warehouse fronting the river. The Port Sanitary Committee of the City Corporation exercises jurisdiction over the waters of the port and over the area within the dock gates, including wharves and buildings. The riverside wharves and buildings, on the other hand, are under the jurisdiction of the several riparian health authorities, those mainly concerned with the landing of food stuffs being the Sanitary Authorities of the City of London, Bermondsey, Southwark and Stepney. Poplar and Lambeth receive food stuffs at one or two wharves only, and quite exceptionally other river districts (Deptford, Greenwich and Woolwich for example) furnish the place of entry for comparatively small consignments of food materials. The suggestion had been made, and at a public local inquiry held in April, 1903, by Dr. Theodore Thomson on behalf of the Local Government Board, this uggestion was supported by the London and India Docks Company, that the jurisdiction of the Port Sanitary Authority (City Corporation) might with advantage be extended to wharves and warehouse premises under the jurisdiction of the Borough Councils. The City Corporation did not resist th's application, but the Borough Councils objected to being deprived of their existing obligations and rights, and with the support of the County Council opposed the transfer. In the result, the Local Government Board decided not to extend the Port Sanitary Authority's jurisdiction. At this inquiry detailed evidence was given by the port, county, city and riparian borough council medical officers on the system of inspection then in operation, and it may be well at the outset to summar'se this evidence, at the same time bringing it up-to-date, by stating that, for purposes of river inspection— The City Corporation in its capacity as Port Sanitary Authority employs three special food inspectors. The City Corporation in its capacity as health authority in the City employs one special wharf and warehouse inspector. The Southwark Borough Council employs a special food inspector, whose attention, wholly devoted to food inspection, is mainly directed to wharves and warehouses on the river. The Stepney Borough Council also employs a special food inspector whose attention, wholly devoted to food inspection, is mainly directed to wharves and warehouses on the river. The Bermondsey Borough Council has no special food inspector—the river wharves and warehouses are almost all in the area assigned to one of the district inspectors, and to these premises a share of this officer's attention, though owing to the other claims upon him, not a very large one, is assigned. In the other riparian boroughs the inspection of food stuffs receives comparatively little consideration, though it probably occupies as large a share of attention, in proportion to the quantity of food received on the several river frontages, and destined to be consumed in London, as in the case of the authorities which employ special food inspectors. The above summary applies to food generally, including meat of all kinds, dairy produce, fresh fruit and vegetables, miscellaneous perishable materials received in the fresh state, and preserved and tinned goods of all sorts. Meat and fish stand, however, on a footing distinct from other foods, inasmuch as, in the main, they pass through the City markets after leaving the riverside. Thus the sanitary staff of the City Health Department includes eight inspectors of slaughter-houses and meat; fresh and refrigerated meat passing through Smithfield is liable to be examined by the City inspectors, and there is, moreover, some examination of animals killed at Deptford at the time of slaughter. The position of affairs as regards fish is altogether exceptional. Almost the entire London supply passes through Billingsgate or through the purlieus of that market. There is, practically speaking, no inspection of the fish either at railway stations or in course of transit by land or water up to the time of its arriving at Billingsgate. The fish trade has its own inspectors appointed by the Fishmongers' Company, and action in particular instances, more particularly as regards shellfish, has been taken by the health department of the City Corporation, but no systematic control by a sanitary authority, such as is now regarded as necessary in the case of other sorts of food, has hitherto been instituted. A considerable experience of the condition of fish arriving at shops, in the poorer parts of London, acquired by officers of the London County Council, more particularly during recent years, shows that the inspection carried out at Billingsgate affords no sufficient security against the consumption of fish unfit for food. The scheme of allotment of duties of riparian inspection, as regards food, having been outlined, it is now necessary to discuss the methods of work of the staff of river food inspectors. These methods were the subject of some discussion by question and answer at the Local Government Board inquiry in 1903. Some of the important difficulties, upon which more recent experience shows that emphasis should be laid, were indeed then only lightly touched upon, but it is convenient to proceed in chronological sequence and to deal first with difficulties already experienced prior to 1903, and then to 3 trace historically the development of the steadily growing sense of the need for strengthening existing powers, and for reconsidering the question of division of responsibility between the various authorities concerned in enforcing the law. One of the first difficulties to attract attention was that of obtaining knowledge as to the arrival of foodstuffs in the port. This difficulty, formidable at the outset, has continued to be felt in boroughs in which special food inspectors have not been appointed. Great importance was attached, at the inquiry of 1903, to the need of such information being made more readily available, and it was suggested that all that was necessary was that sanitary authorities, which had not already done so, should make arrangements to place at the disposal of their officers the Customs' Bill of Entry known as Bill A. This bill, published each evening by the Customs Commissioners, is available for use on the following morning and contains particulars as to vessels arriving in the port during the preceding three or four days. Three years' experience of the use of these bills in some of the riparian districts shows that in the case of perishable goods the information comes as a rule too late, for such goods are necessarily rapidly cleared away and indeed have gone before the officer who relies upon the bill for his information arrives upon the scene. The main outcome of the experience gained in districts with a special food inspector is that this officer learns all that is necessary in the course of his daily round and often many hours in advance of the arrival of the bill. It is possible that improvement might be effected and information of value afforded by telephoning news of the arrival of food stuffs in the port, but in particular districts in which special inspectors have been engaged in keeping the riverside wharves and warehouses under close observation, the need for Bill A, or for acceleration of the arrival of the information contained in Bill A, has not been felt. A second point more than once referred to at the inquiry of 1903 raises issues of great importance. It concerns the distinction drawn between goods " surrendered" and goods "seized." Prior to 1903 it seems clear, reading between the lines of the evidence given, that seizures, properly so-called, were rarely, if ever, made; the inspector was merely called in to certify that unsound food was not fit for human consumption, and such food was then in some instances handed over to be disposed of by the sanitary authority. The fact that the port authority, for example, had never obtained a conviction was stated at the inquiry, and in the evidence given by the Medical Officer of Health of Poplar it was expressly observed " There have been no seizures from the wharves." In the event of its being held that goods in transit were not subject to inspection, the last-named witness seems to have considered that some of the largest wharves and food preserving places in Poplar were exempted from the supervision of his authority, and this view is, I learn from recent inquiry, still accepted in Poplar and limits the action of the officers in that district with regard to such premises. I propose later to refer to the legal difficulties, actual or imaginary, in question, merely noting here that in Poplar they are assumed to be real. I proceed now to comment upon the chief questions of importance which study of the working of the present system of inspection, as practised more particularly during the last three years, brings into prominence. In the first place, it needs to be clearly understood that it is not practicable, even if it were desirable, to inspect in detail all the food-stuffs entering the port. As a matter of fact, the chance any particular article of food will come under examination is exceedingly remote. The mechanical difficulties, coopering, cartage, etc., prohibit anything more than a process of sampling, and the ideal aimed at must necessarily be that of providing an efficient detective agency, which will serve to bring to light the underhand methods of the dishonest trader, rather than that of establishing a scheme of inspection which shall (after examination in detail) guarantee the fitness for human consumption of all the food material now in question. The staff at present engaged in the work of food inspection is small; indeed, the number of inspectors employed for the control of the entire food supplies of the London population is less than that engaged in protecting a comparatively small Prussian town from the risk of one food malady alone, viz., the trichinosis caused by eating measly pork. The disproportion becomes the more striking when an attempt is made to realise the vastness of the food supply of a huge aggregation of population such as that of London. The statement that some 1,500,000 tons of food comes into the Thames in a year, and that this, if closely packed, would occupy some 3,000,000 cubic yards, conveys but little to the mind. A writer in the " Quarterly Review " in 1854, when London numbered only half its present population, endeavoured to fix the ideas of his readers by picturing in imagination a series of armies converging to " their ultimate destination—the great red lane of London humanity "—an army of oxen ten abreast stretching from Peterborough to London, the great western road thronged with a "bleating mass of wool " from as far away as Bristol, seven and a half miles of calves ten abreast, nine long miles of swine, and so on. To bring this picture up to date would involve increasing the size of the armies, but they would not now be ten abreast; the avenues of approach while far less densely packed, would, of course, require to be extended, in the case of oxen to Argentina and Canada, in that of sheep to New Zealand and Australia, the corn must be made to com& from America and Eastern Europe, and there would be need for recognising an almost unending array of preserved and tinned goods which must be thought of as stretching from San Francisco, Texas, Chicago, Alaska and China. The question as to changing proportions borne by land and river traffic during the last fifty years is one, too, which would need in this connection to be borne in mind, but there is another change also, which consideration of the alterations effected in half a century brings to the forefront, and which must be here referred to. London, in 1854, was supplied to a preponderating extent with corn and meat from neighbouring counties, some of its fish came from the Thames,* and it was surrounded by market *The Wandsworth "bawley boats" supplied the London poor with fish caught between Batt.ersea-reach and Kew-bridge, and theie were upwards of 100 "trolling boats" of Barking belonging to different companies. The "British Queen" flourished at Deptford and watercress "luxuriated" in the Fleet ditch in Camden Town.— (" Quarterly Review," 1854.) 4 gardens. The Londoner now knows little or nothing of the sources from which his food supply is derived. Indeed, as a latter day Quarterly Reviewer has remarked (" Quarterly Review," 1899), there has been manifested in the last half century " a tendency to transfer from London nearly every process of food preparation that can be carried on elsewhere." In many cases the change has presumably been greatly to the Londoner's advantage as regards quality, as it undoubtedly has been as regards price, but the removal of the place of origin or manufacture beyond any control London can directly exercise, emphasizes the importance of examination of the food when it enters London, and this in increasing degree as years pass by and the amount brought from without approximates more and more closely to the total quantity consumed. It is not, of course (it may be reiterated), for a moment suggested that it is desirable the officers of London health authorities should make detailed examination of every carcase or tin of food coming into London; but that such inspection as is at present made amounts to the merest occasional and random sampling needs to be insisted upon. The impression might certainly be created on reading the proceedings at the Local Government Board inquiry of 1903, that something like a "ten per cent, examination" for food inspection purposes; of articles coming into the Port of London was, as a rule, then made. Such an estimate would, of course, be altogether wide of the mark. I learn that two men working ten hours a day can examine 120 cases, each containing 48 one-pound tins of salmon, daily. Again, Dr. Collingridge, in a report to the Port Sanitary Authority for the half-year ending 30th June, 1897, pp. 21 and 22, has dealt with the rate of examination of carcases. Taking as data the figures given by Dr. Collingridge for carcases and my own figures for tinned goods, it may be demonstrated without any very elaborate calculation, that even under the most advantageous circumstances, the existing food inspecting staff in London would need to be multiplied ten or twenty times over were anything like a " ten per cent, examination " contemplated. It is important to note here that among the difficulties in the way of adequate inspection, that of providing a sufficient staff of inspectors is by no means one of the most formidable. There is the initial difficulty that the examination of goods in a ship's hold or during transference from the ship to lighters is practically an impossibility, and thus, in fact, the very first essential for examination is a locus in quo. As far as possible the warehouses of the dock companies and the riverside warehouses have been utilised in the past for the purpose of making inspection, but difficulties have from time to time arisen with regard to such use, and as matters stand, the right to examine food there is at any time open to be disputed. Given, however, a place in which to inspect, there must then be made available the labour necessary for the manipulation, incidental to inspection, of packages of goods, and there must also be provision made which would enable the inspector to purchase from the owner such articles as must inevitably be rendered unfit for consumption, e.g., tinned foods, as the result of being opened for examination. The use of public money for such a purpose as that last mentioned finds its parallel in the procedure under the Sale of Food and Drugs Acts. Under existing circumstances the preliminary essentials are lacking, and the inspector with expert knowledge perforce spends the greater part of his time in following goods from place to place, in endeavouring, by favour of wharfingers, docrc managers, lightermen, warehouse employes, etc., to obtain assistance in examination, and in securing by tact and resourcefulness opportunities of satisfying himself of the soundness of goods, and thus, as it were, achieving by diplomacy that for which no legal right can be claimed. The root of the matter has not, however, yet been reached ; the inspection of food in the Port cannot be divorced from food inspection in London generally. The entry into London of unsound food can only be prevented by ensuring that the several component inspecting agencies each play their part in one co-ordinated general scheme of inspection. The present system constitutes posts of observation it is true, but these are so isolated from one another that the dealer in unsound food readily learns how to avoid them, and it is, indeed, obvious that inasmuch as the fraudulent trader will not on his own initiative court inspection of his goods, there is need of a system which will bring the inspector to the goods of the fraudulent trader. Many illustiations of this need might be given, but it will suffice to cite a particularly striking instance which occurred some two years ago. A number of carcases of frozen mutton were damaged before reaching London owing to a breakdown of refrigerating machinery. They were not straightway brought to Smithfield, as in the ordinary course, but were taken direct from a London railway station to a cold store, and were only seized, quite by accident, as it were, in part at the coldstore and in part at a retail butcher's premises in Stepney, their ultimate destination. Even if inspection at markets afforded a complete safeguard against the passage through them of unsound meat, it is obvious, in the light of an occurrence such as this, that as long as no general supervision over food supplies arriving in London by rail and by road, as well as by river, exists, protection is incomplete. It is worthy of note, too, in this connection that even the meat supplied direct to consignees in the City itself, and not passing through Smithfield, escapes inspection. It has been suggested that complete surveillance exercised at all the ports would constitute a sufficient safeguard, but this would only touch the question of the condition of foreign meat on importation, and in no way limit the despatch by rail or road of such meat, or of home-killed meat, which may have become unsound. It is clear, therefore, that nothing short of a complete systeinatised scheme of inspection would meet the case. Experience gained with regard to the diversion of the unsound meat trade into channels which afford security against liability to seizure, finds its parallel in the case of other foods, and, indeed, it is not to be supposed that the fairly close supervision exercised in certain boroughs over food supplies would not tend to discourage the despatch of doubtful consignments to those boroughs and create a prejudice in some minds in favour of modes of entry into the county which do not involve risk of seizure. The first outcome, therefore, of the pioneer work done in London in connection with food 5 inspection is a demonstration of the need of supplementing and co-ordinating the existing local agencies and of evolving a system of control which, while causing the least possible interference with trade in foodstuffs generally, will deal effectively with the fraudulent trader. A second question of importance which emerges into view, as the result of experience of methods of food inspection, is one which has concern with the existing method of dealing with trade refuse. Difficulties are experienced by inspectors in obtaining possession of unsound food. It is said not to be "intended for the food of man," or not to be deposited "for the purposes of sale or of preparation for sale."Traders say they are only "middlemen" and have no control over" goods in transit" and so forth. Once more, it is urged that the vendor should be afforded the opportunity of sorting out the good from the bad before the inspector comes upon the scene, and in practice the exhibition of a notice proclaiming that such sorting has not yet been carried out has, as a matter of fact, again and again rendered the inspector powerless in particular instances. Then there is the question of the cost of disposing of refuse. The owner may have unsound food removed as trade refuse, paying the sanitary authority for the service rendered, or, on the other hand, he may be so fortunate as to find a contractor who will pay him for the privilege of being allowed to remove such waste material. Some large firms destroy their own unsound food, but in cases in which this is done the health authority has no means of accurately knowing how far the instructions given are carried out, and indeed some strong suspicion has been entertained, in particular instances, that leakage has occurred, and that surrendered or condemned goods have after all been consumed as food by employes or others. The not inconsiderable cost of removal of trade refuse by sanitary authorities severely handicaps the honest trader, who, it may be, sees his neighbour over the way actually receiving money for material of a kind he himself has to pay to have removed. An egg merchant recently informed me that considerably larger quantities of bad eggs would be handed over to health authorities for the purpose of destruction if the cost were not so great, and an inspector with many years' experience tells me that since the authority he serves raised, some years ago, their price for removing unsound food from 3s. 6d. to 7s. 2d. a load, much less unsound food has been surrendered. An obvious remedy for these difficulties is the vesting of ownership of unsound food in the sanitary authorities, at the same time imposing upon those authorities the obligation to remove and destroy it free of charge. The adoption of this proposal would make it possible to ensure that unsound food which had been once surrendered or condemned should not find its way back into circulation as a commodity saleable for the food of man. At the present time sanitary authorities in London only quite exceptionally destroy unsound food by their own agents, the services of a contractor being as a rule requisitioned. In some cases the food is " denatured " before it is handed over to the contractor; in others a system obtains by which an officer of the sanitary authority visits the contractor's premises, in order to see tins " spiked," meat treated with chemicals or thrown into digestors, and so on; in other cases still the responsibility of making sure that the condemned food is not eaten by human beings rests with the contractor. In some London boroughs a contractor is prepared to pay traders or sanitary authorities for goods regarded as unsound, and at the time of my inquiry, prices ranging from 30s. a ton downwards were being quoted for condemned meat, the contractor bearing, moreover, the whole cost of removal. The fat constituted presumably the main source of profit derivable from such meat, though I was told in one instance that a uniform price of 1d. a stone was paid for meat of all sorts, however emaciated the carcase might be, and even for "livers." A common practice in the case of the less valuable damaged tins of fruit was for a contractor to remove them free of charge; it was suggested that solder was recoverable from tins and thus gave them some small value. I have been assured that the experience of contractors shows that it is only with extreme difficulty, if at all, that employes can be restrained from abstracting particular pieces of meat or the contents of tins for their own domestic consumption; indeed, the manager of a large business who has had to deal with vast quantities of tinned meat, tells me his firm has abandoned the practice of disposing of the "blown tins" to a contractor, on account of the risk the firm believed themselves to incur of finding their goods associated with outbreaks of illness. It is, of course, obvious that large profits could be made by manipulating condemned food so as to make it again saleable, and I understand that a manure manufacturer, who recently undertook to deal with a number of urrenderedtins of meat, elected to have them removed to premises outside London, which, as the curiosity of an inspector of the London Sanitary Authority concerned led him to ascertain, bore externally the inscription "potted shrimp manufacturer." Clearly, in so important a matter as this the whole responsibility should rest with the sanitary authority, and condemned food should not be trusted out of the hands of the authority's servants. A third point of importance is the need for special supervision in the case of particular classes of premises used in connection with the storage or manipulation of food. This need makes itself particularly felt in connection with inspection of river-born foodstuffs, for most of the large cold stores in London are situated near the river. Its existence in the case of cold storage premises in London generally was recognised by the Public Health Committee some years ago and' was brought by the Council to the notice of the Local Government Board. The suggestion was made that such premises should be registered and that a health authority should have power similar to that given by the existing Dairies and Cowsheds Orders, under wh ch premises, before being used, are required to be approved as being structurally fitted for the purposes contemplated, and should be subsequently subject to inspection. If power to regulate cold storage premises on the lines indicated were given, it would no doubt be deemed desirable to deal also with premises at which sausage-making, potted-meat-manufacture and various preservative processes are carried on, for at all such premises the need for special supervision will of course be generally admitted. 6 Finally, reference must be made to the need of placing legislation as regards inspection of foodstuffs upon a more satisfactory basis. At the present time section 47 of the Public Health (London) Act, 1891, contains the law on the subject, but it is notorious that the course of a health authority taking proceedings under the section is beset with difficulties. The section does not even adequately equip the authority for dealing with unsound food sold by retail at ordinary shop premises: it readily admits of being evaded in cases in which it is sought to apply it to unsound food in transit by water, road or rail, or in the hands of wholesale dealers or middlemen, at railway stations or on dock or warehouse premises. The fact that the Port Sanitary Authority has not secured a single conviction speaks for itself. W. H. Hamer. Public Health Department, 8, St. Martin's Place, W.C. APPENDIX VI. London County Council. SANITARY OFFICERS. Report by the medical officer on the sanitary staffs of the metropolitan boroughs. (Printed, by order of the Public Health Committee, 12th July, 1906.) Public Health Department, 8, St. Martin's-place, November, 1906. I present a return based upon information supplied by the medical officers of health of the City and the metropolitan boroughs. During the last thirteen years returns have been presented to the Public Health Committee giving particulars as to the sanitary inspectors employed in the several districts of London. Each return has shown an increase upon the numbers stated in the preceding return, and the facts which have been ascertained for the purposes of the present return indicate still further increase. The following table shows the number of inspectors employed in London in several years to which the returns relate— Year. Number of sanitary inspectors in the whole of London. Year. Number of sanitary inspectors in the whole of London. 1893 188a 1901 275 1894 219a 1903 301b 1895 228a 1904 313b 1898 256a 1906 319 Thus it will be seen that since 1893 the number of inspectors has increased by nearly 70 per cent, and on the figures of the 1901 census there is now one sanitary inspector to every 1,792 inhabited houses and to every 14,221 persons. Of this average population more than half or 7,679 persons live in tenements of less than 5 rooms and of these persons 2,276 are living more than 2 in a room. The total number of houses let in lodgings on the registers of the sanitary authorities is 21,510, giving an average for each sanitary inspector of 67. In 1904 the number of sanitary inspectors employed in each of the metropolitan boroughs was ascertained and comparison between these numbers and those obtaining in 1906 may thus be made— Metropolitan boroughs. Number of sanitary inspectors. Increase ( + ) or decrease (—) in 1906 compared with 1904. Metropolitan boroughs. Number of sanitary inspectors. Increase (+) or decrease (—) in 1906 compared with 1901. 1904. 1906. 1904. 1906. Batteraea 13 13 - Lewi sham 10 10 Bermondsey 9 9 - Padding ton 12 12 - Bethnal Green 10 10 - Poplar 8 9 + 1 Camberwell 614 13 — l St. Marylebone † 8 †† 9 + 1 Chelsea 4 4 — St. Pancras 16 17 + 1 Deptford 8 7 — l Shoreditch 6 6 - Finsbury 10 11 + 1 Southwark 16 16 - Fulham 7 7 — Stepney 18 18 - Greenwich t 6 5 — l Stoke Newington 3 3 - Hackney tt 17 17 — Wandsworth §§11 §§12 + 1 Hammersmith 9 9 Westminster, City of 12 12 - Hampstead 7 7 — Woolwich 10 10 - Holborn 4 4 — City of London 119 1119 - Islington 20 22 + 2 - Kensington 13 13 — London 313 + 6 Lambeth 13 15 + 2 a Excluding inspectors employed in districts mentioned in Schedule C of the Metropolis Management Act. b Including one inspector who acted as chief clerk. ††Including two temporary inspectors. † Including one temporary inspector. || Including eight meat inspectors. §§ There are also five inspectors concerned with drains and sanitary fittings in old and new houses; these officers are under the direction and control of the surveyors. Of the 319 inspectors now employed in London 38 are women. At the date of the last return 28 of the sanitary inspectors were women. The increase in the total number of inspectors in London since the date of the last return is therefore largely due to the appointment of women inspectors who are now employed in all the London districts except Bcrmondsey, Deptford, Greenwich, Hammersmith, Shoreditch, Stepney and Stoke Newington. Shirley F. Murphy, Medical Officer of Health. printed for THE LONDON COUNTY COUNCIL by southwood, smith and co., ltd., And may be purchased, either directly or through any Bookseller, from T. S. KING AND SON, 2 and 4, Great Smith-street, Victoria-street, Westminster, S.W. Agents for the sale of the publications of th" London County Council. No. 1019. Price 3d., post free, 3gd. 11595—1000—15.1.07 s.s./14860 2 3 SANITARY OFFICERS. Metropolitan borough. Number of sanitary inspectors. Census, 1901. Houses let in lodgings. Duties of sanitary inspector. Assistants. Clerical stall Inhabited houses. Total tenements. renements under 5 rooms. * Orercrowded enements- Population. Population n tenements under 5 rooms. Population in overcrowded tenements. Arerage per sanitary inspector. No. of houses let in lodgings on the register. No. of times a year these houses are inspected. Males Fenaley. Inhibited houses. Tenements. Tenements under 5 rooms. Overcrowded tenements. Population Population in tenements under 5 rooms. Population in overcrowded tenements. Battersea n 2 23,462 38,987 24,089 3,032 168,907 88,999 18,381 1,805 2,999 1,853 233 12,993 6,846 1,414 121 Frequently. The chief inspector supervises generally, inspects in all cases of importance and where statutory proceedings are about to be taken, and is specially concerned with combined drainage. Eight have each an assigned district, in which they are concerned with duties under the Public Health Act. They supervise drainage of new buildings, for which they receive £10 more yearly. One takes samples under the Food and Drugs Acts, and inspects slaughterhouses, butchers' shops, sausage factories, ham and beef shops, etc. One inspects factories, workshops and workplaces. One (female) inspects places employing female labour, and investigates infantile deaths and cases of puerperal fever. She also visits the houses of children who are about to be discharged from isolation hospitals after scarlet fever and diphtheria, and inspects houses let in lodgings. One (female) investigates deaths of infants under one year, visits cases of non-notifiable infectious disease, visits children fed from the council's milk depot, and gives instruction to mothers in the feeding and care of infants. In addition to her salary as sanitary inspector she receives £30 per annum from the borough council. (a) 9 disinfecting assistants. (i) 5 drain-test- ing assistants. (c) 1 mortuary keeper and 1 temporary assistant. 6 Bermondsey 9 15,S17 29,073 22,064 4,307 130,760 86,156 25,726 1,757 3,230 2,452 479 14,529 9,573 2,858 221 at end of 1905. 4 One supervises generally the work of the district inspectors, takes part in house-to-house inspection, and inspects bakehouses, slaughterhouses, cowhouses and houses let in lodgings, offensive trades, factories and workshops, etc. Eight have each an assigned district, in which they are concerned with duties arising under the Public Health, Factory and Workshop, and Food and Drugs Acts. They also supervise drainage work reconstruction. (a) 6 disinfecting assistants. (i) 2 mortuary keepers. (c) 1 shelter caretaker (female) 4 and 1 office youth Bethnalgreen 9 1 14,005 28,209 23,732 6,384 129,680 98,853 38,410 1,400 2,821 2,373 638 12,968 9,885 3,841 495 At least three times. One superintends, and in conjunction with medical officer of health is responsible for the operations of the entire sanitary staff. Six have each an allotted district, in which they are concerned with duties arising under the Public Health Act including the inspection of registered tenement houses. One is concerned with work under the Food and Drugs Acts, the inspection of meat, etc. One supervises the drainage and enforcement of by-laws during construction of new buildings. (The whole of the salary of this officer is paid by the borough council.) One (female) investigates cases of diarrhoea, and reports on the sanitary condition of the premises. She visits houses where births have occurred, and inspects workshops where women are employed. (a) 1 general assistant, (i) 4 disinfectors (c) mortuary keeper 5 and 1 office youth Camberwell 12 1 36,671 56,985 31,926 4,073 259,339 117,648 25,012 2,821 4,383 2,456 313 19,949 9,050 1,924 217 Once, and at irregular periods. One is concerned with smoke nuisances and Food and Drugs Act, and is emergency inspector under all Acts of Parliament relating to public health. Eleven have each an allotted district in which they carry out duties arising under the Public Health and Factory and Workshop Acts and exceptionally under the Food and Drugs Act. One (female) is chiefly concerned with laundries, factories and workshops employing female labour. (а) I superintendent and 7 disinfecting assistants. (б) 1 mortuary keeper. 5, in addition to chief clerk, who was formerly a sanitary inspector. Chelsea 3 1 8,641 17,467 12,082 1,914 73,842 37,723 10,659 2,160 4,367 3,020 478 18,460 9,431 2,665 602 Not specially visited, but visited as part of ordinary house - to house inspection. One acts as chief inspector and carries out duties connected with infectious disease and complaints, and obtains samples under the Food and Drugs Act. Two have an allotted district, in which each is concerned with houseto-house inspection, and inspection under the Factory and Workshop Act, and (with assistants) disinfects clothing and bedding at the disinfecting station. One (female) is concerned with inspection of workshops and outworkers' homes where female labour is employed. She also makes special investigations, and visits mothers of newly-born infants. (a) mortuary keeper, who assists disinfectors when required. (J) 2 disinfecting and draintesting assistants. None. * For the purposes of this report the terra "overcrowed tenements" is applied to those tenement! of less thin5 rooms which at the date of the 1901 census were occupied I 4 5 SANITARY OFFICERS. Metropolitan borough. Number of sanitary inspectors. Census, 1901. Houses let in lodgings. Duties of sanitary inspector. Assistants. Clerical staff. Inhabited houses. Total tenements. Tenements under 5 rooms. * Overcrowded tenements- Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Average per sanitary inspector. No. of houses let in lodgings on the register. No. of times a year these houses are inspected. Males. Females. Inhabited houses. Tenements. Tenements under 5 rooms. Overcrowded tenements. Population Population in tenements under 5 rooms. Population in overcrowded tenements. Deptford 7 15,823 24,615 13,956 1,667 110,398 51,861 9,999 2,260 3,516 1,993 238 15,771 7,408 1,428 269 Onee. Five have each an assigned district in which they perform generally the duties of a sanitary inspector. One is charged with the duties under the Dairies and Milkshops order, Factory and Workshop Act, Canal Boats Acts, and the regulations as to slaughterhouses, knackers' yards, offensive businesses, throughout the borough. One is concerned with infectious disease, prepares statistics and does clerical work. All inspectors are qualified to act under the Food and Drugs Act. (a) 3 disinfecting assistants. 1 Finsbury 9 2 #,280 24,097 20,515 6.373 101,463 78,346 35, <23 843 2,190 1,865 579 • 9,224 7,122 3,247 1,270 Average twice or three times One acts as chief inspector and supervises generally. Six have each an allotted district in which they carry out duties imposed by the Metropolis Management, Public Health and Food and Drugs Acts, and supervise sanitary and drainage works in old buildings. They also supervise houses let in lodgings and are concerned with smoke nuisances. One also has oversight of Regent's Canal (within borough) and boats thereon. One is concerned with Factory and Workshop inspection. One is a meat and market inspector. Two (females) are concerned with the inspection of factories and workshops where females are employed, out-workers' homes, etc., and make special enquiries into infantile deaths and cases of measles. In certain cases they also visit homes of newly-born infants. (a) 1 disinfector. (4) 2 mortuary keepers one of whom also di s i n fects rooms, and the other also works steam disinfector. (c) 1 shelter keeper (who also disinfects rooms). (d) 1 van driver who also assists with disinfection. 2 and 1 office youth. Fulham ... 6 ! 1 18,634 32,137 21,681 2,341 137,289 81,364 14,892 2,648 4,591 3,097 334 19,618 11,623 2,127 329 Twice. 693 Inspections in 1905. Five have each an assigned district, in which they perform all duties arising under the Public Health Act and Factory and Workshop Act. One is employed on duties arising under the Food and Drugs Act and in the inspection of places where food is sold or stored. One (female) is chiefly engaged in the inspection of workshops, etc., where women are employed, but also visits after notification of birth. (а) 2 drainage inspectors. (б) 4 disinfectors and 3 assistants. (c) 1 mortuary keeper 2 Greenwich 5 — 14,240 19,702 10,877 1,199 95,770 41,260 7,947 2,84S 3,940 2,175 240 19,154 8,252 1,589 3 — One is concerned with infectious disease. Four have each an allotted district in which they are concerned with duties under the Public Health and Factory and Workshops Act. (a) 3 disinfecting assistants. 2 Hackney 15 2 30,634 48,794 29,089 3,684 219,272 104,876 22,332 1,802 2,870 1,711 217 12,898 6,169 1,314 463 Once. Twelve have each an assigned district, in which they are concerned with duties arising under the Public Health, Factory and Workshop and Food Adulteration Acts. One of these inspectors performs duties under the Canal Boats Act (for which he gets £26 a year, no part of which is repayable by the London County Council). One is concerned with dairies, cowsheds, milkshops, slaughterhouses and knackers' yards and is also food inspector. Two are engaged upon house-to-house inspection. The inspectors supervise reconstruction and alteration of drains but not in new premises. One (female) inspects workshops, laundries, etc., where female labour is employed. One (female) inspects the houses of outworkers. (a) 1 dust inspector, and one assistant. (i) 9 assistants for disinfecting. (c) 1 mortuary keeper, 1 temporary shelter caretaker (and wife). (d) 1 drain-testing assistant, 1 smoke nuisance assistant. («) varying number of dustmen. 4 and 1 messenger. Hammersmith 9 15,198 I 25,810 15,505 2,185 112,239 55,259 13,192 1,689 2,868 1,723 243 12,471 6,140 1,466 2472 Indefinite. Four have each an assigned district,_in which they are concerned with all duties arising under Public Health (London) Act. One makes a systematic house-to-house inspection of the district. One is employed on houses let in lodgings. One is employed on duties arising under the Food and Drugs Acts and supervision of dustbins. One is concerned with duties transferred from the L.C.C., and also smoke nuisances. One is concerned with factories and workshops. (a) 2 assistants for disinfection. (b) 1 mortuary keeper. (c) 2 drainage inspectors. 3 6 7 SANITARY OFFICERS Metropolitan borough. Number of sanitary inspectors. Census, 1901. Houses let in lodgings. Duties of sanitary inspector. Assistants. Clerical staff. Inhabited bouses. Total tenements. Tenements under 6 rooms. * Overcrowded tenements- Population. Population in tenements under 6 rooms. Population in overcrowded tenements. Inhabited houses. Average per sanitary inspector. Ho. of houses let in lodgings on the register. No. of times a year these houses are inspected. Males. Females. Tenements. Tenements under 5 rooms. Overcrowded tenements. Population Population in tenements under 5 rooms. Population in overcrowded tenements. Hampstead 6 1 11,294 16,998 7,178 864 81,942 24,211 5,215 1,613 2,428 1,025 123 11,706 3,459 745 239 No fixed number of times. Frequency of inspection is governed by character of houses. One supervises generally, makes special inspections, investigates cases of infectious diseases and is responsible for work of disinfecting assistants. Four have each an allotted district, in which they are concerned with duties arising under the Public Health Act. One carries out the inspection of slaughterhouses, dairies, factories and workshops, and takes all samples under the Food and Drugs A^t. One (female) is engaged in the inspection of premises where females are employed, and makes special investigations. (fl) 3 disinfecting assistants. (4) 3 drain-testing assistants, one of whom acts as mortuary keeper. 3 and 1 clerk draughtsman. Holborn... 3 1 4,703 13,790 10,772 2,783 59,405 35,724 14,875 1,176 3,447 2,693 696 14,851 8,931 3,719 759 All houses inspected once. Many more frequently, and when necessary weekly. Three have each an allotted district, in which they are concerned with duties arising under the Public Health, Factory and Workshop and Food and Drugs Acts. One (female) is engaged on special inspections under the direction of the medical officer, such as factories and workshops, restaurants where females are employed, outworkers' homes, the prevention of consumption, the non-notifiable infectious diseases, and infantile mortality. (a) 2 disinfecting assistants. (4) 1 mortuary keeper. 3 Islington.. 20 2 38,645 79,129 55,801 10,071 334.991 196,423 56,948 1,757 3,597 2,536 458 15,227 8,928 2,587 891 The number of times varies, but the aver age in 1905 was 13. One chief inspector supervises work of staff and visits premises when it is necessary to serve a statutory notice. Fourteen have each an allotted district, in which they are concerned with duties arising under the Public Health Act (except as regards houses let in lodgings and workshops), and also inspect milkshops and dairies and visit ice cream factories. One inspects workshops, workplaces and bakehouses. Two inspect houses let in lodgings. One carries out duties under the Food and Drugs Acts. One inspects meat, food, cowsheds and offensive trade premises. Two (females) inspect workshops and out workers' homes where females are employed, and restaurant kitchens. (a) 2 permanent and 1 temporary disinfectors. 7 Kensington 11 2 22,131 38,349 21,115 4,599 176,628 73,425 26,207 1,702 2,950 1,624 354 13,587 5,648 2,016 1985 Variable, according to requirement ol individual cases. One is chief inspector without a district, and exercises supervision. Ten have each an allotted district, in which they are concerned with all duties arising under the Public Health (London) Act. They also obtain samples under the Food and Drugs Act. Two act at one time for three months and then are exempt from this duty for 12 months. No inspector collects samples for analysis in his own district. Two (female) are engaged mainly in the inspection of workshops, workplaces, laundries, etc., where females are employed, but also make inquiries into cases of pulmonary consumption, measles, whooping cough, and infantile diarrhoea. (a) an inquiry officer for cases of infectious diseases who is also overseer of disinfection of houses and infected articles, and 3 disinfectors including one man who acts as engineer. (4) mortuary keeper. (c) sanitary labourer for assisting infesting drains. (d) one female health visitor for the prevention of infant mortality 5 Lambeth 13 2 41,511 70,887 44,495 6,548 301,895 153,184 36,904 2,767 4,726 2,966 436 20,126 10,212 2,460 372 Visited regularly once a year. Twelve have each an allotted district, in which they are concerned with all duties arising under the Public Health and Factory and Workshop Acts. One inspector deals only with smoke nuisances, and carries out duties under the Food and Drugs Act, assisted by a deputy. The district inspectors supervise the execution of drainage works in both new and old houses. Two (females) carry out duties under the Factory and Workshop Act, inspect underground conveniences, and perform duties of a general character. (a) 11 disinfecting assistants. (4) 2 mortuary keepers and a deputy. (c) 1 temporary caretaker of shelter (female) 3 and a boy clerk. 8 SANITARY OFFICERS. Metropolitan borough. Number of sanitary inspectors. Census, 1901. Houses let in lodgings. Duties of sanitary inspector. Assistants. Clerical staff. Inhabited houses. Total tenements. Tenements under 5 rooms. * Overcrowded tenements- Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Average per sanitary inspector. No. of . houses let in lodgings on the register. No. of times a year these houses are inspected. Males. Females. Inhabited houses. Tenements. Tenements under 5 rooms. Overcrowded tenements. Population Population in tenements under 5 rooms. Population in overcrowded tenements. Lewisham 8 2 22,750 27,701 8,561 535 127,495 2,8928 3,416 2,275 2,770 856 53 12,749 2,893 342 17 Weekly. Six have each an assigned district in which they carry out general sanitary duties. One is engaged on duties arising under the Factory and Workshop Act, smoke nuisances and special inspections. One is engaged in house-to-house inspection. Two (females) visit laundries, workplaces, &c., where females are employed, and make special investigations into cases of infectious disease, infantile mortality, etc. (a) 6 disinfecting assistants. (A) 2 drain-testing assistants. 3 Paddington 10 2 17,684 33,661 21,815 3,404 143,976 73,232 19,531 1,474 2,805 1,818 284 11,998 6,103 1,628 1330 Six or more times. Six each supervise a district, performing all duties tinder the Public Health (London) Act; they take charge of drainage works in existing buildings, and attend to notified cases of infectious disease, but one also carries out small duties under the Canal Boats Act, for which a separate salary is assigned. (N.B.—Drainage works in new buildings under direction of surveyor). One has supervision of workshops and work-places, and has generally the enforcement of the Factory and Workshop Acts. Two attend to houses let in lodgings, and the enforcement of by-laws under section 94, Public Health (London) Act, 1891. One has to watch food supplies, and inspect slaughterhouses, cowsheds, dairies, refreshment houses, etc. Ice-cream inspection also falls to him. Two (female) inspect all workplaces where women are employed, and make enquiries into infectious disease not scheduled for notification. (a) inspector under the Food and Drugs Act. (b) mortuary keeper. (c) caretaker and wife at shelter. (d) 4 navvies (employed for opening defective drains, etc.). (f) 1 disinfecting assistant. 4 Poplar 8 1 22,613 35,787 26,216 4,414 168,822 105,497 27,700 2,513 3,976 2,913 490 18,758 11,2 72 3,078 969 A large number very frequently and many also at night. Seven have eacli an assigned district in which they carry out duties under the Public Health, Metropolis Management, Factory and Workshop, Food and Drugs, and Canal Boats Acts. One visits houses let in lodgings. One (female) inspects all places where female labour is employed, and sanitary offices of schools for girls. Also makes enquiries under L.C.C. General Powers Act as to verminous clothing. (a) 1 chief and 4 disinfecting assistants. (b) 5 labourers (who assist inspectors). (c) 1 female attendant at the Glaucus - street shelter. 4 and 1 office youth. St. Marylebone *7 *2 13,536 31,623 22,947 5,180 133,301 74,153 28,147 1,504 3,514 2,549 575 j 14,811 8,239 3,127 758 Bye-laws sent to L.G.B. for approval. Five have each an allotted district in which they are concerned with all duties arising under the Public Health and Food and Drugs Acts, etc. They supervise all drainage work, loth as regards new premises and reconstruction. One is concerned with duties arising under the Factory and Workshop Act and deals with smoke nuisances. One (temporary) acts as dust inspector. One (female) is concerned with duties arising under the Factory and Workshop Act. One (female, temporary) inspects cases of phthisis, schools, and under the Cleansing of Persons Act, &c. (a) 3 disinfecting assistants. (b) mortuary keeper. (c) caretaker of shelter (female) 1 chief and 2 assistant clerks. St. Paneras 15 2 23,715 57,045 45,023 10,158 235,517 155,790 56,423 1,395 3,355 2,648 597 13,842 9,164 3,319 2192 at end of 1905. Twice a year. Thirteen inspectors have each an assigned diestrict in which they deal with infectious diseases, complaints, drainage and nuisances generally. Two inspectors carry out the Food and Drug;s Acts and the by-laws regulating slaughter-houses and dairies. One of these inspectors also carries out duties under the Canal Boat b Act. Of the two female inspectors one visits factories and workshops, and the other, in addition to the duties of a sanitary inspector, makes inquiries into infantile mortality. (o) 3 disinfecting assistants and 1 generalassistant (4) caretaker of mortuaries and coroner's court and 1 contact shelter attendant, and attendant at cleansing station and children'sbaths 1 chief clerk, 7 assistant clerks. 9 * Including one temporary inspector. 11595 b 10 SANITARY OFFICERS Metropolitan borough. Number of sanitary inspectors. Census, 1901. Houses let in lodgings. Duties of sanitary inspector. Assistants. Clerical staff. Inhabited houses. Total tenements. Tenements under 5 rooms. * Overcrowded tenements- Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Average per sanitary inspector. No. of houses let in lodgings on the register. No. of times a year these houses are inspected. Males. Females. Inhabited houses. Tenements. Tenements under 5 rooms. Overcrowded tenements. Population Population in tenements under 5 rooms. Population in overcrowded tenements. Shoreditch 6 – 12,743 27,031 22,940 6,269 118,637 89,580 35,529 2,124 4,505 3,823 1,045 19,732 14,930 5,921 251 If found on inspection to be kept in a satisfactory sanitary condition once a year only. If not, the houses are inspected ac often as may be necessary to secure improvement. Some houses have required frequent visits at short intervals. One is concerned with duties under the Public Health and Factory and Workshop Acts, and generally superintends and assists other inspectors. Also attends to the registration of houses let in lodgings. Each of the five other inspectors has an allotted district in which he performs the various duties arising under the Public Health and Factory and Workshop Acts, including the abatement of smoke nuisances, the supervision of drainage work, both in new and existing houses, and the testing of drains. Each inspector is required to take fcur samples per fortnight under the Food and Drugs Act, and also to take turns of duty in the street markets on Saturdays and Sundays with a view to taking samples and watching the qualities of the food stuff exposed for sale. The inspectors are not restricted to their own districts for taking samples under the Food and Drugs Act. (a) 1 general assistant. (b) 1 disinfeetor and 2 assistants. (c) 1 mortuary keeper. (d) caretaker(female)of shelter. 3 Southwark 13 3 20,878 47,808 39,612 8,133 206,180 147,923 46,073 1,305 2,988 2,476 508 12.886' 9,245 2,880 1241 At least four times a year. Many month1 y, some weekly. One chief male inspector supervises generally the work of the other male inspectors. One acts as a Food and Drugs inspector. Eleven inspectors have each an assigned district in which they are concerned with duties under the Public Health Act, and the inspection of factories and workshops. One chief inspector (female) visits workshops and does special work. Two (female) visit houses let in lodgings. (a) 11 disinfecting assistants. (b) 2 mortuary keepers, and a superintendent and his wife at reception house. The superintendent is concerned with infectious disease. (c) 1 assistant drain tester. 6 Stepney 18 – 31,462 61,113 49,182 16,541 298,600 209,200 99,179 1,748 3,395 2,732 919 16,589 11,622 5,510 2657 Some of the best are only visited once or twice a year. Others are visited practically every month. Fifteen have each an allotted district, and are concerned with duties arising under the Public Health, Factory and Workshop and Food and Drugs Acts. These inspectors supervise the construction of drainage work in old as well as new houses as far as the front wall of the house. One inspector has also duties under the Canal Boats Act. Two are concerned with houses let in lodgings. One inspects wharves and food landed at such premises. (a) 15 disinfecting andgeneral assistants. 7 Stoke Newing- ton 3 – 7,717 11,824 5,813 497 51,247 18,611 2,835 2,572 3,941 1,938 166 17,082 6,204 945 259 All once, some twice annually. The three inspectors have each an assigned district in which they carry out general sanitary duties. (a) 1 disinfecting assistant. 1 Wandsworth 10* 2 37,764 49,756 21,052 1,525 232,034 76,329 10,337 3,147 4,146 1,754 127 19,336 6,360 861 222 Twice and more frequently if any special reason. Nine have each an assigned district in which they carry out duties under the Public Health Act, including all by-laws and repair of drains and sanitary fittings. They also take samples under the Food and Drugs Act if required. Three have small duties under the Canal Boats Act for which a separate allo wance is made. One carries out duties under the Food and Drugs Act over the whole borough, inspects meat, and performs special duties under the Public Health Act as required. Two (females) are chiefly occupied in laundries and workshops which employ female labour. They also visit houses after a notification of birth. (a) 10 disinfecting assistants. (b) 3 mortuary keepers. 4 Westminster (City of) 10 2 18,366 41,244 26,668 4,346 183,011 83,624 23,856 1,530 3,437 2,222 362 15,251 6,969 1,988 1611 578 inspections were made in 1905. Eight district inspectors. Two perform duties under the Food and Drugs Act, abatement of smoke nuisances, inspection of street markets, slaughterhouses, offensive trades, cowhouses, and inspection of food generally. Two (female) are engaged in the inspection of workshops, workplaces, etc., where female labour is employed, and also inspect houses let in lodgings. (al 10 disinfecting and other assistants. (b) 2 mortuary keepers and 1 assistant. (c) 2 women in charge of shelter and 1 cleaner. 8 11 * There are also five inspectors concerned with drains and sanitary fittinfs in old and new houses under the control of the Surveyors, 12 SANITARY OFFICERS. Metropolitan borough. Number of sanitary inspectors. Census, 1901. Houses let in lodgings. Duties of sanitary insDector. Assistants. Clerical staff. Inhabited houses. Total tenements. Tenements under 5 rooms. Overcrowded tenements- Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Average per sanitary inspector. No. of houses let in lodgings on the register. Males. Females. Inhabited houses. Tenements. Tenements under 5 rooms. Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. No. of times a year these houses are inspected. Woolwich 8 2 18,086 24,585 14,017 1,243 117,178 50,985 7,727 1,808 2,458 1,401 124 11,718 5,098 772 265 Two or four times a year. One acts as chief inspector and supervises generally. Seven inspectors have each an assigned district in which they perform duties arising under the Public Health Act. They have also some additional duties ; two are inspectors under the Food and Drugs Acts, and inspectors of dairies and milk shops. One is inspector for the market, slaughterhouses and principal butchers' shops. One is workshop inspector where women are not employed, and cowshed inspector. One (female) does general work, visits houses let in lodgings, and workshops where women are employed. One (female) visits cases of infectious disease voluntarily notified (phthisis, zymotic, enteritis, measles, etc.), houses where births have occurred, and acts as health visitor in the matter of infant feeding. (a) 3 disinfectors. (b) 3 drainage workmen. (c) 1 mortuary keeper. (d) 1 manager and 2 assistants at milk depot. 4 City of London 17† 2 3,865 £,339 3,307 504 26,923 10,625 2.921 203 281 174 27 1,417 559 154 – Two are concerned with notified infectious diseases. One is specially engaged in carrying out the provisions of the Food and Drugs Act. Six are concerned with duties arising under the Public Health Act. Eight inspectors are engaged in meat inspection. Two female inspectors visit workplaces where females are employed, and one of these in addition to the ordinary duties of a sanitary inspector visits houses in connection with births and infantile mortality. (a) 1 disinfecting assistant, (b) 1 mortuary keeper. 3 County of London 281 38 571,768 1,019,546 672,030 124,773 4,536,541 2,449,789 726,096 1,792 3,196 2,106 391 14,221 7,679 2,276 21,510 13 † Includes eight meat inspectors. London Counts Council. Report by Medical Officer submitting the result of a census of homeless persons on the night of 8th February, 1907, together with some information concerning the accommodation for women provided in shelters, homes, and institutions. Ordered by the Public Health Committee to be printed, 21 st March, 1907. On the night of Friday, 8th February, 1907, a census was taken of homeless persons in London, being the third of such censuses organised by the Council. The night was clear and cold, and it is therefore somewhat remarkable that fewer than 50 persons were found taking shelter on staircases or in other places affording some protection from the wind. In all, however, the Council's officers counted 1,998 men, 402 women and 4 children, who might be regarded as homeless. Of these, 862 men and 36 women received soup and bread from the Salvation Army on the Embankment and 156 men were provided with food in the tents of the Church Army. On the same night a census was taken of the number of persons occupying beds in common lodging-houses, with the following result:— Authorised accommodation Number of persons on night of 8th February Number of vacant beds Number of persons turned away—unable to pay, etc. Men. 25,599 20,438 5,161 658 Women. 2,436½ 1,598 838½ 21 Couples. 245 207 38 9 On the same night, 4,263 men slept in Rowton Houses, which had 844 vacant beds; and 642 men in Bruce House, Kemble-street, where there were 57 vacant beds. It would thus appear that there is more than sufficient accommodation for all the homeless persons in London in existing institutions at an average cost of 6d. per night per head. This is, of course, irrespective of the accommodation provided in casual wards, in which, on the night of 8th February, there were 1,137 vagrants; the total accommodation provided in the London casual wards is for 1,882 persons, and there was vacant accommodation therefore for 745 persons. In this connection it is interesting to note the facilities afforded in London for obtaining cheap or froe food. At a large mission hall in Shoreditch about 600 men are fed daily at a very small ccst, a substantial meal being provided for 2d. or 3d. a head. Here too, free food is distributed to 350 men each Sunday, and to 900 men each Thursday. On the Embankment each night from 900 to 1,500 persons are supplied with a meal of soup and bread free of charge. There is, moreover, an institution in Limehouse which sends a man out each night to different parts of London to distribute tickets in the streets to the homeless poor. Each ticket entitles a man to eight ounces of bread, and some 400 tickets are distributed each evening. The distribution of soup and bread on the Embankment begins at 1 a.m., and the tickets for bread in the Limehouse institution are available from midnight to 4 a.m. It is, therefore, somewhat significant that on the morning of the 9th February no applications were received at the Limehouse institution until 2.15 a.m., though from that time until 4 a.m., 277 tickets were presented in exchange for bread. From the information gathered, it would appear that it is possible for a man to live, so far as food is concerned, for a penny a day, provided he takes advantage of the free food distribution and supplements this by purchasing at the low rates food which can be had in the Mission Hall, Shoreditch. The results of the three censuses of homeless persons may be roughly stated as 2,000 in 1904. 2,200 in 1905 and 2,400 in 1907, and it would seem that the estimate made on the first occasion that about 1 in every 2,000 of the London population is homeless, still holds. The information obtained on the night of the 8th instant is summarised in tabular form as follows :— Table I. shows the number of homeless persons and their distribution in certain areas. Table II. shows the authorised accommodation in common lodging houses, the number of beds occupied, the number of beds vacant, and the number cf persons who, for various reasons, were turned away. Table III. shows the number of beds for men only in shelters, at the present time not licensed as common lodging houses. Table IV. is extracted from Table II. and shows that, on the night of the census, free beds were provided in licensed common lodging houses for 546 men, 16 women, and 42 children, and that 513 men received a bed in return for work in the labour homes of the Church Army and Salvation Army. Among the free beds in ordinary common lodging houses are included 162 beds paid for by the Church Army, and 343 beds provided in Medland Hall free shelter. All the 42 children were accommodated in Dr. Barnardo's Homes. fruited for THE LONDON COUNTY COUNCIL by sodthwoud, smith and oo., uza. And may be purchased, either directly or through any Bookseller, from P. S. KINO AND SON, 2 and 4, Great Smith-street. Victoria-street, Westminster, 8.W., Agents for the sale of the Publications of the London County Council No. 1055. Price Id., post free l½d. 13528—250—3.6.07 S.S./17316 2 Table V. shows the accommodation available for women only in shelters, homes, and institutions which cannot be classed as common lodging houses, and the extent to which this accommodation was _ma.de use of on the night of 8th .February. In some fe.w cases where the precise figures were not available the average number of residents has been inserted. 8, St. Martin s-place, W.C. 21st' February, 1907. (Signed) Shirley F. Murphy, Medical Officer of Health. TABLE I. Homeless Poor Census. Classification of homeless poor according to districts. District Men. Women. Children. 1. Hyde Park Corner, Knightsbridge, Kensington, Hammersmith, Edgware-road, Harrowroad, Paddington and Kilburn 154 60 2. Grosvenor-road, Chelsea-embankment, Sloane-street, Brompton-road. Lillie-rood to River *3. City West, Embankment, Westminster, Soho, St. James's Park, Marble Arch 11 3 I 1,256 59 — 4. Islington, Clerkenwell. Hoxton, Holloway, King's Cross, Gray's Inn-road, Camden Town... 58 89 — 5. Bethnal-green-road, Kingsland-road, Hackney-road 3 5 — t6. Spitalfields, Whitechapel-road, Bethrial-green-road, Cambridge-road, Bishopsgate 246 96 — 7. City East, Shadwell, Poplar, Limehouse 148 28 3 8. Borough, Southwark, Lambeth, Kennington, Clapham 118 61 — 9. Beimondsey, Elephant, Old Kent-road, Camberwell, Peckham, Albert-embankment, Westminster-bridge-road, Vauxhall 4 1 — Totals 1,998 402 4 *Including 862 men and 36 wom»n on Embankment for free food and 156 men at the Church Army tents. †Including 25 men and 2 women buying cheap food at Salvation Army shelter in Whitechapel-road. TABLE IT. Common Lodging Houses. Sanitary district. No. of Houses Accommodation. Census on 8th—9th Feb., 1907. Number of vacant beds on 8th—9th Feb., 1907. Number of persons turned away unable to pay, etc. Males. Females. Couples. Males. Females. Couples. Males. Females. Couples. Males. Females. Couples. Battersea 8 157 78 23 122 16 6 35 62 17 – – Bermondsey 5 885 — — 651 — — 234 — — 37 — — Bethnal-green 15 717 — — 544 — — 173 — — 8 — — Camberwell 6 537 — — 432 – — 105 — — 8 — — Chelsea 9 337 52 — 247 41 — 90 11 — 14 — City of London 1 452 — — 452 — — — — — 33 — — Deptford 8 1,194 49 — 826 33 — 368 10 — 17 — — Finsbury 8 543 — — 452 — — 91 — — 92 — — Fulham 2 60 — — 46 — — 14 — — — — — Greenwich 4 157 — — 102 — — 55 — — 8 — — Hackney 6 401 — — 291 — — 110 — — 3 — — Hammersmith 9 466 — 4 333 — 3 133 — 1 — — — Hampstead — — — — — — — — — — — — — Holbom 30 1,807 162 — 1,518 137 — 289 25 — 8 – — Islington 42 1,178 217 18 932 140 12 246 77 6 30 3 1 Kensington 24 439 272 — 315 160 — 124 112 — — — — Lambeth 7 702 — — 488 — — 214 — — 34 — — Lewisham 1 30 — 17 — — 13 — — — — — Paddington 7 195 40 — 137 22 — 58 18 — — — — Poplar 10 1,198 — — 879 — — 319 — — 30 — — St. Marylebone 17 1,321 84 — 1,184 43 — 137 41 — 2 3 — St. Pancras 10 767 112 — 607 55 — 160 57 — 1 — — Shoreditch 11 731 — 621 — — 110 — — 5 — — Southwark 43 3,171 492 — 2,592 290 — 579 202 — 70 10 — Stepney 67 5,634 754 180 4,496 563 172 1,138 191 8 202 4 8 Stoke Newington 1 37 — 35 — — 2 — — 1 — — Wandsworth 9 176 20 159 5 14 17 4 6 2 — — Westminster 19 1,759 75 — 1,490 60 — 269 15 — 43 — — Woolwich 24 548 44 — 470 33 — 78 11 — 10 1 — Totals 403 25,599 2,436J 245 20,438 1,598 207 5,161 8381 38 658 21 9 ½ = 1 child. Note.—In addition to the figures given above there were in Rowton Houses on the same night, 4,263 men, and in iiruce House, Kemble-street, Westminster, 642 men. ' 3 TABLE IV. Number of bedsin licensed common lodging houses occupied on the night of 8th February, 1907, for which no payment was made by the occupiers. , Sanitary district. Free beds. For labour. Males. Females. Children. Males only. Bethnal-green 31 71 Finsbury — — — 140 Holborn 5 — — — Kensington — — 25 — Poplar 130 — — — St. Pancras — — — 96 Shoreditch 25 — — — Stepney 350 16 17 206 Westminster 5 — — — Totals 546 16 42 513 Number of beds unoccupied on'night ofcensus — 56 — 8 TABLE V. Shelters, homes and institutions where women are accommodated. District and identification number. Accommodation. No. of residents. Class. Charge per day or week. Battersea. (1) 22 20 Poor women over 60 5/- or 6/- a week. Bermondsey. (1) 9 2 Rescue home 5/- per week. (2) 30 23 Free shelter Free. Chelsea. (1) 30 30 Rescue home Free. (2) 8 8 Rescue home 6/- per week. (3) 31 31 Candidates for foreign missions 5/- a week. (4) 18 8 Servants' home 3/6-4/6 lodging only. Deptford. (1) 2 — Y.W.C.A., shop assistants, teachers, etc. 1/– 1/6 a day. Finsbury. (1) 126 126 Blind and crippled girls from 14 to 18 Free. TABLE III. Number of beds for men only in.shelters occupied on the night of 8th February, 1907 Sanitary district Free beds. For labour Men. Boys. Men. Bermondsey 33 — – Fulham — — 26 Holborn 32 — — Islington — — 22 Poplar — — 26 Southwark — . — 199 Stepney 167 9 15 Westminster 25 — — Totals 257 9 288 Number of beds unoccupied on night of census 10 13 4 District and identification number. Accommodation. No. of residents. Class. Charge per day or week. Fulham. (1) 30 28 Rescue home Free. (2) 50 50 Rescue home Free. (3) 210 205 Rescue home Free. (4) 10 8 Rescue home Free. Greenwich. (1) 15 9 Y.W.C.A. students, teachers, etc. 10/— 13/6 a week. (2) 18 15 Poor girls. Free (3) 8 5 Remand cases Free. Hackney. (1) 14 14 Rescue homo Free. (2) 17 16 Rescue Home Free. (3) 50 50 Training home for homeless girls Free. (4) 40 26 Do. Free. (5) 8 8 Rescue home Free. (6) 14 10 Rescue home Free. (7) 20 10 Rescue home Free. (8) 44 40 Remand cases 2/6 a week. (9) 30 19 Rescue home. Free. (10) 50 50 Rescue and training home Free. (11) 34 34 Inebriate rescue home Free. Hammersmith. (1) 7 7 Y.W.C.A. students, teachers, etc. — (2) 10 9 Poor girls 5/- a week. (3) 18 16 Jewish rescue home Free. (4) 10 9 Women over 60 52/- a year, Id. a week rent, Id. doctor. Hampstead. (1) 17 11 Business girls, teachers, domestics 7/- to 8/6 per week (2) 6 6 Shelter Free (3) 9 9 Charity home 8/- a week. (4) 48 48 Training home 5/- a week. (5) 36 36 Do. 5/- a week. (6) 22 18 Clerks, dressmakers, etc. 4/6 a week lodging only. (7) 20 20 Training home. Free. Hoi.born. (1) 34 14 Shelter Free. (2) 17 22 Refuge Free. (3) 9 9 Y.W.C.A., waitresses, etc. 5/- to 7/6 a week (4) 14 10 Working girls 6/- a week (5) 37 36 Business girls, clerks, etc. 9/- to 18/- a week, Islington. (1) 30 30 Training home 6/- a week paid by guardians. (2) 25 23 Y.W.C.A., clerks, milliners, teachers 3/6 a week lodging ; 14/- with food. (3) 20 19 Y.W.C.A 14/- a week. (4) 60 36 Clerks, teachers, etc. 8/6- 12/6 a week. (5) 19 18 Do. 10/6 a week. (C) 11 8 Servants 5/- a week. (7) 30 20 Y.W.C.A — (8) 38 28 Training home. 8/- to 10/- a week, some free. (9) 30 29 Rescue home Free. Kensington. (1) 12 12 Y.W.C.A. clerks, shop assistants 3/6 to 5/6 lodging only ; food extra. (2) 80 45 Business girls, clerks . 10/6 to 12/6 a week. (3) 14 11 Training home 5/- a week. (4) 15 14 Rescue home Free. (5) 13 10 From Lock hospital Free. (6) 17 15 Aged women 52/- a year. (7) 48 46 R.C. Home. Free. (8) 15 13 Young servants 7/- a week. (9) 5 5 Aged women 50/-a year, 52d. rent. (10) 9 9 Do Do. (11) 9 9 Do Do. (12) 28 28 Working girls — (13) 150 150 Aged women Free. 5 District and identification number. Accommodation. No. of residents. Class. Charge per day or week. Lambeth. (1) 37 26 Teachers, typists 3/- to 5/- lodging only. (2) 12 9 Rescue home Free. (3) 15 14 Y.W.C.A., clerks, etc 12/6 a week. (4) 8 8 Rescue home 5/- a week. Lewisham. (1) 5 1 Y.W.C.A., shop assistants, clerks, 10/6 to 12/6 a week. teachers (2) 73 65 Salvation Army training home 5/- a week. (3) 30 30 Various Free or 5/- a week. (4) 4 4 Rescue home Free. (5) 4 4 Rescue home Free. Paddington. (1) 56 38 Milliners, dressmakers 7/- to 8/6 a week. (2) 18 18 Servants Free. (3) 17 17 Houseless poor asylum Free. (4) 10 10 Social home 6/- to 8/6 a week. (5) 6 6 Widows 1/- a week ; food extra. (6) — 28 Single women, first child only £16 a year. (7) 10 10 Servants' home 5/- a week, 10/- to 15/boarders. Poplar. (1) 5 4 Working girls 2/6 a week. (2) 3 3 Rescue home Free. (3) 8 — Maternity home Free. (4) 8 8 Rescue home Free. (5) 12 12 Working girls From 3/6 a week. St. Marylebone. (1) 21 17 Servants 3/6 to 4/2 a week. (2) 18 15 Do 4/- a week. (3) 96 96 Y.W.C.A., business girls 4/6 to 6/- a week. (4) 23 23 Church Army home Free. (5) 10 10 Do. Free. (6) 8 8 Do. Free. (7) 44 44 Houseless poor asylum Free. (8) 26 26 Aged servants, etc 10/6 to 20/- a week. (9) 16 16 Rescue home Single, free or 2/6 ; maternity, 5/- a week. (10) 12 12 Aged servants 10/- a week. (11) 12 11 Servants 7/- a week. (12) 12 8 Rescue home 5/- a week. St. Pancras. (1) 21 6 Refuge Free. (2) 6 6 Refugo Free. (3) 10 5 Rescue home Free or 5/- a week. (4) 21 21 Rescue home Free. (5) 8 6 Rescue home 5/- a week. (6) 25 25 Rescue homo, first fall only Free or 7/6 a week. (7) 12 10 Do. Do. 5/- a week. (8) 8 3 Poor gentlefolk Free. (9) 45 20 For fallen women, first fall only Free; if able, pay for doctor and nurse. Southwark. (1) 53 46 Working girls 7/- a week. (2) 90 26 — 3/6 lodging only. (3) 19 13 — Free. (4) 11 11 Business girls 7/- to 11/- a week. (5) 14 14 Rescue home Froe or 5/- a week. Stepney. (1) 25 13 Girls' home 1/- a day, board and lodging. (2) 8 3 Working girls 5/6 a week. (3) 73 73 Rescue homo Free. (4) 112 108 Shelter Free. (5) 63 60 Working girls 3/6 a week board and lodging Stoke Newinqton. (1) 90 82 Training home Free. Wandsworth. (1) 20 8 Laundry hands and servants 7/- a week (2) 8 5 Servants 10/3 a weak. 13528 b 6 District and identification number. Accommodation. No. of residents. Class. Charge per day or week. Westminster. (1) 31 20 Refuge Free. (2) 11 4 Servants 7/- a week. (3) 6 6 Servants 7/- a week. (4) 3 3 Y.W.C.A., business girls 7/- to 10/- a week. (5) 24 23 — 8/- a week. (6) 40 34 Girls' club 4/- lodgings, 12/- with food. (7) 81 79 Art students, etc 14/- to 21/- a week. (8) 126 120 Do. Do. (9) 57 54 Do Do. (10) 9 Rescue home 5/- or 7/- a week. (11) 12 10 Rescue homo Free. (12) 21 16 Business girls, teachers 3/- to 4/- lodging only. (13) 7 7 Aged women Free. (14) 7 7 Rescue home Free (15) 18 16 Rescue home Free. Woolwich. (1) 10 6 Y W.C.A. teachers, telegraphists, etc. 3/- to 4/- lodging only, 11/6 to 13/6 with food. (2) 6 3 Rescue home 2/6 a week. (3) 12 11 Maternity home, some rescue cases 7/- to 10/- a week. Totals 3,792 3,296 Employment agencies where sleeping accommodation is provided. Total number of agencies. Total number of rooms. Total number of beds in such rooms. Number of persons. Total number of persons. Awaiting situations. In employment, but regularly sleeping at agency. 38 191 498 243 57 300 For the number of servants sleeping in servants' homes and agencies I am indebted to the Chief Officer of the Public Control Department. 8, St. Martin's-pla<:e, W.C. 21 st February 1907. Shirley F. Murphy, Medical Officer of Health. : *