London Countn Council. LCC 16, 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 1907. (Printed ly order of the Council.) PRINTED BY SOUTHWOOD, SMITH & CO., LTD., 93 & 94, LONG ACHE, W.O. 18560 London Countn Council. Report of the Public Health Committee, submitting the report of the Medical Officer of Health of the County of London for the year 1907. In submitting the report of the Medical Officer of Health of the County of London, we are able for the third year in succession to state that the death-rate recorded has not exceeded that of any previous year. In 1905 the death-rate was 15.1, lower than ever before; in 1906 it was again 15.1; and in 1907 it fell to 146. If comparison be made between the years 1905, 1906 and 1907 and the decennial period 1891-1900, it will be found that there was a gain to the community of 19,000, 19,000 and 22,000 lives, respectively, in the three recent years, representing a gain in "life capital" for the three-year period of upwards of 2,000,000 years of life. It should be noted, moreover, that the birth-rate for 1907 (25.6) is the lowest on record in London since the institution of civil registration. The report contains tables giving some interesting contrasts between two selected districts— Hampstead and Shoreditch—differing widely in their social circumstances. In the former district the proportion per cent, of domestic servants to families is 16 times as high as in the latter, while, on the other hand, in Shoreditch the percentage of the population living under conditions of "overcrowding" is nearly 30 per cent., as compared with only 6-4 percent, in Hampstead. The difference in the character of the populations in the two districts finds its natural reflection in the mortality statistics, and it transpires that in Shoreditch the general death-rate is practically twice as high, the phthisis death-rate nearly three times as high, and the infantile mortality nearly twice as high, as it is in Hampstead. On turning to the "expectation of life," this is at birth nearly 16 years less in Shoreditch than in Hampstead, both among males and females; and at each age the figures for the two districts stand in marked contrast. The population of Shoreditch is, as the Medical Officer says, but a sample of a much larger population in London and elsewhere whose mortality is increased by causes which must be regarded as largely preventable. Epidemic diseases.—The death-rate from the principal epidemic diseases in 1907 is very low only 1.42. No death occurred from smallpox, and the deaths from measles, influenza, diphtheria enteric fever, diarrhoea and phthisis were below the average, but those from scarlet fever and whooping cough were above the average. The report makes reference to the causes which have contributed to the decline of the phthisis death-rate, and an instructive comparison is instituted between England and Ireland is respect to the behaviour of "phthisis" and of "all causes less phthisis" in the two countries. While in England there is marked improvement under both these heads, Ireland has maintained not only its high deathrate from phthisis but also from "all causes less phthisis." There appears much reason for thinking that the improvement in the social circumstances of the English population has been the material cause of an increased resistance to disease generally, and this has been specially manifested in the decline of the phthisis death-rate. The reported prevalence of cerebro-spinal fever in Glasgow and Belfast, in 1906, caused us to have enquiry made which resulted in our asking the Council on 26th February, 1907, to make an Order requiring cases of the disease to be notified for a period of six months, and we subsequently extended this for a further period of eighteen months. During the year 1907, 25 deaths were attributed in London to this disease, a number in excess of the average number recorded in the last few years. Probably this increase was an indirect effect of requiring cases of cerebro-spinal meningitis to be notified. In Glasgow, with one-sixth of the population of London, 847 deaths were attributed to this cause during 1907. Dr. Wanklyn has studied the cases notified in London, and the results of his observations are given in Appendix I. By-laws regulating offensive businesses.—During the year the Council made new by-laws regulating offensive businesses. The principle of the use of the "closed chamber" is extended by these by-laws to all offensive processes, and improvement in the method of ventilation of these chambers is required. 18560 A 2 * 4 Removal of house refuse.—In connection with complaints as to the manipulation of house refuse at the depot of the Borough Council of Bethnal Green, the question of fly nuisance assumed prominence in the summer months. We instructed the Medical Officer to report generally on this subject, and a report prepared by Dr. Hamer dealing with nuisance from flies is appended. (See Appendix II.) Common lodging houses.—A number of particulars are supplied under this head in the Medical officer's report and the result of enquiry as to the occupation of 2,900 common lodging house inmates is given. The report also refers to a census of " homeless persons " taken on the night of the 8th February, 1907 (see Appendix III). Seamen's lodging houses.—Communications have passed between the Council and the Board of Trade as to the desirability of an Order being issued rendering obligatory the annual licensing of seamen's lodging houses. Houses let in lodgings.—Information is given concerning the operation of by-laws relating to houses let in lodgings and a tabular statement with regard to the action taken in this connection by the several sanitary authorities during the year appears on page 68. Inspection of food.—The report gives account of the action taken in London with reference to food inspection. Education (Administrative Provisions) Act, 1907.—Reference is made in the report to this Act, which provides for the medical inspection of school children and for the remedial treatment of school children suffering from ill-health. This Act marks a large advance in public health legislation inasmuch as it gives opportunity for bringing within the scope of the administration of public health authorities matters concerning the personal hygiene of the greater part of the juvenile population. County Hall, John Davies, Spring Gardens, S.W. Chairman. 22nd December, 1908. SIXTEENTH 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 London mortality in the year 1907 compared with the mortality in the decennium 1891-1900 9 Deaths at all ages from certain diseases and groups of diseases 10 Crude and corrected rates in sanitary areas 11 Deaths at the several age-periods in sanitary areas 12 Comparison of" life expectation " in two selected London districts 12 Rates from all causes and from specified causes in sanitary areas 15 Infant mortality 15 Principal Epidemic Diseases 21 Smallpox and Vaccination 23 London vaccination returns 25 Number of children for whom certificate* of conscientious objection together with the number of children not finallii accounted for per cent, of births 26 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 29 Scarlet Fever 30 Age and sex distribution 31 Scarlet fever and elementary schools 32 Diphtheria 33 Comparative case-rates in sanitary areas 35 Age and sex distribution 35 Diphtheria and elementary schools 36 Whooping-cough 37 Typhus 39 Enteric Fever 40 Age and sex distribution 41 Diarrhoea 42 Erysipelas 44 Puerperal Fever 45 Influenza, Bronchitis and Pneumonia 46 Phthisis 46 Crude and corrected death-rates in sanitary areas 47 Deaths at the several age-periods in sanitary areas 48 Ln relation to overcrowding 49 Voluntary notification 51 Cancer 51 Crude and corrected death-rates in sanitary areas 52 Deaths from sarcoma, carcinoma, and cancer (otherwise undefined) at the several age-periods in sanitary areas 52 In relation to overcrowding 54 Cerebro-spinal Fever 55 Anthrax 56 Glanders 56 Meteorology 57 Part II.— Dairies, Cowsheds and Milkshops 58 Tuberculosis of the udder in cows58 Offensive Businesses 60 Nuisances 62 Smoke nuisance 62 Nuisance from stable manure 63 Removal of house refuse 63 Removal of offensive matter 63 Nuisance from flies 63 Nuisance from sewers 63 Housing of tub Working Classes Act, 1890 63 Proceedings under Part I. of the Act 64 Proceedings under Part II. of the Act 64 Proceeding* under Part III. of the Act 64 Death-rates among persons resident in County Council buildings 65 Proceedings in respect of houses represented under Part II. of the Act as unfit for human habitation 65 Common Lodging Houses 66 Occupations of some inmates of common lodging houses 67 Homeless persons 67 Seamen's lodging houses 67 TABLE OF CONTENTS—continued. page Houses let in Lodgings 68 Water supply to tenement houses 69 Houses infested with Vermin 69 Revenue Act, 1903 70 Underground Rooms 71 Overcrowding 71 Factory and Workshop Act, 1901 71 Table showing proceedings of sanitary authorities under the Factory and Workshop Act... 72 Places where Food is Prepared for Sale 75 Sale of Ice Cream 75 Inspection of Food. 76 Disinfection 78 Shelters 78 Mortuaries 78 Cleansing of Persons Act, 1897 79 London Equalisation of Rates Act, 1894 80 Midwives Act, 1902 81 Water Supply 92 Sanitary Inspectors 93 Education (Administrative Provisions) Act, 1907 93 Medical Inspection of School Children 93 Medical Officers of Health of London Sanitary Areas 94 Appendices— I.—Report on Cerebro-spinal Fever. II.—Report on Nuisance from Flies. III.—Report on Homeless Persons in London. IV.—Report on the Sanitary Staffs of the Metropolitan Sanitary Authorities. LIST OF DIAGRAMS. facing page Diagram I.—Marriages, 1851-1907 6 „ II.—Births, 1851-1907 6 ,, III.—Deaths (all causes) 1841-1907 8 ,, IV.—Infant Mortality, 1858-1907 15 ,, V.—Smallpox (mortality) 1841-1907 23 ,, VI.—Measles (mortality) 1841-1907 26 ,, VII.—Measles and Whooping-cough (monthly deaths) 1891-1907 27 ,, VIII.—Scarlet Fever {mortality) 1859-1907 30 ,, IX.—Scarlet Fever (admissions to hospitals of Metropolitan Asylums Board, per cent, of total notified cases in London) 1890-1907 30 „ X.—Scarlet Fever (monthly notified cases and case-mortality) 1891-1907 31 „ XI.—Diphtheria and Croup (mortality) 1859-1907. 33 ,, XII.—Diphtheria (admission to hospitals of Metropolitan Asylums Board, per cent, of total notified cases in London) 1890-1907 33 ,, XIII.—Diphtheria (monthly notified cases and case-mortality) 1891-1907 34 ,, XIV.—Whooping-cough (mortality) 1841-1907 37 „ XV.—Typhus (mortality) 1869-1907 39 „ XVI.—Enteric Fever (mortality) 1869-1907 . 40 ,, XVII.—Enteric Fever (weekly notified casts, 1907, and mean weekly notified cases, 1890-1907) 40 „ XVIII.—Enteric Fever (monthly notified cases and case-mortality) 1891-1907 41 ,, XIX.—Diarrhoea, Dysentery and Cholera (mortality) 1841-1907 42 ,, XX.—Phthisis (mortality—males and females) 1851-1907 47 KEPORT OF THE MEDICAL OFFICER OF HEALTH. 1907. PART I. The mean temperature of the air during 1907 was on the whole slightly below the average, this difference being especially marked in the months of February, June, July, and August, but also manifested, although in less degree, in the months of January, April and May. In the remaining months the mean temperature was above the average, the excess being most marked in the months of March, November and December. The rainfall during the year, as a whole, was also below the average, the difference being most marked in the months of July and September, and also manifested, although in less degree, in the months of January, February, March, May and August. In each of the remaining months of the year the rainfall was somewhat above the average, this difference being most marked in the month of April. The marriage-rate (17.0) was slightly below the marriage-rate of the preceding year (17.1). The birth-rate (25.6) was the lowest on record in London since the institution of civil registration. The death-rate (14'6) was the lowest on record in London. The infant mortality was also the lowest on record, a result to which the comparatively low temperature experienced in the third quarter of the year has largely contributed. The number of deaths from diseases of the respiratory system was below the annual average number of the preceding 10 years, and the number of deaths from pneumonia above the average. No death occurred from small-pox, and the deaths from measles, influenza, diphtheria, enteric fever, diarrhoea and phthisis were below the average ; while the deaths from scarlet fever, whooping-cough and cancer were above the average. Population. The population of the Administrative County of London, estimated to the middle of the vear 1907, was 4,758,218. The population of the City of London and each of the metropolitan boroughs, as constituted by the London Government Act of 1899, estimated to the middle of 1907, are shown in the following to hi ft Sanitary areas.—Population (middle of 1907). Sanitary area. Estimated population (middle of 1907). Sanitary area. Estimated population (middle of 1907). Paddington 149,909 Shoreditch 115,662 Kensington 181,842 Bethnal Green 130,831 Hammersmith 122,337 Stepney 308,923 Fulham 166,749 Poplar 171,086 Chelsea 74,857 South wark 209,781 Westminster, City of 172,219 Bermondsey 128,263 St. Marylebone 127,718 Lambeth 318,538 Hampstead 91,137 Battersea 181,736 St. Pancras 236,753 Wandsworth 281,419 Islington 347,017 Camberwell 277,059 Stoke Newington 53,813 Deptford 116,510 Hackney 232,993 Greenwich 107.222 Holborn 55,134 Lewisham 152,532 Finsbury 96,732 Woolwich 129,336 London, City of 20,310 Marriages. The number of marriages in the Administrative County of London in 1907 (52 weeks) was 40,541, giving an annual rate of persons married of 17'0 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. 1851-60 206 1902 17.8 1861-70 20-3 1903 17.5 1871-80 191 1904 17.0 1881-90 17-6 1905 16.9 1891-1900 17-8 1906 17.1 1901 17-6 1907 17.0 18560 B 6 The accompanying diagram (I.) shows the marriage-rate in each year since 1850, in relation to the mean marriage-rate of the period 1851-1907- In the year 1907 among the males 3"2 per cent, married were under 21 years of age, and among the females 11"8 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 minors per cent, of total marriages. Period. London. England and Wales. Males. Females. Males. Females. 1851-60 2.8 11.9 5.7 18.0 1861-70 3.6 14.6 6.8 20.1 1871-80 4.7 16.9 8.0 22.0 1881-90 5.5 18.9 6.8 20.7 1891-1900 4.7 16.5 5.4 17.5 1901 4.4 15.0 5.0 16.0 1902 4.0 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 1906 3.5 12.9 4.3 14.6 The decline in the marriage-rate of London is discussed in the Annual Summary of the Registrar General, who shows that if the marriage-rate of 1907 be compared with the marriage-rate of 1870-72, it has decreased by 12 per cent., if based on the total population, and by 21 per cent., if based upon the total number of marriageable persons, i.e., on the unmarried and widowed portion of the population, aged 15 years and upwards. This latter figure, the Registrar General states, may be said to represent more accurately than the former the fall in the marriage-rate in the period under review. Births. The number of births registered in the Administrative County of London in 1907 (52 weeks) was 121,408, giving a birth-rate of 256 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 1907 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 1907 25.61 The corresponding figures for England and Wales are as follows:— England and Wales—Birth-rates. Period. Birth-rate por 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 1907 26.3 1 For the purposes of these rates the births in the principal lying-in institutions have been distributed to the district tQ .which they belong, . Diagram I Marriages. Diagram R Births.- 7 The accompanying diagram (II.) shows the London birth-rate in each year since 1850, in relation to the mean birth-rate of the period 1851-1907. 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 1902-6 and in the year 1907:— Birth-rates in sanitary areas. Sanitary area. Births,1 1907 (52 weeks). Birth-rate1 per 1,000 persons living. Legitimate births' per 100 married females aged 15-45. 1902-6. 1907. 1902-6. 1907. Paddington 3,258 23.3 21.8 19.2 18.1 Kensington 3,448 20.0 19.0 18.5 17.4 Hammersmith 3,092 26.9 25.3 20.7 19.4 Fulham 4,617 32.0 27.8 21.0 18.5 Chelsea 1,513 21.9 20.3 19.0 17.6 Westminster, City of 2,962 18.0 17.2 16.1 15.4 St. Marylebone 2,663 21.7 20.9 18.0 17.7 Hampstead 1,368 17.2 15.1 16.0 13.9 St. Pancras 5,837 27.3 24.7 20.3 18.6 Islington 8,646 26.6 25.0 20.3 19.0 Stoke Newington 1,068 21.5 20.0 18.0 16.8 Hackney 5,653 26.3 24.3 21.2 19.7 Holborn 1,066 22.2 19.4 17.7 15.5 Finsbury 2,871 31.3 29.8 24.1 22.9 London, City of 277 14.7 13.7 16.5 15.3 Shoreditch 3,802 34.4 33.0 26.3 25.2 Bethnal Green 4,152 34.9 31.8 27.4 25.1 Stepney 10,361 36.4 33.6 28.3 26.2 Poplar 5,282 33.3 31.0 26.4 24.5 Southwark 6,232 31.9 29.8 23.4 21.8 Bermondsey 4,054 32.8 31.7 26.0 25.1 Lambeth 7,806 27.0 24.6 20.6 18.7 Battersea 4,615 28.0 25.5 20.3 18.5 Wandsworth 7,176 26.8 25.6 21.1 20.1 Camberwell 6,733 27.1 24.4 21.7 19.6 Deptford 3,292 29.3 28.3 22.2 21.6 Greenwich 2,599 26.6 24.3 21.8 19-8 Lewisham 3,635 25.3 23.9 20.1 19-0 Woolwich 3,330 29.3 25.8 21.6 18-9 London 121,408 27.6 25. 6 21.7 20-2 It will be seen from the above table that the differences in the birth-rates of the several sanitary districts are very marked, ranging from 13.9 in Hampstead to 26.2 in Stepney, when the rates based on the number of married females are compared. The Registrar-General has compared the birth-rate of London, in 1870-2 with that of subsequent periods, showing these rates when calculated on the total population, and on the female population aged 15-45 years, and further has compared rates belonging to the same periods of legitimate births calculated on the married female population, and of illegitimate births calculated on the unmarried and widowed female population aged 15-45 years. When compared with the birth-rate in 1870-2, the birth-rate of 1907 has decreased by 26.7 per cent, when calculated on the total population, and 29'8 per cent, when calculated on the female population aged 15-45 years, the legitimate birth-rate has declined 251 per cent, when calculated on the married female population aged 15-45 years; and the illegitimate birth-rate has declined 37'9 per cent, when calculated on the unmarried and female population of that age period. The Registrar-General finds reason for stating that approximately 19 per cent, of the decline in the birth-rate of the last 37 years is due to the decrease in the proportion of married women of conceptive ages in the female population, and over 5 per cent, is due to the decrease in illegitimacy. Some of the remaining 76 per cent, of the decrease, he states, may be ascribed to changes in the age constitution of married women, but he thinks that much of it is due to other than natural causes. Deaths. The number of deaths in the Administrative County of London in 1907 (52 weeks) was 69,268, giving an annual death rate of 14'6 per 1,000 persons living. 1 See footnote (1), page 6. 18560 B 2 8 The death-rate in successive periods has been as follows :— AH Causes—Death-rates. Feriod. Death-rate (All Causes) per 1,000 persons living. Period. Death-rate (All Causes) per 1,000 persons living. 1841-50 24-8 1902 17-21 1851-60 23-7 1903 1521 1861-70 24-4 1904 1611 1871-80 ... 22-5 1905 15-11 1881-90 20-5 1906 151* 1891-1900 19T1 1907 14-61 1901 17-11 The death-rate in each year since 1840 in relation to the mean death-rate of the period 1841-1907 is shown in diagram III. This death-rate is the lowest recorded since the institution of civil registration. The following table has been prepared for the purpose of comparing the death-rate of London with those of other English towns having populations which exceeded 200,000 persons at the census of 1901. The columns showing "death-rates corrected for age and sex distribution" have been obtained by multiplying the crude death-rates by the "factors for correction" published by the Registrar-General in the Annual Summary for 1907. All Causes—Death-rates per 1,000 persons living. Town. Estimated Population (middle of 1907.) Crude death-rate per 1,000 persons living. Death-rate per 1,000 persons living (corrected for age and sex distribution). 1897-1906. 1907. 1897-1906, 1907. London 4,758,218 17.41 14-61 18.31 15.31 Liverpool 746,144 22.3 19-0 23.9 20.3 Manchester 643,148 21.5 18-1 24.0 20.2 Birmingham 553,155 19.4 16-2 20.9 17.4 Leeds 470,268 18.2 15-3 .19.9 16.7 Sheffield 455,553 19.1 17-1 20.6 18.4 Bristol 367,979 16.2 13.2 16-6 13.6 West Ham2 308,284 17.2 14.6 18.4 15.6 Bradford 290,323 17.1 14.8 18.9 16.4 Newcastle-on-Tyne 272,969 20.2 15.9 21.8 17.1 Hull 266,762 18.1 16.1 18.6 16.5 Nottingham 257,489 17.9 17.5 18.9 18.4 Salford 236,670 21.3 17.7 23.5 19.6 Leicester 236,124 16.0 12.7 17.1 13.6 London had therefore (comparing the corrected death-rates) both in the decennium 1897-1906, and the year 1907 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. 1897-1900. 1907. Town. 1897-1906. 1907. London 17.41 14.61 St. Petersburg 25.0 24.7 Paris 18.6 18.5 Berlin 17.3 15.4 Brussels 15.8 13.7 Vienna 19.5 17.3 Amsterdam 15.2 13.4 Rome 19.1 18.2 Copenhagen 16.9 15.2 New York 19.4 18.5 Stockholm 16.0 13.9 It will be seen from the foregoing table that in the decennium 1897-1906 the London deathrate was exceeded by the death-rates of Paris, St. Petersburg, Vienna, Rome and New York, and in 1907 was lower than that of any except Brussels, Amsterdam and Stockholm. 'These death-rates are fully corrected for institutions, i.e., by the exclusion of deaths of persons not belonging to, but occurring in, institutions situated within London, and by the inclusion of deaths of persons belonging to London, but occurring in London institutions situated outsido the Administrative County. 2 As extended in 1905. 3 All death-rates in this report relating to foreign towns are calculated upon figures published by the EegistrarOeneral. Diagram M Deaths (all Causes). 9 London mortality in 1907 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 1907. The figures for the year 1907 are fully corrected for institution deaths (see footnote ('), page 8), 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. Death-rates per 1,000 living at the several age-periods in 1907 as compared with those of the decennium 1891-1900. Age-period. Males. Females. Mean deathrate 1891-1900. Death-rate 1907. Difference per cent. Mean deathrate 1891-1900. Death-rate 1907. Difference per cent. 0— 71.97 46.21 —35.8 61.99 39.44 —36.4 5— 4.97 3.41 —31.4 5.17 3.61 —30.2 10— 2.46 1.65 —32.9 2.48 1.83 —26.2 15— 3.47 2.52 —27.4 2.94 2.34 —20.4 20— 4.59 3.13 —31.8 3.46 2.44 —29.5 25— 7.36 5.07 —31.1 5.65 3.91 —30.8 35— 14.22 10.50 —26.2 10.68 7.79 —27.1 45— 23.14 19.03 —17.8 17.12 13.57 —20.7 55— 40.68 35.21 —13.4 31.01 25.85 —16.6 65— 77.78 75.42 — 3.0 63.44 57.99 — 8.6 75— 154.13 143.57 — 6.9 134.56 124.34 — 7.6 85 and upwards 284.10 348.66 +22.7 265.77 317.41 + 19.4 All ages 20.88 15. 72 -24-7 17-88 13-53 -243 It will be seen from this table that the rate of mortality in 1907 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 3.19 In the following table the number of deaths occurring in the year 1907 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 1907. 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 :— 10 Table II. Lives and " Life-capital" gained or lost in 1907, as compared with the decennium, 1891-1900. Age-group. Deaths calculated according to mean death-rates of 1891-1900. Deaths occurring in the year 1907. Gain ( + ) or loss (—) of lives in the year 1907, by fluctuation of mortality. Gain (+) or loss (—) of " life capital" in the year 1907 by fluctuations of mortality. Males. Years. 0— 18,714 12,015 + 6,699 + 336,022 5— 1,148 788 + 360 + 17,960 10— 536 360 + 176 + 8,027 15— 760 553 + 207 + 8,541 20— 1,046 714 + 332 + 12,301 25— 2,867 1,975 + 892 + 27,697 35— 4,187 3,090 + 1,097 + 26,306 45— 4,738 3,897 + 841 + 14,928 55— 5,065 4,384 + 681 + 8,410 65— 4,487 4,351 + 136 + 1,085 75— 2,754 2,565 + 189 + 928 85 and'upwards 519 637 - 118 - 356 All Ages—Males 46,821 35,329 + 11,492 + 461,849 Females. Years. 0— 16,105 10,246 +5,859 + 314,394 5— 1,206 842 + 364 + 19,467 10— 551 406 + 145 + 7,148 15— 718 571 + 147 + 6,606 20— 946 666 + 280 + 11,374 25— 2,594 1,795 + 799 + 27,478 35— 3,477 2,537 + 940 + 25,277 45— 3,920 3,106 + 814 + 16,313 55— 4,585 3,822 + 763 + 10,629 65— 5,175 4,730 + 445 + 3,960 75— 4,208 3,888 + 320 + 1,718 85 and upwards 1,140 1,362 - 222 - 708 All Ages—Females 44,625 33,971 + 10,654 + 443,656 Total—Persons 91,446 69,300 + 22,146 + 905 505 It will be seen from the preceding table that during the year 1907, compared with the decennium 1891-1900, there has been a saving of 22,146 lives, representing a gain to the community of 905,505 years of " life-capital." 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 1907 under certain of the more important headings in the lisit of causes of death, as compared with the annual average deaths of the preceding 10 years, corrected for increase of population. (Continued on next paye.) Number of deaths, 1907, compared with the annual average deaths of the preceding decennium, 1897-1906. Cause of death. Diminution in 1907. Excess in 1907. Smallpox 168 Measles 408 Scarlet Fever — 118 Typhus 2 — Influenza 113 — Whooping Cough — 30 Diphtheria 536 — Pyrexia (origin uncertain) 2 — Enteric Fever 321 — Diarrhoea 2,490 — Pneumonia — 967 Erysipelas 17 — 11 Cause of Death. Diminution in 1907. Excess in 1907. Tuberculous Phthisis 1,100 - Phthisis Tuberculous Meningitis 109 — Tuberculous Peritonitis ) 319 Tabes Mesenterica Other Tuberculous Diseases (including Scrofula) 89 — Cancer — 306 Premature Birth 299 — Diseases of Nervous system 1,793 Diseases of Circulatory system1 Diseases of Respiratory system 1,827 — Diseases of Digestive system 1,190 — Diseases of Urinary system — 150 Childbirth and Puerperal Septic Diseases 64 — Accident 598 — Homicide 19 — Suicide 9 — All other Causes 994 — Net diminution 10,896 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 1907 ; the mean death-rates for the period 1902-6 are also shown for the purposes of comparison. Crude and corrected death-rates 2 (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), 1902-6. 1907. 1902-6. 1907. 1902-6. 1907. England and Wales 18.19 1.0000 - — — — — — London 17.31 1.0511 15.7 14.6 16 .5 15.3 1,000 1,000 Paddington 17.04 1.0677 13.5 13.5 14.4 14.4 873 941 Kensington 16.88 1.0778 14.3 13.7 15.4 14.8 933 967 Hammersmith 17.47 1.0414 15.0 14.3 15.6 14.9 945 974 Fulham 17.39 1.0462 15.0 13.2 15.7 13.8 952 902 Chelsea 17.56 1.0361 16.1 15.0 16.7 15.5 1,012 1,013 Westminster, City of 16.22 1.1217 13.9 13.0 15.6 14.6 945 954 St. Marylebone 17.08 1.0652 16.3 15.0 17.4 16.0 1,055 1,046 Hampstead 16.13 1.1280 9.9 9.0 11.2 10.2 679 667 St. Pancras 17.40 1.0456 16.8 15.0 17.6 15.7 1,067 1,026 Islington 17.51 1.0391 15.1 14.7 15.7 15.3 952 1,000 Stoke Newington 17.43 1.0438 12.7 11.5 13.3 12.0 806 784 Hackney 17.46 1.0420 14.2 13.6 14.8 14.2 897 928 Holborn 16.90 1.0766 18.8 17.4 20.2 18.7 1,224 1,222 Finsbury 17.57 1.0355 20.8 18.7 21.5 19.4 1,303 1,268 City of London 16.55 1.0993 17.3 16.8 19.0 18.5 1,152 1,209 Shoreditch 17.34 1.0493 20.0 20.5 21.0 21.5 1,273 1,405 Bethnal-green 18.01 1.0102 19.2 17.5 19.4 17.7 1,176 1,157 Stepney 17.41 1.0450 18.7 15.9 19.5 16.6 1,182 1,085 Poplar 17.64 1.0314 18.3 16.9 18.9 17.4 1,145 1,137 Soutliwark 17.41 1.0450 19.2 18.0 20.1 18.8 1,218 1,229 Bermondsey 17.76 1.0244 19.5 18.3 20.0 18.7 1,212 1,222 Lambeth 17.63 1.0320 15.7 14.6 16.2 15.1 982 987 Battersea 16.96 1.0728 14.3 13.3 15.3 14.3 927 935 Wandsworth 17.25 1.0547 12.9 12.3 13.6 13.0 824 850 Camberwell 17.54 1.0373 14.6 13.9 15.1 14.4 915 941 Deptford 17.31 1.0511 15.6 14.1 16.4 14.8 994 967 Greenwich 17.82 1.0210 14.0 12.7 14.3 13.0 867 850 Lewisham 17.46 1.0420 12.1 11.5 12.6 12.0 764 784 Woolwich. 17.02 1.0690 13.8 12.5 14.8 13.4 897 876 It will be seen from the foregoing table (comparing the corrected death-rates) that in the quinquennium 1902-6, Finsbury (21 *5) had the highest rate and Hampstead (11'2) the lowest; in the year 1907, Shoreditch (21"5) had the highest, the lowest again obtaining in Hampstead (10'2). The following table shows the number of deaths3 (All Causes) occurring at the several age periods in each of the sanitary areas of the Administrative County of London during the year 1907 (365 days) — 1 For purposes of comparison deaths from Infective Endocarditis are included under this heading. 2 All death-rates in this report relating to metropolitan sanitary areas are fully corrected for institutions—see footnote ('), page 8. 3 See footnote ('), page 8. 12 All Causes—Deaths at the several age-periods in sanitary areas—1907 (365 days). Age-period. 0- 1- 2- 3- 4- Under 5. 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 & up wards All Ages. Paddington 357 114 50 27 20 568 39 19 29 40 99 173 226 237 311 220 61 2,028 Kensington 448 131 55 36 34 704 57 24 38 41 123 188 259 336 339 294 102 2,505 Hammersmith 361 108 40 20 18 547 26 16 29 39 101 132 187 231 221 177 54 1,760 Fulham 562 156 62 34 25 839 63 30 45 55 107 187 202 215 258 124 57 2,182 Chelsea 184 59 24 10 9 286 16 9 18 20 49 90 110 153 209 122 36 1,118 Westminster, City of 303 87 27 17 6 440 36 15 33 50 111 223 275 336 373 274 81 2,247 St. Marylebone 271 99 32 22 12 436 30 17 23 27 105 193 215 272 312 213 65 1,908 Hampstead 97 31 13 9 5 155 20 9 9 13 50 54 86 114 147 118 42 822 St. Pancras 620 218 89 58 28 1,013 84 32 45 64 213 300 393 436 498 370 92 3,540 Islington 996 315 117 72 44 1,544 102 61 70 97 308 399 492 656 730 471 157 5,087 Stoke Newington 107 23 5 5 6 146 12 13 6 12 28 52 64 69 108 79 24 613 Hackney 659 166 88 52 36 971 91 31 59 75 167 227 315 374 415 341 106 3,172 Holborn 132 63 17 7 5 224 11 8 15 18 56 104 134 126 145 96 12 949 Finsbury 375 136 51 35 19 616 35 17 25 35 94 179 183 224 249 121 32 1,810 London, City of 26 8 5 2 2 43 3 o O 2 5 17 35 50 46 59 54 18 335 Shoreditch 570 219 100 60 43 992 57 37 39 48 104 198 230 249 226 143 43 2,366 Bethnal-green 564 187 81 37 24 893 57 25 45 47 123 169 223 244 244 169 36 2,275 Stepney 1,216 383 176 85 71 1.931 140 £6 85 84 278 414 473 534 495 298 94 4,882 Poplar 660 240 94 71 34 1,099 81 40 38 47 144 213 273 331 340 201 79 2,886 Southwark 848 317 117 60 47 1,389 77 29 62 69 224 356 388 417 444 240 75 3,770 Bermondsey 502 177 73 54 28 834 61 19 41 36 115 199 223 289 260 193 65 2,335 Lambeth 935 287 111 84 37 1,454 101 45 75 92 276 355 455 571 584 492 151 4,651 Battersea 528 160 65 47 40 840 77 32 51 60 145 179 245 276 269 186 53 2,413 Wandsworth 714 175 63 37 35 1,024 94 41 62 67 187 240 321 374 508 420 134 3,472 Camberwell 771 256 98 77 46 1,248 98 69 48 80 210 289 368 417 512 373 114 3,826 Deptford 351 91 53 38 19 552 46 14 41 33 92 129 168 169 190 155 45 1,634 Greenwich 253 88 40 14 19 414 35 13 25 37 69 103 145 150 187 136 44 1,358 Lewisham 322 74 31 24 22 473 46 15 23 41 95 118 156 199 250 240 86 1,742 Woolwich 371 108 52 32 23 586 35 27 43 48 75 129 144 161 198 133 35 1,614 London .„ 14,073 4,476 1,829 1,126 757 22,261 1,630 766 1,124 1,3803,770 5,6277,003 8,206 9,081 6,45[ 51,999 69,300 Comparison of " life expectation " in two selected London districts. The tables on page 11 show that the mortality rate varies very considerably in the several sanitary areas of London, the highest death-rate, that of Shoreditch, being more than double that obtaining in Hampstead, which had the lowest death-rate in 1907. In view of these wide differences it is of interest to compare these two districts from the point of view of the " life expectation " of their populations—in other words, to translate their mortality rates into figures showing " life expectation " at certain ages and thus to show, by a method which admits of more accurate comparison, the marked differences in the viability of the two populations concerned. The widely different character of the two populations under consideration as regards social condition may to some extent be gauged by reference to the Census report of the year 1901. Thus in Hampstead the proportion per cent, of domestic indoor servants to families or separate occupiers was as high as 81'4, while in Shoreditch the figure was only 5*7. Again, the proportion of the population living more than two in a room in tenements of less than five rooms was in Hampstead 6*37 per cent., while in Shoreditch the proportion was 29"95 per cent. An analysis of the figures relating to the occupation of tenements of le3s than five rooms in the two districts is shown in the following table, and the figures afford a good index to the relative social condition of the populations concerned:— Table I. Shoreditch.—Population, 118,637 ; total tenements, 27,031. Tenements with No. of tenements. Percentage of all tenements. Total occupants. Percentage of population in each group of tenements. Average occupants per room. Overcrowding. No. of 1 to 4 roomed tenements with more than 2 occupants per room. No. of occupants of such tenements. Percentage of population in such tenements. 1 room 6,705 24.8 15,093 12.7 2.25 2,305 8,335 7.03 2 rooms 7,509 27.8 29,026 24.5 1.93 2,439 14,442 12.17 3 5,102 18.9 24,902 21.0 1.63 1,114 8,782 7.40 4 „ 3,624 13.4 20,559 17.3 1.42 411 3,970 3.35 Total 22,940 84.9 89,580 75.5 — 6,269 35,529 29-95 Hampstead.—Population, 81,942 ; total tenements, 16,998. 1 room 1,096 6.4 1,819 2.2 1.66 177 614 0.75 2 rooms 2,331 13.7 7,257 8.9 1.56 423 2,465 3.01 3 „ 2,331 13.7 8,729 10.7 1.25 203 1,550 1.89 4 „ 1,420 8.4 6,406 7.8 1.13 61 586 0.72 Total 7,178 42.2 24,211 29.6 - 864 5,215 6.37 13 The difference in the character of the populations of these two districts finds its natural reflection in the mortality statistics, and the following table showing the " all causes " and phthisis death-rate and infant mortality obtaining in the two districts for each of the last seven years serves to illustrate this fact:— Table II. Year. All causes—Death-rate per 1,000 living. Phthisis —Death-rate per 1,000 living. Infant mortality—Deaths under 1 year of age per 1,000 births. Hampstead. Shoreditch. Hampstead. Shoreditch. Hampstead. Shoreditch. 1901 11.9 22.3 0.91 2.23 104 197 1902 12.1 21.8 0.84 1.89 87 174 1903 11.2 20.4 0.73 2.42 88 171 1904 11.5 21.4 0.82 2.27 113 188 1905 10.5 20.7 0.82 2.04 94 167 1906 10.6 20.6 0.66 2.09 77 163 1907 10.2 21.5 0.69 2.19 69 150 Average 1901-7 111 21.2 0.78 2.16 90 173 The short life tables which follow have been based on the mortality figures for the period 1901-5, and have been constructed on the modification of Dr. Farr's short method, introduced by the late Dr. Hay ward, and described by him in the "Journal of the Royal Statistical Society," vol. lxii-, Part III. The chief difficulty in preparing tables of this kind relating to sanitary areas in London has been the absence of reliable mortality figures at the required age-periods in which due correction has been made for deaths of persons belonging to the district occurring in public institutions outside the district, and the deaths of persons not belonging to the district occurring in public institutions within the district. Since the year 1896, however, by reason of the opportunities which the Council has afforded me, I have been able to obtain from the records of the Registrar-General the number of deaths at each age-period, fully corrected for deaths occurring in institutions in each of the sanitary areas comprised in the administrative county. The following Table III. shows the expectation of life at certain ages in Hampstead and Shoreditch, the figures for London are also shown; the latter, however, relate to the decennium 1891-1900, and are taken from the extended life table for London appended to the annual report for the year 1901 :— Table III. Age. X Males. Females. Taking Hampstead Ex as 100, Shoreditch expectation of life is represented by— Expectation of life, E*. Excess in Hampstead compared with Shoreditch. Expectation of life, Ex. Excess in Hampstead compared with Shoreditch. London. 1891-1900 Hampstead. 1901-1905 Shoreditch. 1901-1905 London. 1891-1900 Hampstead. 1901-1905 Shoreditch. 1901-1905 Males. Females. At birth 40.98 55.29 39.30 15.99 45.33 59.46 43.65 15.81 71 73 At age 5 51.60 59.84 50.85 8.99 55.12 62.87 54.07 8.80 85 86 „ 10 47.84 55.60 46.76 8.84 51.49 58.66 50.04 8.62 84 85 „ 15 43.40 51.07 42.38 8.69 47.10 53.96 45.68 8.28 83 85 „ 20 39.13 46.80 38.07 8.73 42.77 49.39 41.33 8.06 81 84 „ 25 34.96 42.42 33.91 8.51 38.46 44.83 37.03 7.80 80 83 „ 30 30.94 38.06 29.94 8.12 34.30 40.33 32.86 7.47 79 81 „ 35 27.25 33.84 26.22 7.62 30.42 35.93 28.89 7.04 78 80 „ 40 23.87 29.93 22.89 7.04 26.80 31.66 25.23 6.43 76 80 „ 45 20.65 26.25 19.82 6.43 23.29 27.55 21.81 5.74 75 79 „ 50 17.60 23.40 16.91 6.49 19.91 23.63 18.60 5.03 72 79 „ 55 14.76 19.50 14.17 5.33 16.72 19.89 15.61 4.28 73 78 „ 60 12.14 16.38 11.49 4.89 13.74 16.29 12.82 3.47 70 79 „ 65 9.76 13.57 9.08 4.49 11.01 12.94 10.29 2.65 67 80 „ 70 7.66 11.38 7.10 4.28 8.59 9.89 8.09 1.80 62 82 ,, 75 5.91 9.26 5.53 3.73 6.57 7.31 6.24 1.07 60 85 The effect of the conditions which adversely affect longevity are strikingly exemplified in the foregoing table. It will be seen that the " expectation of life " at birth in Shoreditch is nearly 16 years less than in Hampstead both among males and females, and at each age shown in the table the figures 18560 o 14 relating to the two districts are in marked contrast. After every allowance has been made for the undoubted advantages which Hampstead, compared with Shoreditch, enjoys by reason of its topographical position it may be fairly claimed that the figures relating 1:o Shoreditch serve to show how much yet remains to be done for the improvement of the physical well-being of a large section of the community, notwithstanding the material advances which have been made in the direction of the improvement of public health in recent years. For it must be remembered that the population of Shoreditch is but a sample of a much larger population in London and elsewhere whose mortality rates are increased by causes which must be regarded as largely preventable. The death-rates of several of the large Metropolitan boroughs closely approximate to those of Shoreditch, and if the figures relating to these districts were translated into terms of "life expectation" the results would probably compare as unfavourably with those of Hampstead as do the results obtained for Shoreditch. Another interesting comparison between the two districts which can be instituted is that of the number surviving in each district at each age out of 100,000 born, and these figures are shown in the following table :— Table IV. Nvmber surviving at certain ages out of 100,000 born in Hampstead and Shoreditch, 1901-1905. Age. Males. Females. Hampstead. Shoreditch. Hampstead. Shoreditch. 0 100,000 100,000 100,000 100,000 5 85,062 69,862 87,432 73,453 1 15 83,210 67,627 85,850 71,134 25 80,870 64,962 84,352 68,859 35 77,875 60,161 82,079 65,073 1 45 71,900 51,482 77,993 58,014 t 55 62,396 39,883 70,679 47,380 65 48,825 26,228 58,763 33,092 75 29,739 10,946 38,328 16,221 This table shows tkat the average unit in Shoreditch begins life under more adverse conditions than the average unit in Hampstead, but whether those who survive the greater risks to infant life which obtain in Shoreditch are still subject at the later ages to conditions which are more adverse to longevity will be better seen on reference to the following table (V.), which shows the numbers surviving given age-periods out of 1,000 entering them; by this method of comparison, the effect of a high infant mortality on the total survivors at any age out of a given number born is eliminated, and the effects of the conditions affecting longevity obtaining for particular age-periods can be more clearly appreciated. Table V. Of 1,000 entering given age-periods, the number surviving through the period. Age-period. Males. Females. Hampstead. Shoreditch. Hampstead. Shoreditch. 0—5 851 699 874 735 5—15 978 968 982 968 15—25 972 961 983 968 25—45 889 792 925 843 45—65 679 509 753 570 This table shows, therefore, that, judged by the mortality experience of the period 1901-5, the conditions which adversely affect longevity in Shoreditch compared with Hampstead are operative at each age-period shown in the table, although the effect of these conditions varies with the age-period. Thus, comparing males in the two communities, out of 1,000 born in Shoreditch 301 die before reaching five years of age, while in Hampstead, out of 1,000 born, only 149 die before reaching the age of five years. Again, out of 1,000 children aged five in Shoreditch 32 die before reaching the age of 15, while in Hampstead the corresponding number is 22. At ages 25-45, when probably, so far as the community is concerned, the economic value of life is at a maximum, the differences in the two communities is most marked. Thus, of 1,000 males aged 25 living in Shoreditch 208 die before reaching the age of 45 years, while the corresponding figure for Hampstead is only 111. Diagram JY Infant Mortality, (Deaths under one year of age per 1000 births.) Htm Death-rite iaS8-IM. tSf per 1,000 births to Dtith-ntt 1858-130} 140per tflOO births. 15 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 t1/ page 8) 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 47 and 52 respectively. Death-rates per 100,000 living from All Causes, and from Specified Causes, in each of the several sanitary areas, 1907 (365 days). Sanitary area. Measles. Rheumatic Fever. Carcinoma. Sarcoma. Cancer (not otherwise defined). Tabes Mesenterica. Tuberculous Meningitis. Phthisis. Other Tuberculous and Scrofulous Diseases. Pneumonia. Other 1 Respiratory Disease^. All other Causes. All Causes. Paddington 26 10 75 4 41 9 19 105 13 129 139 783 1,353 Kensington 18 4 65 6 47 10 20 108 9 135 146 810 1,378 Hammersmith 46 5 73 4 35 7 15 121 12 162 145 814 1,439 Fulham 41 5 60 5 30 5 .13 119 17 131 120 763 1,309 Chelsea 56 8 55 3 37 7 20 152 16 136 150 854 1,494 Westminster, City of 11 7 62 4 31 8 11 135 10 163 114 749 1,305 St. Marylebone 14 5 49 6 65 8 14 145 20 125 176 867 1,494 Hampstead 14 3 54 7 19 9 16 68 9 80 74 549 902 St. Pancras 38 6 62 5 24 7 20 161 17 172 139 844 1,495 Islington 38 6 50 5 46 7 23 131 19 177 146 818 1,466 Stoke Newington 13 13 56 7 58 7 13 88 19 88 97 684 1,143 Hackney 27 5 47 4 37 9 18 115 21 136 128 814 1,361 Holborn 22 11 53 4 25 13 16 239 27 187 149 975 1,721 Finsbury 52 1 51 9 29 7 34 234 20 190 239 1,005 1,871 London, City of 5 — 89 5 39 — 5 212 15 167 182 930 1,649 Shoreditch 104 7 50 4 40 17 36 206 31 182 221 1,148 2,046 Bethnal Green 54 1 37 10 38 13 37 193 24 218 176 938 1,739 Stepney 48 6 42 4 26 12 27 152 32 185 145 901 1,580 Poplar 56 7 55 5 18 12 35 134 18 168 221 958 1,687 Southwark 54 if 1 61 7 24 8 23 204 22 257 182 948 1,797 Bermondsey 41 10 74 10 16 21 27 189 30 241 197 964 1,820 Lambeth 34 9 72 7 28 14 15 153 13 148 148 819 1,460 Battersea 38 9 42 0 36 10 19 123 19 133 128 761 1,328 Wandsworth 23 9 49 6 44 5 14 96 14 101 98 775 1,234 Camberwell 44 7 43 5 39 9 19 128 14 147 155 771 1,381 Deptford 46 12 48 3 17 9 21 138 21 151 134 802 1,402 Greenwich 54 9 51 3 23 4 21 104 8 119 104 767 1,267 Lewisham 11 7 64 9 24 8 13 92 17 88 96 713 1,142 Woolwich 53 5 46 4 37 10 16 122 16 110 121 708 1,248 London 38 7 55 6 34 9 20 139 18 155 145 830 1,456 Infant Mortality. The deaths of children under one year of age in the Administrative County of London during 1907 (52 weeks) numbered 14,114, being in the proportion of 116 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 1,000 births. 1841-50 157 1902 1401,2 1851-60 155 1903 1301,8 1861-70 162 1904 1451,2 1871-80 158 1905 1301,2 1881-90 152 1906 1311,8 1891-1900 1581 1907 116 1,2 1901 1481,2 The accompanying diagram (IV.) shows the infant mortality in each year since 1857 in relation to the mean infant mortality of the period 1858-1907, 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. 18560 1 See footnote (1) page 8. 2 See footnote (1) page 6. C 2 16 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. 1897-1906. 1907. Town. 1897-1906. 1907. London 1481 1161 Bradford 160 124 Liverpool 180 144 West Ham 166 131 Manchester 182 146 Newcastle 166 123 Birmingham 182 147 Hull 169 127 Leeds 170 130 Nottingham 181 165 Sheffield 180 145 Salford 188 140 Bristol 137 100 Leicester 174 131 London had therefore both in the period 1897-1906 and in 1907 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 1902-6 and for the year 1907 :— Sanitary areas—Deaths under one year of age per 1,000 births. Sanitary area. Deaths under one year of age, 1907. (52 weeks) Deaths under one year of age per 1,000 births. 1902-6. 1907. Paddington 355 118 109 Kensington.. 441 140 128 Hammersmith 362 140 117 Fulham 565 140 122 Chelsea 185 135 122 Westminster, City of 303 115 102 St. Marylebone 268 130 101 Hampstead 95 90 69 St. Pancras 628 132 108 Islington 1,000 125 116 Stoke Newington 107 113 100 Hackney 634 128 112 Holborn 140 132 131 Finsbury 373 159 130 London, City of 26 121 94 Shoreditch 569 167 150 Bethnal Green 574 151 138 Stepney 1,217 144 117 Poplar 653 152 124 Southwark 858 153 138 Bermondsey 498 156 123 Lambeth 940 134 120 Battersea 527 131 114 Wandsworth 709 118 99 Camberwell 773 131 115 Deptford 355 136 108 Greenwich 259 129 100 Lewisham 327 109 90 Woolwich .. 373 116 112 London 14,114 1351 1161 It will be seen from the foregoing table that both in the period 1902-6 and the year 1907 Shoreditch (167 and 150 respectively) had the highest infantile death-rate and Hampstead (90 and 69 respectively) had the lowest. The reports of Medical Officers of Health of the several sanitary areas of the Administrative County for the year 1907 contain tables prepared in accordance with the instructions of the Local Government Board giving the number of deaths, from all causes and certain specified causes, of infants 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 gee footnote (1), page 8. 17 Infant mortality during the year 1907. Deaths from stated causes in weeks and months under one year of age (365 days). Cause of death. 1 Under 1 Week. 1-2 Weeks. 2-3 Weeks. 3-4 Weeks. Total under 1 Month. 1 ]-2 Months. 2-3 Months. 3-4 Months. 4-5 Months. 5-6 Months. 6-7 Months. 7-8 Months. 8-9 Months. 9-10 Months. 10-11 Months. 11-12 Months. Total Deaths under one year. Common Infectious Diseases— Small-pox - - - - - - - - - - - - - - - - - Chicken-pox — — — — — — — 1 — — 2 — — 1 — 1 5 Measles — — 2 — 2 8 1 2 5 20 26 31 65 72 70 98 400 Scarlet Fever 1 — — 1 2 — — 2 2 1 3 5 3 4 3 10 35 Diphtheria and Croup — — — 2 2 2 2 1 1 3 2 7 5 12 9 7 53 Whooping Cough — 1 4 12 17 68 69 48 44 52 64 78 80 62 87 77 746 Diarrhoeal Diseases— Diarrhoea, all forms 2 9 12 12 35 108 108 139 120 101 95 93 78 66 60 47 1,050 Enteritis (not tuberculous) 6 19 20 26 71 64 64 77 72 51 50 25 42 34 20 28 598 - Gastritis, Gastrointestinal Catarrh 6 7 9 6 28 23 19 17 14 7 12 10 3 3 2 4 142 Wasting Diseases— Premature Birth 1,545 232 201 115 2,093 141 34 15 5 8 — — 2 1 2,299 Congenital Defects 336 74 49 28 487 60 31 16 15 4 5 13 8 4 2 645 Injury at Birth 105 7 1 1 114 3 117 Want of Breast-milk 7 8 3 4 22 12 13 6 10 2 8 — — 1 74 Atrophy, Debility, Marasmus 327 133 119 105 684 317 238 198 129 74 60 37 33 31 19 28 1,848 Tuberculous Diseases— Tuberculous 1 2 1 2 6 9 10 18 15 27 24 27 20 32 24 27 239 gitis Tuberculous Peritonitis : Tabes Mesenterica 1 3 4 14 13 29 16 16 14 9 10 5 13 10 153 Other Tuberculous Diseases 1 1 — 2 4 14 24 32 30 22 28 20 21 17 20 32 264 Erysipelas — 4 6 3 13 15 5 4 3 1 2 4 2 2 — 1 52 Syphilis 17 17 15 20 69 40 41 24 22 5 4 5 4 7 4 1 226 Rickets — — 1 1 2 1 2 4 3 4 10 5 7 9 10 58 Meningitis (not Tuberculous) 4 1 4 3 12 8 12 19 19 13 20 24 28 19 19 17 210 Convulsions 92 65 56 30 243 86 59 43 30 27 29 19 18 20 13 16 603 Bronchitis 14 50 63 54 181 238 160 114 83 85 81 75 65 76 63 63 1,284 Laryngitis — — — 2 2 2 1 — — 3 1 4 — — 2 — 15 Pneumonia 20 35 23 38 116 159 150 137 102 122 121 127 145 149 154 147 1,629 Suffocation, overlaying 82 28 23 26 159 71 76 54 27 9 10 4 5 4 — 2 421 Other causes ... 192 66 64 38 360 115 67 62 52 44 58 53 44 42 36 46 979 Total (All Causes) 2,758 760 676 533 4,727 1,579 1,198 1,060 820 700 723 680 684 668 631 675 14,145 Comparison may be made between the number of deaths from the several causes in this table with those of the two antecedent years by reference to the following table:— Cause of death. ' 1905. 1906. 1907. Small-pox __ Chicken-pox 3 3 5 Measles 389 420 400 Scarlet Fever 34 18 35 Diphtheria and Croup.. 52 59 53 Whooping Cough 623 502 746 Diarrhoea 3,423 4,468 1,790 Enteritis (not tuberculous) Gastritis, Gastro-intestinal Catarrh Premature Birth 2,423 2,208 2,299 Congenital Defects 547 613 645 Injury at Birth 99 113 117 Want of Breast-milk 2,281 2,130 1,922 Atrophy, Debility, Marasmus Tuberculous Meningitis 273 241 239 Tuberculous Peritonitis : Tabes Mesenterica 192 225 153 Other Tuberculous Diseases 284 246 264 Erysipelas 64 50 52 (Continued on next page.) 18 Cause of death. 1905. 1906. 1907. Syphilis 271 233 226 Rickets 79 67 58 Meningitis (not tuberculous) 300 302 210 Convulsions 803 660 603 Bronchitis 1,276 1,043 1,284 Laryngitis 25 23 15 Pneumonia 1,490 1,335 1,629 Suffocation, overlaying 462 417 421 Other causes 1,004 1,009 979 Total 16,397 16,385 14,145 It is thus seen that the marked reduction in 1007 of infant mortality on that of 1905 and 1906 is largely due to the reduction in the deaths from diarrhoeal diseases, consequent upon the relatively low temperatures which prevailed in the summer of 1907. The total deaths from all causes at ages in this table may be compared with similar figures included in the Annual Reports for the years 1905 and 1906. The deaths in the three 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 Mouths. 4-5 Months. 5-6 Months. , 6-7 Months. l 7-8 Months. 8-9 Months. 9-10 Months. 10-11 Alonths. 11-12 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 1907 2,758 760 676 533 4,727 1,579 1,198 1,060 820 700 723 680 684 668 631 675 14,145 This table therefore shows that, as compared with 1906, the reduction in the number of deaths is entirely due to reduction of those which occurred after the first month of life, during which, indeed, there was actual increase in 1907. The following life table, which is based upon the figures shown in the table on page 17, 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 two columns of the table are taken from similar tables published in recent annual reports, and will enable comparison to be made between the three years 1907, 1906 and 1905 in this respect:— London—1907. Life Table for the first 12 months of life (based on the mortality of the year 1907). 1907. 1907. 1906. 1905. Age-period. Registered deaths. Probability of living for one month. Number living at the beginning of each month of age. Number living at the beginning of each month of age. Number living at the beginning of each month of age. X 1907. Px lx 1 X 1 X ~12 is 12 I12 12 0—1 month 4,727 •96139 100,000 100,000 100,000 1—2 months 1,579 •98662 96,139 96,298 96,115 2—3 „ 1,198 •98973 94,853 94,957 94,701 3—4 „ 1,060 •99086 93,879 93,834 93,594 4—5 „ 820 •99288 93,021 92,820 92,647 5—6 „ 700 •99391 92,359 91,963 91,841 6—7 „ 723 •99368 91,797 91,107 91,076 7—8 „ 680 •99402 91,217 90,338 90,354 8—9 „ 684 •99396 90,672 89,612 89,693 9—10 „ 668 •99407 90,124 88,939 89,011 10—11 „ 631 •99439 89,590 88,238 88,357 11—12 „ 675 •99398 . 89,087 87,627 87,722 0—1 year 14,145 — 88,551 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 :— 19 Deaths at each interval of age (under one year) from All Causes in sanitary areas in 1907 (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 Months. Total under 1 Year. Paddington 73 20 18 18 129 55 27 15 21 20 14 22 15 7 12 17 354 Kensington 93 24 18 20 155 55 36 28 19 22 25 22 17 16 15 23 433 Hammersmith 68 17 22 16 123 41 24 25 22 19 15 26 15 12 19 21 362 Fulham 111 28 31 19 189 61 49 43 36 21 27 26 28 30 31 24 565 Chelsea 32 10 11 11 64 19 14 16 10 5 14 6 8 6 12 8 182 Westminster,City of 85 19 15 7 126 32 24 18 26 13 15 6 9 17 6 11 303 St. Marylebone 55 19J: 14 10 98 37 26 14 17 17 17 5 8 12 10 3 264 Hampstead 21 5} 5 9 40 18 5 7 4 3 2 7 4 1 1 6 98 St. Pancras 116 41 22 27 206 81 46 50 38 22 29 27 37 30 26 32 624 Islington 187 58 51 34 330 105 84 63 58 48 55 44 68 45 51 45 996 Stoke Newington... 29 6 6 4 45 9 8 4 9 2 3 6 3 7 2 4 102 Hackney 156 39 31 22 248 91 61 48 33 23 27 31 32 24 25 24 667 Holborn 22 5 4 7 38 14 16 11 8 4 8 6 7 9 5 6 132 Finsbury 64 17 23 20 124 39 31 33 21 15 23 21 14 12 14 21 368 London, City of ... 3 — 2 2 7 3 4 2 — 3 3 — 1 1 24 Shoreditch 84 18 21 20 143 55 71 46 34 28 38 36 33 29 29 27 569 Bethnal Green 108 33 31 16 188 53 44 38 35 36 29 37 30 24 25 35 574 Stepney 209 46 73 34 362 142 96 94 71 70 66 54 53 72 61 76 1,217 Poplar 125 32 25 16 198 74 52 57 35 43 28 32 31 42 32 29 653 Southwark 145 44 42 28 259 84 74 63 45 41 43 52 54 49 53 41 858 Bermondsey 97 28 17 16 158 51 46 41 34 19 35 29 23 19 22 24 501 Lambeth 189 47 44 43 323 98 79 89 55 54 41 42 42 44 32 42 941 Battersea 124 31 25 22 202 54 47 37 28 22 27 20 20 23 29 17 526 Wandsworth 140 44 36 21 241 76 62 56 45 42 30 32 38 33 29 31 715 Camberwell 135 43 34 42 254 84 64 64 42 39 44 35 39 31 40 69 805 Deptford 77 25 12 14 128 44 31 21 21 17 12 12 18 27 15 10 356 Greenwich 54 15 10 3 82 23 19 21 15 21 12 14 17 13 10 12 259 Lewisham 73 27 17 10 127 41 22 29 19 14 18 13 12 15 8 7 325 Woolwich 83 19 16 22 140 40 36 27 19 17 23 17 8 18 17 10 372 London 2,758 760 676 533 4,727 1,579 1,198 1,060 820 700 723 680 384 668 631 675 14,145 With a view to the consideration of the eSect of social condition on the rates of infant mortality at different periods during the first year of life, the following table has been prepared, in which the rates of infant mortality obtaining for groups of districts (arranged on the basis of the amount of overcrowding shown by the census of 1901) can be compared :— Infant mortality and overcrowding1—1907. Age-period. Proportion of overcrowding in groups of sanitary districts. Under 7.5 per cent. 7.5 to 12.5 per cent. 12.5 to 20.0 per cent. 20.0 to 27.5 per cent. Over 27.5 per cent. Under 1 week 20.9 23.7 23.7 21.4 22.0 1-2 weeks 6.1 6.3 6.6 6.9 5.4 2-3 „ 4.8 5.5 5.3 5.2 7.0 3-t „ 4.0 4.7 4.2 4.5 4.2 Under 1 month 35.8 40.2 39.8 38.0 38.6 1-2 months 11.0 12.9 13.4 13.7 13.6 2-3 „ 8.0 9.8 9.7 10.3 11.4 3-4 „ 7.4 9.0 8.2 8.7 10.0 4-5 „ 5.8 6.5 7.0 6.8 7.6 5-6 „ 4.7 5.7 5.8 5.3 7.0 6-7 „ 4.6 5.4 6.4 6.2 7.4 7-8 „ 4.5 5.3 5.5 5.7 7.0 8-9 „ 3.9 5.5 5.8 6.7 6.1 9-10 „ 4.5 5.3 5.2 6.3 6.5 10-11 „ 3.5 5.2 5.1 6.0 6.1 11-12 „ 3.5 5.7 5.4 5.2 7.5 0-3 months 54.8 62.9 62.9 62.0 63.6 3-6 17.9 21.2 21.0 20.8 24.6 6-9 13.0 16.2 17.7 18.6 20.5 9-12 „ 11.5 16.2 15.7 17.5 20.1 0-12 months 97.2 116.5 117 .3 118 .9 128.8 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. 20 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 overcrowded groups of districts are compared. This agrees with the figures in corresponding tables published in previous annual reports. 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. 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—1907. 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. 115 118 125 141 III. 115 117 136 137 IV. 113 116 143 152 V. 116 137 158 175 It will be seen from this table that in each successive trimester of the first year of life the difference in the mortality obtaining for the several groups of districts becomes more pronounced. These figures are in agreement with the results obtained from a comparison of the figures of 1905 and 1906, which have been published in previous reports. Suffocation of Infants. The subject of the suffocation of infants in bed has received considerable attention during 1908 in connection with the provisions of the Children Bill. This Bill provides that when it is proved that the death of an infant under three years of age was caused by suffocation whilst the infant was in bed with some other person over sixteen years of age, and that that other person was at the time of going to bed under the influence of drink, that other person shall be deemed to have neglected the infant in a manner likely to cause injury to its health, within the meaning of the Act. In this connection the following table is of interest, and shows that when groups of London sanitary are&s arranged in order of their condition as to "overcrowding" are considered, the mortality among infants caused by " suffocation in bed " progressively increases from the least to the most overcrowded groups. Mortality of infants due to suffocation in bed. Number of group of sanitary districts in order of overcrowding.1 Proportion of overcrowding' in groups of sanitary districts. Death-rate from suffocation in bed per 100,000 births. I. Under 7.5 per cent 157 II. 7-5 to 12.5 „ 248 III. 12-5 to 20. 0 „ 367 IV. 20 0 to 27.5 „ 456 V. Over 27 .5 524 London 16 01 per cent. 339 During the year the Council received from midwives practising in London weekly lists of the patients attended by them, and in this way the addresses of 26,993 patients were obtained. In 862 cases the child was either stillborn or had died before the weekly list was prepared. The addresses of the surviving infants were communicated with as little delay as possible to the medical officers of health of the districts to which the births belonged. Only in one instance did the medical officer of health not desire to receive this information, while in some districts the medical officers of health obtained further information as to births in their districts by arrangement with the registrars of births. The annual reports of medical officers of health show that the homes were visited either by a woman sanitary inspector or by a health visitor, or in some districts by voluntary workers, acting in co-operation with the medical officer of health. Leaflets have been distributed and advice given on infant feeding. Milk depots for the supply of milk to infants have been established in Battersea, Finsbury, Lambeth and Woolwich, and in Holborn arrangements have been made with a milk company to supply special milk on the order of the medical officer of health. With a view to the prevention of infant mortality, a law was enacted in 1907 requiring the notification to the medical officer of health of births in the districts of those authorities who adopted the Act. The duty of notification is imposed upon the father if residing in the house where the birth takes place, and any person in attendance upon the mother at the time of, or within six hours after, 1 See footnote (1) pege 19. 21 the birth. In London the medical officer of health is required to send weekly to the London County Council a list of all notices of births received by him during the past week. The resolution of -the local authority adopting the Act does not take effect until the consent of the Local Government Board has been obtained thereto. I recently addressed a circular letter to medical officers of health in London, asking whether their authorities had adopted the Act, and what provision had been made in their districts for utilizing the knowledge thus obtained. The following tabular statement is based upon information supplied in reply to this inquiry. Infant mortality.—Summary of replies to circular letter to medical officers of health, 20th October, 1908. Sanitary area. Whether Notification of Births Act, 1907, adopted. Whether adoption confirmed by L.G.B. Staff engagod in visiting homes -where births have recently occurred. Female sanitary inspectors. Health visitors. Whether any voluntary health visitors. 1 Paddington Yes Yes 2 2 Yes Student Inspectors. Kensington Yes Yes — 2 Health Society Hammersmith No — — 1 — Fulham Yes Yes 1 Yes Chelsea No — — Westminster Yes No — 20 Marylebone Yes Yes 2 + 1 temp. Health Society Hampstead Yes Yes 1 +1 to be appointed Health Society Pancras Yes Yes 2 Yes Islington Yes Yes — — Stoke Newington Yes Yes — 6 Hackney No — — — Holborn Yes Yes 1 — Finsbury Yes Yes 2 — London, City of Yes Yes 1 — Shoreditch No — — Bethnal Green No 1 — Stepney No — — — Poplar Yes Yes — 1 60 Southwark Yes Yes 3 Yes Bermondsey Yes Yes — 1 to be apptd. — Lambeth Yes Yes — 1 — Battersea Yes Yes 1 Yes Wandsworth No 2 1 Camberwell No — Deptford No — — Greenwich No Yes — Lewisham No — Woolwich Yes Yes 1 — 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 diarrhoea during 1907 (52 weeks) was 6,720, giving an annual death-rate of 1'42 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 1902 2.212 1851-60 5.13 1903 1.752 1861-70 5.23 1904 2.142 1871-80 3-86 1905 1.702 1881-90 3.05 1906 1.932 1891-1900 2.68 2 1901 2.22 1907 1-42 2 1 Origin uncertain. Originally described as simpla continued fever. ' See footnote (1), page 8. 18560 V 22 It will be seen from the following table that in the decennium 1897-1906, 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 1907 had a lower death-rate than any, except Leeds, Bristol, Bradford, Newcastle-on-Tyne and Leicester. Principal Epidemic Diseases—Death-rates per 1,000 persons living. Town. 1S97-1906. 1907. Town. 1897-1906. 1907. London 2.22 1 1.42 1 West Ham 3.38 2.18 Liverpool 3.36 2.01 Bradford 1.91 0.89 Manchester 3.08 1.72 Newcastle-on-Tyne 1.97 1.37 Birmingham 2.85 1.78 Hull 2.96 1.77 Leeds 2.52 1.26 Nottingham 2.45 2.25 Sheffield 3.30 2.64 Salford 3.83 2.14 Bristol 1.87 0.79 Leicester 2.55 0.90 The following table shows that the London death-rate from six of these principal epidemic diseases, viz. : smallpox, measles, scarlet fever, diphtheria, whooping cough and enteric fever, was, both in the decennium 1897-1906 and the year 1907, higher than the death-rates of all the under-mentioned foreign towns, except St. Petersburg:— Six Principal Epidemic Diseases—Death-rates per 1,000 persons living. Town. 1897-1906. 1907. Town. 1897-1906. 1907. London 1.37 1 1.10 1 St. Petersburg 3.11 2.97 Paris 0.75 0.59 Berlin 0.95 0.74 Brussels 0.60 0.42 Vienna 0.92 0.70 Amsterdam 0.86 0.70 Rome 0.95 0.70 Copenhagen 0.78 0.62 New York 1.24 1.03 Stockholm 0.87 0.43 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 1907, and the death-rates for the period 1902-6:— Principal Epidemic Diseases.—Death-rates in sanitary areas. anitary area. Deaths, 1907 (52 weeks). Death-rate per 1,000 persons living. 1902-6. 1907. Paddington 170 1.46 1.13 Kensington 189 1.49 1.04 Hammersmith 142 1.97 1.16 Fulham 288 2.58 1.73 Chelsea 108 1.54 1.44 Westminster, City of 122 0.96 0.72 St. Marylebone 123 1.52 0.97 Hampstead 46 0.63 0.51 St. Pancras 275 1.91 1.17 Islington 434 1.61 1.25 Stoke Newington 54 1.21 1.02 Hackney 319 1.88 1.37 Holborn 70 1.65 1.28 Finsbury 176 2.77 1.83 London, City of .. 17 0.90 0.85 Shoreditch 348 3.16 3.01 Bethnal Green 256 2.51 1.96 Stepney 608 2.75 1.97 Poplar 361 2.94 2.11 Southwark 398 2.56 1.90 Bermondsey 219 2.75 1.71 Lambeth 402 1.77 1.28 Battersea 243 1.96 1.34 Wandsworth 326 1.61 1.16 Camberwell 396 1.74 1.43 Deptford 171 2.19 1.47 Greenwich 154 1.75 1.44 Lewisham 128 1.30 0.85 Woolwich 177 1.59 1.38 London 6,720 1.941 1.42 1 See footnote (1),pugo 8. Diagram Y Smallpox. ' •UOI///W J*d$Qz £0€i-/iei *44990 23 It will be seen from the foregoing table that the death-rate from the principal epidemic diseases was, both in the period 1902-6 and the year 1907, highest in Shoreditch (3*16 and 3 01 respectively), and lowest in Hampstead (0'63 and 0 51 respectively). The death-rates from these diseases during each of the four quarters of the year were as follows : First quarter, 1'33 ; second quarter, 1"56; third quarter, 1*42; and fourth quarter 1'36 per 1,000 persons living. Smallpox and Vaccination. There were no deaths from smallpox in the Administrative County of London during the year 1907 ; one death was attributed to cowpox. The death-rates from smallnox in successive neriods have been as follows :— Smallpox. Period. Death-rate per 1,000 persons living. Period. Death-rate per 1,000 persons living. 1841-50 0.402 1902 0.2821 1851-60 0.280 1903 0.0031 1861-70 0.276 1904 0.0051 1871-80 0.457 1905 0.002 1881-90 0.145 1906 — 1891-1900 0.0101 1907 — 1901 0.0511 The smallpox death-rate in each year since 1840 in relation to the mean smallpox death-rate of the period 1841-1907 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 1,000 persons living. 1890 60 0.014 1891 114 0.027 1892 425 0.100 1893 2,815 0.653 1894 1,193 0.274 1895 980 0.223 1896 225 0.050 1897 104 0.023 1898 33 0.007 1899 29 0.006 1900 86 0.019 1901 1,700 0.375 1902 7,796 1.675 1903 416 0.090 1904 489 0.105 1905 74 0.016 1906 31 0.007 1907 8 0 .002 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 1897-1906 the London death-rate was higher than that of any, except Liverpool, West Ham and Hull; in 1907 London had no deaths from smallpox, Bristol and Hull being the only large towns where deaths occurred, not, however, sufficient to give an appreciable death-rate. Smallpox—Death-rates per 1,000 persons living. Town. 1897-1906. 1907. Town. 1897-1906. 1907. London 0.031 West Ham 0.06 _ Liverpool 0.03 — Bradford 0.01 - Manchester 0.01 — Newcastle-on-Tyne 0.01 - Birmingham 0.00 — Hull 0.08 0.00 Leeds 001 — 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. 18560 1 See footnote (1), page 8. D 2 24 The following table shows that the London smallpox death-rate was in the decennium 18971906 higher than that of any of the under-mentioned foreign towns except Paris, Brussels, and St. Petersburg, and in 1907 Paris, Vienna and St. Petersburg were the only towns which had an appreciable death-rate from smallpox :— Smallpox—Death-rates per 1,000 persons living. Town. 1897-1906. 1907. Town. 1897-1906. 1907. London 0 .031 St. Petersburg 0.08 0.02 Paris 0.04 0-02 Berlin 0.00 0.00 Brussels 0.03 — Vienna 0.00 0.02 Amsterdam 0.00 — Rome 0.00 0.00 Copenhagen — — New York 0.02 0.00 Stockholm 0.00 *— In this table O'OO indicates that the deaths were too few to give a rate of O'OOo ; where no death occurred — is inserted. The following table shows the smallpox cases notified, deaths, case-rates, and death-rates in the year 1907, the case-rates in the decennium 1897-1906, and the death-rates in the period 1902-6 in the several sanitary areas of the Administrative County— Smallpox—Case-rates and death-rates in sanitary areas. Sanitary area. Notified cases, 1907 (52 weeks). Case-rate per 1,000 porsons living. Deaths, 1907. (52 weeks). Death-rate per 1,000 persons living. 1897-1906. 1907. 1902-6. 1907. Paddington — 0.1 — 0.03 Kensington — 0.1 — — 0.01 - Hammersmith — 0.1 — — 0.02 - Fulham — 0.1 0.02 Chelsea — 0.1 0.02 - Westminster, City of — 0.2 - - 0.05 - St. Marylebone 1 0.2 0.0 - 0.04 - Hampstead 1 0.0 0.0 - 0.01 - St. Pancras 1 0.3 0.0 - 0.07 - Islington — 0.1 — - 0.03 - Stoke Newington — 0.2 — - 0.03 - Hackney — 0.2 — - 0.06 - Holborn — 0.8 — - 0.16 - Finsbury — 0.3 — - 0.08 - London, City of 2 0.2 0.1 - 0.05 - Shoreditch 1 0.4 0.0 - 0.13 - Bethnal Green — 0.6 — 0.11 - Stepney — 0.6 — - 0.17 - Poplar 1 0.5 0.0 - 0.11 - South wark — 0.3 — - 0.07 - Bermondsey — 0.3 — - 0.05 - Lambeth — 0.2 — - 0.04 - Battersea — 0.2 0.03 - Wandsworth — 0.1 0.02 - Camberwell — 0.2 - 0.05 - Deptford — 0.2 — - 0.06 - Greenwich — 0.1 — - 0.04 - Lewisham 0.1 0.02 Woolwich 0.2 0.06 Port of London 1 - — - London 8 0.2 0.0 - 0.061 - 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. The following table shows the number of cases of smallpox notified in London in each week of the year 1907— 1 See footnote (1), page 8. 25 Smallpox—Weekly notified rases—1907. Week ended. No. of cases notified. Week ended. No. of cases notified. \Y eek ended. No. of cases notified. January 5 1 May 11 September 14 „ 12 — 18 — 21 - „ 19 — 25 — 28 - „ 26 — June 1 — October 5 - February 2 — 8 — 12 - 9 — 15 — 19 - 16 — 22 — 26 - „ 23 1 29 — November 2 1 March 2 — July 6 — 9 - 9 — 13 — 16 - 16 — 20 — 23 - 23 — 27 — 30 - 30 — August 3 — December 7 - April 6 1 10 1 14 - 13 — 17 — 21 1 20 — 24 — 28 - 27 2 31 — May 4 - September 7 Five of the persons certified to have smallpox were subsequently found not to be suffering from this disease. The only cases of actual smallpox known to have occurred in London during the year 1907 were the following :— One case in Greenwich, in February. The patient was an officer on board a vessel from Brazil, which had landed a case of smallpox at Liverpool, before the ship arrived in the Thames. The officer in question was removed at Gravesend, first to the Seamen's Hospital in Greenwich, where the case was notified, and afterwards to the Denton Hospital. An engineer on board the same vessel was at the same time found to be suffering from smallpox. He was removed direct to the Denton Hospital from Gravesend, and is, therefore, not included in the London cases. One case in Hampstead, in April. The patient was the manager of a shipping company, who had contracted the disease in Madeira, or on the voyage home. One case in Poplar, in August. The patient was a seaman on board a British vessel from which he was paid off in Rotterdam, on August 2nd. He travelled to Poplar and sickened on August 4th. 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 I8.4 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 1905 18.9 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, 11; 1902, 0-8; 1903, 1-0; 1904, 1 1; 1905, 12. 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:— 26 Number of children for whom certificates of conscientious objection were obtained together with the number of children not finally accounted for (including cases postponed) per cent of births. Metropolitan Union. 1898. 1899. 1900. 1901. 1902. 1903. 1904. 1905. Bethnal-green 67.0 48.2 49.2 52.2 44.1 44.9 42.8 42.0 Camberwell 41.2 29.7 23.0 20.0 21.4 21.8 23.6 23.4 Chelsea 17.3 14.9 16.0 13.4 14.9 13.9 10.0 8.9 Fulham 15.4 12.6 13.7 12.0 11.8 12.7 11.5 10.8 St. George, Hanover-square 11.1 9.0 7.1 5.8 7.5 5.1 4.9 4.4 St. George-in-the-East 34.6 35.0 33.5 30.6 29.7 27.7 15.7 17.3 St. Giles and St. George 32.5 33.0 33.6 30.7 27.1 24.9 17.9 20.4 Greenwich 17.2 14.2 13.8 12.6 11.1 11.1 10.4 9.7 Hackney 49.0 38.6 40.4 38.5 26.1 25.5 26.9 28.2 Hammersmith 13.8 11.7 9.1 8.3 9.4 7.2 7.4 8.0 Hampstead 15.4 10.3 11.0 10.0 9.2 9.5 9.2 9.2 Holborn 43.8 31.8 28.5 27.6 23.2 20.7 20.4 20.6 Islington 31.1 29.2 26.2 21.6 17.7 17.0 15.9 17.5 Kensington 13.5 10.2 9.2 9.0 7.2 6.6 6.6 5.5 Lambeth 30.6 25.2 20.6 22.2 20.4 21.0 16.9 17.3 Lewisham 27.8 22.6 20.7 15.7 13.5 15.4 14.0 13.8 London, City of 25.4 18.3 14.2 11.3 11.3 11.8 13.0 15.3 Marylebone 18.0 20.9 17.7 14.6 12.5 10.8 10.4 10.8 Mile End Old Town 68.9 69.9 68.0 66.1 58.8 59.8 47.3 47.1 St. Olave (Bermondsey) 32.5 23.6 21.8 18-0 17.5 16.3 16.6 15.7 Paddington 14.7 14.6 13.5 11.0 10.1 11.7 12.7 13.3 St. Pancras 36.7 36.1 32.9 32.8 26.2 25.3 23.1 22.1 Poplar 63.6 50.1 49.0 49.1 44.2 46.9 45.4 45.3 Shoreditch 68.8 52.4 53.0 44.7 36.4 36.6 34.8 36.7 South wark 32.6 30.3 27.6 26.8 25.4 24.9 24.3 24.2 Stepney 48.6 46.9 44.4 44.3 37.2 35.8 32.9 32.9 Strand 25.2 19.7 19.2 16.1 19.0 18.6 15.0 11.8 Wandsworth and Clapham 32.2 25.1 23.0 20.5 19.2 17.2 16.3 14.8 Westminster 17.4 14.8 12.2 13..3 13.4 12.1 11.0 8.2 Whitechapel 11.8 14.5 13.1 10.5 9.5 10.1 9.1 10.6 Woolwich ^ 10.2 8.3 7.5 9.8 9.7 7.1 7.2 6.6 London 34.4 28.7 26.8 25.2 22.1 21.7 20.2 20.1 In respect of vaccination, London compares unfavourably with the provinces, and has, indeed, done so for many years. During the first five years of the present decennium some improvement has been manifested, but the proportion not finally accounted for, in regard to vaccination (including cases postponed), has, in London, in each of these years, been more than double the proportion in the rest of England. During these years there were nearly 651,000 births in London, leaving at the end of 1905, after subtraction of deaths, some 530,000 children under five years of age. In 1902 there was a vast amount of vaccination of the London population, who in the presence of smallpox had resort to public vaccinators and private practitioners for protection against that disease. Information supplied to me by the Clerks of 21 Unions showed that the numbers of primary vaccinations at all ages was in that year over 60 per cent, more than the number in 1900, and thus probably some deduction has to be made from figures based upon the proportions of births unaccounted for in respect of vaccination, or in which vaccination was postponed, but these figures afford reason for thinking that in 1905 there were over 100,000 unvaccinated children under five years of age in London. The existence of so large a proportion of unvaccinated children in London is necessarily always a standing danger, although considerable intervals of time may elapse without actual injury resulting. % Measles. The deaths from measles in the Administrative County of London during 1907 (52 weeks numbered 1,801, as compared with 1,909 in 1906 The death-rates from this disease per 1,000 persons living in 1907 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 1902 0.511 1851-60 0.53 1903 0.441 1861-70 0.58 1904 0.491 1871-80 0.51 1905 0.371 1881-90 0.64 1906 0.411 1891-1900 0.581 1907 0.381 1901 0431 1 See footnote (1), page 8. Diagram YL Measles Diagram HI 7" Measles & Whooping' Cough. (Deaths 1891 1907.) — 27 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. Death-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 1907 3.29 1 The death-rate in each year since 1840 in relation to the mean death-rate of the period 1841—1"907> 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 1891-1907 is shown in diagram VII. The following table shows the deaths and death-rates from measles in 1907 (52 weeks) in each of the sanitary areas of the County :— Measles—Death-rates in sanitary areas. Sanitary area. Deaths, 1907 (52 weeks). Death-rate per 1,000 persons living. 1902-6. 1907. Paddington 38 0.33 0.25 Kensington 31 0.37 0.17 Hammersmith 54 0.50 0.44 Fulham 70 0.57 0.42 Chelsea 42 0.45 0.56 Westminster, City of 19 0.19 0.11 St. Marylebone 18 0.41 0.14 Hampstead 12 0.13 0.13 St. Pancras 88 0.52 0.37 Islington 131 0.43 0.38 Stoke Newington 7 0.23 0.13 Hackney 60 0.37 0.26 Holborn 12 0.44 0.22 Finsbury 49 0.76 0.51 London, City of .. 1 0.14 0.05 Shoreditch 119 0.70 1.03 Bet hnal-green 71 0.52 0.54 Stepney 155 0.55 0.50 Poplar 96 0.60 0.56 Southwark 112 0.66 0.54 Bermondsey 52 0.76 0.41 Lambeth 107 0.35 0.34 Battersea 69 0.50 0.38 Wandsworth 65 0.36 0.23 Camberwell 122 0.38 0.44 Deptford 54 0.52 0.46 Greenwich 58 0.31 0.54 Lewisham 17 0.21 0.11 Woolwich 72 0.22 0.56 London 1,801 0.441 0.38 1 In the distribution of measles mortality throughout the year 1907, the highest death-rate obtained in Shoreditch (1'03), and the lowest in the City of London (0-05). For the period 1902-6, Finsbury (0-76) and Bermondsey (076) had the highest measles death-rate, and Hampstead (0-13) the lowest. The death-rates from this disease in each of the four quarters of the year 1907 were as follows—first quarter, 0'39 ; second quarter, 0*55 ; third quarter, 0-34 ; and fourth quarter, 0*24, 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 1907. 1 See footnote (1') page 8. 28 Measles—Mortality among children at ages 0-5 in sanitary areas—1907. Sanitary area. Death-rate per 1,000 children living aged 0-5, 1907. Sanitary area. Death-rate per 1,000 children living aged 0-5, 1907. Sanitary area. Death-rnte per 1,000 ' children living aged 0-5, 1907. Paddington 2.63 Stoke Newington 1.22 Bermondsey 3.04 Kensington 2.13 Hackney 2.18 Lambeth 3.04 Hammersmith 3.94 Holborn 2.70 Battersea 3.01 Fulham 3.09 . Finsbury 4.28 Wandsworth 2.02 Chelsea 6.30 London, City of 0.87 Camberwell 3.68 Westminster, City of 1.49 Shoreditch 8.13 Deptford 3.41 St. Marylebone 1.42 Bethnal Green 3.92 Greenwich 4.37 Hampstead 1.53 Stepney 3.47 Lewisham 0.80 St. Pancras 3.46 Poplar 4.13 Woolwich 4.13 Islington 3.40 Southwark 4.30 London 3.29 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,2 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 :— Measles and overcrowding,2 1901-7. Proportion of overcrowding 2 in groups of sanitary areas. Measles death-rate at ages 0-5 years 1901-7, per 1,000 living. Under 7-5 per cent. 2.23 7-5 to 12-5 „ „ 3.52 12-5 to 20 0 „ „ 4.00 20 0 to 27-5 „ „ 4.60 Over 27-5 „ „ 4.48 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 1897-1906 the London death-rate was exceeded by the death-rates of Liverpool, Manchester, Sheffield, West Ham and Salford, and in the year 1907, was lower than that of any of these towns, except Manchester, Leeds, Bristol, Bradford and Leicester. Measles—Death-rates per 1,000 persons living. Town. 1897-1906. 1907. Town. 1897-1906. 1907. London 0.471 0-38 1 West Ham 0.54 0.51 Liverpool 0.50 039 Bradford 0.32 0.17 Manchester 0.70 036 Newcastle-on-Tyne 0.39 0.44 Birmingham 0.43 0-57 Hull 0.44 0.66 Leeds 0.47 0-22 Nottingham. 0.34 0.78 Sheffield 0.52 0-86 Salford . 0.83 0.44 Bristol 0.44 0-09 Leicester 0.30 0.27 The following table shows that the London measles death-rate was, both in the decennium 18971906 and the year 1907, higher than those of any of the under-mentioned foreign towns, except St. Petersburg:— Measles—Death-rates per 1,000 persons living. Town. 1897-1906. 1907. Town. 1897-1906. 1907. London 0 .471 0.38 1 St. Petersburg 0.63 0.91 Paris 0.26 0.16 Berlin 0.22 0.19 Brussels 0.17 0.08 Vienna 0.41 0.31 Amsterdam 0.37 0.27 Rome 0.29 0.25 Copenhagen 0.17 0.18 New York 0.19 0.17 Stockholm 0.14 0.12 1 See footnote (1), page 8. 2 See footnote (1), page 19. 29 The following table shows the number of deaths from measles at the 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 page 8). Measles—Deaths at the several age-periods in sanitary areas—1907 (365 days). Age-period. 0— 1— 2— 3— 4— Under 5. 5— 10— 15 and upwards. All Ages. Paddington 10 13 9 1 2 35 4 - 39 Kensington 5 16 4 4 2 31 1 - — 32 Hammersmith 19 23 6 2 2 52 4 - — 56 Fulham 10 32 16 4 5 67 2 - — 69 Chelsea 7 19 10 2 2 40 1 - 1 42 Westminster, City of 2 8 6 2 — 18 1 - — 19 St. Marylebone 1 9 3 2 — 15 2 - 1 IS Hampstead 3 7 1 — — 11 1 1 — 13 St. Pancras 20 34 15 10 5 84 5 - — 89 Islington 28 53 23 14 9 127 5 - — 132 Stoke Newington 2 2 1 1 — 6 1 - — 7 Hackney 15 18 9 11 3 56 6 - — 62 Holborn 4 6 1 — 1 12 — - — 12 Finsbury 12 27 2 7 2 50 — - — 50 London, City of — — — — 1 1 — - — 1 Shoreditch 30 45 19 16 8 118 2 - — 120 Bethnal Green 12 36 11 7 • 4 70 1 - — 71 Stepney 36 61 27 17 2 143 4 - — 147 Poplar 14 45 20 ll — 90 4 - 1 95 Southwark 25 51 19 10 6 111 2 - — 113 Bermondsey 9 26 8 4 3 50 2 — — 52 Lambeth 26 47 18 7 6 104 3 - — 107 Battersea 15 30 13 5 3 66 3 - — 69 Wandsworth 20 22 7 8 3 60 6 - — 66 Camberwell 24 55 17 12 8 116 5 - 1 122 Deptford 18 12 10 3 5 48 5 - 1 54 Greenwich 14 22 9 1 8 54 3 - 1 58 Lewisham 2 8 1 2 — 13 3 1 — 17 Woolwich 12 25 16 6 4 63 6 - — 69 London 395 752 301 169 94 1,711 82 2 6 1,801 Medical officers of health derive their information as to the existence of cases of measles mainly from the teachers of elementary schools. The majority of the annual reports show the number of cases of this disease concerning which the medical officers of health received intimation, and the following table has been compiled from the information thus supplied :— Measles. Sanitary area. No. of cases of measles, 1907. Sanitary area. No. of cases of measles, 1907. Sanitary area. No. of cases of measles, 1907. Paddington 1,284 Hackney 1,267 Lambeth 2,770 Kensington 528 Holborn 144 Battersea 931 Hammersmith 538 Finsbury 47 Wandsworth 1,602 Fulham 665 Shoreditch 470 Deptford 726 Chelsea 289 Bethnal Green 713 Greenwich 1,245 Westminster 566 Poplar 808 Lewisham 546 Hampstead 347 Bermondsey 452 Woolwich 1453 Islington 2,065 In the absence of notification of measles, the following figures contained in the annual reports of the medical officers of health of Paddington and Fulham are of interest:— Age distribution of cases of measles. Paddington. Ages 0- 1- 2- 3- 4- 5- 13- 15- 56 176 152 170 227 473 3 22 Fulham. Ages 0- 1- 2- 3- 4- 5- 6- 7- 10 12 27 36 60 137 231 111 49 12 18560 £ 30 The disinfection of rooms which have been occupied by cases of this disease is undertaken in a number of districts, and efforts are made to impress upon parents the necessity of recognising the risks of infection of measles. The medical officers of health of Holborn and Bethnal Green state that of 144 cases in the former district and 713 in the latter, 35 and 261 children respectively were found to be without medical attendance. In his report for 1907, Dr. Davies, of Woolwich, recurs to the need of skilled nursing of cases of measles. In some degree this want may be met by the employment of health visitors, whose advice should prove of material value, even although they may not be able to take part in the actual nursing. In this connection the qualifications of health visitors will need to be considered. In numerous districts, the closure of classes or of departments of elementary schools has been resorted to with a view to limiting the spread of infection by school attendance. In respect to early school-closure, which had been experimentally practised in Woolwich, Dr. Davies writes that, " it must be allowed to have failed as a means of preventing the spread of measles, and, except in special cases, has been discontinued." Scarlet Fever. The cases of scarlet fever notified in the Administrative County of London during 1907 (52 weeks numbered 25,925, compared with 20,329 in 1906. The number of deaths registered from this cause was 644 in the year 1907 (52 weeks), compared with 533 in 1906. The death-rate and case-rate in 1907 have been the highest, and the fatality the lowest, recorded in the present decennium. The lowest case-rate recorded in this decennium was in the year 1903, and the case-rate has increased year by year since that date and generally with decreasing fatality. The scarlet fever case-rates, death-rates and case-mortality for 1907 and preceding periods are 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 0.1P 4.3 2.6 1907 0.142 5.5 2.5 The death-rate in each year since 1858 in relation to the mean death-rate of the period 18591907 will be seen on reference to diagram VIII. The monthly case-rate and case-mortality in each of the years 1891-1907 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 1897-1906 the London scarlet fever death-rate was lower than that of any of the under-mentioned English towns, except Bristol, West Ham and Hull, and in 1907 was exceeded by the death-rates of Liverpool, Manchester, Birmingham, Sheffield, West Ham, Salford and Leicester:— Scarlet Fever—Death-rates per 1,000 persons living. Town. 1897-1906. 1907. Town. 1897-1900. 1907. London 0.1l2 0.142 West Ham 0.11 0.18 Liverpool 0.28 0.18 Bradford 0.17 0.04 Manchester 0.18 0.16 Newcastle-on-Tyne 0.12 0.08 Birmingham 0.20 0.17 Hull 0.11 0.06 Leeds 0.16 0.12 Nottingham 0.13 0.02 Sheffield 0.22 0.23 Salford 0.30 0.26 Bristol 0.10 0.07 Leicester 0.15 0.17 The following tables shows that in the decennium 1897-1906 the London scarlet fever deathrate was exceeded by the death-rates of Stockholm, St. Petersburg, Berlin, Vienna and New York, and in 1907 was higher than that of any, except St.. Petersburg and New York:— 1 The Infectious Disease (Notification) A,ct came into force in 1889, 2 See footnote (1\ page 8. Diagram WL Scarlet Feyer. Diagram IX Number of admissions to Hospitals of the Metro " Asylums Board per cent of total cases notified in London 1890~ IS 07. Diagram x Scarlet Feyer. 31 Scarlet Fever—Death.rates per 1,000 persons living. Town. 1897.1906. 1907. Town. 1897.1906. 1907. London 0.111 0.141 St. Petersburg 0.53 0.59 Paris 0.04 0.12 Berlin 0.21 0.09 Brussels 0.03 0.07 Vienna 0.12 0.12 Amsterdam 0.03 0.06 Rome 0.01 0.00 Copenhagen 0.09 0.02 New York 0.20 0.19 Stockholm 0.15 0.07 The following table shows the scarlet fever cases, deaths, case.rates, and death.rates for the year 1907, the case.rates for the decennium 1897.1906, and the death.rates for the period 1902.6 in the several sanitary districts of the County :— Scarlet I'ever—Case.rates and death.rates in sanitary areas. Sanitary area. . Notified cases, 1907 (52 weeks). Case.rate per 1,000 persons living. Deaths, 1907 (52 weeks). Death.rate per 1,000 persons living. 1897.1906. 1907. 1902.1906. 1907. Paddington 577 3.0 3.9 13 0.07 0.09 Kensington 532 2.4 2.9 9 0.08 0.05 Hammersmith 581 3.3 4.8 10 0.08 0.08 Fulham 668 4.4 4.0 14 0.09 0.08 Chelsea 219 2.9 2.9 2 0.09 0.03 Westminster, City of 418 2.5 2.4 12 0.07 0.07 St. Marylebone 435 2.7 3.4 19 0.11 0.15 Hampstead 320 2.8 3.5 5 0.06 0.06 St. Panoras 848 3.9 3.6 26 0.13 011 Islington 1,216 3.9 3.5 22 o.io 0.06 Stoke Newington 252 3.5 4.7 10 0.05 019 Hackney 1,808 4.4 7.8 43 0.09 0.19 Holborn 157 3.2 2.9 2 0.07 0.04 Finsbury 505 4.4 5.2 17 0.16 0.18 London, City of 97 2.9 4.8 1 0.10 0.05 Shoreditch 877 3.9 7.6 28 0.13 0.24 Bethnal Green 1,288 4.7 9.9 43 0.15 0.33 Stepney 3,128 4.2 10.2 83 0.12 0.27 Poplar 1,285 3.8 7.5 44 0.12 0.26 Southwark 1,275 4.5 61 35 014 0.17 Bermondsey 1,021 5.2 8.0 36 0.17 0.28 Lambeth 1,478 3.4 4.7 40 0.09 013 Battersea 977 4.6 5.4 19 o.io o.io Wandsworth 1,321 3.8 4.7 24 0.08 0.09 Camberwell 1,571 4.4 5.7 37 0.09 013 Deptford 777 4.9 6.7 14 013 012 Greenwich 661 3.7 6.2 10 0.08 0 09 Lewisham 604 3.5 4.0 12 0.08 0.08 Woolwich 1,027 4.4 8.0 14 0.07 O.ll Port of London 2 London 25,925 3.9 5 .5 644 0.10 0.141 The above table shows that the increased prevalence of the disease manifested in London as a whole occurred in every district, except Fulham, Westminster, St. Pancras, Islington andHolborn. 1 he most notable increases were in Hackney, Shoreditch, Bethnal.green, Stepney, Poplar and Woolwich. It will also be seen from the foregoing table that the scarlet fever death.rate was, in the period 1902.6, highest in Bermondsey (0p17) and lowest in Hampstead (0'06); in the year 1907, Bethnal. green (0*33) had the highest death.rate, and Chelsea (0'03) the lowest. The scarlet fever death.rates obtaining in London in the four quarters of the year 1907, were as follows : first quarter, 0'09 ; second quarter, 0'12; third quarter, 014; and fourth quarter, 019 per 1,000 persons living. 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 1907. It will be seen that at all.ages the case.rate was higher among females than among males, while the death.rate and fatality were higher among the latter. In the age groups adopted for the purposes of this table the greatest 18560 1 See footnote (1), page 8. e 2 32 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 in both sexes among children under one year of age:— Scarlet FeverT—1907. Age.period. Males. Females. Notified cases. Deaths. Case mortality per cent. Rates per 100,000 living. Notified cases. Deaths. Case mortality per cont. Rates per 100,000 living. Cases. Deaths. Cases. Deaths. All Ages 12,094 338 28 538 15 13,831 310 22 551 12 0— 139 18 12.9 241 31 130 14 10.8 227 24 ]— 526 38 7.2 1,029 74 438 39 8.9 857 76 2 806 58 7.2 1,561 112 828 59 7.1 1,609 115 3— 1,163 64 5.5 2,312 127 1,166 49 4.2 2,290 96 4— 1,327 39 2.9 2,696 79 1,306 43 3.3 2,666 88 5— 4,935 79 1.6 2,136 34 5,795 68 1.2 2,484 29 10— 1,811 17 0.9 831 8 2,398 15 0.6 1,079 7 15— 656 9 1.4 299 4 670 10 1.5 274 4 20— 343 6 1.7 150 3 523 5 1.0 191 2 25— 300 4 1.3 77 1 460 5 1.1 100 1 35— 73 5 6.8 25 2 93 3 3.2 29 1 45— 14 1 7.1 7 0 16 — — 7 — 55 & upwards 1 — — 0 - 8 - — 3 Scarlet Fever and Elementary Schools. In connection with the reduction in the number of notified cases during the summer holiday of the schools it may be stated that the summer holiday of the London County i Council schools began in 1907 on Thursday, the 25th July, i.e., the latter part of the 30th week, and the schools re.opened on Monday, the 26th August, i.e., at the beginning of the 35th week. If the number of cases notified in the four weeks which would be most subject to holiday influence be compared with the number of cases notified in the four preceding and four subsequent weeks, the results shown in the following table are obtained :— 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 270 1,540 316 _ holiday influence (28th to 31s£) Four weeks of holiday influence 259 1,429 304 —4.1 —7.2 —3.8 (32nd to 35th) Four weeki following weeks of 283 2,065 389 + 93 +44.5 + 28.0 holiday influence (36th to 39th) The medical officer of health of Hackney comments on a steady and rapid rise in the notifications of scarlet fever in his district, extending from the first week in September until the third week of October, and which is illustrated by a chart contained in his report. Dr. W arry thus writes :— "The special feature connected with this outburst of scarlet fever is its relation to schools and school attendance The outbreak may be said to have begun in the first week in June, steadily increasing until the last week in July, when a considerable fall took place which was continued until the last week in August, after which the disease rapidly increased, as described above. The period of remission during the month of August corresponded very closely with the summer closure of the schools, and subsequent increase with their re.opening. Other evidence pointing to this outbreak being largely due to school attendance is forthcoming in the fact that not a few cases of desquamation were found amongst scholars still attending school—the discovery of such cases usually following notification of some case of scarlet fever. An examination of the chart seems to show that the outbreak began before the midsummer holidays, but that these holidays were insufficient to stay the course of the outbreak. From the point of view of preventive medicine, I think this outbreak affords an illustration where the medical inspection of scholars prior to the resumption of school.work, would have been of immense value in preventing the spread of infectious disease. One is constantly meeting with this rise in the incidence of infectious disease immediately after the long summer holidays, and in this particular case I am of opinion that if it had been possible to examine all the children attending the infants' departments at the opening of the schools, the outbreak would not have assumed the proportions it did. In private schools, after long holidays, no child is taken back unless provided with a certificate that the child is free from infectious disease, and has not knowingly been exposed to such during the holidays I do not think it is practicable to apply this system to the Council's schools ; but I think the children, at least, of the infants' departments should be medically examined after the summer holidays before being allowed to commence school.work. If this were done, I believe it would result in a diminished prevalence of infectious disease." '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. Diagram XI Diphtheria. Afca/? Death.rate I8SS.I907 Z63 per million Mean Death.rate 1859.1307 386per million Diagram JEL Admissions to Hospitals of the Metropolitan Asylums Board per cent of total cases notified in London. 1890.1907. 33 The medical officer of health of Lewisham also urges that steps should be taken to ensure that children who have been exposed to infectious diseases should not return to school at the termination of the holidays, and he suggests that parents of children returning to school should for this purpose be required to make a declaration on a prescribed form that the children have not been so exposed within a certain period. The prevalence of scarlet fever among school children is commented on in many of the reports and closing of class.rooms in school departments is recorded in the reports relating to Shoreditch, Bermondsey, Deptford, Battersea, Wandsworth, Lewisham and Woolwich. In Hampstead, some two.thirds of 62 children resident in a boarding school were attacked, the source of infection being eventually found to be a boy who was observed to be desquamating. A localised outbreak in Bethnal. green was found to be due to children playing with a child, the nature of whose illness was not recognised until the subsequent cases occurred. An outbreak of scarlet fever occurred in Wandsworth in a childrens' residential home due to infection from a nurse, who was the first person to be attacked, and an outbreak which occurred in a Poor Law School in Woolwich had its origin in infection received by the children while attending a public elementary school. The distribution of cases in invaded homes is shown in the reports relating to Westminster and Paddington. Thus, in Westminster, where 418 were notified, two cases occurred in one house in 25 instances, three cases in one house in 10 instances, and four cases in one house in one instance ; and, in Paddington, where 579 cases were notified, two cases occurred in one house in 63 instances; three cases in one house in 21 instances, four cases in one house in seven instances, five cases in one house in two instances, six cases in one house in two instances, and seven cases in one house in one instance. 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 about the same as in the preceding year. Diphtheria. The cases of diphtheria (including membranous croup) notified in the Administrative County of London in 1907 (52 weeks) numbered 8,771, compared with 8,045 in 1906. The number of deaths registered from this cause was 781 in 1907 (52 weeks) compared with 691 in 1906. The increase in the number of deaths has been proportionately greater than the increase in the number of cases. It must be always remembered that variations in case.rate and case.mortality may be affected by variations in the extent of use of bacteriological methods of diagnosis, the effect of which would be to increase the number of clinically mild cases of the disease. The diphtheria case.rates, death.rates, and case.mortality in 1907, 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 l l 1871—80 0.12 l l 1881—90 0.26 l i 1891—1900 0.492 2.6 19.0 1901 0.29 2 2.7 10.9 1902 0.25 2 2.3 10.8 1903 0.16 2 1.7 9.6 1904 0.16 s 1.6 10.0 1905 0.12 2 1.4 8.4 1906 0152 1.7 8.6 1907 0.16 2 1.8 8.9 The death.rate in each year since 1858 in relation to the mean death.rate of the period 1859. 1907 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 1891.1907 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 1897.1906 the London rate was higher than that of any except Leeds, Sheffield, West Ham, Salford and Leicester, and in 1907 was exceeded by the rates of Birmingham, Bristol, West Ham, Newcastle.on.Tyne, Hull and Salford. Diphtheria—Death.rates per 1,000 persons living. Town. 1897.190(5. 1907. Town. 1897.1906. 1907. London 0.28 2 0'162 West Ham 0.45 0.24 Liverpool 0.25 0.15 Bradford 0.21 0.15 Manchester 0.18 0.16 Newcastle on.Tyne 0.16 0.19 Birmingham 0.22 0.18 Hull 0.23 0.25 Leeds 0.33 0.14 Nottingham 0.16 0.16 Sheffield 0.43 0.12 Salford 0.36 0.31 Bristol 0.27 0.17 Leicester 0.46 0.07 1 The Infectious Disease (Notification) Act came into force in 1889. 2 See footnote (1), page 8. 34 I lie following table shows that in the decennium 1897.1906 the London diphtheria death.rate exceeded that of any of the under.mentioned foreign towns, except Stockholm, St. Petersburg and Newyork, and in 1907 was higher than that of any of these towns except St. Petersburg, Berlin, Vienna and New York :— Diphtheria—Death.rates per 1,000 persons living. Town. 1897.1906, 1907. Town. 1897.1906. 1907. London 0.28 1 0.16 1 St. Petersburg 0.82 0.61 Paris 0.14 0.08 Berlin 0.22 0.22 Brussels 0.10 0.09 Vienna 0.25 0.17 Amsterdam 0.12 0.10 Rome 0.09 0.11 Copenhagen 0.13 0.07 New York 0.52 0.41 Stockholm 0.38 0.10 The following table shows the diphtheria cases, deaths, case.rates, and death.rates for the year 1907, the case.rates for the decennium 1897.1906, and the death.rates for the period 1902.6, in the several sanitary districts c— Diphtheria.—Case.rates and death.rates in sanitary areas. Sanitary area. Notified Oases, 1907 (52 weeks). Case.rate per 1,000 persons living. Deaths, 1907. (52 weeks). Death.rate per 1,000 persons living. 1897.1906. 1907. 1902.6. 1907. Paddington 169 1.6 1.1 20 0.11 0.13 Kensington 250 1.3 1.4 24 0.10 0.13 Hammersmith 215 1.8 1.8 18 0 .19 0.15 Fulham 605 3.1 3.6 38 0.20 0.23 Chelsea 158 1.7 2.1 7 0.11 0.09 Westminster, City of 145 1.3 0.8 17 0.08 0.10 St. Marylebone 128 1.4 1.0 16 0.13 0.12 Hampstead 112 1.3 1.2 7 0.08 0.08 St. Pancras 349 2.2 1.5 30 0.20 0.13 Islington 482 1.8 1.4 41 0.14 0.12 Stoke Newington 118 1.7 2.2 7 0.11 0.13 Hackney 543 3.0 2.3 47 0.18 0.20 Holborn 64 1.9 1.2 10 0.11 0.18 Finsbury 155 2.7 1.6 16 0.20 0.17 London, City of 28 1.9 1.4 5 0.15 0.25 Shoreditch 223 2.2 1.9 20 0.17 0.17 Bethnal Green 290 3.0 2.2 18 0.24 0.14 Stepney 751 2.7 2.4 93 0.23 0.30 Poplar 360 3.2 2.1 50 0.32 0.29 Southwark 422 2.9 2.0 36 0.18 0.17 Bermondsey 319 2.7 2.5 21 0.18 0.16 Lambeth 327 2.0 1.0 47 0.13 0.15 Battersea 359 2.3 2.0 38 0.10 0.21 Wandsworth 636 2.2 2.3 40 0.18 0.14 Camberwell 405 2.6 1.5 39 0.15 0.14 Deptford 318 2.8 2.7 25 0.19 0.22 Greenwich 257 2.3 2.4 18 0.19 0.17 Lewisham 302 2.2 2.0 18 0.15 0.12 Woolwich 279 2.3 2.2 15 0.17 0.12 Port of London 2 - - - - London 8,771 2.3 1.8 781 0.17 1 0..161 It will be seen from the foregoing table that in the period 1902.6 the diphtheria death.rate was highest in Poplar (0\32) and lowest in the City of Westminster (0'08) and Hampstead (0'08); in the year 1907, Stepney (0.30) had the highest death.rate, and Hampstead (0'08) the lowest. The diphtheria death.rates in each of the four quarters of the year 1907 were as follows: first quarter, 0'19; second quarter, 0'J .'5; third quarter, 0"14 ; and fourth quarter, 0.20 per 1,000 persons living. 1 o 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 1891.1907 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. Diagram XU1 Diphtheria. 35 Diphtheria. Sanitary areas.—Comparative ease.rates (London taken as 100). Sanitary aroa. Comparative caso.rate (London case.rate takon as 100). 1891. 1892. 1893. 1894. 189o. 1896. 1897. 1898. 1899. 19u0. 1901. 1902. 1903. 1904. 190j. 1906. 1907. Paddington.. 104 77 73 117 74 66 91 98 68 44 89 65 59 63 50 71 61, Kensington.. 78 60 68 63 86 70 67 49 51 74 52 43 59 63 50 59 78 Hammersmith 195 164 87 72 77 67 49 58 58 85 74 70 82 106 143 135 100 Fulham 61 58 78 126 139 99 109 145 135 178 174 126 118 125 129 147 200 Chelsea 138 110 83 107 143 184 107 79 61 74 56 78 76 50 50 129 117 Westminster, City of 58 91 57 53 61 53 59 67 50 59 52 70 59 50 50 71 44 StMarylebone 70 81 88 78 64 66 53 64 47 59 74 78 100 56 71 65 56 Hampstead 105 96 73 53 61 84 47 65 48 74 70 52 59 44 57 65 67 St. Pancras 89 95 103 83 90 64 76 78 79 93 148 152 129 94 86 71 83 Islington 152 119 86 103 70 106 73 60 68 70 100 113 82 63 71 76 78 Stoke New. ington 83 113 97 77 70 70 52 59 34 111 104 83 47 75 107 53 122 Hackney 131 147 135 108 93 89 122 152 106 107 167 139 141 156 121 100 128 Holborn 52 89 79 61 66 61 104 102 46 70 i04 87 53 60 57 71 67 Finsbury 118 82 130 81 86 112 170 163 93 74 107 100 76 94 100 118 89 CityoiLondon 59 130 60 49 51 74 71 60 68 89 96 161 65 106 50 47 78 Shoreditch 124 89 131 95 80 97 103 80 103 111 104 83 76 100 114 71 106 BethnalGreen 154 230 181 168 143 114 144 100 89 115 133 104 112 206 164 112 122 Stepney 106 132 112 123 157 150 128 93 89 107 104 113 106 169 150 118 133 Poplar 191 148 214 159 179 133 141 105 83 141 137 117 147 250 207 88 117 Southwark 71 72 116 113 86 106 102 151 207 141 100 113 100 87 107 112 111 Bermondsey 68 60 84 126 80 99 97 90 177 133 93 91 76 94 93 153 139 Lambeth 88 97 91 83 88 74 83 103 121 104 63 70 65 69 100 76 56 Battersea 144 123 132 122 97 81 125 178 116 70 59 74 106 81 79 88 111 Wandsworth 74 83 84 79 60 51 100 114 99 74 74 135 124 100 93 118 128 Camberwell 69 65 67 112 140 180 154 102 156 130 122 113 82 63 64 76 83 Deptford 72 68 86 153 225 113 141 132 121 111 144 104 241 106 93 153 150 Greenwich 60 43 84 85 137 189 82 105 122 89 74 78 124 94 100 229 133 Lewisham 48 74 82 70 57 122 85 127 170 126 85 130 118 56 79 106 111 Woolwich 32 68 66 66 81 96 91 86 100 115 67 91 88 81 157 176 122 London 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 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 1907. At " all.ages " the incidence of attack was, as in preceding years, greater on females than on males, while the incidence of death and the fatality were higher among the latter. 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 one and females of two years of age. The fatality was greatest among males of under one and females of one year of age Diphtheria}—1907. Age.period. Males. Females. Notified Cases. Deaths. Case mortality per cent. Rates per 100,000 living. Notified Cases. Deaths. Case mortality per c nt. Rates per 100,000 living. Cases. Deaths. Cases. Deaths. All Ages 4,007 393 9 8 178 17 4,764 407 8.5 190 16 0— 122 31 254 211 54 93 21 22.6 162 37 1— 353 83 23.5 691 162 292 69 236 571 135 2 362 68 18.8 701 132 396 73 18*4 770 142 3— 498 62 12.4 990 123 468 69 14.7 919 136 4— 488 52 10.7 991 106 515 43 8.3 1,051 88 5— 1,351 85 6.3 585 37 1,674 107 6.4 718 46 10— 399 3 0.8 183 1 552 6 11 248 3 15— 156 3 1.9 71 1 225 4 1.8 92 2 20— 106 1 0.9 46 0 178 2 11 65 1 25— 113 2 1.8 29 1 247 5 2.0 54 1 35— 40 1 2.5 14 0 78 3 3.8 24 1 45— 10 — — 5 — 30 2 6.7 13 1 55 & upwards 9 0 u 22.2 4 1 16 3 18.7 6 1 1 See footnote ('), page 32. 36 Diphtheria and Elementary Schools. In connection with the question of the reduction in the prevalence of the disease among persons of school age during the summer holiday when the schools are closed it has been thought well to include, as in previous reports, the following table. The summer holiday of the schools of the London County Council began on Thursday, the 25th July, i.e., the latter part" of the '30th week, and the schools re.opened on Monday, the 26th 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—1907. 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) 117 426 124 — — — Four weeks of holiday influence (32nd to 35th) 182 315 108 + 12.8 —20.1 —12.9 Four weeks following weeks of holiday influence (36th to 39th) 123 500 119 —6.8 + 58.7 + 10.2 Prevalence of diphtheria among the scholars of particular schools are recorded by the medical officers of health of Kensington (Gloucester.grove School), Fulham (Townmead.road, Hugon. road and Peterborough Schools), Chelsea (St. George's Home), Stoke Newington (St. Mary's School, Barn.street, andOldfield.roadSchool), Wandsworth (Oldridge.road, Smallwood.road, TootingGraveney and Roehampton Schools), Camberwell (a North Camberwell school), Deptford (Clifton.road and Clyde. street Schools), Greenwich (St. Paul's School, Randel.place and Blackheath.road), Lewisham (St. Philip's School, Sydenham, and Lewisham.bridge Schools), and Woolwich (Bostall.lane School). In some instances classrooms or school departments have been closed on account of diphtheria prevalence among the scholars, and in other instances particular children have been excluded from school. In July of 1906 the Council authorised the Education Committee to refuse during the presence of diphtheria in any district, re.admission to school of children excluded on account of diphtheria, or sore throat, until such children shall have obtained a medical certificate of freedom from infection based on a bacteriological examination. The ability to control the spread of diphtheria in schools by the exclusion of particular scholars is referred to in the report of the medical officer of health of Greenwich. He writes :— An outbreak which occurred during the year in connection with one of the schools in this district was only checked by and when this method was rigidly enforced. Occasional notifications of cases of diphtheria, in connection with the children attending this school, particularly the infants' department, also in the families frcm which children came to the school, although the actual scholar was not a patient, had been received. I called, and had a conversation with the head teacher, seeing the children thus in attendance, who all appeared well; there were, however, a large number of absentees, many being reported ill with measles ; I arranged with the head teacher for all suspicious children actually attending school to have their throats examined bacteriologically, with the result that, out of 47 children examined, a positive result was given in eight cases. All these children were excluded from school, a circular letter being sent to the parents in each case, recommending that medical advice should be obtained, and it was arranged with the head teacher that no children who were absent from school on the day of the examination should be re.admitted until they produced a certificate to the effect that bacteriological examination of the throat had given a negative result, and from this time the cases of diphtheria in this school ceased. The medical officer of health of Fulham also writes : Diphtheria was again most prevalent in Sands End Ward, particularly during the last four months of the year, when 130 cases were reported in that district. There was a special incidence among children attending three of the schools in the ward, viz., Townmead.road, Peterborough and Hugon.road. The notifications were swollen by the " carrier cases," i.e., cases in which the diphtheria bacillus was found though the children showed no signs of illness which were detected in these schools consequent upon the bacteriological examination of the throats of the children in the classes in which cases occurred. In Townmead.road School, five children harbouring the bacillus were found in one of the infants' classes, three in one of the girls' classes and one in each of three other infant classes. In Peterborough School eight cases were found in the boys' department, four classes being affected, and six in the infants' department, distributed among three classes. In Hugon.road School three "carriers" were found in the girls' department and two in the infants,' At Townmead and Hugon.road Schools the exclusion of the bacteriological cases was successful in checking the extension of the disease, and this was also the case in the boys' department of Peterborough School, but in the infants' department of that school cases of clinical diphtheria continued to be reported until the school was closed for the Christmas holidays, and there have been no cases since it was re.opened. The medical officer of health of Lewisham writes : "The system of excluding carrier cases has been tried, and but for our insistence on closing the class.rooms of certain schools, serious results might Diagram HV Whooping Cough. 37 have occurred." It is not, however, clear how far this conclusion is based upon a complete application of the method, for he also writes "In regard to diphtheria, an attempt is sometimes made by the Education Authority to exclude what are termed carrier cases. These are cases having the disease in such a mild form as to permit attendance at school without detection. A bacteriological examination is made in regard to a selected few, and the children who are reported to be suffering from pseudo.diphtheria or diphtheria are excluded. There is much to be said for this plan, provided that a swab is taken from every child in the classroom. The mere selection of a few is not sufficient nor can absolute reliance be placed upon bacteriological examination of one swab only." In this connection the sufficiency of the administration for this purpose may well receive the attention of the Council. Information is much needed concerning the relation of so called carrier cases to clinically recognisable diphtheria. The extent to which carrier cases may exist in schools which are clinically free from the disease, the existence in the home of other carrier cases with the case of the child attending school, the evidence which is to be found in the home of the ability of the carrier case to infect other members of the family with clinically recognisable diphtheria, and the conditions under which such cases acquire an infective ability are matters much needing investigation, and further, the question whether a child harbouring the Klebs Loeffler bacillus can by convenient treatment be freed from this organism is well deserving of experimental inquirv. In a number of reports information is given concerning the number of cases from which material was examined bacteriologically and the results obtained. Thus— District. No. examined. No. positive. District. No. examined. No. positive. Fulham 431 167 Shoreditch 18 4 Chelsea 90 41 Poplar 267 96 Westminster, City of 101 21 Bermondsey 696 122 St. Marylebone 38 13 Lambeth 538 26 St. Pancras 71 27 Battersea 386 116 Islington 1,226 492 W andsworth 454 147 Stoke Newington 138 59 Deptford 150 45 Hackney 246 *81 Greenwich 1,299 221 Holborn 13 2 Lewisham 341 93 Finsbury 122 51 W oolwich 679 128 In the annual reports relating to Paddington and Fulham the distribution of cases of diphtheria in houses is shown. Thus in Paddington, where 160 cases were notified, in 13 instances two cases, and in three instances three cases occurred in one house. In Fulham, where 536 houses were invaded, in 40 instances two cases, in eight instances three cases, in three instances four cases, and in one instance five cases occurred in one house. I n Fulham in each of two houses in which cases occurred the diphtheria bacillus was isolated from the throat of a cat which had shown signs of illness. Proportion of cases of diphtheria removed to hospital. It will be seen from diagram XII. that the proportion of cases of diphtheria removed to the hospitals of the Metropolitan Asylums Board was about the same as that in the preceding year. Whooping.cough. The deaths from whooping.cough in the Administrative County of London during the year 1907 (52 weeks) numbered 1,786, as compared with 1,226 in 1906. The death.rates from this disease in 1907 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 1902 0.401 1851—60 0.88 1903 0.351 1861—70 0.88 1904 0.321 1871—80 0.81 1905 0.321 1881—90 0.69 1906 0.261 1891—1900 0.501 1907 0.381 1901 0.351 1 See footnote (M, page 8. 18560 P 38 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 :— 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 2.871 1891—1900 4.211 1906 2.331 1901 3.131 1907 3371 The death.rate in each year since 1840 in relation to the mean of the period 1841.1907 is shown in diagram XIV., while the deaths in each month since 1890 in relation to the mean monthly deaths of the period 1891.1907 are shown in diagram VII., page 27. It will be seen from the following table that in the decennium 1897.1906 the London whooping. cough death.rate was exceeded by the death.rates of Liverpool, Manchester, Birmingham, W est Ham, Salford and Newcastle.on.Tyne , and in the year 1907, was exceeded by the death.rates of Liverpool, Manchester, West Ham, Newcastle.on.Tyne, Nottingham and Salford. Whooping.cough—Death.rates per 1,000 persons living. Town. 1897.1906. 1907. Town. 1897.1906. 1907. London 0.372 0.382 West Ham 0.46 0.54 Liverpool 0.48 0.43 Bradford 0.24 0.28 Manchester 0.44 0.49 Newcastle.on.Tyne 0.41 0.48 Birmingham 0.45 0.34 Hull 0.35 0.37 Leeds 0.35 0.34 Nottingham 0.31 0.51 Sheffield 0.37 0.35 Salford 0.49 0.61 Bristol 0.35 0.10 Leicester 0.31 0.06 The following table shows that the London whooping.cough death.rate was, both in the decennium 1897.1906 and the year 1907, higher than that of any of the undermentioned foreign towns. Whooping.cough—Death.rates per 1,000 persons living. Town. 1897.1906. 1907. Town. 1897.1906. 1907. London 0.372 0.382 St. Petersburg 0.21 0.22 Paris 0.12 0.11 Berlin 0.26 0.20 Brussels 0.12 0.06 Vienna 0.09 0.05 Amsterdam 0.25 0.17 Rome 0.08 0.11 Copenhagen 0.31 0.33 New York 0.12 0.09 Stockholm 0.16 0.12 The following table shows the whooping.cough deaths and death.rates for the year 1907 and the death.rates for the period 1902.6 in the several metropolitan sanitary districts :— 1 Including deaths of Londoners in the Metropolitan Workhouses, Hospitals, and Lunatio Asylums outside the County, but excluding those of non.Londoners in the London Fever Hospital, the Metropolitan Asylums Hospitals and the Middlesex County Asylum, within the County of London. 2 See footnote (1), page 8. Diagram XY Typhus. 39 Whooping.cough—Death.rates in sanitary areas. Sanitary area. Deaths, 190 (52 weeks). Death.rate per 1,000 persone living. 1902.6. 1907. Paddington 52 0.21 0.35 Kensington 81 0.24 0.45 Hammersmith 33 0.29 0.27 Fulham 75 0.37 0.45 Chelsea 25 0.29 0.33 Westminster, City of .. 25 0.15 0.15 St. Marylebone 44 0.20 0.35 Hampstead 12 0.12 0.13 St. Pancras 78 0.37 0.33 Islington 124 0.34 0.36 Stoke Newington 19 0.28 0.36 Hackney 68 0.28 0.29 Holborn 28 0.28 0.51 Finsbury 52 0.49 0.54 London, City of 7 0.18 0.35 Shoreditch 101 0.57 0.88 Bethnal Green 60 0.46 0.46 Stepney 102 0.44 0.33 Poplar 82 0.46 0.48 Southwark 103 0.42 0.49 Bermondsey 55 0.41 0.43 Lambeth 111 0.33 0.35 Battersea 68 0.38 0.38 Wandsworth 112 0.26 0.40 Camberwell 118 0.32 0.43 Deptford 37 0.38 0.32 Greenwich 26 0.33 0.24 Lewisham 51 0.23 0.34 Woolwich 37 0.28 0.29 London 1,786 0.331 0.381 It will be seen from the foregoing table that both in the period 1902.6 and the year 1907 the highest whooping.cough death.rate obtained in Shoreditch (0'57 and 0'88 respectively), and the lowest in Hampstead (012 and 0.13 respectively). The whooping.cough death.rates in each of the four quarters of the year 1907 were as follows : first quarter, 0'45 ; second quarter, 0'57 ; third quarter, 0'31 ; and fourth quarter, 0'18 tier 1,000 persons living. As in the case of measles some of the annual reports show the number of cases of whooping cough which became known to the medical officers of health in 1907, and the following figures are thus supplied:— No. of cases. No. of cases. No. of cases. Paddington 589 Islington 831 Bermondsey 408 Kensington 597 Hackney 678 Lambeth 887 Hammersmith 337 Finsbury 211 W andsworth 930 Chelsea 142 Shoreditch 368 Woolwich 598 Westminster 323 Typhus. There were no deaths from typhus registered in the Administrative County of London during the year 1907. 1 See footnote ('), page 8. 18560 F 2 40 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 •001 1 1901 •001 1 1902 •ooo 1 1903 •001 1 1904 — 1905 — 1906 — 1907 In this table '000 indicates that the deaths were too few to give a rate of .0005 ; where — is inserted no death occurred. The death.rate in each period since 1868 in relation to the mean death.rate of the period 1869.1907 is shown in diagram XV. During the year 1907 five persons were certified to be suffering from typhus—one resident in Hackney, one in Holborn, one in Bethnal.green, one in Stepney, and one in Lambeth. Of these five cases only three were actual cases of this disease. The first case occurring in February, was that of a girl aged 14 years of age, who had lived in Sutton.street and Lucas.street, Stepney, for a month before she sickened. She was employed in a laundry. The source of her infection was unknown. The second, also occurring in February, was that of a woman aged 50 living with another woman in a single room, in Holborn. The source of her infection was unknown. The third, occurring in April, was that of a Russian immigrant, a male aged 19. He had arrived in England 12 days before his attack. In no instance was there any extension of disease from these people. Enteric Fever. The number of cases of enteric fever notified in the Administrative County of London during 1907 (52 weeks) was 1,394, compared with 1,600 in the year 1906. The deaths from this disease numbered 194 in 1907 (52 weeks), compared with 260 in 1906. The case.rate and death.rates per 1,000 persons living and the case.mortality per cent, in 1907 and preceding periods were as follows :— Enteric Fever. Period. Death.rate per 1,000 persons living. Case.rate per 1,000 persons living. Case.mortality per cent.. 1871—80 0.24 2 2 1881—90 0.19 a 2 1891—1900 0.14 1 0.8 18.2 1901 0.11 1 0.7 15.6 1902 0.12 1 0.7 15.8 1903 0.08 1 0.5 15.7 1904 0.06 0.4 15.1 1905 0.05 1 0.3 15.1 1906 0 06 1 0.3 16.2 . 1907 0.041 0.3 13.9 The death.rate in each year since 1868 in relation to the mean death.rate of the period 1869.1907 is shown on diagram XVI. The notified cases in each week of 1907 may be compared with the average weekly notifications of the period 1890.1907 on reference to diagram XVII. The monthly case.rate and case.mortality in each of the years 1891.1907 in relation to the mean of the whole period is shown in diagram XVIII. The following table shows the enteric fever cases, deaths, case.rates and death rates for the year 1907, the case.rates for the decennium 1897.1906, and the death.rates for the period 1902.6 in the several sanitary districts— 1 See footnote ('), page 8. 2 The Infectious Disease (Notification) Act came into force in 1889. Diagram IYI Enteric Fever, Diagram XYI1 Enteric Fever. 7 Diagram XVIII Enteric Fever. 41 Enteric Fever—Case-rates and death-rates in sanitary areas. Sanitary area. Notified cases, 1907 (52 weeks). Case-rate per 1,000 persons living. Deaths, 1907 (52 weeks). Death-rate per 1,000 persons living. 1897-1906. 1907. 1902-6. 1907. Paddington 34 0.5 0.2 5 0.06 0.03 Kensington 40 0.5 0.2 6 0.06 0.03 Hammersmith 40 0.5 0.3 6 0.06 0.05 Fulham 58 0.5 0.3 8 0.07 0.05 Chelsea 21 0.4 0.3 3 0.04 0.04 Westminster, City of 51 0.5 0.3 8 0.06 0.05 St. Marylebone 31 0.6 0.2 2 0.06 0.02 Hampstead 21 0.4 0.2 2 0.05 0.02 St. Pancras 55 0.8 0.2 4 0.08 0.02 Islington 95 0.7 0.3 13 0.07 0.04 Stoke Newington 15 0.5 0.3 3 0.05 0.06 Hackney 108 0.9 0.5 21 0.12 0.09 Holborn 14 0.7 0.3 2 0.07 0.04 Finsbury 23 0.7 0.2 2 0.10 0.02 London, City of 9 0.9 0.4 2 0.05 0.10 Shoreditch 36 0.8 0.3 6 0.09 0.05 Bethnal Green 55 0.8 0.4 7 0.08 0.05 Stepney 120 0.8 0.4 21 0.09 0.07 Poplar 81 1.0 0.5 11 0.09 0.06 Southwark 80 0.7 0.4 11 0.08 0.05 Bermondsey 45 0..8 0.4 7 0.08 0.05 Lambeth 54 0.5 0.2 5 0.07 0.02 Battersea 44 0.6 0.2 4 0.07 0.02 Wandsworth 69 0.4 0.2 11 0.07 0.04 Camberwell 82 0.5 0.3 8 0.06 0.03 Deptford 34 0.6 0.3 6 0.06 0.05 Greenwich 18 0.7 0.2 5 0.06 0.05 Lewisham 32 0.4 0.2 1 0.04 0.10 Woolwich 27 0.4 0.2 4 0.07 0.03 Port of London 2 - - – London 1,394 0.6 0.3 194 0.071 0.041 It will be seen from the foregoing table that among the several sanitary areas in the period 1902-6 the enteric fever death-rate was highest in Hackney (0.12), and lowest in Chelsea (0.04) and Lewisham (0.04); in the year 1907 the City of London (0.10) had the highest enteric fever death-rate and Lewisham (0.01) the lowest. The death-rates from enteric fever in London, in each of the four quarters of the year 1907, were as follows: first quarter, 0.05; second quarter, 0 03 ; third quarter, 0 03 ; and fourth quarter, 0 06, 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 1907. The case-rate, death-rate, and 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 males aged 20-25 and upon females aged 10.15; the greatest incidence of death was upon males aged 20-55 and upon females aged 25-35. The fatality was greatest among a both males and females aged 45-55. Enteric Fever'—1907. 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 714 119 16 7 32 5 680 90 13.2 27 4 0— – – ) 1— 1 – 2— 6 -3 9.7 12 1 6 " 6 17.1 13 2 3— 8 5 4— 16 24 • 5— 78 5 6.4 34 2 84 ) 5 6.0 36 2 10— 73 2 2.7 33 1 87 5 5.7 39 2 15— 90 14 15.6 41 6 87 13 14.9 36 20— 112 18 16.1 49 8 97 9 9.3 35 5 3 25— 170 31 18.2 44 8 168 28 16.7 37 6 35— 105 24 22.9 36 8 78 15 19.2 24 5 45— 34 16 47.1 17 8 28 6 21.4 12 3 55 & upwards 21 6 28.6 10 3 16 3 18.7 6 1 1 See footnote (1), page 8. 2 See footnote (1), page 32, 42 The only accounts of the occurrence of groups of cases in which a common cause was suspected are contained in the reports of the medical officers of health of Fulham, Chelsea and Battersea. The accounts in the Fulham and Chelsea reports refer to the same outbreak, involving two persons resident in Fulham and five persons resident in Chelsea—the latter including all the persons resident in a house in Chelsea, except the male head of the family, who escaped. Six of these persons were related and were frequently together, and the infection may have been received on the 5th May, an occasion when they all dined together. The seventh case was the servant in the Chelsea house. Suspicion attached to the consumption of watercress, which, on the 5th May, was eaten by all except the servant, who had, however, prepared it for table. The source of the watercress could not be discovered. The account in the Battersea report relates to three groups of cases. The first group consisted of nine persons, each living in a separate house, and all attacked between the 28th July and 17th August. The source of infection could not be discovered. The second of these groups included five persons living in the same house. The first, who was an eater of fried fish, was attacked the beginning of February, and was removed to hospital. In the beginning of April his wife and child and a child living in the top of the house were notified to be suffering from the disease, and three weeks later the mother of this latter child was also notified, the first case having been in the hospital the whole time. The third group, comprising four persons, occurred in one house. A child living in the upper part of a house was certified on the 23rd September to be suffering from enteric fever. He was looked after by a family living in the lower part of the house, and on the 4th October the mother and two children of this family were certified to be suffering from this disease. Dr. Lennane suggests that a faulty drain may have been the cause of the second of these groups, and that in the ease of the third of these groups the first case may have infected the others. In other reports a proportion of the cases is attributed to infection from person to person. The difficulty of determining the extent to which infection from person to person maintains enteric fever in London is, however, considerable, as the widely different intervals of time which may elapse between the date of infection and the date when the symptoms of the disease are sufficiently conspicuous to lead to notification may easily obscure the existence of a cause such as an infected food supply, common to all the cases of a group In a number of the reports the consumption of some particular article of food, some two weeks or so before the illness begins, is mentioned as a possible cause. Altogether, of 513 cases of enteric fever occurring in districts the reports for which give the necessary information, the number of cases regarded as possibly due to the following articles of food was —mussels, 16 cases; oysters, 14; periwinkles, 6; cockles, 4; whelks, 1; crabs, 1; shellfish, unspecified, 31; fried fish, 14; watercress, 6; ice cream, 6. The number of cases associated with shellfish equals 14 per cent, of the total cases occurring in these districts, and the total number of cases associated with articles of food of all descriptions equals 19 per cent, of all the cases. Infection in the laboratory (Hampstead) is mentioned as the cause of one attack and immersion in the Thames (Fulham) as another. A number of years ago Dr. Hartt, the then medical officer of health of Greenwich, found reason for attributing several attacks of enteric fever in that district to bathing in the Thames. The Widal test is frequently employed for the diagnosis of enteric fever in London, and in many districts sanitary authorities give opportunities for this test to be used at the public charge. Some of the reports show the number of examinations thus made, from which it appears that out of 393 cases a positive result was obtained in 127 instances, or 33 per cent. Diarrhœa. The deaths in the Administrative County of London during 1907 (52 weeks) attributed to epidemic diarrhoea and infective enteritis numbered 780, while 763 deaths were attributed to diarrhoea and dysentery. The corresponding figures for 1906 were 2,872 and 1,635 respectively. The age-distribution of the deaths in 1907 was as follows:— Diarrhœa—Deaths1 at the several age-periods—1907. Disease. Under 1 year. 1-5. 5–20. 20-40. 40-60. 60-80. 80 and upwards All ages. Epidemic diarrhoea (infective enteritis) 625 119 8 5 8 12 3 780 Diarrhoea and dysentery 499 94 8 36 40 58 28 763 Total 1,124 213 16 41 48 70 31 1,543 No accurate comparison can be made of the deaths from epidemic diarrhoea for a long series of years in London, diagram XIX, however, shows the death-rate from cholera, dysentery, and diarrhcea combined, in relation to the mean death-rate of the period 1841-1907 in each year since 1840, and it is thus seen that the death-rate of 1907 is the lowest since 1841, a result to which the low temperature which prevailed in the summer must be regarded as largely contributory. The following table shows that the London diarrhoea death-rate was in the decennium 18971906 lower than the death-rate of any of the undermentioned large English towns, except Bristol, 1 See footnote (1), page 38. Diagram XIX Diarrœha, Dysentery & Cholera. 43 Bradford and Newcastle-on–Tyne, and in 1907 was lower than that of any except Bristol, Bradford, Newcastle-on-Tyne, and Leicester:— Diarrhœa—Death-rates per 1,000 persons living. Town. 1897-1906. 1907. Town. 1897-1906. 1907. London 0 851 0.321 West Ham 1.55 0.66 Liverpool 1.61 0.73 Bradford 0.79 0.17 Manchester 1.42 0.50 Newcastle-on-Tyne 0.78 0.14 Birmingham 1.38 0.43 Hull 1.57 0.37 Leeds 1.04 0.38 Nottingham 1.25 0.63 Sheffield 1.53 0.99 Salford 1.57 0.44 Bristol 0.60 0.32 Leicester 1.22 0.31 The deaths and death-rates from diarrhoea for the year 1907, and the death-rates for the period 1902-6 in each of the sanitary areas of London, are shown in the following table:— Diarrhœa—Death-rates in sanitary areas: Sanitary area. Deaths, 1907 (52 weeks). Death-rate per 1,000 persons living. 1902-6. 1907. Paddington 42 0.65 0.28 Kensington 38 0.63 0.21 Hammersmith 21 0.83 0.17 Fulham 83 1.26 0.50 Chelsea 29 0.54 0.39 Westminster, City of 41 0.35 0.24 St. Marylebone 24 0.56 0.19 Hampstead 8 0.18 0.09 St. Pancras 49 0.54 0.21 Islington 102 0.50 0.29 Stoke Newington 8 0.46 0.15 Hackney 80 0.78 0.34 Holborn 16 0.52 0.29 Finsbury 40 0.98 0.41 London, City of 1 0.23 0.05 Shoreditch 74 1.37 0.64 Bethnal Green 57 0.95 0.44 Stepney 153 1.15 0.50 Poplar 78 1.24 0.46 Southwark 101 1.01 0.48 Bermondsey 48 1.10 0.38 Lambeth 92 0.76 0.29 Battersea 45 0.78 0.25 Wandsworth 74 0.64 0.26 Camberwell 72 0.69 0.26 Deptford 34 0.85 0.29 Greenwich 37 0.74 0.35 Lewisham 29 0.57 0.19 Woolwich 34 0.72 0.26 London 1,510 0.77 0.321 It will be seen from the foregoing table that the diarrhoea death-rate was in the period 1902-6 highest in Shoreditch (1.37), and lowest in Hampstead (0.18); in the year 1907, Shoreditch (0.64) had again the highest death-rate, the lowest obtaining in the City of London (0.05). The diarrhoea deathrates in London in each of the four quarters of the year 1907, were as follows : first quarter, 0.16 ; second quarter, 0.16; third quarter, 0.46 ; and fourth quarter, 0.49, per 1,000 persons living. The report of Dr. Davies, the medical officer of health of Woolwich, contains some interesting observations on the low diarrhœal mortality of that district in 1907. During the summer quarters of the years 1905-6-7 a system of notification of zymotic enteritis and visitation of the homes of the patients by a female sanitary inspector has been in force in Woolwich. He compares the Woolwich death-rate of that quarter in the period 1901–1 with that of the corresponding quarter of 1905-7, and finds that in the first period it was 2.30 per 1,000 living, and in the second period, 1.53 per 1,000 living, i.e., it has declined 34 per cent. In London, as a whole, the diarrhoea mortality of the two periods has been 2.27 and 1.91, showing a decline of 16 per cent. The Woolwich figures are undoubtedly small for the purpose of safe inference and the natural †luctuations of diarrhœal mortality in different localities have to be considered, but the results so far as they go are encouraging. 1 See footnote (l), page 8. 44 Erysipelas. The deaths from erysipelas in the Administrative County of London during 1907 (52 weeks) numbered 189, as compared with 245 in 1906. The age-distribution of these deaths was as follows:— Erysipelas—Deaths1 at the several age-periods— 1907. Under 1 Year. 1-5. 5-20. 20-40. 40-60. 00-80. 80 and upwards. All ages. 50 9 3 16 38 60 13 189 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 0.2 171 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 1907 4,497 0.95 189 0.04 The number of cases of erysipelas notified and the case-rate for the year 1907, together with the case-rate in the decennium 1897-1906, in the several sanitary areas are shown in the following table:— Erysipelas.—Case-rates in sanitary areas. Sanitary area. Notified Cases, 1907 (52 weeks). Case-rate per 1,000 persons living. 1897-1906. 1907. Paddington 124 1.0 0.8 Kensington 127 1.0 0.7 Hammersmith 78 l.0 0.6 Fulham 130 l.0 0.8 Chelsea 44 0.8 0.6 Westminster, City of 102 0.8 0.6 St. Marylebone 134 1.4 1.1 Hampstead 56 0.6 0.6 St. Pancras 183 1.2 0.8 Islington 254 0.9 0.7 Stoke Newington 30 0.8 0.6 Hackney 311 1.3 1.3 Holborn 39 1.5 0.7 Finsbury 109 1.4 1.1 London, City of 15 0.8 0.7 Shoreditch 138 1.5 1.2 Bethnal Green 247 2.0 1.9 Stepney 473 1.5 1.5 Poplar 187 1.3 1.1 Southwark 256 1.4 1.2 Bermondsey 143 1.4 1.1 Lambeth 226 0.9 0.7 Battersea 175 1.0 1.0 Wandsworth 214 1.0 0.8 Camberwell 264 1.1 1.0 Deptford 145 1.3 1.2 Greenwich 93 1.1 0.9 Lewisham 86 0.7 0.6 Woolwich 113 0.7 0.9 Port of London 1 London 4,497 1.1 0.9 1 See footnote (1), page 38. The following table shows the age and sex distribution of the notified cases of erysipelas in 1907— Age-period. All Ages. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75 and upwards. Males 1,958 192 100 73 105 108 233 372 356 232 134 53 Females 2,539 206 102 116 137 129 310 457 476 288 212 106 Persons 4,497 398 202 189 242 237 543 829 832 520 346 159 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 largely exceeds the number of males attacked. Puerperal Fever. The deaths in the Administrative County of London during the year 1907 (52 weeks) attributed to puerperal fever1 numbered 152, as compared with 187 in 1906. 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.2 1891 221 222 1892 337 313 1893 397 352 1894 253 210 1895 236 208 1896 277 225 1897 264 215 1898 247 184 1899 326 209 1900 237 169 1901 253 184 1902 311 201 1903 233 170 1904 273 198 1905 292 183 1906 298 187 1907 254 152 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-rate' per 1,000 living. Death-rate' 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 1.61 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 1907 0.05 2.09 0.03 1.25 The subject of puerperal fever occurring in the practice of midwives will be found on reference to the administration of the Midwives Act, 1902, see pp. 87, et seq. 1 Including deaths from puerperal septicaemia and puerperal pyaemia. 2 See footnote (1), page 38. 13560 G 46 Influenza, Bronchitis and Pneumonia. The deaths attributed to influenza, which in 1906 numbered 895, rose to 967 in 1907. The deaths from bronchitis numbered 6,010 in 1907, compared with 5,373 in 1906. In 1907 there were 7,538 deaths attributed to pneumonia, an increase of 952 over the number occurring from the same cause in 1906. The deaths from these diseases since 1889 have been as follows:— Influenza, Bronchitis and Pneumonia. Year. Deaths1 from Influenza. Deaths 1 from Bronchitis. Deaths 1 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 1907 967 6,010 7,538 The distribution of deaths from influenza throughout the year for each of the years 1890 to 1907 is shown in the following table:— Influenza—Deaths 1 registered in London in four-weekly periods—1890-1907. Number of weeks. 1890. 1891. 1892. 1893. 1894. 1895. 1896. 1897. 1898. 1899. 1800. 1901. 1902. 1903. 1904. 1905. 1906. 1907. 1—4 303 9 1,308 52 272 59 37 40 244 66 1,016 57 77 141 67 £4 56 291 5—8 167 7 637 96 96 164 58 55 368 259 298 75 224 103 62 119 44 186 9—12 75 8 119 162 69 1,343 61 94 193 430 130 134 298 89 74 119 98 104 13—16 39 29 42 180 56 257 50 121 140 302 172 102 89 54 62 75 129 81 17—20 13 770 33 125 32 106 50 96 61 121 105 81 58 46 40 56 105 48 21—24 5 1,044 22 72 27 35 33 54 51 82 57 30 35 37 21 38 40 41 25—28 6 242 15 49 19 28 17 26 25 42 16 21 20 25 17 16 21 25 29—32 6 51 7 23 17 14 15 18 27 27 12 18 7 18 5 4 20 14 33—36 3 32 9 23 20 17 10 13 10 11 11 11 16 6 9 11 15 18 37—40 6 13 6 18 14 15 12 19 17 19 15 12 13 17 24 22 18 19 41—44 5 15 20 28 29 22 27 29 46 55 17 23 35 13 92 39 35 42 45—48 13 35 18 152 41 47 56 35 49 61 55 44 65 44 98 44 86 39 49—52 6 81 28 546 58 49 56 71 52 342 46 56 99 51 138 52 228 59 Phthisis. The deaths from phthisis in the administrative County of London during 1907 (52 weeks) numbered 6,651, as compared with 6,775 in 1906. 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 1907 1.403 1 See foonote (1), page 38 2 The deaths occurring in the 53rd week of the years 1890, 1896 and 1902 are excluded from these figures. 3 See footnote (1) page 8. 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.) Diagram XX 47 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 1851-1907 (males and females) is shown in diagram XX. 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-rates per 1,000 persons living, in the County of London and the several sanitary districts. Sanitary area. Standard deathrate.1 Factor for correction for age and sex distritribution. Crude death-rate. Corrected death-rate. Comparative mortality figure. (London 1,000.) 1902-6. 1907. 1902-6. 1907. 1902-6. 1907. London 1.74 1.00000 1.532 1.402 15.3 1.40 1,000 1,000 Paddington 1.80 0.96659 1.08 1.09 1.04 1.05 680 750 Kensington 1.78 0.97419 1.28 1.03 1.25 1.00 817 714 Hammersmith 1.74 0.99600 1.34 1.20 1.33 1.20 869 857 Fulham 1.69 1.02786 1.31 1.19 1.35 1.22 882 871 Chelsea 1.83 0.95018 1.58 1.50 1.50 1.43 980 1,021 Westminster, City of 1.95 0.89205 1.58 1.37 1.41 1.22 922 871 St. Marylebone 1.85 0.93836 1.69 1.48 1.59 1.39 1,039 993 Hampstead 1.75 0.98862 0.78 0.70 0.77 0.69 503 493 St. Pancras 1.80 0.96551 1.78 1.66 1.72 1.60 1,124 1,143 Islington 1.75 0.99145 1.39 1.32 1.38 1.31 902 936 Stoke Newington 1.77 0.97914 1.32 0.94 1.29 0.92 843 657 Hackney 1.68 1.02969 1.31 1.17 1.35 1.20 882 857 Holborn 1.97 0.87894 2.84 2.58 2.50 2.27 1,634 1,621 Finsbury 1.72 1.01050 2.23 2.33 2.25 2.35 1,471 1,679 City of London 1.89 0.91946 1.59 2.02 1.46 1.86 954 1,329 Shoreditch 1.66 1.04206 2.06 2.10 2.15 2.19 1,405 1,564 Bethnal Green 1.59 1.08984 2.10 1.90 22.9 2.07 1,497 1,479 Stepney 1.65 1.05281 1.91 1.56 2.01 1.64 1,314 1,171 Poplar 1.66 1.04772 165 1.33 1.73 1.39 1,131 993 Southwark 1.74 0.99829 2.31 2.03 2.31 2.03 1,510 1,450 Bermondsey 1.65 1.05026 1.91 1.88 2.01 1.97 1,314 1,407 Lambeth 1.75 0.99258 1.46 1.53 1.45 1.52 948 1,086 Battersea 1.69 1.02483 1.33 1.25 1.36 1.28 889 914 Wandsworth 1.72 1.01050 1.00 0.95 1.01 0.96 660 686 Camberwell 1.68 1.3522 1.31 1.31 136 1.36 3.6 1.36 889 971 Deptford 1.69 1.02969 1.28 1.34 1.32 1.38 863 986 Greenwich 1.67 1.04143 1.22 1.08 1.27 1.12 830 800 Lewisham 1.69 1.02543 0.89 0.93 0.91 0.95 595 679 Woolwich 1.70 1.01881 1.49 1.25 1.52 1.27 993 907 It will be seen from the foregoing table (comparing the corrected death-rates) that among the several sanitary areas in the quinquennium 1902-6, Holborn (2.50) had the highest phthisis death-rate and Hampstead (0.77) the lowest; in the year 1907 Finsbury (2.35) had the highest death-rate, the lowest again obtaining in Hampstead (0.69). The death-rates from phthisis in each of the four quarters of the year 1907, were as follows: first quarter, 173; second quarter, 1.41; third quarter, 112 ; and fourth quarter, 134, per 1,000 persons living. The following table enables comparison to be made between the phthisis death-rates in the several sanitary areas for each of the years 1901-1907, inclusive. These death-rates are corrected for differences in the age and sex constitution of the various populations, and it will be seen that while there is a general tendency to decline in the death-rates, there is a considerable difference in the amount of decline in the rates of the different districts. To facilitate comparison the districts are arranged in the ascending order of their death-rates in the first year shown in the table, viz., 1901. 1 The standard death-rate used in the calculation of the "factors for correction" has been calculated to more than the two places of decimals shown in the table. 2 See footnote (1), page 8. 18560 48 Phthisis.— Corrected death-rates1 per 1,000 persons living (1901-1907). Metropolitan Borough. 1901. 1902. 1903. 1904. 1905. 1906. 1907.[/#.##] Hampstead 0.90 0.84 0.73 0.82 0.82 0.66 0.69 Lewisham 0.92 1.09 0.86 0.92 0.87 0.84 0.95 Paddington 1.06 1.01 1.02 1.16 0.93 1.08 1.05 Wandsworth 1.15 0.91 0.96 1.13 1.03 1.02 0.96 Greenwich 1.20 1.24 1.17 1.39 1.31 1.24 1.12 Deptford 1.22 1.15 1.39 1.46 1.26 1.32 1.38 Stoke Newington 1.32 1.23 1.20 1.68 1.30 1.02 0.92 Kensington 1.33 1.26 1.22 1.40 1.11 1.24 1.00 Hammersmith 1.41 1.42 1.46 1.37 1.16 1.24 1.20 Fulham 1.41 1.42 1.42 1.47 1.25 1.16 1.22 Battersea 1.49 1.34 1.32 1.46 1.37 1.31 1.28 Islington 1.50 1.49 1.39 1.54 1.25 1.22 1.31 Camberwell 1.53 1.56 1.26 1.42 1.25 1.30 1.36 Hackney 1.57 1.47 1.31 1.43 1.18 1.34 1.20 Chelsea 1.59 1.38 1.49 1.73 1.43 1.49 1.43 Lambeth 1.64 1.69 1.98 1.44 1.37 1.36 1.52 Westminster 1.68 1.59 1.51 1.36 1.35 1.24 1.22 St. Marylebone 1.77 1.80 1.72 1.58 1.37 1.46 1.39 Woolwich 1.79 1.52 1.48 1.70 1.55 1.36 1.27 St. Pancras 1.80 1.82 1.76 1.82 1.47 1.75 1.60 Poplar 1.87 1.78 1.82 1.82 1.60 1.62 1.39 Bermondsey 1.88 1.97 1.83 2.23 1.88 2.11 1.97 London, City of 2.10 1.55 1.46 1.45 1.23 1.60 1.87 Stepney 2.20 2.00 2.21 2.23 1.81 1.81 1.64 Finsbury 2.21 2.30 2.30 2.42 2.04 2.20 2.35 Shoreditch 2.32 1.89 2.42 2.27 2.04 2.09 2.19 Bethnal Green 2.35 2.15 2.29 2.35 2.22 2.45 2.07 Holborn 2.47 2.65 2.76 2.51 2.50 2.08 2.27 'Southwark 2.51 2.62 2.40 2.36 2.13 2.06 2.03 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.—1907 (305 days). Age-period. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 and upwards All Ages. Paddington 7 1 1 4 16 33 36 33 14 10 2 – 157 Kensington 3 3 2 9 13 54 37 43 24 8 1 – 197 Hammersmith 4 — 2 6 15 40 36 27 18 — – – 148 Fulham 12 3 8 18 20 32 37 44 16 7 1 – 198 Chelsea 3 — 1 4 0 23 28 20 19 10 1 – 114 Westminster, City of 6 2 3 9 11 33 54 59 30 15 9 1 232 St. Marylebone 7 2 5 9 7 33 60 30 18 13 1 – 185 Hampstead 1 2 — 5 4 20 14 10 3 3 – – 62 Sr.. Pancras 13 3 2 15 18 79 95 87 47 18 4 – 381 Islington 21 4 3 16 31 112 115 81 49 19 1 – 455 Stoke Newington 1 — 1 3 3 10 14 9 5 1 – – 47 Hackney 9 2 2 15 33 59 65 49 25 5 2 1 267 Holborn 2 1 — 6 7 19 23 27 22 12 8 – 132 Finsbury 8 1 3 8 17 39 54 52 34 10 — – 226 Loudon, City of .. — — — 1 2 7 12 11 3 5 2 – 43 Shoreditch 16 5 2 13 17 42 63 48 27 5 – – 238 Bethnal Green 8 5 9 U 14 15 53 58 53 22 17 4 – 252 Stepney 13 6 2 22 36 94 139 80 58 20 1 – 471 Poplar 8 2 6 11 12 57 66 33 23 9 2 – 229 Southwark 17 9 3 15 29 93 119 77 50 12 3 – 427 Bermondsey 9 5 2 13 15 48 67 46 28 10 – – 243 Lambeth 25 9 7 23 31 103 104 82 66 26 10 1 487 Battersea 7 6 5 16 21 53 30 47 33 4 1 – 223 Wandsworth 9 6 4 26 25 63 46 60 20 11 1 – 271 Camberwell 14 5 6 18 30 79 73 83 33 10 3 – 354 Deptford 3 5 2 12 15 32 37 34 17 4 – – 161 Greenwich 6 2 3 5 15 19 34 21 5 1 – – 111 Lewisham 4 1 3 8 15 33 38 23 8 6 – 1 140 Woolwich 4 2 6 17 20 29 37 28 9 5 1 – 158 London 240 92 87 341 501 1391 1596 1297 726 276 58 4 6609 1 See footnote (1), page 8. 49 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, 1901-7. 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. Factor for correction for age and sex distribution. Corrected deathrate per 1,000 persons living. Corrected death-rate (London, 1,000). Under 7.5 per cent. 1.067 1.718 1.00991 1.078 709 7.7 to 12.5 per cent. 1.349 1.705 1.01761 1.373 903 12.5 to 20 per cent. 1.456 1.771 0.97969 1.426 938 20.0 to 27.5 per cent. 2.009 1.805 0.96124 1.931 1,270 Over 27.5 per cent. 2.015 1.651 1.05090 2.118 1,393 London 1.520 1.735 1.0000 1.520 1,000 Tables similar to the above have been published in several previous annual reports, and the close relationships existing between "social condition" as measured by "overcrowding" and phthisis mortality is conspicuous. It will be seen that in the most overcrowded group of districts the death rate from phthisis is approximately twice that in the least overcrowded group. The decline in phthisis mortality is being maintained in London, the rate of mortality in the year 1907 being less than that of any year which has preceded it. The rate of 1907 is, indeed, less than half that of the decennium 1861-70, less than 50 years ago. The statistics of phthisis mortality have been examined by many students of public health, who have endeavoured to derive from them indications of the particular circumstances which have brought about this decline, in the hope that they will supply a basis for administrative effort capable of producing more rapid decline than that which has already been observed. The fact which first claims recognition and which stands in the forefront of all consideration of the question is that this diminution has occurred without any effort being especially directed to the attainment of this end. Among the points of interest which have been observed in the behaviour of phthisis mortality, is that the decline in the mortality of females has been greater than in that of males. A likely hypothesis of this difference in the behaviour of the mortality of the two sexes is that the tendency of the times has been for the increase of employment of men in indoor occupations to be greater than the increase of women to be so employed, urbanisation, thus affecting the male sex in larger degree than the female sex. A second hypothesis, which may also be borne in mind, is that improvement in the dwelling began at an earlier date than improvement in the workshop. It may be that both factors have been concerned in producing this result. The broad fact, however, remains that both sexes have participated, in respect of phthisis, in the improvement in the social condition of the population, and in this improvement must be included not only dwelling and workshop, but the food of the people. Whether this improvement has resulted in making the population more resistant to a contagium of constant virulence, or whether the virulence of the phthisis contagium has itself declined must be matter for speculation. The relative strength of each of the two opposing forces must finally determine the death-rate, but there is much reason for thinking that the power of resistance is the all-important factor in determining the liability to attack from a widely distributed infection. In the study of this subject, the statistics of mortality in Ireland have been examined in comparison with those of England and Scotland, for the reason that while in the two last countries phthisis has declined, the disease appears in large degree to have behaved differently in Ireland, and so inferences have been drawn from this difference in behaviour and suggestions for administrative action have been made which are based upon social differences, real or conjectural. It is impossible to discuss these differences in the short space available in an annual report, but it may be pointed out that the decline in phthisis mortality in England and Scotland has been accompanied by decline in mortality from other causes less phthisis, as will be seen from the following figures:— England and Wales. Rates per 1,000,000 persons living. Period. All causes. Phthisis. All causes, less Phthisis. Death-rate. 1871-80. 100. Death-rate. 1871-80. 100. Death-rate. 1871-80. 100. 1871—80 20,485 100 2,190 100 18,295 100 1881—90 18,734 91 1,775 81 16,959 93 1891—00 18,194 89 1,391 64 16,803 92 1901—05 16,006 78 1,215 55 14,791 81 See footnote (1), page 19. 50 Scotland. Period. All causes. Phthisis. All causes, less Phthisis. Death-rate 1871-80. 100. Death-rate per 100,000 1871-80. 100. Death-rate 1871-80. 100. 1871—80 21,637 100 2,389 100 19,244 100 1881—90 19,161 89 1,989 83 17,172 89 1891—00 18,402 85 1,685 71 16,717 87 1901—05 16,882 78 1,445 60 15,537 80 Thus with decline of the phthisis death-rate at all ages there has been decline of the death-rate from all causes, and from all causes less phthisis; and if lessons are to be learnt from the behaviour of phthisis mortality in Ireland, the statistics of that country in this respect should be compared with those of England and Scotland. It should, of course, be borne in mind that large numbers of uncertified deaths, and deaths from ill-defined causes included in the Irish figures largely detracts from their value for comparative purposes in this connection, but the following are the rates obtaining from the available data. Ireland. Period. All causes. Phthisis. All causes less Phthisis. Death-rate. 1871-80. 100. Death-rate. 1871-80. 100. Death-rate. 1871-80. 100. 1871—80 18,244 100 1,954 100 16,290 100 1881—90 17,942 98 2,099 107 15,843 97 1891—00 18,321 100 2,134 109 16,187 99 1901—05 17,602 96 2,153 110 15,449 95 Ireland, therefore, differs from England and Scotland in the fact that while the death-rate from phthisis has somewhat increased in Ireland, the death-rate from all causes, and from all causes less phthisis, does not manifest the same decline as in England and Scotland. The facts are more conspicuous when the mortality at ages 20-65 years are examined, the age period at which phthisis mortality especially occurs. Thus:— England. * Death-rates per 1,000,000 persons living, ages 20-65. Period. All causes. Phthisis. All causes less Phthisis. Death-rate. 1871-80. 100. Death-rate. 1871-80. 100. Death-rate. 1871-80. 100. 1871—80 13,660 100 3,333 100 10,327 100 1881—90 12,489 92 2,735 82 9,754 94 1891—00 11,660 85 2,177 65 9,483 92 1901—05 10,328 76 1,884 57 8,444 82 Ireland. Death-rates per 1,000,000 persons living, ages 20-65. Period. All causes. Phthisis. All causes less Phthisis. Death-rate. 1871-80. 100. Death-rate. 1871-80. 100. Death-rate. 1871-80. 100. 1871—80 12,713 100 2,966 100 9,747 100 1881—90 12,975 102 3,120 105 9,855 101 1891—00 13,077 102 3,144 106 9,933 102 1901—05 12,668 99 3,105 104 9,563 98 Ireland, therefore, has maintained not only its high death-rate from phthisis but its high deathrate from all causes less phthisis. Phthisis, indeed, so far as the figures can be trusted, has in one respect behaved in Ireland as phthisis does in England, i.e. the mortality from this disease has behaved much in the same way as the mortality from all causes less phthisis. In seeking explanation of the maintenance of phthisis mortality in Ireland, and of the decline of phthisis mortality in England, it is impossible to ignore the behaviour in the two countries of the mortality from all causes less phthisis. There is, indeed, much reason for thinking that improve- 51 ment in the social circumstances of the English population has been the material cause of an increased resistance to disease generally, but specially manifested in the decline of the phthisis death-rate. The issue by the Local Government Board of a report by Dr. H. Timbrell Bulstrode, on " Sanatoria for Consumption and Certain other Aspects of the Tuberculosis Question," provides for the use of local authorities, and indeed ail who are concerned in the work of the prevention of tuberculous disease, a comprehensive statement of the experience which has been gained in dealing with this disease. So far as the patient is concerned, the whole trend of Dr. Bulstrode's story is that early recognition of the disease and early treatment are absolute essentials, and in this connection he gives account of the German system of workmen's insurance, which leads to early medical investigation of the cause of ill-health and to early treatment of phthisis when this disease is found to exist, a system which it is claimed in Germany has been operative in reducing the phthisis mortality of that country. In this connection consideration may well be given to the question whether the opportunities for medical treatment of sickness among the poor in London are such as to lead to the detection of this disease at a stage when remedial measures can be more hopefully applied. Not less important is the "after care" of the patient— a question which experience is increasingly showing to be a necessary part of the scheme for dealing with the phthisical patient. On the further question whether institutional treatment should be provided for the person suffering from advanced disease, it matters little whether the claim for such treatment is based upon hypothesis of the communicability of the disease from the sick to the healthy or upon the desire to relieve the sufferer so far as this is possible, for it must be admitted that among the poor the maintenance of the patient during a long period of failing health is often an insupportable burden, and it is difficult for the community to resist the claims which the instincts of humanity make upon it in such circumstances. Concerning the value of segregation, the opinions of competent writers differ. Difficulties, however, stand in the way of the view that the evidence adduced affords sufficient ground for the belief that the decline in the death-rate would be materially accelerated by the more extended use of institutional treatment of advanced cases of the disease. An organised system by which knowledge of the existence of cases of the disease may be focussed on the medical officer of health would obviously be of advantage, especially if it were in his power to ensure that the necessary opportunity were given for the treatment of the sufferer. Dr. Bulstrode's report does not, however, provide any definite evidence that compulsory notification has led to better results than voluntary notification, the success of both depending in the main upon the question whether in connection with notification the inducement of assistance to a patient can be held out. The recently announced intention of the Local Government Board to require notification to the medical officers of health of cases of phthisis met with in poor-law practice should provide information of the existence of many cases which occur under circumstances in which the services of that officer can be most usefully employed. A system of voluntary notification of cases of phthisis has been adopted in the majority of London sanitary districts, and the notification is followed by visits to the patient's home by an officer of the sanitary authority, who gives advice as to the prophylactic measures which are considered desirable. The districts in which this system of notification is in force and the number of cases notified in 1907 is shown in the following table:— District. No. of Cases. District. No. of Cases. Kensington 231 Holborn 171 Hammersmith 109 Finsbury 217 Fulham 151 London, City of 42 Chelsea 10 Southwark 335 Westminster, City of 110 Bermondsey 112 Hampstead 55 Lambeth 322 St. Pancras 355 Wandsworth 14 Islington 137 Greenwich 107 Stoke Newington 38 Lewisham 56 Hackney 157 Woolwich 150 Cancer. The deaths from cancer in the Administrative County of London during 1907 (3G5 days), numbered 4,487, a decrease of 102 on the year 1906. The death-rates from this disease in successive periods have been as follows Cancer. Period. Death-rate per 1,000 persons living. Period. -rate per 1,000 persons living. 1851-60 0.42 1902 0931 1861-70 0.48 1903 0.961 1871-80 0.55 1904 0.921 1881-90 0.68 1905 0.931 1891-1900 0.85 1906 0.981 1901 0.881 1907 0.951 1 See footnote (1), page 8. 52 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 arc shown in the following table, together with the death.rates for each sanitary area, corrected by their application. Owing to the changes of area in the sanitary districts of London caused by the London Government Act of 1899, the death.rates since 1900 are the only figures available for comparative purposes, but it can be seen from these figures that differences in the age and sex constitution of the population are partially responsible for the differences in the crude death.rates obtaining in the several districts. Cancer. Crude and corrected death.rates per 1,000 persons living in the County of London and the several sanitary districts. Sanitary area. Standard death. rate.1 Factor for correction for age 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). 1902.6 1907. 1902.6. 1907. 1902.6. 1907. London 087 1.00000 0.942 0.952 0.944 0.95 1,000 1,000 Paddington 0.98 0.89478 1.06 1.20 0.95 1.07 1,011 1,126 Kensington 1.02 0.85622 0.98 1.18 0.84 1.01 894 1,063 Hammersmith 090 0.96811 0.99 1.12 0.96 1.08 1,021 1,137 Fulham 0.77 1.13828 0.83 0.95 0.94 1.08 1,000 1,137 Chelsea 1.03 0.84874 1.14 0.95 0.97 0.81 1,032 853 Westminster, City of 0.96 0.91348 1.04 0.97 0.95 0.89 1,011 937 Marylebone 0.99 0.88571 1.18 1.20 105 1.06 1,117 1,116 Hampstead 092 0.94816 1.03 0.80 0.98 0.76 1,043 800 St. Pancras 0.92 0.95229 1.03 0.91 0.98 0.87 1,043 916 Islington 0.90 0.96704 1.02 1.01 0.99 0.98 1,053 1,032 Stoke Newington 0.98 0.89387 1.01 1.21 0.90 1.08 957 1.137 Hackney 0.88 0.99341 0.86 0.88 0.85 0.87 904 916 Holborn 0.95 0.91924 1.02 0.82 0.94 0.75 1,000 789 Finsbury 0.84 1.04071 0.82 0.89 0.85 0.93 904 979 London, City of .. 106 0.82316 1.35 1.33 1.11 1.09 1,181 1,147 Shoreditch .. 0.79 1.10518 0.86 0.94 0.95 1.04 1,011 1,095 Bethnal Green 0.78 1.12077 0.87 0.85 0.98 0.95 1,043 1,000 Stepney 0.74 1.17976 0.77 0.72 0.91 0.85 968 895 Poplar 0.81 1.08327 0.79 0.78 0.86 0.84 915 884 Southwark 0.82 1.06350 0.92 0.92 0.98 098 1,043 1,032 Bermondsey 0.81 1.08462 0.87 1.00 0.94 1.08 1,000 1,137 Lambeth 0.92 0.95333 1.03 1.07 0.98 1.02 1,043 1.074 Battersea 0.79 1.10798 0.92 0.88 1.02 0.98 1,085 1,032 Wandsworth 0.88 0.99116 0.96 0.99 0.95 0.98 1,011 1,032 Camberwell 0.87 1.00483 0.90 0.87 0.90 0.87 957 916 Deptford 0.81 1.07396 0.94 0.68 1.01 0.73 1,074 768 Greenwich 0.87 1.01064 0.83 0.77 0.84 0.78 894 821 Lewisham 0.92 0.95333 0.91 0.97 0.87 0.92 926 968 Woolwich 0.78 1.11933 0.82 0.87 0.92 0.97 979 1,021 It will be seen from the foregoing table (comparing the corrected death.rates) that in the quinquennium 1902.6 among the several sanitary areas the City of London (1.11) had the highest cancer death-rate and Kensington (0.84) and Greenwich (0.84) the lowest; in the year 1907 the City of London (1.09) had again the highest, the lowest obtaining in Deptford (0.73). The following tables (a), (b), and (c) show the deaths during 1907 (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.— Deaths2 at the several age-periods in sanitary areas.— 1907 (365 days). Age-period. 0. 5. 10. 15. 20. 25. 35. 45. 55. 65. 75. S5and upwards All Ages Paddington 1 — — 1 — — — 2 1 1 — — 6 Kensington 1 — — — 1 — 3 1 1 3 1 11 Hammersmith — — — 1 — — — 2 1 1 — 5 Fulham 1 — — — 1 1 — 1 3 1 — — 8 Chelsea — — 1 1 — — — — — — — — 2 Westminster, City of — — — — — — 3 — 2 2 — — 7 St. Marylebone — — 1 — — 1 1 2 2 1 — — 8 Hampstead — 1 — — — 2 — — 2 — 1 — 6 St. Pancras — 1 — 1 1 3 1 2 1 1 — — 11 Islington 1 2 — 1 — 2 2 2 3 3 2 — 18 Stoke Newington — — — — — .. 1 2 1 — — — 4 continued, on next page. 1 See footnote (1), page 47. 2See footnote (1), page 8. 53 ##]Age-period. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 and upwards All ages. Hackney — 2 — — 1 – 1 2 1 1 2 – 10 Holborn — — — 1 – – – – 1 – – – 2 Finsbury 1 — — 3 – 1 3 1 – – – – 9 London, City of — — — – – – 1 – – 1 Shoreditch 1 — — – 1 1 2 – – – 5 Bethnal Green 1 2 1 – – 2 2 – 3 2 – – 13 Stepney 1 — — — – 3 1 – 4 3 – – 12 Poplar — — 1 1 1 – 4 1 – – – 8 Southwark — 1 — 1 1 – 1 5 4 1 – 14 Bermondsey 1 1 2 2 — — 2 2 1 2 — — 13 Lambeth 3 — 2 1 1 3 2 1 5 – 3 – 21 Battersea 3 1 2 1 1 3 2 1 2 1 1 – 18 Wandsworth 1 — – 1 3 5 1 1 4 – 16 Camberwell 1 — 2 1 – 2 4 2 1 2 – – 15 Deptford — — — 1 – – – 2 – 1 – – 4 Greenwich — — – – – 1 1 – – 1 – – 3 Lewisham 1 1 1 – 1 2 2 3 2 – – 13 Woolwich 1 — – – 1 1 – – 1 – 1 – 5 London 19 12 13 15 9 30 35 39 46 34 16 – 268 (b) Carcinoma.—Deaths1 at the several age-periods in sanitary areas.—1907 (365 days). Age-period. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- Bo and upwards All Ages. Paddington – – – – – – 10 26 26 33 15 3 113 Kensington – – – – – – 11 26 '40 20 19 2 118 Hammersmith — — 1 — 2 8 19 27 18 13 1 89 Fulham – – – – – 7 17 14 25 29 6 2 100 Chelsea — — _ — – 4 6 9 17 5 — 41 Westminster, City of — — — — 1 3 10 27 24 30 12 — 107 St. Marylebone — — — — – 2 5 11 20 12 12 — 62 Hampstead — — — — – — 4 13 12 14 4 2 49 St. Pancras – – – – – 5 15 35 45 31 12 3 146 Islington — — — 1 1 3 22 38 48 45 12 5 175 Stoke Newington — — 1 — – — 4 2 9 10 4 — 30 Hackney — — — — 1 1 12 20 36 27 10 2 109 Holborn – – – – – 2 2 6 7 10 1 1 29 Finsbury — — — — – 1 4 9 14 18 3 — 49 London, City of .. – – – – – 2 2 8 5 — 1 18 Shoreditch — — — — – 3 13 27 10 4 1 58 Bethnal Green – – – – – 1 6 12 17 7 6 — 49 Stepney — — — — – 5 18 34 31 31 11 1 131 Poplar — — — — 1 6 9 25 27 19 6 1 94 Southwark — — — — 1 2 13 23 43 35 9 – 128 Bermondsey – – – – – 2 11 22 34 17 9 — 95 Lambeth — — — — – 5 23 57 63 55 20 7 230 Battersea — — — — – 1 9 18 25 15 7 1 76 Wandsworth — — — — 1 2 11 31 36 39 16 139 Camberwell — — — — – 2 10 29 35 29 13 1 119 Deptford — — — — – 2 3 15 20 11 4 1 56 Greenwich – – – – – 1 5 15 18 12 3 1 55 Lewisham — — — 1 6 25 21 29 14 1 97 Woolwich – – – – – 2 6 9 12 22 8 — 59 London – — 2 1 6 60 261 582 759 650 258 42 2621 (c) Cancer (otherwise undistinguished).—Deaths1 at the several age-periods in sanitary areas.—1907 (365 days). Age-period. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 35 and upwards All Age*. Paddington – – – – – – 8 12 1 22 2 61 Kensington – – – – 1 8 15 2 24 8 2 86 Hammersmith – — — 1 1 4 9 18 6 3 1 43 Fulham Chelsea – — — 1 — 1 1 5 4 15 2 16 9 8 9 4 3 — 50 28 Westminster, City of – – – – – 3 5 9 15 8 12 1 53 St. Marylebone – — — 1 2 15 29 29 7 — 83 Hampstead – — — — – 2 3 4 7 1 — 17 St. Pancras – – – – – 4 3 8 22 13 6 — 56 Islington – — — — — — 13 23 45 59 16 3 159 continued on next page. 18560 1 See footnote (1), page 8. H 54  Age–period. 0. 5. 10. 15. 20. 25. 35. 45. 55– 65. 75. 85 and upwards \11 ages. Stoke Newington – – – – – – 2 8 11 5 4 1 31 Hackney — — — — 1 2 6 20 26 26 5 — 86 Holborn – – – – – – – 6 5 3 — — 14 Finsbury – – – – – 1 — 7 8 6 6 — 28 London, City of – – – – – – 2 3 1 1 1 8 Shoreditch – – – – – 6 13 13 9 4 1 46 Bethnal Green – – – – – 1 5 9 16 14 5 — 50 Stepney – – – – – 3 15 18 19 19 6 1 81 Poplar — — — — 1 1 1 13 6 5 3 — 30 Southwark – – – – – 1 8 8 13 15 5 — 50 Bermondsey – – – – – 1 2 4 8 5 1 — 21 Lambeth – – – – – – 7 21 27 21 13 1 90 Battersea – – – – – 1 4 16 18 22 4 1 66 Wandsworth – – – – – 4 9 25 33 37 16 — 124 Camberwell — 1 — — — 2 10 13 40 24 12 5 107 Deptford – – – – – 1 1 7 5 5 1 — 20 Greenwich — – — — 1 1 2 5 7 5 4 — 25 Lewisham — – — — — — 2 6 10 13 6 — 37 Woolwich – – – – – – 7 7 15 14 5 — 48 London — 1 — 1 4 31 141 319 486 434 163 18 1598 The following table shows the proportional age.distribution of the deaths in London during 1907 (365 days) classified under the three headings— Cancer— Deaths1 at each age.period per 1,000 deaths at All Aget—1907 (365 days). [####]Age.period. All ages. Under 35. 35. 45. 55. 65. 75. 85 and upwards. Sarcoma 1,000 366 130 145 172 127 60 – Carcinoma 1,000 26 100 222 290 248 98 16 Cancer 1,000 23 88 200 304 272 102 11 Total 1,000 46 97 210 288 249 97 13 In the report for the year 1906, a table was included showing the cancer death.rates in the period 1901.6 in areas presenting different degrees of overcrowding,2 the object being to compare the death.rates of population differently circumstanced in respect of social condition. The following table shows the corresponding death.rates for the period 1901.7:— London, 1901.7. Cancer death.rates1 in relation to overcrowding. Percentage of overcrowding in each group of sanitary areas. Crude cancer death.rate per 1,000 persons living. Standard death. rate.3 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. 0.930 0.883 0.99003 0.921 988 7.5 to 12.5 per cent. 0.923 0.864 1.01180 0.934 1,002 12.5 to 20 per cent. 0.975 0.921 0.94919 0.925 992 20. to 27.5 per cent. 0.999 0.904 0.96704 0.966 1,036 Over 275 per cent. 0.810 0.774 1.12946 0.915 982 London 0.932 0.874 1.ooooo 0.932 1,000 The figures shown in the table appear to indicate that there is no relation between cancer mortality and social condition, as judged by overcrowding, and in this respect the behaviour of cancer differs altogether from that of phthisis (see page 49). Dr. G. B. Longstaff has raised question whether the difference between the two sexes in the frequency with which cancer attacks the throat may be due to differences in the habit of the two sexes in respect to smoking, the male being more frequently attacked in that locality than the female. Dr. Bashford has stated in a recent report of the Imperial Cancer Research Fund that cancer of the skin of the abdomen is practically unknown in Europe, but is frequent in Kashmir, and that the natives of Kashmir irritate the abdominal wall by wearing a charcoal oven round the waist. Again, in Europe, he states, cancer of the floor of the mouth is rare in women. In Ceylon and India women suffer from cancer of the side of the mouth, and this is due to the fact that women chew betel nut and sleep with the plug in the cheek at the exact spot where cancer starts. 1 See footnote (1) page 8. 2 See footnote (1), page 19. 3 See footnote (1), page 47 55 Cerebro-spinal Fever. Reports of the prevalence of cerebro-spinal fever in Glasgow and Belfast indicated the need for watchfulness over any cases of this disease which might occur in London. There had been no special manifestation of this disease in London, the number of deaths attributed to this cause in London having been in 1902, 4; 1903, 6; 1904, 6; 1905, 5; and 1906, 4. It appeared desirable, however, that, in anticipation of possible increase of the number of deaths in London attributed to this disease, and to the further possibility that an increase in the number of cases might occur without immediately manifesting itself in the death returns, that the disease should be notified and suspected cases should, as far as possible, be studied. Hence on the 12th February, 1907, the Public Health Committee presented the following report to the Council:— We have had under consideration the prevalence of cerebro-spinal fever in Glasgow and Belfast, and have received from the medical officer a report on the subject. It does not appear, from the returns issued by the RegistrarGeneral, that there has been any increase of deaths in London under the headings which might be thought of as possibly including cases of this disease. Moreover, the medical officer has inquired at the principal general hospitals and children's hospitals in London, with a view to learning whether there is reason for thinking that cases of this disease in its epidemic form are occurring in London, and the information we have received from these sources is altogether reassuring. We are, none the less, of opinion that systematic inquiry should be made, for some time to come, into cases of disease which raise question as to cerebro-spinal fever, and, for this purpose, we shall submit to the Council on 26th February, 1907, the earliest possible date, a recommendation that, for a period of six months, cases of cerebro-spinal fever shall be notified in London. We are not at the present proposing to extend to this disease any other provisions of the Public Health (London) Act, 1891, to allow the precedent of notification of chickenpox, concerning which the Council has in the past made similar orders at times of prevalence of small-pox. In our report to be presented later we shall deal with the question of providing facilities for the diagnosis of the disease. On the 26th February the Council made an Order requiring cases of cerebro-spinal fever (epidemic cerebro-spinal meningitis) to be notified for a period of six months, and Dr. Wanklyn was instructed to proceed to Glasgow with a view to learning any lessons which the experience of that city might teach in respect of this disease. Later, question arose as to whether the term epidemic cerebro-spinal meningitis included cases of posterior basal meningitis, and the Council sought the advice of the President of the Royal College of Physicians, Sir Richard Douglas Powell, Bart., who appointed a Committee to advise on this matter, the Committee consisting of Sir Thomas Barlow, Bart., M.D., Dr. F. E. Batten, Dr. W. H. Hamer, Dr. Rolleston and Dr. G. F. Still. The recommendation of this committee and the action taken thereon is shown in the following report which the Public Health Committee presented to the Council on the 18th of June:— In connection with the notification of the disease, a question was raised whether the term " cerebro-spinal fever " includes, for the purposes of notification, cases of posterior basal meningitis. On this point we deemed it necessary to consult the President (Sir Richard Powell, Baronet) of the Royal College of Physicians, who appointed a committee to advise on the question, and that committee has reported as follows— " We find clinically that, although as regards symptomatology and duration there are some differences which might separate the most marked cases of cerebro-spinal fever (epidemic cerebro-spinal meningitis) and posterior basal meningitis from one another, nevertheless intermediate cases occur in which such differentiation is impracticable. It cannot (at present) be maintained by experts with absolute certainty that there is any demonstrable difference in the bacteriology of the two diseases. The organism which is commonly associated with each disease is microscopically the same (meningococcus, micrococcus intracellularis, diplococcus intracellularis meningitidis), such variations as may be met with being dependent on minor differences in cultural characters. It is noteworthy that, so far as has been ascertained at present, both diseases tend to occur during the earlier months of the year, and that, although the occurrence of the disease in both instances is epidemic, in neither has it the characteristics of a spreading malady. The committee recommend— (i.) That, inasmuch as the season in which the disease is liable to be prevalent will not recur for seven to nine months, the order of notification at present issued should continue in force for a period of two years, in order to cover two possible epidemic periods. (ii.) That, in the order of notification distributed to practitioners, it should be stated that for notification purposes the disease at present known as posterior basal meningitis is included under the term cerebro-spinal fever. (iii.) That, after notification, further details of the cases should be obtained (a) in hospitals through the courtesy of the medical officers in charge, (6) in private by a special officer available to investigate the case bacteriologically or otherwise if desired, in association with the practitioner in charge." We are confident that the Council will value highly the advice so courteously given by the President of the Royal College of Physicians and his colleagues who composed the committee. The operation of the notification order now in force will continue until 12th September, 1907 ; but we shall shortly submit a recommendation to give effect to recommendation (i.), and, if and when such extended order be made, we shall cause medical practitioners in the county to be informed that, for the purposes of notification, the disease at present known as posterior basal meningitis is included under the term cerebro-spinal fever, but that the term cerebro-spinal fever is not to be interpreted to include cases of meningitis due to tubercle, syphilis, middle-ear disease or injury. As regards recommendation (iii.), we are in communication with the medical officers in charge of the London hospitals with a view to their co-operating with the Council in furnishing details of the cases under their care. The metropolitan medical officers of health already co-operate with the Council in obtaining particulars of cases of the fever occurring in London, and we propose that the services of Dr. Wanklyn, the assistant medical officer of health, should be available with a view to the investigation of cases in association with medical practitioners in London, should they so desire. In this connection we desire to express our appreciation of the opportunities courteously afforded by Dr. Chalmers, the medical officer of health of Glasgow, to Dr. Wanklyn, who, acting under our authority, recently visited Glasgow with a view to studying the course of the outbreak of cerebro-spinal fever in that city. We are making arrangements as regards the bacteriological investigation suggested by the committee, the Council having on 26th February, 1907 (p. 460), sanctioned expenditure not exceeding £200 in respect of precautionary measures against the spread of the disease. On the 9th July the Council made an Order extending the period of notification of cerebro-spinal 18560 56 meningitis for a further period of eighteen months, and in their communication to medical practitioners, informing them of the Order, the Council stated that on the advice of a committee appointed by the President of the Royal College of Physicians, they had decided that for notification purposes the disease known at present as posterior basal meningitis is included in the term "cerebro-spinal fever," but that the term was not to be interpreted to include cases of meningitis due to tuberculosis, syphilis, middle-ear disease or injury. During the year, from the time of the Order coming into force until the end of the year, the number of cases notified and deaths registered were as follows :— No. of cases. Deaths. No. of cases. Deaths. No. of cases. Deaths. March 9th 1 1 June 15th 4 — Sept. 21st 4 — „ 16th 5 1 „ 22nd 4 — „ 28th 1 1 „ 23rd 4 — „ 29th 2 — Oct. 5th 3 — „ 30th 5 2 July 6th 1 — „ 12th 2 — April 6th 5 — „ 13th 3 — „ 19th 1 — „ 13th 4 1 „ 20th 1 1 „ 26th 2 — „ 20th 3 — „ 27th 7 2 Nov. 2nd 1 1 „ 27th 4 — Aug. 3rd 5 — „ 9th 1 — May 4th 4 1 „ 10th 4 1 „ 16th — — „ 11th 6 2 „ 17th 3 3 „ 23rd 5 1 „ 18th 7 2 „ 24th 2 1 „ 30th 1 — „ 25th .. 4 1 „ 31st 4 — Dec. 7th 1 — June 1st 1 1 Sept. 7th 6 1 „ 14th 1 — „ 8th 7 — „ 14th 1 — „ 21st 2 — „ 28th 3 - During the year 1907 twenty-five deaths were attributed to this disease, or about four times the average number of deaths in the last few years. It is probable that this increase in the number of deaths due to this disease was an indirect effect of requiring cases of cerebro-spinal meningitis to be notified. It is interesting to note that in the same year in Glasgow, which has a population equal to about one-sixth that of London, there were notified 998 cases of cerebro-spinal fever, while 847 deaths were attributed to this cause, giving a fatality of nearly 85 per cent. After deducting from the 25 deaths in London one which occurred in the period before notification was required, there were 135 cases and 24 deaths, and the London fatality was thus less than 18 per cent. Dr. Wanklyn has, as far as was found practicable, studied the London cases, and the results of this observations during the year will be found in Appendix I. Among the 135 cases notified were included many which further observation showed were not cases of cerebro-spinal meningitis, and among those cases which were fatal the death was often attributed to another cause. Anthrax. But one death from anthrax was registered during the year, that of a waterside labourer in Bermondsey, who had been handling dry hides. His death occurred in March, and during the same month another man employed in Bermondsey, in connection with foreign hides, was attacked, but recovered. In May a man living in Poplar was attacked. He stated that he had not been working in connection with skins or hides for some months. In June a labourer in Bermondsey, in contact with foreign leather, was attacked, and in December a warehouseman in Bermondsey, associated with foreign hides, was attacked. A further case, that of a stevedore employed in the Royal Albert Docks, was removed to the Poplar Hospital. Two cases of anthrax recorded by the medical officer of health of Finsbury were notified to him. He states that the first was a man aged 20 on August 7th. This man was employed in carrying hair after boiling or dyeing by a firm in Bunhill-row. The second was a girl aged 15½ years, a dressmaker's apprentice. Her neck was accidentally scratched by her uncle's finger-nail on September 10th, while they were playing together. Her uncle worked for the above-named firm in Bunhill-row, but neither he nor his family had suffered from anthrax. Glanders. Four deaths due to glanders are known to have occurred in London during the year. The first was that of an omnibus driver which occurred in the Seamen's Hospital, Greenwich. The shed in which he worked was examined by a veterinary inspector, but no case of glanders was discovered. The second death was that of a cab driver, which occurred in the Southwark Infirmary in the beginning of April. A visibly affected glandered horse was detected in the stud with which this man was associated. The third death was that of a window cleaner, in the Southwark Infirmary, on the 13th August. He had never been associated with horses, but his landlord owned five horses which, however, were examined by a veterinary inspector and reported to be healthy. The fourth death was that of a greengrocer, which occurred in the Bolingbroke Hospital, Wanda. 57 worth, on the 12th September. He was probably infected by a glandered horse which stood in a stable belonging to the deceased and which had been slaughtered on the 16th August. The three last deaths were registered as being due to glanders. In 1906 the Council decided to appoint a permanent staff of veterinary inspectors wholly employed in their service, and the Board of Agriculture made an Order requiring in London the notification of cases of glanders in animals to veterinary surgeons. In 1907 a new Order was made by the Board which came into force on the 1st January, 1908. This Order, which extends to England and Wales and Scotland, includes in the definition of diseased an animal" in which the application of the mallein test has resulted in definite evidence of disease," and requires the slaughter of all diseased animals, the compensation for diseased animals being raised to one half their value, with a maximum of £25 for a horse. The Order further authorises the detention of "suspected animals" or animals which have been exposed to infection, the application of the mallein test to such animals with the permission of the owner, and imposed the obligation on the local authority to employ such test on the demand of the owner. 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 1907 was 49.7 deg Fahrenheit, or 0.4 degrees below the average of the preceding 65 years. The rainfall during the year amounted to 22.25 inches, a decrease of 1.87 inches on the average of the preceding 65 years. The temperature and rainfall in each month of the year 1907 are shown in the following table:— Temperature and Rainfall—1907. Month. Temperature of the air. Departure of mean monthly temperature from average of 65 years, 1842.1906. Rain. Absolute maximum. Absolute minimum. Mean for month. Number of days it fell. Amount collected. deg. F. deg. F. deg. F. deg. F. Inches. January 51 22 38.3 —01 10 1.09 February 51 24 37.6 —2.2 14 1.27 March 69 24 44.0 + 1.5 10 0.91 April 72 29 47.4 —0.7 16 314 May 82 34 53.4 —0.4 18 1.47 June 76 43 57.8 —2.5 15 2.65 July 79 43 60.0 —3.7 13 0.97 August 79 44 61.6 —1.3 13 1.92 September 83 35 58.7 +0.5 6 0.62 October 68 36 511 +0.7 24 3.25 November 60 29 44.8 + 1.4 9 2.23 December 57 28 41.6 +2.0 15 2.73 58 PART II. Dairies, Cowsheds and Milkshops. The County Council received during the year 234 applications for cowhouse licences, of which 233 were granted. The number of applications for licences received during the last fourteen years and the number granted are shown in the following table. It will be seen that the number c these premises in London is continually decreasing. No. of applications No: of premises for received. which licences were granted. 1894 456 446 1895 427 416 1896 405 393 1887 379 374 1898 357 354 1899 338 330 1900 323 321 1901 306 295 1902 294 291 1903 282 277 1904 266 259 1905 257 255 1906 244 240 1907 234 233 In 1903 effort was made, in conjunction with the medical officers of health of London districts, to secure uniform statistical statement of the several proceedings of the sanitary authorities. Tables showing these proceedings included in this report have therefore, in the main, been compiled from tabular statements in the annual reports of medical officers of health or from figures otherwise contained in their reports. The following table relating to cowsheds has been thus prepared :— Cowsheds. Sanitary area. Number of cowshed premises. Number of inspections by the sanitary authority 1907. Number of prosecutions by sanitary authority 1907. On register at end of 1906. Added in 1907. Removed in 1907. On register at end of 1907. Paddington 1 – 1 3 Kensington 1 – — 1 41 — Fulham 2 – — 2 24 — Chelsea 3 – 1 2 48 — Westminster, City of 2 – — 2 48 — St- Marylebone 6 – — 6 — St. Pancras 9 – — 9 196 — Islington 9 – 2 7 107 — Stoke Newington 2 – — 2 — Hackney 22 – 1 21 238 — Holborn 1 – — 1 52 — Finsbury 5 – — 5 19 — Shoreditch 7 – — 7 17 — Bethnal Green 15 – — 15 81 — Stepney 38 – — 38 69 Poplar 15 – — 15 68 — Southwark 5 – — 5 51 — Bermondsey 7 – — 7 64 — Lambeth 14 – — 14 — Battersea 3 – — 3 14 — Wandsworth 15 – 2 13 68 — Camberwell 17 – 1 16 285 — Deptford 5 – — 5 51 — Greenwich 4 – — 4 11 — Lewisham 15 – — 15 169 — Woolwich 17 – – 17 85 — 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. 59 In view of the inability of the Council to control the disposal of animals thus certified, t h Council in 1904 obtained power to remove and slaughter any cows suspected to be suffering from tubercular disease of the udder. The cows in the London cowsheds have since the date of the Dairies Order of 1899 been periodically inspected by the County Council's veterinary inspector, with a view to the detection of cows suffering from tubercular disease of the udder. During the year 1907 there were five inspections of all the cows in the London cowsheds, and the results of the veterinary inspector's examination are shown in the following table:— Examination of cows for tubercular disease of the udder—Summary of the reports of the Council's Veterinary Inspector for the year 1907. Details of Examination. 1st period, 13th Dec. (1906)—20th March (1907). 2nd period, 21st March— 19th June (1907). 3rd period, 20th June— 6th Sept. (1907). 4th period, 7th Sept.— 9th Nov. (1907). 5th period, 10th Nov. (1907)—11th Jan. (1908). Total number of cows examined 3,764 3,842 3,682 3,437 3,648 Affected with disease or defects of the udder 194 183 254 279 224 Clinically affected with tubercular disease of the udder 4 2 3 2 1 Suspected cases of tubercular disease of the udder — — 2 2 5 Subjects of acute mastitis 14 12 8 12 4 Affected with chronic induration of the udder 5 7 7 15 3 Atrophy of one or more quarters 143 117 148 141 144 Injuries, abscesses, simple eruptions, strictures and obliterations of milk ducts 10 8 25 25 13 Hypertrophied udders without induration 1 2 8 8 1 Giving milk of poor quality (dried-off cows) 15 34 52 25 44 Affected with general tuberculosis — 1 1 — — Suffering from chronic diarrhoea — — — — — Giving stringy milk 28 ~~ The reports of the Council's veterinary inspector also show the action taken for the elimination of tuberculous cows from the London cowsheds, thus:— First period.— One cow exhibited marked clinical symptoms of tubercular disease of the udder, and was seized and slaughtered. In three other cases in which tubercular disease of the udder was suspected, an examination of the milk from each cow was made. One of the cows died while the milk was in course of examination, and was removed to the knacker's yard by order of the owner. As regards the other two, tubercle bacilli were found in the milk and the cows were seized and slaughtered under the Act. Second period.— Three cows suspected to be affected with tubercular disease of the udder were seized and slaughtered under the Act, without bacteriological examination of the milk. On postmortem examination, two of them were found to be affected with tubercular disease of the udder. The third animal, although free from tubercular disease of the udder, was in a dropsical condition, and the carcase was condemned by the meat inspector as unfit for human food. Third period.— Two cows suspected to be affected with tubercular disease of the udder were seized and slaughtered under the Act, without bacteriological examination of the milk. On postmortem examination, both were found to be affected with tubercular disease of the udder. A sample of milk was taken from one cow and submitted for examination. At the time the sample was taken this animal showed symptoms of general tuberculosis, but no direct evidence of disease of the udder. The microscopic examination gave a negative result, but the inoculation test proved that the milk was tuberculous. Prior to the result of the examination of the milk being known, the animal in question was, by direction of the owner, sent to the Metropolitan Cattle Market for slaughter. Fourth period.— Of two cows presenting clinical evidence of tuberculosis of the udder, one was seized under the Act and slaughtered. The other animal was destroyed by order of its owner. Samples of milk from two other cows presenting symptoms of pulmonary tuberculosis were taken. On examination, a negative result was obtained from one sample and a positive result from the other. In the latter case, before the result [of the examination had been obtained, the cow from which the sample was taken was sold and removed to the country, where, it is stated, she was killed. Fifth period.— One cow which presented clinical evidence of tuberculosis of the udder was seized and slaughtered under the Act. Samples of milk were taken from five cows presenting symptoms of tuberculosis, and, on examination, a negative result was obtained from two samples and a positive result from three. The animals found to be affected with tubercular disease of the udder were seized and slaughtered under the Act. Milkshop premises. The following table shows the number of milkshop premises at the end of 1906 and 1907 in the several sanitary districts of London, the number of inspections and the proceedings taken. The table 60 has been compiled from information contained in the annual reports or has been supplied since these reports were received c— Sanitary area. Number of premises. Number of inspections, 1907. Number of notices, 1907. Number of prosecutions, 1907. On register at end of 1906. Added in 1907. Removed in 1907. On register at end of 1907. Paddington 178 6 9 175 272 Kensington 299 14 34 279 1,519 54 — Hammersmith 314 38 52 300 1,277 96 — Fulham 292 10 45 257 972 17 Chelsea 128 1 3 126 165 1 Westminster, City of 332 66 12 386 662 St. Marylebone 253 343 Hampstead 112 7 5 114 421 9 — Islington 618 54 140 532 2,145 62 1 Stoke Newington 51 53 Hackney 368 36 31 373 981 16 2 Holborn 187 18 27 178 878 10 — Finsbury 256 15 12 259 481 67 — London, City of 581 55 30 606 Shoreditch 288 18 22 284 3,410 10 — Bethnal Green 373 17 42 348 1,350 43 Stepney 1,016 69 48 1,037 1,928 26 3 Poplar 360 349 1,664 4 — Southwark 346 78 27 397 720 16 — Bermondsey 255 18 5 268 739 52 1 Lambeth 490 33 523 Battersea 264 55 65 254 710 72 — Wandsworth 352 59 48 363 981 42 — Camberwell 598 32 31 599 1,310 — Deptford 198 54 49 203 541 4 — Greenwich 220 12 22 210 298 25 — Lewisham 160 32 27 165 311 8 — Woolwich 150 21 28 143 340 The desire is expressed in several of the annual reports for increased powers to refuse to register milk vendors whose premises do not come up to the required standard and to remove from the register such milk vendors who are already registered, and satisfaction is expressed with the proposal of the County Council to seek powers from Parliament for these purposes. The Council's General Powers Bill for 1908 contained a clause with this object, which, after modification in respect of the tribunal of appeal, has since received Parliamentary sanction. Several of the reports state that greater cleanliness than before is being observed in the conduct of this business. It is, however, especially in respect of the management of dairy farms in the country that improvement is needed. Abundant evidence is contained in the reports of the medical inspectors of the Local Government Board of the neglect in many districts to observe even elementary conditions of cleanliness in cowsheds, and urban communities, like London, where milk derived from these cources is consumed, have no redress. A return presented to the House of Commons, dated the 13th May, 1907, showed that in a quarter of the rural districts, regulations under the Dairies, Cowsheds and Milkshops Order of 1885, had not been made. No information is given in this return as to whether the regulations are enforced in those districts where they have been made. The Council's General Powers Bill of 1907, contained a clause dealing with milk so dirty as to be unfit for human consumption, but this clause was deleted from the Bill on the second reading, in the expectation that the Government would in the next session introduce a measure for improving the conditions under which milk is produced. With respect to tuberculous milk, clauses empowering the Council inter alia to take samples of milk in London and to prohibit the supply of milk from cows having tubercular disease of the udder were also included in the General Powers Bill of that year and after modification, received the sanction of Parliament. These powers are those contained in " the model clauses " and are practically all that the legislature is prepared to assent to in private Bills at the present time. While they are, admittedly, in their actual form, difficult of administration, they nevertheless give opportunity for the gradual development of useful administrative action. The most urgent need at the present time is a system of veterinary inspection by local authorities of cows in dairy farms and the elimination of the milk of tuberculous animals from the milk supply in order that urban communities be protected against the risk of tuberculous disease due to tuberculous milk. Offensive Businesses. In the year 1907 the County Council received 301 applications for licences for slaughterhouses and granted 294. The following table shows the number of applications received and the number of slaughterhouses licensed in recent years. It will be seen that the number of these premises is continually decreasing— 61 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 1893 442 429 1906 310 308 1899 419 411 1907 301 294 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, 1907, by S. A. No. of notices, 1907, by S.A. On Register at end of 1906. Removed in 1907. On Register at end of 1907. Paddington 8 1 7 589 – Kensington 12 — 12 217 – Hammersmith 11 2 9 258 17 Fulmar 4 — 4 30 1 Chelsea 6 — 6 148 — Westminster, City of 1 — 1 52 — St. Marylebone 8 — 8 76 — Hampstead 5 — 5 117 — St. Pancras 21 2 19 — Islington 39 2 37 2,531 — Stoke Newington 7 — 7 39 — Hackney 25 — 25 380 — Holborn 1 — 1 16 1 Finsbury 3 — 3 78 — London, City of 1 7 — 7 — Shoreditch 9 1 8 37 — Bethnal Green 6 — 6 39 — Stepney 10 — 10 30 — Poplar 19 1 18 55 — Southwark 6 — 6 65 — Bermondsey 2 — 2 48 — Lambeth 27 3 24 — Battersea 6 1 5 80 — Wandsworth 21 1 20 361 2 Camberwell 15 — 15 149 — Depfford 4 — 4 45 — Greenwich 5 — 5 23 1 Lewisham 16 — 16 170 1 Woolwich 11 — 11 97 5 During the year the following authorised offensive businesses were discontinued, the business of a fat melter in two instances in Wandsworth, the business of a bone boiler in one instance in Wandsworth, the business of an animal charcoal manufacturer in one instance in Wandsworth, and the business of a gut scraper in one instance in Hackney. No offensive business was during the year established anew in London with the consent of the County Council. The number of authorised offensive businesses other than that of slaughterer of cattle in London, except those under the jurisdiction of the City Corporation, was at the end of the year as follows :— Fat melters 22 Tripe boilers22 Glue and size manufacturers 5 Knackers 5 Fellmongers 6 Bone boilers 5 Manure manufacturers 3 Soap boilers 13 Tallow melters 10 Gut manufacturers 4 95 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. 1 The seven slaughter-houses in the City of London are not licensed by the London County Council. 18560 I 62 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 1907. No. of Inspections, 1807. Sanitary area. No. on Register *at end of 1907. No. of Inspections, 1907. Kensington 1 37 Poplar 9 57 Hammersmith 4 96 Southwark 7 79 St. Marylebone 2 Bermondsey 12 135 St. Pancras 2 Lambeth 4 Islington 7 118 Battersea 2 29 Hackney 2 12 Wandsworth 6 111 Finsbury 1 Camberwell 4 Shoreditch 1 6 Deptford 4 51 Bethnal Green 1 6 Greenwich 2 Stepney 8 16 Woolwich 1 In 1907 the Council made new bylaws for the following offensive businesses (1) bone boiler, manure manufacturer and tallow melter; (2) soap boiler, (3) tripe boiler, (4) gut scraper and cat-gut maker or cat-gut manufacturer, (5) fat melter or fat extractor, (6) glue and size manufacturer, (7) knacker, (8) fellmonger, (9) dresser of fish skins and decided to apply to the Local Government Board for their confirmation. A material point in which these bylaws differ from those which they supersede is in the extension of the principle of the use of a " closed chamber " to all offensive processes and in improvement in the method of ventilation of these chambers. Nuisances. Smoke nuisance. References in the annual reports to smoke nuisances indicate that among the chief offenders are electricity generating stations and bakehouses. Dr. Reginald Dudfield is able to report that during the last three years there has been decreasing evidence of smoke nuisance in Paddington, a result which, he says, is partially attributable to the removal from the borough of the Great Western Company's electric generating station. Dr. Priestley states that in 1907 no nuisance was experienced from the 37 shafts from the potteries in that district, a result in part explicable by the firms in question employing smoke inspectors of their own to observe hourly the chimney shafts, and by a system of a bonus distribution once or twice a year to those stokers against whom there were no complaints of neglect. The need for amendment of the law continues to be urged, so as to substitute other words for " black smoke," and thus secure some definition of the amount of smoke which is to be prohibited. The following table, which is compiled from information contained in the annual reports, shows the action taken by sanitary authorities in respect of smoke nuisance during the year. Sanitary Area. Observations and inspections. Nuisances and complaints. Intimations. Notices. Summonses. Paddington 119 Kensington Hammersmith 34 (promises) 8 16 Fulham 10 5 Chelsea 1 Westminster, City of 2,417 48 106 15 2 St. Marylebone 653 observations 22 1 2 496 inspections Hampstead 4 St. Pancras 762 15 Islington 825 Stoke Newington 1 Hackney 1,639 2 58 3 Holborn 104 13 3 Finsbury 130 41 20 16 3 London, City of 341 12 12 Shoreditch 27 1 Bethnal Green 560 (premises) 34 Stepney 104 3 Poplar 102 56 48 6 Southwark 525 66 22 8 8 Bermondsey 271 (chimneys) 55 Lambeth 580 64 4 Battersea 75 68 12 16 Wandsworth 60 3 Camberwell 82 Deptford 188 29 29 Greenwich 305 8 Lewisham 176 7 2 1 Woolwich 106 10 10 * The business at some of these premises was discontinued during the year 1907; 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. 63 Nuisance from stable manure. Nuisance from stable manure is less frequently mentioned in the reports for the year 1907 than in some antecedent years, probably in some degree owing to the cooler weather which prevailed in the summer months. In several reports it is stated that removal of manure from all stables and cowsheds was required to be effected every forty-eight hours, and the frequency with which this is done no doubt determines to a considerable extent the amount of nuisance which manure causes. A table contained in the report of the medical officer of health of Southwark gives particulars concerning the stables in that borough. 686 stables were inspected during 1907, this number probably including all which were in occupation. Peat or moss litter, frequently a fruitful source of nuisance at the time of removal, was used in 45 stables, straw in 528, and other kinds of litter in 113. The manure was stored in a waggon in 51 instances, in concrete or brick receptacles in 294, in a cage or in an iron receptacle in 205, and in 136 instances there were unsatisfactory receptacles or none at all. Concerning frequency of removal, the table shows that the manure was removed every day from 244 stables, every two days from 213, every three days from 154, once a week from 73, and once a fortnight from two. Removal of house refuse. So far as the subject of removal of house refuse is discussed in the annual reports, it is shown that this duty is being satisfactorily performed. The by-laws of the County Council require that the refuse shall be removed from all premises not less than once a week, and further facilities are required to be given by householders to sanitary authorities desirous of instituting a system of daily removal in the whole or in parts of their districts, the householders being then under the obligation, after due notice, to put the house refuse upon the pavement in suitable receptacles. In some districts removal is effected from some houses or parts of districts more frequently than once a week. A system of daily removal is being gradually extended in Westminster, Poland-street being added in 1907 to the streets from which the removal is daily. Dr. Allan states, moreover, that the refuse is being removed from the houses in that borough earlier in the day than before. The house refuse in Holborn is removed at least twice a week in the months of April to October, and oftener if required by the medical officer of health, and once a week in the rest of the year. In Shoreditch the refuse is removed weekly and in many cases on request daily. The system of weekly removal for which the by-law provides has led to great reduction in the number of " complaints" by householders. In Islington, in 1907, these complaints numbered only 55, in Hackney 89, and in Finsbury 92. The number of refusals on the part of householders is still large, in Hackney amounting to some four or five thousand per week. This matter, however, is one the sanitary authorities can control, inasmuch as refusal to permit the removal constitutes " obstruction," for which a penalty can be obtained. Nuisance from flies. Conspicuous prevalence of flies in the vicinity of the depot of the Borough Council of Bethnal Green led the Public Health Committee to instruct me to report generally on the subject of fly nuisance resulting from deposits of house refuse and manure in London. The work of inquiry was intrusted to Dr. W. H. Hamer, who had the assistance of a number of the Council's inspectors in the Public Health Department. Arrangements were made for fly papers to be exposed in suitable places in the neighbourhood of collections of house refuse, horse stable manure, cow manure, etc., and the flies thus caught were duly counted. Evidence was abundantly forthcoming of the effect of these collections in producing fly nuisance, and the inquiry showed the necessity for the prompt removal of such material from inhabited localities. Dr. Hamer's report is appended (see Appendix II). Removal of offensive trade refuse. In the last annual report it was stated that a system of collection of offensive trade refuse (fish offal) by the sanitary authorities was in operation in the City, Woolwich, Finsbury, Wandsworth and Greenwich, a contractor being employed for this purpose in the City, Wandsworth and Greenwich. In the rest of London generally the removal is effected by firms engaged in this occupation without the intervention of the sanitary authority. In several districts there were prosecutions for infringement of the County Council's by-laws prescribing the times within which offensive matter may be conveyed through the streets and the conditions to be observed in removal. Nuisance from sewers. In the report relating to Fulham there is mention of the flooding of basements from sewers being surcharged. After exceptional rainfall on the 29th July, and subsequent days, such floodings occurred in various parts of that borough. It is expected that in future such occurrences in that locality will be prevented on the completion of the Council's sewer in Hammersmith in course of construction. Flooding from a local sewer is mentioned in the report of the medical officer of health of Lambeth. It was decided to deepen the sewer so as to prevent recurrence. Complaints of offensive emanation from sewer ventilators are mentioned in a few reports. The medical officer of health of Woolwich states that complaints as to the County Council's new outfall sewer were under consideration, with the result that openings in the sewer were closed. Housing of the Working Classes Act. No new schemes under this Act were undertaken by the Council during 1907. The following is a summary of the action taken during the year. 18560 12 64 Proceedings by the County Council under Part I. of the Act. Garden-row (St. Luke) scheme.— On the 23rd April the Housing of the Working Classes Committee reported the completion of Chadworth-buildings, providing accommodation for 720 persons in 9 tenements of four rooms, 67 of three rooms', 58 of two rooms, one cottage of four rooms, one cottage of three rooms, and 19 shops. The clearance of the areas comprised in the scheme involved the displacement of 1,193 persons of the working class, and re-housing accommodation has been made for 1,216 persons. Webber-row (Southwark) scheme.— On the same day the Committee reported the completion of Mawdeley-buildings, the last block on this estate. In addition to 10 shops fronting on Waterloo-road, with store rooms on the ground floor, the buildings contain accommodation for 210 persons in 20 tenements of three rooms, 16 of two rooms, 4 of one room, and 18 cubicles. Accommodation has thus been provided on the estate for 1,130 persons, the clearance of the areas included in the scheme involving the displacement of 997 persons of the working class. Warner-street (Holborn) area.—Account of this area was given in the last annual report, On the 23rd April, 1907, the Housing of the Working Classes Committee further reported on the area as follows :— On 3rd July, 1906 (p. 86), we reported that a local inquiry had been held by the Local Government Board with reference to the official representation made by the medical officer of health of the Metropolitan Borough of Holborn in relation to the Warner-street (or Italian colony) area in the borough. At the inquiry the Chandos Land and Building Society, which owns the freehold of the greater portion of the property comprised in the area, gave an undertaking to demolish many of 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 then existing, and as other owners agreed to observe any suggestions affecting their particular properties, the inquiry was adjourned. The owners of the property subsequently arrived at a complete agreement with the Council's medical officer and the medical officer of health of Holborn, and steps were immediately taken to clear the courts and to discontinue the use of the underground rooms as living rooms. The owners having done all that was promised, to the satisfaction of the borough council, the inspectors did not consider it necessary to hold the adjourned inquiry on 15th April, 1907, and there is no need for the preparation of a clearance scheme under the Housing of the Working Classes Act, 1890. This was a case in which the Council did not feel justified in incurring the heavy expenditure which would be involved in dealing with the area by way of a scheme as prescribed by the Act, as it was probable that in the near future the property in the area would be redeveloped by the freeholders. The Council may therefore regard the result of the inquiry with satisfaction, a considerable improvement in the sanitary conditions of the property having been effected without expending the large amount of public money which would have been necessary if the Council had been compelled to deal with the area under the provisions of Part I. of the Housing of the Working Classes Act, 1890. Proceedings by the County Council under Part III. of the Act. Norbury estate.— On the 19th February the Committee reported the completion of 59 cottages on section A of the Norbury estate, and the Council accepted a tender of £12,794 for the erection of 52 cottages on the first part of section B of the estate. Totter down-fields estate.— On the 26th February the Committee reported the completion of 157 additional cottages on section B of the Totterdown-fields estate, constituting the completion of the development of section B. on which there have been provided 429 cottages and 2 shops, the accommodation being sufficient for 5,376 persons in 726 tenements. On the 16th July the Council accepted a tender of £5,800 for the erection of 19 cottages on the first part of section C, and on the 12th November a tender of £14,648 for the erection of 67 cottages on the second part of section C of this estate. White Hart-lane estate.— On the 14th May the Council accepted a tender of £22,200 for the erection of 103 cottages on the second part of section B of this estate. Proceedings by District Councils under Part II. of the Act. Brantomc-place and Prospect-terrace (St. Pancras) scheme.— On the 8th February the County Council approved revised plans for a block of dwellings to be erected by the borough council in the Brantome-place area, the building to be six storeys in height and to provide accommodation for 432 persons in 36 tenements of two rooms, and 48 tenements of three rooms, with a lodge, and with a storeroom, workshop, and a drying-room in the basement. In June the borough council obtained sanction for an amended scheme for the erection in the Prospect-terrace area buildings for the accommodation of 356 persons in 36 tenements of three rooms, and 34 tenements of two rooms, with lodge and 12 baths and drying room. Proceedings by District Councils under Part III. of the Act. The medical officer of health of Chelsea records the gift by Lord Cadogan of a plot of land of an area of nearly half an acre, situated on the south side of Grove-cottages. The borough council had under consideration plans for the erection of working-class dwellings on the site. In connection with unhealthy areas, Dr. Alexander reports that the houses in the Gaudy-court area, Poplar, 12 in number, which he had represented under Part I. of the Act, had been greatly improved. Dr. McCleary reports that the houses in the Kilburn-vale area in Hampstead, which had been represented by his predecessor under Part I. of the Act, had been substantially improved. Dr. Bate reports that the houses in the Brady-street area in Bethnal Green, which he had represented under Part I. of the Act, remained in the same condition, and that no real improvement is possible without a comprehensive scheme for the clearing and reconstruction of the whole area. Dr. Annis reports the completion of the works for the improvement of the Greenwich market and the approaches thereto. 65 Death-rates obtaining among persons resident in the Council's buildings, 1907. The following death-rates obtaining among tenants of the Council's dwellings relate to buildings within the County which were occupied during the whole of the year 1907. The population thus dealt with comprised 23,634 persons, and the death-rate at " all ages" after correction for age and sex distribution was 13.8 per 1000 living, compared with 14.6 for London:— Death-rate per 1,000 living. Cause of death. Council's London dwellings All Causes—All Ages 13.8 14-6 ,, ,, age 0.5 36.8 42-8 „ „ ,, 5-20 2.5 2.1 „ ,, ,, 20 and upwards 13.4 15.2 Diarrhoea 0.9 0.3 Principal epidemic diseases (excluding Diarrhoea) 1.2 1.1 Phthisis 13 14 Tuberculous diseases other than Phthisis 0.7 0.2 Bronchitis 1.6 1.3 Pneumonia 1.3 1.6 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, 1907:— Sanitary area. Total number of houses con- corning which the Council has received information that representations have been made from the 1/1/07 to the 31/12/07 Number of houses dealt with by owners, without Magisterial intervention. Number of houses for which closing orders were granted. Number of houses for which closing orders were refused. Number of houses represented but subsequently dealt with under Public Health (London) Act, 1891. Still closed. Demolished. Improved. Total. Still closed. Demolished. Improved. Total. Battersea _ _ _ _ _ _ _ _ _ _ _ Bermondsey _ _ _ _ _ _ _ _ _ Bethnal Green _ __ _ _ _ _ Camberwell _ _ _ _ _ _ _ _ Chelsea _ _ _ _ _ _ _ _ _ Deptford — _ _ _ _ _ _ — _ _ Finsbury _ — _ _ _ _ _ _ _ _ _ Fulham l 1 _ _ 1 _ _ _ _ Greenwich _ _ _ _ _ _ Hackney _ _ _ _ _ _ _ _ _ Hammersmith _ _ _ _ _ Hampstead _ _ — _ _ _ — — _ — Holborn _ _ _ _ _ _ _ _ — _ — Islington — _ _ _ _ _ _ _ _ — — Kensington 7 _ _ _ _ 7 — _ 7 _ _ Lambeth _ _ _ _ _ _ _ — _ _ Lewisham _ _ _ _ _ _ _ _ — _ _ Paddington _ _ _ _ _ — _ _ _ _ _ Poplar _ _ _ _ _ _ _ _ _ _ _ St. Marylebone 1 _ _ 1 1 — _ _ _ _ — St. Pancras 1 — — 1 1 _ _ — _ _ — Shoreditch — _ — _ — _ _ — _ _ — Southwark _ — _ — — _ — _ _ — — Stepney _ _ _ _ _ _ _ _ _ _ _ Stoke Newington _ _ _ _ — _ _ _ _ _ _ Wandsworth _ _ — _ _ — _ _ — _ — Westminster, City of _ — — _ _ _ _ — — _ — Woolwich 2 2 _ _ 2 _ _ _ _ _ _ Total 12 3 _ 2 5 7 _ 7 _ _ 66 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 lodgers, 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 2,133 16 15 96 3 0 102 166 1902 491 28.970½* 40,512 1,449 22 21 98 4 0 120 684 1903 470 28,893 33,402 4,790 6 6 26 11 0 98 53 1904 451 28,896 27,501 2,970 15 14 62 6 0 74 66 1905 413 27,57 1½* 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 1907 395 28,6511½* 33,630 2,307 3 3 12 9 0 81 27 In the year 1907 proceedings before the Magistrates were instituted in 3 instances, resulting in 3 convictions, the penalties amounting to £11— with costs amounting to £1 9s. The number of cases of notifiable infectious disease reported in common lodging houses were as follows :— Erysipelas, 14; scarlet fever, 7; diphtheria, 5; enteric fever, 1—total, 27. 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, on 31st December, 1907:— Sanitary district. No. of houses. Men. Authorised accommodation. Total. Women. Couples. Battersea 8 157 78 23 281 Bermondsey 5 1,078 — — 1,073 Bethnal Green 14 709 — — 709 Camberwell 6 536 — — 536 Chelsea 9 337 52 — 389 Deptford 8 1,159 80 — 1,239 Finsbury 8 543 – — 543 Fulmar 1 43 — — 43 Greenwich 4 157 — — 157 Hackney 6 401 — — 401 Hammersmith 9 466 — 4 474 Hampstead — — — — — Holborn 30 1,797 162 — 1,959 Islington 43 1,229 215 18 1,480 Kensington 24 427 272 — 699 Lambeth 7 702 — — 702 Lewisham 1 30 — — 30 Paddington 7 195 40 — 235 Poplar 9 1,142 — — 1,142 St. Marylebone 17 1,321 84 — 1,405 St. Pancras 10 727 111 — 833 Shoreditch 12 774 — — 774 South wark 44 3,195 492 — 3,687 Step Dey 61 5,455 752 180 6,567 Stoke Newington 1 37 — — 37 Wandsworth 9 176 5½ 20 221J Westminster, City of 18 2,359 75 — 2,434 Woolwich 24 547 44 — 591 London— excluding the City of London 395 25,699 2,462½ 245 28,651$ * ½ One child. † The number of deaths stated in the above table includes all the deaths actually occurring in common lodging houses and a few deaths occurring in public institutions among porsons of the common lodging house class, which are brought to the knowledge of the inspectors in certain cases in which death is followed by an inquest. 67 At the end of 1906 inquiry was made of some 2,900 residents in common lodging houses as to their professed occupations. As was to be expected, the unskilled worker was in the great majority. Thus 540 were general labourers, and 381 were porters. If to this number are added 183 waterside labourers, 116 bill posters and sandwichmen, and the labourers associated with particular trades, such as painters and bricklayers, a total number of persons is obtained amounting to more than half the number of whom inquiry was made. Among the skilled workers, engineers, printers, cabinet makers and metal workers are in the majority. Of professed beggars, there were 21, cabminders 50, "loafers" 9, and tramps 1. Six persons described themselves as independent. There were 21 soldiers and 26 sailors ; of the soldiers most were pensioners and lived on their pensions. The principal classes are shown in the following table :— Profession or occupation. No of Profession or occupation. Persons. Persons. General labourers 540 Shoemakers 35 Street sellers, etc. 426 Engineers and labourers 33 Porters 381 Shoeblacks 32 Waterside labourers 183 Carpenters and labourers 32 Carmen and ostlers 169 Domestic servants 27 Bill posters 116 Navvies 26 Painters and labourers 81 Sailors 26 Tradesmen 77 Cabinet makers 26 Bricklayers and labourers 61 Tailors 23 Potmen 53 Firemen 23 Cabminders 50 Soldiers 21 Metal workers 42 Beggars 21 Printers 38 *Others 321 Clerks 37 2,900 Homeless persons. On the night of the 8th February, 1907, effort was made to ascertain the number of persons in London who, being without homes, passed the night in the street or on the staircases of tenement houses of which the street doors are left unfastened. This number in 1907 was 2,400, in 1904 similar inquiry led to some 2,000 such persons being found, and in 1905 in the same way some 2,200 such persons were discovered. An estimate made, as the result of the first two inquiries, that homeless persons were in the proportion of about 1 in every 2,000 of the population, appears to approach accuracy. It is interesting to note that on the night of the inquiry in 1907 accommodation in the casual wards for 745 persons remained unoccupied, the total accommodation provided in London, which is sufficient for 1,882 persons, being occupied by 1,137 only. Appended to this report is a more detailed account of the results of this inquiry. (See Appendix III). 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. In the following table will be seen the number of houses, the authorised number of lodgers, the number of convictions with the penalties inflicted, and other particulars, during each year since the supervision of seamen's lodging houses was undertaken by the Council:— 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 cases of infectious disease. 1902 97 1,665 2,842 – – – – – 1903 102 1,748 1,956 4 2 1 1 16 0 7 1904 90 1,585 1,298 10 3 3 11 7 0 10 1905 77 1,509 1,509 15 5 5 9 13 6 1 1906 84 1,551 1,431 38 9 8 43 7 0 2 1907 82 1,550 2,169 70 8 7 38 19 0 5 In the year 1907 proceedings before the magistrate were instituted in 8 instances, resulting in 7 convictions, the penalties amounting to £30 16s., with costs amounting to £8 3s. The number of cases of notifiable infectious disease reported in seamen's lodging houses were five all being cases of scarlet fever. Of this number four of the patients were children belonging to the family of one of the keepers. On the 31st December, 1907, the total number of seamen's lodging houses under supervision was 82, situated in the following metropolitan boroughs:— * Including 1 journalist, 2 doctors, 1 comedian, 1 "kitchen lawyer," 11 musicians, 2 horse copers, 4 slaters. 68 Metropolitan borough. Houses. Lodgers. Poplar 18 398 Stepney 63 1,126 Woolwich 1 26 Total 82 1,550 Licensing of Seamen's Lodging Houses. During the year application was made for, and a licence was granted in respect of the New German Sailors' Home, situated in Rich-street, West India Dock-road. This house is the only licensed seamen's lodging house in the County. It accommodates some 64 seamen lodgers. The Council has no power at present to compel keepers to apply for a licence, although it has power to grant licences on applications by the keepers of such houses. Communications have passed between the Council and the Board of Trade as to the desirability of an Order being issued rendering obligatory the annual licensing of seamen's lodging houses, but the matter is still under consideration. Houses Let in Lodgings. In the last report the position of the several sanitary authorities was stated in respect of amendment of the by-laws for houses let in lodgings consequent upon decisions of the High Court in 1904 in the cases of Stiles v. Galinski and Nokes and Nokes v. the Mayor, Aldermen, and Councillors of Islington. There has since been no change in that position. The following table shows the number of houses on the registers at the end of 1907. and other particulars :— Registered houses let in lodgings. Number of houses. Sanitary area. On register at end of 1906. Added in 1907. Removed in in 1907. On register at end of 1907. No. of Inspections, 1907. No. of Notices, 1907. No. of Prosecutions, 1907. Paddington 1,272 48 – 1,320 8,643 * 121 * — † 4,295 † 6 Kensington 1,981 53 6 2,028 9,304 * 47 * — † 1,187 † 7 Hammersmith 2,852 432 379 2,905 154 Fulham 114 — — 114 — — – Chelsea 602 — 5 597 337 * 5 * — † 100 * – Westminster, City of 1,602 — 30 1,572 2,237 4 St. Marylebone 758 758 Hampstead 239 76 — 315 527 34 – St. Pancras 2,296 2,316 2,429 * 1,394 † 118 Islington 891 No register under new bylaws. 12,236 * 120 * — † 1,274 † 11 Stoke Newington 246 243 243 Hackney 463 226 226 * 7 † 79 Holborn 690 1 5 686 1,325 * 11 * † 275 † — Finsbury 1,254 — 21 1,233 11,463 * 67 * † 3,191 † 8 London, City of 315 304 370 Shoreditch 266 11 5 272 419 140 5 Bethnal Green 501 23 15 509 2,637 696 1 Stepney 2,812 284 393 2,703 2,768 * 314 * 6 † 1,148 † 18 Poplar 960 93 1,020 2,736 * 72 • 1 Night 292 † 367 † 2 Southwards 1,248 17 10 1,255 Bermondsey 224 – 1 223 426 * 4 * † 79 †– Lambeth 372 — 372 1 Battersea 123 — 123 Frequent 102 – Wandsworth 218 11 — 229 513 * 14 * t 362 † 5 Camberwell 217 – — 217 1,025 * 9 * 1 — † 305 † 2 Deptford 269 – — 269 — — – Greenwich 3 10 13 — — – Lewisham 15 — — 15 159 * 4 – † 29 – Woolwich 307 28 5 330 758 337 4 * For overcrowding. + For other conditions. 69 The following observations of medical officers of health on the subject of houses let in lodgings are deserving of note:— Hammersmith.— "The registered premises were visited as often as time would allow by the special inspector appointed for that purpose. There can be no doubt that the official influence obtained by the registration of premises has a very good effect in improving the sanitary condition of the dwellings and preventing overcrowding." Hampstead.—" The condition of these houses has improved since they have been placed upon the register, but the beneficial effect of registration will not be secured until the houses are more frequently inspected, and this will not be practicable without an increase in the sanitary staff." The number of houses on the register at the end of 1907 was 315, and Dr. McCleary states that the number of tenement houses in Hampstead which need to be dealt with under the by-laws relating to houses let in lodgings is over 800. Poplar.— "In a district with a population of 170,000, and containing over 22,000 houses, the [seven] sanitary inspectors cannot carry out the duties under the by-laws for houses let in lodgings or occupied by members of more than one family." " I unhesitatingly suggested for the consideration of the Committee that another inspector should be appointed for houses let in lodgings." The context shows that this appointment was not made. Wandsworth.— "No difficulties have arisen during the year in carrying out these by-laws, and I am able to report that all these premises have been kept in much better condition since being placed Qn the register." St. Pancras.— In his annual report Dr. Sykes discusses the question of the exemption clauses to be included in the by-laws for houses let in lodgings in St. Pancras, the borough council deciding that the by-laws should not apply to tenement houses—(1) when the landlord resides upon the premises and the sub-letting is not to more than one family, and (2) where the number of separate dwellings in which the house is sub-let does not exceed one-third of the total number of habitable rooms in the house, and no such dwelling contains less than two habitable rooms. The Local Government Board have recently held an inquiry into the question of the confirmation of these bylaws, but the decision of the Board has not yet been announced. Paddington.— Dr. Reginald Dudfield includes in his report a comparison of the statistics of morbidity and mortality of the inhabitants of registered houses let in lodgings with similar statistics for the Borough of Paddington as a whole, which show that there was a larger incidence of the notifiable infectious diseases on the former than on the latter population, and that the mortality from " all causes" in the former was twice that. in the latter, the difference being especially marked in respect of deathrates from measles, scarlet fever, diphtheria, diarrœhal diseases, phthisis, and other tubercular diseases. There is no doubt that the regulation under by-laws of houses let in lodgings provides the most effectual means of maintaining in wholesome condition the dwellings occupied by the poorest and by the most negligent classes of the population. It is well recognised that the unsatisfactory conditions which are frequently found in these houses are often contributed to by the habits of the inmates, and in this connection the following extract from the report of Miss Middlebrooke, the woman sanitary inspector of Woolwich, which is quoted in the report of the medical officer of health, will be read with interest:— In visiting the houses let in lodgings, not only is attention paid to the condition of the walls, ceilings, floors, roofs, window sash-frames, and other structural defects, but an endeavour is also made to educate the tenants to a higher standard of cleanliness, and decency of living. Efforts are made to induce those housewives who are inclined to be slatternly to be orderly and methodical in their houses. Many women are under the impression that, so long as they wash their floors, the rest of the room does not matter in the least. They are apparently blind to the cobwebs on the walls and ceilings, that paintwork coated with black grease, the accumulations of dirt in the corners of the rooms, and filthy carpets which would bo better dispensed with altogether. Special attention is given to the following:— To the state of the bedding, which is too often found in a deplorable condition, out of repair, soaked with filthy matter, offensive and verminous, destitute of proper coverings, pillowslips and sheets. To the receptacles for slops; these are often coated with a slimy foul matter, and are frequently the cause of serious nuisance. To the spaces under the beds, which are used for the disposal of dirty clothing, old boots, and rubbish. To the cupboards used for the storage of food ; these are usually found in a most unsatisfactory state as regards cleanliness and order. To the use of heavy, dirty, light-obstructing window curtains and blinds. Water supply to tenement houses. During the year the Council obtained the sanction of Parliament to a provision which was included in the London County Council (General Powers) Act, 1907, and which empowers sanitary authorities to require a supply of water to the upper storeys of tenement houses. This provision came into force on the 1st January, 1908. Houses infested with Vermin. The powers contained in section 20 of the London County Council (General Powers) Act, 1904, are being increasingly used by sanitary authorities for the cleansing of premises infested with vermin. The annual reports supply the following information as to proceedings under this section in 1907:— 18560 70 Houses infested with vermin. Number of premises cleansed. Paddington 146 premises. Finsbury 30 occupancies Kensington 137 „ Shoreditch 181 rooms. Hammersmith 11 premises. Bethnal Green 336 „ Fulham 116 rooms. Stepney 1,399 „ Chelsea 267 Poplar 212 „ Westminster 119 premises. Southwards 1,053 „ St. Marylebone 43 rooms. Lambeth 4 „ Hampstead 24 „ Wandsworth 100 premises. St. Pancras 191 „ Camberwell 10 „ Islington 135 premises. Deptford 11 rooms. Stoke Newington A considerable number. Lewisham 6 premises. Holborn 91 premises. Woolwich 148 rooms. Revenue Act, 1903. Under section 11 of the Revenue Act, 1903, on the certificate of the medical officer of health that the house is so constructed as to afford suitable accommodation for each of the families or persons inhabiting it, with due provision for their sanitary requirements, there is exemption from or reduction of inhabited house duty, as follows:— (1) Where a house, so far as it is used as a dwelling house, is used for the sole purpose of providing separate dwellings— (a) The value of any dwelling in the house which is of an annual value below twenty pounds shall be excluded from the annual value of the house for the purposes of inhabited house duty; and (b) The rate of inhabited house duty, in respect of any dwelling in the house of an annual value of twenty pounds, but not exceeding forty pounds, shall be reduced to threepence; and (c) The rate of inhabited house duty, in respect of any dwelling in the house of an annual value exceeding forty pounds, but not exceeding sixty pounds, shall be reduced to sixpence. For the purposes of these provisions medical officers of health were called upon to certify numerous houses during the year, and in some instances the application was granted, in others it was refused, while in others, again, it was only granted after alterations had been made to meet the conditions necessary before certification. The Act appears to be instrumental in ensuring a higher standard of dwelling accommodation than before. It is stated in two of the annual reports (Hampstead and Hammersmith) that among the conditions which are insisted upon is the ventilation of gas stoves into the external air. The number of applications received and certificates granted during 1907 is shown in the following table:— Sanitary area. No. of houses for which applications for certificates were received during year. No. of tenements comprised therein. No. of tenements for which certificates were Granted. Refused. Deferred. Paddington 19 162 136 73 Kensington 22 74 72 2 — Hammersmith 86 232 46 6 145 Fulham 72 179 59 92 28 Chelsea 9 62 20 42 — Westminster, City of 17 130 117 9 4 St. Marylebone 72 9 Hampstead 22 105 12 — 93 Islington 34 259 149 110 — Hackney 5 51 51 — — Holborn 29 152 16 136 — Finsbury 3 174 174 — — Shoreditch 3 3 3 Bethnal Green 30 86 58 28 — Stepney 75 545 416 129 — Poplar 6 — 6 houses — Southwark 29 premises — 29 Bermondsey 18 58 58 — — Lambeth 40 168 68 10 90 Battersea 15 43 8 35 — Wandsworth 64 143 121 22 — Camberwell 47 131 109 22 — Deptford 74 148 148 — — Greenwich 2 4 — 4 — Lewisham 308 619 294 325 — Woolwich 1 — – 1 71 Underground Rooms. In a number of districts the illegal occupation of underground rooms was dealt with during the year. Dr. Harris comments on the fact that there are now comparatively few such rooms illegally occupied in Islington, but that a few are occasionally discovered. The number of such rooms dealt with in the several sanitary areas is shown in the following table:— No. of No. of rooms No. of _ rooms No. of sanitary area. illegally rooms Sanitary area. illegally rooms occupied. closed. occupied. closed. Kensington 14 14 Holborn 19 19 Fulham 2 2 Finsbury 6 — Chelsea 1 1 Bethnal Green 5 Westminster 47 47 Stepney 116 57 Hampstead 7 2 Lambeth 5 — St. Pancras 88 Battersea 91 91 Islington 25 25 Greenwich 2 2 Hackney 2 — Overcrowding. The annual reports show that the number of instances in which overcrowding was found was much the same in 1907 as in 1906. There is reason for thinking that in recent years greater attention has been paid by sanitary authorities to the abatement of the nuisance, and Dr. Newman states that in Finsbury there has been an enormous reduction in overcrowding, the reduction having been effected mainly in the years 1901-5. The improved facilities for travelling between the areas outside London and within London, and the considerable increase of dwelling house accommodation on the borders of London, must inevitably reduce the density of population in London, but the persistent efforts of sanitary authorities will always be required to control overcrowding of tenements by persons who do not attach importance to the necessity of adequate space within the dwelling in proportion to the number of occupants. The greatest difficulty occurs in the cases where the wage earnings are but scanty, and practically insufficient to enable payment to be made for more than the one room in which the family are found to dwell. This is well brought out in a statement which Dr. Brown includes in his report relating to Bermondsey. The following table is compiled from information supplied by the reports of medical officers of health:— No. of Sanitary area. dwelling- No. No. of rooms over- remedied. prosecutions. crowded. Paddington 416 295 — Kensington 40 40 — Fulham 37 37 — Chelsea 14 14 — Westminster, City of 71 71 Hampstead 8 8 — St. Pancras 73 73 Islington 266 166 — Stoke Newington 4 Hackney 99 99 — Holborn 44 44 — Finsbury 121 121 — London, City of 19 19 1 Shoreditch 80 80 — Bethnal Green 212 Stepney 833 833 7 Poplar 41 41 1 Southwark 497 Bermondsey 63 63 — Lambeth 11 Battersea 129 129 — Wandsworth 87 87 — Camberwell 97 97 — Deptford 24 24 Greenwich 21 21 — Lewisham 45 45 — Woolwich 85 85 — Factory and Workshop Act, 1901. Every medical officer of health is required under the provisions of sections 132 of the Factory and Workshop Act, 1901, to report specifically on the administration of this Act in workshops in their districts and a form of table has been prepared for the exhibition of those particulars which lend themselves to statistical statement. From this table and from information contained in the annual reports the following summary table has been prepared:— 18560 K 2 72 TABLE SHOWING PROCEEDINGS OF LONDON SANITARY Premises, Particulars, Class, Sc. Paddington. Kensington. Hammersmith. Fulham. Chelsea. City of Westminster. St. Marylebone Hampstead. St. Pancras. Islington. Stoke Newington. 1. Inspections. Factories (including factory laundries) 244 144 554 75 _ 81 24 132 178 557 16 Workshops (including workshop laundries) 1,571 2,819 1,465 646 510 3,204 1,926 1,100 1,193 2,557 167 Workplaces (other than outworkers' TYPATYl IQAQ\ 48 348 238 135 — 843 898 635 318 1,500 10 UI CIIllOCS J Total (Inspections) 1,863 3,311 2,257 S56 510 4128 2,848 1,867 1,689 4,614 193 2. Defects Found. Nuisances under the Public Health Acts. Want of cleanliness 68 235 138 69 9 613 62 33 82 970 36 Want of ventilation 4 31 3 3 1 150 2 1 31 — Overcrowding 4 8 — 2 8 37 1 8 2 9 — Want of drainage of floors — 19 14 4 — 35 — 1 — 45 1 Other nuisances 22 137 86 8 7 767 15 91 10 601 30 Sanitary accommodation ( Insufficient 6 6 6 2 24 . 2 7 28 2 J Unsuitable 17 84 30 25 470 8 16 9 198 25 ( Not separate for sexes — 6 1 3 — 170 3 2 — 19 Offences under the Factory ife Workshop Act. Illegal occupation of underground bakehouse (s. 101) — — — — — 4 — — — — — Breach of special sanitary requirements for bakehouses (ss. 97-100) — 6 97 15 — — — 28 — — Other offences (excluding offences relating to outwork) — 5 7 — — 10 1 27 — Total (defects found) 115 537 382 135 27 2,270 91 164 139 1,928 94 3. Homework. Outworkers' Lists (s. 107). Received twice in the year from employers ' Number of Lists 76 89 7 26 62 654 1S8 114 47 608 30 Number of outworkers corresponding thereto 440 867 15 81 604 7,807 1,695 359 200 5,056 276 Received once in the year from employers ( Number of Lists. 25 10 34 5 10 12 66 13 7 SOS 4 | Number of out1 workers corrosl ponding thereto 42 42 74 16 24 124 796 11 18 2,355 25 Number of addresses of outworkers received from other Councils 385 317 277 258 92 432 1,504 54 974 2,7£8 541 Number of addresses of outworkers forwarded to other Councils 283 707 129 48 518 3,199 1,248 382 177 1,341 112 Prosecutions f Failing to keep lists or permit inspection 1 thereof Failing to send lists . Outivorkers' Premises. Number of inspections of outworkers' premises 377 473 362 163 — — 324 101 371 937 204 Outwork in unwholesome premises (s. 108) Instances 1 21 19 11 2 34 Notices served 1 21 19- 468 11 2 34 — ! Prosecutions 2 Outwork in infected premises (ss. 109, 110) / Instances 11 17 98 52 3 i Orders made (s. 110) 4 — | Prosecutions I (ss. 109. 1101 4. Registered Workshops. Workshops on the Register at the end of 1906. Bakehouses r i • * * " 67 96 61 69 39 92 78 35 187 256 28 Laundries 118 216 305 79 30 47 \ 2,831 f 6 74 134 24 Other workshops 1,318 1,324 447 368 500 2,685/ 1 \ 463 454 1,373 153 Total (number of workshops on the Register) . 1,503 1,636 813 516 569 2,824 2,909 504 715 1,763 205 5. Other Matters. Matters notified to H.M. Inspector of Factories. Failure to affix abstract of the Factory and Workshop Act (s. 133) 39 55 22 213 41 41 2 198 4 Action taken in matters referred by H.M. Inspector as remediable under the Public Health Acts but not under the Factory and Workshop Act (s. 6). Notified by H.M. Inspector 19 30 34 10 15 116 47 — 7 6 4 Reports (of action taken)sent to H.M. Inspector 18 16 10 10 15 116 37 7 4 4 Other Underground Bakehouses (s. 101). — 5 18 4 2 2 — — Certificates granted during ,^1907 — — 1 — — — — — In use at the end of 1907 58 75 33 50 32 77 70 22 160 101 18 AUTHORITIES UNDER THE FACTORY AND WORKSHOP ACT. Hackney. Holborn. Finsbury. City of London. Shoreditch. Bethnal Green. Stepney. Poplar. Southwark. Bermondsey. Lambeth. Battersea. j Wandsworth. Camberwell Deptford; Greenwich. Lewisham. Woolwich. 80 79 867 2,387 103 88 70 330 167 78 10 621 683 172 130 71 142 28 2,413 988 2,185 4,087 3,435 3,681 4,066 1,627 2,311 239 ) ( 1,558 3,148 2,700 516 428 1,314 286 — 2,270 677 887 818 922 55 512 2,883 595 ',808 I 1 1,738 1,868 811 274 140 689 — 2,493 3,337 3,729 7,361 4,356 4,691 4,191 2,469 5.361 912 818 3,917 5,699 3,683 920 639 2,145 314 225 85 180 944 465 317 541 589 1,100 162 173 184 222 104 440 96 114 63 35 9 35 182 2 15 74 10 18 3 4 3 17 — 4 2 3 10 25 2 5 43 2 8 46 4 18 5 22 5 4 2 — 3 8 14 7 8 2 45 45 3 15 5 — 5 10S 56 596 1,938 39 253 19 260 1,044 218 356 220 187 46 86 25 45 60 6 5 22 29 2 5 63 2 12 8 — 4 6 5 1 2 1 1 8 167 101 221 1 865 61 165 5 9 2 97 255 116 98 42 42 18 75 1 22 5 11 72 2 5 36 4 4 6 7 2 3 4 — — — 1 — 1 1 — 15 — — — — 23 — — 12 — 53 8 — — 11 — — — — 94 — — — — — — 2 — — — — — — — — 595 279 1,172 5,073 573 768 809 878 2,243 558 817 591 545 218 573 162 246 161 357 116 270 1.298 38 178 240 134 122 52 92 130 156 F4 37 86 26 3,769 755 5,400 13,475 1,166 3,280 3,414 2,309 1,049 613 417 387 1,812 568 199 210 190 85 6 25 128 14 11 39 5 40 4 45 2 18 5 — 29 17 428 31 182 729 282 175 254 153 246 16 360 2 44 32 53 191 2,959 305 83.3 193 3,103 2,613 7,139 1,606 1,090 851 861 368 322 1,380 529 184 173 52 1,973 518 5,353 16,570 1,147 1,707 1,489 1,099 697 259 235 191 325 540 354 85 115 30 — — — — — — — — — — — — — — — — — — — — — 9 — — — 4 1 3 — — 726 195 214 259 2,242 5,474 4,302 2,124 1,184 1,049 751 349 958 487 245 304 360 511 116 57 33 40 7 — 195 523 — 97 57 31 — — 40 4 — __ — _ 2 3 11 — 307 — 25 6 9 6 39 8 — — — — — -- 112 31 61 29 69 93 176 105 112 86 207 80 159 183 76 67 99 56 109 13 21\ 3,112 j 34) 1,7781 21 45 63 37 } 1,437 f 34 114 77 12 21 74 17 953 952 1,902/ 1.213J 2,446 435 2,456 624 { 410 1,498 1,226 195 158 498 148 1,174 996 1,984 3,141 1,316 1,871 2,643 585 2,631 747 1,644 524 1,771 1,486 283 246 671 221 38 11 82 93 44 24 36 11 36 37 58 25 7 10 24 3 44 2 25 21 32 44 127 49 11 O 35 4 6 9 3 2 2 — 14 2 25 21 9 44 89 49 10 2 35 4 6 9 3 — 2 — T6 O 38 4 11 — — — — 13 — — — 50 26 40 23 42 30 60 33 41 33 72 31 48 66 28 19 23 25 74 Comparison between some of the statistics of the years 1904-7 may conveniently be made thus:— 1904. 1905. 1906. 1907. Number of workshops on register 34,488 35,187 36,632 37,891 Number of inspections 84,600 86,071 79,526 81,171 Total number of defects found 18,922 19,023 19,407 22,071 Want of cleanliness 5,752 6,522 7,206 8,319 Want of ventilation 799 828 736 652 Overcrowding 413 347 461 295 Sanitary conveniences Insufficient 403 284 296 256 Unsuitable or defective 3,645 3,411 3,717 4,229 Not separate for sexes. 308 239 251 388 The registers therefore, show an increased number of workshops dealt with in 1907, compared with antecedent years, an increase in the numbers of inspections as compared with the numbers in 1906, and an increase in the numbers of " defects " found, this last increase as well as the increase in the number of cases of want of cleanliness have been manifested throughout the whole period. On the other hand there has been some decrease in the cases of want of ventilation, and also in the number of instances of overcrowding, and further, whilst insufficiency of sanitary accommodation has decreased, there has been increase in the number of cases in which the sanitary conveniences were found to be unsuitable or defective or in which separate accommodation was not provided for the two sexes. It is, of course, difficult to state to what extent the differences in these figures are due to variations in the character and amount of inspection carried out by the authorities in the years under consideration. The difficulty of dealing with basement rooms which are occupied as workshops, is discussed in the annual report of Dr. Parkes, the medical officer of health of Chelsea, who writes: "Considerable difficulty has been experienced with regard to the ventilation of these rooms more especially during the winter months when artificial lighting is continually being used. Basement workrooms are generally large, but the means of ventilation and lighting are not in satisfactory proportion to the cubic space. It often happens, therefore, that more workers are allowed by law to be accommodated than is desirable." He mentions, moreover, that there are twenty-two basement workrooms in Chelsea occupied by milliners and dressmakers with accommodation for about 180 workers. The Public Health law prescribes the conditions with which underground rooms must comply for the purpose of being separately occupied as dwellings, and there is need for regulations governing the use of such rooms as workshops. There is increasing employment by sanitary authorities, for the purposes of inspection under this Act, of special inspectors as distinct from " district inspectors " upon whom devolve all the usual duties under the Public Health Act. Such special inspectors are now employed in more than one-third of the districts. Women inspectors are employed for the inspection of workshops where the workers are females in the large majority of districts, indeed the only authorities not providing such officers are the Borough Councils of Stoke Newington, Hammersmith, Shoreditch, Stepney, Bermondsey, Deptford, and Greenwich. In the annual reports relating to the City of London and St. Marylebone the statement is made that the staff of inspectors is inadequate for the purposes of the duties which have to be performed in connection with this branch of work. The Secretary of State made a further Order in 1907 under the provisions of sections 107,108 and 110 of the Factory and Workshop Act, 1901. This Order, which was a consolidating Order, applied Section 107 relating to lists of outworkers, and Section 108 relating to employment in unwholesome premises to the following trades in addition to those subject to the Order of the 15th August, 1905, which was repealed, viz., the making of artificial flowers, nets (other than wire), tents, sacks, boxes of cardboard, chip, etc. and baskets, the covering of racquet and tennis balls, pea picking, feather sorting, and the carding of buttons, hooks and eyes, pins and hair-pins. In November, endeavour was made by the Home Office through a conference with medical officers of health to arrange for observations on uniform lines to obtain information as to the physical, social, and economic effects of the industrial employment of women before and after childbirth in connection with the suggested extension of Section 61 providing for absence from work of women for at least a month after childbirth. In this way in a number of localities the effect of such employment upon the birth-rate and infant mortality will be studied The Factory and Workshop Act, 1907, repeals, as regard laundries, section 103 of the Act of 1901, constituting them non-textile factories or workshops according as power is used or not, and withdraws the exemption of laundries attached to charitable institutions and of those in which in addition to the members of the family, only two non-resident persons are employed. The Act makes special provision as regards the hours of employment in laundries, other than laundries ancillary to a business carried on in any premises which apart from the provisions of the Act, are a factory or workshop, and further provides that in every laundry (a) If mechanical power is used, a fan or other efficient means shall be provided, maintained, and used for regulating the temperature in every ironing room, and for carrying away the steam in every washhouse; (b) all stoves for heating irons, must be sufficiently separated from any ironing room or ironing table, and gas irons emitting any noxious fumes must not be used; and 75 (c) the floors must be kept in good condition and drained in such manner as will allow the water to flow off freely. This Act came into force on the 1st January, 1908. Places where food is prepared for sale. The annual reports show that the powers conferred on Sanitary Authorities by the Council's General Powers Act of 1902 for controlling the conditions under which ice cream is prepared for sale, have been usefully administered during the year. In a few of the reports the unsatisfactory conditions found in the vendors premises and which needed remedy are specified. These conditions related in the main to want of cleanliness and appear to have been found for the most part on premises occupied by foreigners who are largely employed in this trade. In one or two of the reports it is stated that as the result of administration there has been considerable improvement in the conditions under which ice creams are manufactured. In the following table the numbers of these premises in the several sanitary areas and other particulars are shown. Ice cream premises. Sanitary area. Number of places. No. of inspections 1907. No. of notices 1907. \ No. of prosecutions 1907. On register at end of 1906. Added in 1907. Removed in 1907. On register at end of 1907. Paddington 146 1 7 140 141 – – Kensington 146 19 — 165 312 37 – Hammersmith 205 15 20 200 795 37 – Fulham 105 55 3 157 225 15 – Chelsea 39 — 39 21 2 – Westminster, City of 116 39 — 155 155 — – St. Marylebone 84 – Hampstead 72 6 — 78 177 4 – Islington 230 — — 230 242 22 – Stoke Newington 34 36 Hackney 158 141 141 13 – Holborn 42 5 6 41 118 2 – Finsbury 98 4 12 90 199 33 – London, City of 233 207 1 – Shoreditch 69 27 2 84 158 21 – Bethnal Green 68 13 10 71 265 35 1 Stepney 86 8 9 85 155 30 – Poplar 139 130 273 13 – Southwark 84 83 20 1 Bermondsey 70 — — 70 291 54 — Battersea 104 16 10 110 284 18 – Wandsworth 229 36 30 235 323 39 – Camberwell 233 27 22 238 467 16 – Deptford 114 19 12 121 217 5 – Greenwich 106 22 10 118 148 52 – Woolwich 68 20 12 76 219 3 – The inspection of other premises where food is prepared for sale was continued during the year and this inspection is now part of the systematic work undertaken by the sanitary authorities. Such places are "workplaces" within the meaning of the Factory and Workshop Act, but except in the matter of sanitary conveniences, there were no powers applicable to these premises other than the general powers of the Public Health (London) Act. With a view to the better control of the conditions under which food is prepared for sale the Council resolved to include in their General Powers Bill of 1908 provisions relating to this subject and these provisions after some modification have been since sanctioned by Parliament. The trades carried on in these premises are of a varied sort. Restaurant kitchens especially were under observation and in a number of instances were improved, the Council's by-law prohibiting direct communication between water closets and such places being utilized for this purpose. In the reports relating to the Cities of London and Westminster and to the Metropolitan Boroughs of Islington and Finsbury, the condition of basement kitchens is particularly referred to. The number of premises where food is dealt with which were brought under inspection in the several sanitary areas and the number of inspections so far as this information can be gathered from the annual reports is shown in the following table:— 76 Premises used Premises used for the preparation Inspections. for the preparation Inspections, and sale of food. and sale of food. Paddington 593 1,096 Shoreditch 237 Kensington 80 Bethnal Green 232 922 Hammersmith 96 Stepney Fulham 95 Poplar 231 978 Chelsea 61 98 Southwark 274 1,059 Westminster, City of 787 2,012 Bermondsey 306 St. Marylebone 240 415 Lambeth 558 Hampstead 438 716 Battersea 252 St. Pancras 559 1,242 Wandsworth 473 650 Islington 452 746 Camberwell 202 287 Stoke Newington 24 Deptford 113 251 Hackney 11 Greenwich 109 173 Holborn 359 1,994 Lewisham 53 Finsbury 268 Woolwich 127 London, City of 188 188 Inspection of Food. The annual reports of medical officers of health supply information concerning the seizure of unwholesome articles of food in their districts. In the City the seizures and surrenders of diseased and unsound meat amounted to 1,038 tons; of poultry, etc., 142 tons; of fruit, vegetables, condensed milk, etc., 194 tons 9 cwt.; at riverside wharves, of fish condemned by the officers of the Fishmongers Company in Billingsgate Market 783 tons; and of fish seized by the officers of the Corporation 9 cwt. In Finsbury, which borders on the City, and where is situated the so-called" extra Corporation" market, a special food inspector is employed, and 33 tons 13 cwt. of diseased meat were confiscated, together with decomposed meat, poultry, fruit, vegetables, etc., amounting to 66 tons, 9 cwt. In Islington the total amount of food condemned during the year was 2 tons 1 cwt. In Bermondsey 26 tons 13 cwt. of food were surrendered and, in addition there were several seizures of other unsound articles of food. In Stepney 368 tons 3 cwt. of unsound food were destroyed ; in the last two districts are situated wharves where a considerable amount of food stuff is received. In Southwark, in which wharves are also situated, and where a special food inspector has been appointed, the surrenders and seizures of unsound articles of food were considerable, including 10,000 rabbits seized at the cold stores on one of the wharves. In Poplar, in which district there are also wharves, a quantity of preserved food was surrendered and other articles of food were seized. In the remaining districts seizures of unsound food were made, but of smaller quantities, and in numerous instances prosecutions followed and convictions were obtained. Among the articles seized in Poplar were a number of blown tins containing various articles of food, leading to seizures in Shoreditch, Stepney, Poplar, Southwark and Camberwell. This food had been brought from a shed in Shoreditch and was in the ownership of a man who, the medical officer of health of Southwark reports, was the reputed owner of several large eating houses in London. It is said that some of these tins had been returned from South Africa. This man was convicted and fined. An important seizure of liquid eggs was made in 1907 by the medical officer of health of Stepney. Dr. Thomas found on some premises in Commercial-street a number of casks, some containing the yolks of eggs only and others containing the whites and yolks of eggs, while one cask contained the whites of eggs only. The eggs, which were rotten, were mixed with boracic acid. The defendant alleged that they were intended to be used for leather dressing in Germany, and subsequently it was put forward that they were to be used for the feeding of poultry. It was shown, however, that he sold liquid eggs to bakers and confectioners and it was admitted that a baker who bought liquid eggs from the defendant had been convicted and fined some eighteen months previously for having rotten eggs on his premises. The defendant was fined £50 with respect to 18 casks of mixed yolk and whites ; £50 with respect to six casks of putrid yolks and £10 10s. costs. Later, a baker was also fined for having liquid eggs unfit for food upon his premises. The articles dealt with in Stepney included a number of tins of essence of meat which had been returned from South Africa. These tins were examined at the wharf, and 2,554 were found to be unsound and were destroyed. Account is given in the reports of the medical officers of health of the City and of Southwark of the poisoning of children through eating kaloo nuts. Altogether some thirteen children are known to have suffered from irritant poisoning from this cause. Some of these children were admitted into Guy's Hospital, where the cause of their illness was recognised. Dr. Collingridge states that the nuts were a consignment of 16 cwt. of a kind unknown to the dealer, who had purchased them from a ship's captain as a speculation. The bulk was deposited on the premises of a cocoanut and general fruit merchant in [the City,1) who] had sold some of them to costermongers. By the aid of the police the nuts were rapidly recovered before any considerable mischief had occurred. The nuts were the seed of a species of Aleurites, a native of China, believed to be the chief source of Chinese wood oil. Among the articles seized in Hackney and Finsbury were ox intestines used for the making of black puddings. These intestines were affected with a parasitic disease œso phagostomum columbianum, 77 an embryo worm which, causes " nodular disease of the intestine of the sheep," a disease which is said to be prevalent in the United States. Judging from the annual reports, increased activity was manifested in 1907 in the examination of food stuffs and in seizing those articles of food which were found to be diseased or unsound and especially were articles of food arriving at the wharves more thoroughly dealt with. In the early part of the year the Public Health Committee of the Council had under consideration the need of inspection of food entering London, and in February presented to the Council the following report:— We have from time to time reported on the subject of the necessity for improved administration for the inspection of food entering London, and on 20th November, 1906 (p. 1258), we presented a report on the subject by Dr. Hamer. A copy of this report has been sent to the Local Government Board. The medical officer has continued his inquiries into the subject, and has presented to us a further report, in which he estimates the total bulk of food-stuffs reaching London annually at between 2½ and 3 million tons, of which rather more than two-thirds arrive by water, and less than one-third by rail, and of which three-fifths are consumed by the inhabitants of London, the remaining two-fifths merely passing through in the course of transit elsewhere. The total imports may be sub-divided into three classes, viz.— (i.) Meat, fish, milk, butter, lard, eggs, etc., approximately 1,000,000 tons. (ii.) Fruit and vegetables (including preserved fruit and sugar) 500,000 tons. (iiii) Grain and flour (estimated as grain) 1,400,000 tons. and as regards class (i.) which, from the point of view of public health, specially needs examination, it is estimated that the amount introduced by railway is practically equivalent to that which arrives by sea. An important point is that, although a considerable proportion of the total amount of food entering is taken to certain well-known markets, no insignificant amount is conveyed directly to the retailer, a fact not generally recognised, it being a prevalent opinion that a complete system of market inspection is all that is necessary for the prevention of the sale of food unfit for human consumption. The information obtained in the course of the inquiry proves that 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, and, further, that 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, although they have undergone no inspection when the animals were killed, and are certainly not destined to undergo inspection in any London market, are probably intended for human consumption. We have ordered that a copy of the report, which contains detailed information collected on the subject, shall be sent to the Local Government Board for their information. The Local Government Board subsequently addressed to Town Clerks and to the Clerks of Urban and Rural District Councils a letter in which reference is made to the alleged practice of some dealers of disposing of the carcases of cows suffering from tuberculosis and other wasting diseases, in such a way that there is risk that they will be used as food by the poorer classes in London and other large towns, and advising that in the administration of the Dairies, Cowsheds and Milkshops Orders, the officers should observe the conditions of the cows and, where any animal is clearly diseased and presumably unfit for food, should take such steps as are practicable to ensure that in the event of the animal being slaughtered the carcase is disposed of properly. The Board also suggested that cattle markets, slaughterhouses and knackers' yards should be watched so that no animal the condition of which appears to render it unfit for human consumption is disposed of in such a mann er that it is likely to be used for this purpose. Public Health (Regulations as to Food) Act, 1907. With a view to the better control of the food supply, the Public Health (Regulations as to Food) Act was enacted in 1907. The Act confers powers on the Local Government Board to make regulations as to the importation, preparation and storage of articles of food for the prevention of danger arising to public health. The regulations may (a) Provide for the examination and taking of samples of any such articles, (b) Apply as respects any matters to be dealt with by the regulations, any provision in any Act of Parliament dealing with the like matters, with the necessary modifications and adaptations; (c) Provide for the recovery of any charges authorised to be made by the regulations for the purposes of the regulations or any services performed thereunder. Since the passing of the Act, the Local Government Board issued a report by their Inspector of Foods, Dr. G. S. Buchanan, on the subject of (1) Imported Boneless Scrap Meat, (2) Tuberculosis and Imported Pork, and (3) Imported Tripe, Tongues and Kidneys which are heavily dosed with preservatives. Concerning boneless scrap meat, Dr. Buchanan points out that (a) no inspection of such meat can suffice to detect disease, (b) that it is not prudent to regard it as free from disease solely on the declaration of the importers or of any guarantee of inspection by the Government concerned, (c) that it is possible it may have been derived from tuberculous animals, (d) that it is desirable that sausage makers should obtain meat which is readily identifiable with particular parts of a carcase and have some knowledge of the meat they use, and (e) that boxes of frozen meat have been found to show signs of decomposition at an early stage after they have been thawed and that it is not desirable that imported sausage meat with unknown and sometimes large quantities of chemical preservatives should be sold. With respect to tuberculosis and imported pork, Dr. Buchanan recommends that the following conditions should be observed: Pork imported as carcases to be required to consist of entire carcases including the head and lymphatic glands about the throat, and pork imported in portions less than the entire carcase to be enclosed in boxes, barrels, bags or other receptacles bearing an official mark which has been accepted by the Board, the Board's acceptance of any proposed mark, as an official mark to depend upon the efficiency of the inspection in the importing country, as a guarantee that the 18560 L 78 carcases were free from tuberculosis in any degree. Concerning imported tripe, tongues, or kidneys, Dr. Buchanan recommends that the introduction from abroad at English ports should be prohibited of tripe (whether cooked or uncooked), tongues and kidneys, which arrive in receptacles containing any preparation consisting of or comprising boric acid ; borax or other borates ; sulphurous acid or sulphites. Disinfection. The provision of a disinfecting station in Paddington which has long been a matter of discussion was still under consideration at the end of 1907, no decision having been arrived at during the year. Dr. Reginald Dudfield reports that several proposals had been before the Borough Council and the majority of them rejected. In the meantime the work of disinfection of infected articles is being done by a contractor. Dr. T. Orme Dudfield reports favourably of the new disinfecting station which has been provided in Kensington and states that the Borough Council had prepared plans for the erection of four cottages for the occupation of the men employed in the work of disinfection, and had applied to the Local Government Board for sanction to borrow about £1,300, the cost of their construction. The Board, however, took exception to the plans on the ground that the bedrooms were unnecessarily large and the cost excessive, and the Borough Council thereupon decided to defer further consideration of the matter for six months. Dr. Millson calls attention to the insufficient accommodation afforded by the two disinfecting stations in Southwark. The want of laundry accommodation and of means of dealing with articles which cannot be disinfected by heat are pointed out; the floor space of one is said to be too small and there' is absence of bathing facilities for the men employed in disinfection or accommodation for the storing and changing of clothes when work is over, or for taking meals. Dr. Millson states that "in consequence all the men intimately concerned with the disinfection of rooms and clothing mix freely with the outside public under conditions likely to cause infectious disease." Dr. Alexander discusses in his report relating to Poplar the cost of manufacture of "Electrolytic Disinfecting Fluid," which is prepared from a solution of sodium chloride and of magnesium chloride, and he states that the reduction in the cost of disinfectants effected thereby has been sufficient to pay for the cost of the plant and to leave a surplus of nearly £400. Shelters. The disinfection of rooms by "spraying" instead of by fumigation which has been more largely adopted in recent years has had its effect in the lessened extent of use of the shelters by persons needing accommodation during the disinfection of their homes. The following figures which are extracted from the annual reports show the extent to which the shelters in several of the districts were used during the year. No. of No. of persons accommodated. persons accommodated. Fulham 2 Bethnal Green 14 Chelsea 53 Stepney 309 Westminster, City of 5 Southwark 1,077 St. Marylebone 27 Bermondsey 96 St. Pancras 21 Lambeth 0 Islington 18 Battersea 33 Hackney 188 Wandsworth 14 Finsbury 43 Greenwich 3 families. London, City of 22 Woolwich 0 Shoreditch 6 Mortuaries. It is interesting to note the extent of use of mortuaries in London. During 1907, 8,552 bodies (of which 110 were those of persons who died from infectious disease) were received into the mortuaries belonging to the several sanitary authorities, or more than twelve percent, of the bodies of all the persons who died during the year. The increase in the extent to which mortuaries have been used in recent years is no doubt largely due to the improvement in the character of the accommodation which has been provided, since the passing of the Public Health Act, and in this connection it is interesting to note that Dr. Allan reports that in Westminster while the number of bodies removed to the mortuaries to await inquest has lately declined, there has been increase in the number removed while awaiting interment. It is still the practice of undertakers to receive on their premises the bodies of persons awaiting burial, and this subject was in 1907 under the consideration of the Borough Council of Islington on the report of their medical officer of health. Dr. Harris thus writes in his annual report:— In the early part of the year the Medical Officer of Health drew the attention of the Public Health Committee to the objectionable practice which obtains among undertakers of keeping on their premises coffins containing dead bodies, which, for sanitary and other reasons, have been removed from residences of the deceased before the day of burial, and, consequently, the Town Clerk was directed to communicate with all the undertakers in the borough to point out that such a practice was fraught with danger to the health of the workmen employed in these premises as well as of the public. He was also instructed to say that with a view to providing suitable accommodation for this purpose in Islington, arrangements had been made for the mortuary in Holloway -road to be placed at the disposal of undertakers who found it necessary to take charge of dead bodies prior to the day of burial, and to add 79 that the Public Health Committee trusted that their efforts in this direction would result in the abandonment by undertakers of the present practice. Accordingly on the 7th March a circular was addressed to the above effect to every undertaker in the borough. It is with regret that it is to be reported that none of them has seen fit to take advantage of this offer. No doubt, nothing will be done until legislation gives power to the Sanitary Authority to prevent bodies being kept on undertakers' premises while awaiting burial and elsewhere than in a mortuary. The number of bodies received into the mortuaries of the several sanitary authorities during the year is shown in the following table:— Sanitary Area. Total number of bodies removed. Number of infectious bodies removed. Sanitary Area. Total number of bodies removed. Number of infectious bodies removed. Paddington 290 3 Shoreditch 349 3 Kensington 340 2 Bethnal Green 345 Hammersmith 227 – Stepney 713 9 Fulham 174 5 Poplar 417 5 Chelsea 157 2 Southwark 550 5 Westminster, City of 358 4 Bermondsey 224 9 St. Marylebone 394 3 Lambeth 350 2 Hampstead 84 — Battersea 302 14 St. Pancras 427 12 Wandsworth 171 3 Islington 644 2 Camberwell 314 6 Stoke Newington 35 – Deptford 80 Hackney 434 1 Greenwich 156 Holborn 143 — Lewisham 141 5 Finsbury 369 13 Woolwich 171 2 London, City of 193 – The only proposed changes in connection with mortuary accommodation in London are that in Poplar arrangements have been made for the utilisation of a portion of a site in Cottage-street and High-street for a mortuary and of the rest of the site for a Coroner's court, and in Lambeth for the erection of a mortuary in Norwood on a freehold site in Romany-road adjoining the Norwood cemetery. The Cleansing of Persons Act. In the parliamentary session of 1907, the Council obtained powers to remove from school and to cleanse children suffering from verminous conditions, power being also given to arrange with sanitary authorities for the use of their cleansing and disinfecting stations. Powers were also conferred upon the Council in respect of verminous persons in common lodging-houses. Sanitary authorities have been slow to avail themselves of the powers conferred upon them by the Cleansing of Persons Act of 1897. Practically no provision has been made for the administration of the Act in Deptford, Greenwich, Hammersmith, Hampstead, Lambeth, Lewisham, Paddington, and Westminster. The extent of use of any provision made is in some degree governed by the character of the population, but also largely depends upon the nature of the accommodation provided and upon the adequacv of the steps taken to make its existence known. The annual reports supply the following information as to the number of persons cleansed during the year:— Adults. Children. Persons. St. Marylebone 8,592 5,771 Finsbury 34 St. Pancras 1,373 2,242 Shoreditch 7 Islington 9 305 Bethnal Green 6 Hackney 148 310 Poplar 764 Holborn 254 12 Camberwell 231 Southwark 22 43 Bermondsey 48 331 Battersea 504 117 Wandsworth 3 30 Woolwich 62 195 The following references to the subject appear in the several annual reports :— Kensington.— Dr. T. Orme Dudfield suggests that the Borough Council might co-operate with the County Council in regard to the cleansing at the casual wards, Mary-place, of the inmates of common lodging-houses, and states that for the needs of the schools in the northern division of the borough the nucleus of a station exists at the Council's schools, Sirdar-road, where on the playing roof of one of the buildings baths supplied with hot and cold water were provided some years ago, but are not now in use. Stoke Newington.— Dr. Kenwood states that at the close of 1906 the Public Health Committee decided to treat children with verminous bodies and clothing, as adult verminous persons have hitherto been treated under the Act, and that it is necessary to utilize the Hackney Borough station, which is a 18560 L 2 80 long distance from Stoke Newington, and he points to the need of a suitable station for this purpose near the Town Hall. City of London.— Dr. Collingridge writes that arrangements were made in February, 1907, that the names and addresses of verminous children should be sent to him, and if after inspection it was found necessary an Order on the guardians should be granted for cleansing and disinfecting the child. Southwark.— Dr. Millson reports that a bath room with undressing and waiting rooms together with disinfectant apparatus and rooms, have been provided adjoining the reception house. Adults and children are treated at different times in the day. Care is taken that the two sexes shall be bathed at different times, only children of different sexes under six years of age being allowed to be in the bath rooms at the same time. Bermondsey.— Dr. Brown writes that for systematic cleansing of school children the accommodation is insufficient. There would require, for instance, to be a proper waiting room and an attendant or two if the children were to be sent in any large number. Battersea.— Dr. Lennane points out " the desirability of extending this really useful sanitary work. The resources of the present station are strained to the utmost to cope with the numbers of applicants requiring to be cleansed," and he suggests the erection of suitable buildings on waste land adjoining the reception house and belonging to the Borough Council. Woolwich.— Dr. Davies attributes the smallness of the number of women who resort to the cleansing station to the fact that there is no female attendant for the bath, the only person in charge being the man who has the care of the general disinfecting station, and he says the need of a female attendant for the children, who come in large numbers, is also noticeable, as children often come to the baths unattended and haye to be refused admission. There is much need for sanitary authorities to consider very seriously the position in which London is placed in respect of this subject, which is of grave importance in connection with the health and moral improvement of the more unfortunate of the population. The helplessness of the class of persons who suffer from verminous conditions makes it certain that without the aid sanitary authorities can give under the Cleansing of Persons Act, little progress will be made in the way of advancement. There is opportunity for these authorities to inquire into the conditions obtaining in the homes of children to which their attention is directed by the Education authority, and in this connection the powers to appoint health visitors conferred by the London County Council (General Powers) Act, 1908 are ample. There is power to give opportunity for the cleansing of adult persons and for the disinfection of the clothes of such persons who may desire to rid themselves of this loathsome condition. There is power for the County Council to require persons frequenting common lodging-houses and shelters and who are thus suffering to avail themselves of the opportunities for this purpose, which the sanitary authorities are authorised to provide, but the first and necessary condition for successful treatment of these persons is the existence throughout London of properly constructed, arranged, and equipped stations with the necessary attendants, conveniently situated and made widely known, where body and clothes can be dealt with. It is difficult to believe that the pressing need of adequate provision can be fully appreciated when it is recollected that ten years have elapsed since the Cleansing of Persons Act of 1897 became law, and when it is seen how ill-provided many of the London sanitary authorities are at the present time with the means for affording assistance to persons in this distressful condition. The London Equalisation of Rates Act, 1894. The Equalisation of Rates Act provides that the London County Council shall in each year form a fund equal to a rate of sixpence in the pound on the rateable value of London. The contribution from each parish to the fund is to be in proportion to its rateable value. The fund thus formed is to be distributed among the sanitary districts in proportion to their population. Where a sanitary district comprises two or more parishes, and the aggregate of the contributions from such parishes is less than the grant apportioned to the district, the difference shall be paid out of the fund to the sanitary authority of the district, and no payment towards any equalisation charge shall be required from any parish in the district. Subject to the above, when the contribution from a parish is less than the grant due, the difference shall be paid out of the fund to the sanitary authority of the district forming or comprising the parish ; and if it exceeds the grant to the parish, the Council shall, for the special purpose of meeting the excess, levy on the parish a county contribution as a separate item of the county rate. Every sum paid to a sanitary authority must be applied in defraying the expenses of the sanitary authority incurred under the Public Health (London) Act, 1891, and so far as not required for that purpose those incurred in respect of fighting, and so far as not required for that purpose those incurred in respect of streets, and where the sanitary district comprises two or more parishes the sum paid must be apportioned among such parishes in proportion to their population, and the amount apportioned to each parish credited to each parish in the reduction of the rate required from such parish towards the above-mentioned expenses. The sanitary authority is required to render annually to the Local Government Board a return showing the amount of the sum to be paid and the total expenses incurred in respect of the three subjects mentioned. If the Local Government Board, under section 101 of the Public Health (London) Act, are satisfied that the sanitary authority have been guilty of such default as in such section mentioned, and have made an order limiting a time for the performance of the duty of the authority, the London 81 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, 1907, and the amount of excess of contribution over grant, or of grant over contribution in respect of each district for the year ended 31st March, 1908— Sanitary area. Estimated population, 6th April, 1907. Equalisation charge, being excess of contribution over grant for year ended 31st March, 1908. Net grant, being excees of grant over contribution for year ended 3let March, 1908. £ s. d. £ s. d. Paddington 145,283 4,798 – – – Kensington 183,197 16,918 3 4 – Hammersmith 119,768 — 7,771 3 3 Fulham 156,705 — 14,242 6 — Chelsea 72,286 5,925 3 _ — Westminster, City of 172,041 110,970 19 3 — St. Marylebone 128,606 17,857 15 6 — Hampstead 87,638 6,369 1 1 St. Pancras 229,825 8,565 5 6 Islington 336,628 29,830 2 1 Stoke Newington 52,543 3,435 2 8 Hackney 221,704 21,108 15 2 Holborn 54,015 13,504 15 - — Finsbury 102,679 1,697 15 1 — London, City of 24,318 127,199 - 11 — Shoreditch 116,878 — 7,082 - 6 Bethnal-green 128,876 — 16,386 15 5 Stepney 286,934 — 29,733 7 9 Poplar 168,085 — 18,375 12 6 Southwark 197,749 — 13,786 19 9 Bermondsey 128,607 — 6,404 2 2 Lambeth 308,774 — 23,331 6 - Battersea 172,912 — 13,804 1 6 Wandsworth 308,663 — 22,091 5 4 Camberwell 267,910 — 28,530 9 - Deptfor 112,777 — 10,321 17 5 Greenwich 102,838 — 7,778 14 4 Lewisham 162,893 — 11,691 7 11 Woolwich 136,454 — 12,420 2 3 Inner Temple 127 602 4 11 — Middle Temple 107 343 18 6 — Balance of Fund 1900-1 retained pendfinancial adjustments under the London Government Act, 1899 503 19 11 Midwives Act, 1902. The number of midwives whose names up to the end of the year 1906 had been placed on the Roll of the Central Midwives Board was 24,400, and of these 2,350 gave London addresses. During the year 1907, 368 additional names of midwives were added to the London list as the result of the examinations held by the Central Midwives Board, bringing the total to 2,718. The classification of these midwives was as follows — Possessing certificates from the Obstetrical Society of London 1,611 Possessing certificates from a recognised hospital 213 Having passed the examination of the Central Midwives Board 710 Enrolled by virtue of having been in bona fide practice as midwives a year prior to the passing of the Act 184 2,718 These figures do not represent the midwives actually practising in London at the present time, but only the numbers who at the time of enrolment gave addresses in London. Some of these midwives have removed to other parts of the country; the majority act as monthly nurses, while others again are on the staffs of hospitals and institutions. London being one of the largest training centres, many pupils qualify in London and afterwards go abroad, or to other parts of the country to practise. It is only those midwives who are actually practising as such who come under the Council's supervision and about 82 whom information is available. During the year, 491 midwives (or less than 18 per cent, of the number enrolled) gave notice of intention to practise, 28 gave notice of working temporarily in London and 17 notices were received that midwives residing in adjoining counties had acted on specific occasions in the County of London. Of these 491 notices, 388 were received from midwives who had previously practised in London, and 103 were notices sent by midwives for the first time. During the year, 4 deaths of midwives were reported, 41 midwives removed from the county, 34 to other parts of England and 7 abroad, 7 gave up practice on account of ill-health, 10 gave up practice for other reasons, and 11 were found on being visited to be acting only in the capacity of monthly nurse. 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 requisite apparatus and antiseptics, the keeping of case books and registers, and the sending in of the prescribed notices to the local supervising authority. Two inspectors possessing medical qualifications carried out these duties, Miss Lila S. Greig, M.B., L.M., D.P.H., and Miss Ida R. Shields, M.B., B.S. In addition to the routine inspections, special investigations are made into all cases of a septic character occurring in the practice of midwives, and much useful information has been collected. It has also been the practice of the inspectors to explain to midwives any difficulties that may arise in the course of their work, and to suggest methods for the better performance of their duties. The inspectors have also on many occasions accompanied midwives to deliveries and in their subsequent visits in order to obtain fuller information concerning their mode of practice. During the year, 1,443 visits of inspection were paid, including visits in special cases as well as routine inspections. In 737 instances the reports were satisfactory, in 175 unsatisfactory, in 434 the midwife was either out, away or ill, and in 97 it was found that the midwife had ceased to practise or had removed to some other address. The large proportion of cases (some 30 per cent.) in which the midwife was out may be explained by the fact that the practice of making appointments with midwives has been abandoned, except in a very few instances where an interview with the midwife is urgently needed. In the two previous years it was found expedient to make appointments, partly as a sort of introduction and partly in deference to the susceptibilities of women, who for many years had worked entirely without supervision and who by the passing of the Midwives Act were suddenly brought under inspection and had to conform to many rules and regulations. However necessary these appointments may have been at the beginning of a new regime, it is obvious that they gava opportunity for preparation on the part of midwives for the inspector's visit and the object of the inspection was thus often lost. The 175 unsatisfactory reports referred to 118 midwives. Of these midwives 74 were found unsatisfactory on one occasion only, 32 on two occasions, 11 on three occasions and 1 on four occasions. 220 midwives had no unsatisfactory reports during the year, while the rest were either found not to be practising or were out when called upon. There is a decided improvement in the work of midwives and the proportion of unsatisfactory reports has fallen from about 20 per cent, in 1906 to just over 12 percent, in 1907. Midwives are classed according to their general work, and an endeavour is made to visit the most unsatisfactory six times a year, the fairly satisfactory class four times in the year, while some two visits a year are paid to the satisfactory ones. In most of the cases where the report was unfavourable the inspector drew the attention of the midwife to the particular rule that had been broken and at a further inspection was able to report favourably. In cases of serious breaches of the rules or persistent neglect after caution by the inspector the matter was brought to the notice of the Midwives Act Committee, and a letter of caution was sent to the midwife. The latter course was adopted in 39 cases. The following were the reasons for the cautionary letter:— Omitting to send in required notices 6 Not advising the calling in of a doctor early enough to a weakly infant 14 Not advising the summoning of medical aid to a mother when required by rules to do so 4 Neglect to observe rules as to cleanliness 5 Neglect to observe rule as to antiseptics 4 Not possessing the required apparatus 4 Not keeping register as required 1 * Leaving a pupil in charge of a patient 1 39 For more serious offences the midwives were summoned to appear before the Committee. In four instances the midwives were verbally cautioned, one for employing an uncertified substitute, two for neglect in cases of puerperal fever, and one for persistent neglect to send required notices. Two women were suspended from practice for not possessing the required apparatus or antiseptics and thus rendering themselves liable to be a source of the spread of infection. The suspension was withdrawn when the required articles had been obtained. In one instance a midwife was reported to the Central Midwives Board under Section 8 of the Act as having been convicted under the Infant Life Protection Act of neglect of infants under her care. A sentence of 9 months imprisonment was imposed by the magistrate and the Board removed the name of this woman from the Roll. 83 In 8 instances the Council found a prima facie case of malpractice, negligence or misconduct and reported to the Board to that effect. The following were the charges — Charge. Action taken by Central Midwives Board. Medical help not summoned in a case of retained placenta. (Patient subsequently died) Name of midwife removed from Roll. Outfit incomplete, register improperly kept. Drugs administered and no record kept Case not heard by Board during 1907. *Medical help not called in case of perineal tear Case not proceeded with. *Medical help not called in case of perineal tear Case not proceeded with. Neglect of rules as to cleanliness and use of antiseptics Midwife cautioned. Neglect of rules as to cleanliness Name of midwife removed from Roll. Neglect of rules as to cleanliness and use of antiseptics Name removed from Roll. Neglect of rules as to apparatus. Attending a confinement before being disinfected after a case of puerperal fever Name removed from Roll. Some 10 midwives were reported to be more or less illiterate, but their registers and notes were as a rule kept by their relatives and notices regularly sent in. Several midwives who had committed slight infringements of the rules were advised to attend the Council's classes for midwives, with a view to making them better acquainted with the requirements of the rules. Two midwives are Italians and practise exclusively amongst the Italian population of London, and some 25 Jewish midwives practise chiefly among the Jewish population of East London. Breaches of the rules were said to have been due in a few cases to the fact that these midwives were not able to understand the rules in English. The Jewish Board of Guardians was approached with reference to this difficulty and kindly consented to translate into Yiddish those sections of the rules bearing upon the duties of midwives. Copies of these rules in Yiddish have now been supplied to the Jewish midwives. Unregistered women.— A number of names of women practising midwifery, but not certified by the Central Midwives Board, have been reported to me from time to time. A list of 119 names has been made, and periodic visits are paid to ascertain whether they are infringing the provisions of the Midwives Act. During the year 43 names were added to the list and enquiries made as to the practice of these women. In 8 cases there was some evidence of infringement of Section 1 (1) of the Act; 5 were dealt with by a letter of caution threatening proceedings if the infringement were again reported. In three instances legal proceedings were taken and a conviction followed. A fine of 5s. was imposed in each of two cases, and in the third case— that of a woman who had been certified but whose name had been removed from the Roll of the Central Midwives Board— a fine of 10s. and 23s. costs was imposed. At the time of the passing of the Midwives Act the Council issued a leaflet drawing attenti on to the Act, and stating the means to be adopted to secure certification. This leaflet was sent to a large number of women who were at that time practising midwifery, and those who did not become certified were at least made aware of the provisions of the Act, and the use of the title of midwife by uncertified persons is consequently not often found. Medical help notices.— The rules of the Central Midwives Board provide that in certain circumstances, which are given in detail, a midwife must advise that medical help must be called, and another rule places upon the midwife the duty of reporting within 24 hours to the Local Supervising Authority whenever medical help is thus advised and the reason for requiring it. During the year 1907, 2,533 of these notices were received. This is a slight increase on the figures for previous years. (In 1905 1,113 notices and in 1906 2,320 notices were received.) This increase is no doubt in part due to a fuller knowledge on the part of midwives of the rules requiring them to send these notices, and also to the fact that midwives are better recognising the necessity for calling medical help in cases in which there is the slightest sign of danger to their patients. Notice of sending for medical help on one or more occasions was "given by 310 midwives. It therefore appears that of the 490 midwives who gave notice of intention to practise, 180 sent in no notices of calling medical help; of these 180 midwives many are resident in hospital and Poor Law institutions, working under medical supervision, and though they are compelled by the Act to give notice of intention to practise, they are exempted from the necessity of observing the rales as to giving notice of calling medical aid. The remainder of those not giving notices were midwives who only attend cases occasionally. 1 midwife sent in 83 of these notices. 1 „ „ 70 „ „ 5 midwives sent over 50 each. 2 midwives sent in 40-50 „ 4 „ „ 30-40 „ 13 „ „ 20-30 „ 56 „ „ 10-20 „ 228 „ „ less than 10 *In these two cases the Council had cautioned the midwives, but the coroner had made a representation to the Central Midwives Board, and in order that the Board might hear the case fully, a formal representation was made. The Board decided that the caution administered by the Council met the case and did not proceed further with it. 84 The reasons assigned on the form for advising that medical help be called were as follows — Pregnancy— Abortion or miscarriage 30 Deformed pelvis 11 Swelling or growth on cervix |3 Ante-partum haemorrhage 102 General health of patient 93 239 Labour— Presentations— Abnormal vertex 18 Difficult breech 34 Foot 16 Transverse 42 Hand or arm 20 Knee 1 Shoulder 7 Face 23 Funis 17 — 178 Placenta pœrvia 30 Twin birth 2 Triple birth2 Prolapse of cord 26 Prolapse of vagina or uterus 3 Prolonged labour— Forceps used 47 No record of use of forceps 419 Retained placenta 91 Adherent placenta 104 Laceration of perineum or injury to soft parts 187 Flooding 11 Sub-involution of uterus 4 1,104 Lying-in— Excessive sickness 8 Abdominal swelling or tenderness 15 Offensive lochia 5 Rigor 6 Rise of temperature 155 Unusual swelling of breasts 14 Post-partum haemorrhage 97 White leg 6 Convulsions or eclampsia 10 Collapse or exhaustion 32 Mania 2 Other illness of patient 46 Sudden death 1397 Child- Partial asphyxia 19 Injuries received during birth 6 Malformations or obvious deformity 44 Concealed defect 19 Dangerous feebleness 448 Inflammation of the eyes 42 Malignant jaundice 13 Cyanosis 33 Inflammation of umbilicus 3 Bleeding from umbilical cord 5 Convulsions 44 White asphyxia 2 Circumcision 1 Death of child 36 Still-birth 42 Other conditions in child 32 —789 Infectious disease in patient's house 2 Reason not stated 2 2,533 It is estimated that about 30,000, some 25 per cent., of the births in London are attended annually by midwives, and if this estimate is approximately correct it would appear from the above 85 figures that in 8 4 percent, of the cases medical aid is sought for some reason. In 5'8 per cent, of the cases attended medical help is sought for the mother, and in 2'6 per cent, the child requires attention by a doctor. It will be noticed that of the cases in which medical aid was sought on behalf of the child, in no less than 56 per cent, the reason assigned was dangerous feebleness due in a large measure to prematurity. In connection with the subject of premature birth, the Council authorised the purchase of samples of drugs which are suspected to be taken as abortifacients. These drugs are largely advertised under various descriptions, and with a view to ascertain whether any injurious ingredients entered into their composition, samples were analysed by the Council's chemist. In none of the samples obtained was there any recognised abortifacient, but most of the drugs contained strong purgatives. Still-births.— During the year 240 midwives reported the occurrence of still-births in their practice, the number of such still-births reported being 740. The adoption of a form for notifying still-births, copies of which were sent to each midwife, has no doubt led to a larger number of these cases being reported, the numbers for 1905 and 1906 being respectively 405 and 574. 1 midwife reported 16 still-births 16 1 „ „ 15 „ 15 1 . „ 12 „ 12 3 midwives reported 11 still-births each 33 1 midwife reported 10 „ 10 3 midwives reported 9 still-births each 27 3 „ „ 8 „ „ 24 5 „ „ 7 „ ,, 35 18 „ „ 6 „ „ 108 22 „ „ 5 „ „ 110 21 „ „ 4 „ „ 84 32 „ „ 3 „ „ 96 41 „ „ 2 „ 82 88 „ „ 1 88 240 midwives reported all together 740 still-births. If this figure represents the total number of still-births in the practice of midwives, it would mean that some 2.5 percent, of the children delivered by midwives in London were still-born. The figures, which have kindly been furnished by the Secretary of the Royal Maternity Charity (an organisation which has district midwives working in all parts of London), show that of 2,414 births attended by their midwives (including cases where a doctor was called in to deliver) 84, or 3 47 per cent., of the infants were still-born. A comparison of these percentages raises the question whether all the still-births occurring in the practice of midwives have been notified. The form in which still-births were notified provided for information as to (a) Sex of child. (b) Whether full term or premature (number of months). (c) Whether child macerated or not. (d) Presentation. This form has since been adopted by the Central Midwives Board and is prescribed in the Rules. The information under (a) showed that 411 still-born children were males, 322 females, in 5 cases the sex was not stated, while in two cases the sex could not be determined. The following table shows the information under the headings (b) and (c). Condition of child. Total cases. Period of gestation. Period not stated. Full term. 8 months. 7 months. 6 months. Under 6 months. Macerated 367 129 69 102 52 8 7 Not macerated 342 209 47 43 33 7 3 No statement 31 5 4 4 4 4 10 Total 740 343 120 149 89 19 20 Information as to (d) is as follows: — Presentation. No. of cases. Vertex 377 Complicated vertex 29 Breech 129 Complicated breech 5 Footling 41 Transverse 11 18560 M 86 Presentation. No. of cases. Face or brow 5 Hand or arm 3 Funis 9 Cord 4 Placenta prævia 3 Prolapse of umbilicus 1 Born in membrane 1 Born before arrival of midwife and presentation not known 57 No statement 65 Total 740 The following table shows, as regards still-births occurring at full term or of 8 months gestation, the presentations, etc., and whether the infants were stated to be macerated or not. Presentation, etc. Full term. 8 months gestation. Not macerated. Macerated. Not macerated. Macerated. Vertex 93 87 25 36 Complicated vertex 14 4 3 6 Breech 46 7 10 7 Complicated breech 3 1 1 1 Footling 8 3 3 4 Transverse 3 1 2 1 Hand or arm 2 — — — Funis 7 1 — — Cord 4 — — — Placenta prævia 1 1 — — Twin birth — 4 — — Born before arrival (all presentations) 13* 6 — 8 Deformed child — 3 — 3 Delivered by forceps — 1 — — No statement as to presentation 15† 10 3† 3 209 129 47 69 From the above table and the footnote(*) it appears that of the 256 not macerated infants, 68, or 26 per cent., presented by breech, whereas of the 198 macerated, only 16 or 8 per cent., were breech cases. In 57 cases of still-birth some additional information was supplied. Thus— History of injury to, or illness of mother 7 Delayed labour 4 Jaundiced infant 1 Excessive liquor amnii 1 Abnormally large child 1 Hydrocephalic child 2 White asphyxia 1 Cord round neck 4 Ante-partum hæmorrhage in mother 1 Triplets (one still-born) 1 Twins (one still-born) 20 Twins (both still-born in 5 instances) 10 Deformed child 3 History of previous still-births 1 57 Death of Mother or Child.—The Rules of the Central Midwives Board provide that when the death of the mother or child occurs before the arrival of a medical practitioner, a midwife must give notice to the local supervising authority. 74 of these notices were received, in 9 instances the mother died, and in 65 instances the child died before the arrival of a medical man. Inquests.—Inquests are held in such cases as the above, and also frequently in cases where a medical practitioner, though present before death occurs, is not in attendance during the greater part of the illness. By the courtesy of the London coroners, notice of inquests is given in cases where a *Of the 13 full term not macerated infants born before midwife's arrival where the presentation was given, 3 were vertex, 8 breech and 2 footling. †Of the 18 not macerated infants of full term or 8 months gestation where the presentation was not stated, 14 were born before the midwife arrived. 87 midwife was in attendance, and one of the Council's inspectors is permitted to be present. The inspector is often referred to on points arising under the Midwives Act, and the Rules. Much useful information as to the practice of midwives is often elicited in the course of such inquests, and many uncertified women, whose practice has hitherto been unknown to the inspectors, have been brought to notice as the result of inquiries into the deaths of mothers or infants. During the year, 129 inquests were attended by the Council's inspectors, 14 where the mother and 115 where the infant died. Of these cases 14 were attended by uncertified women. The following table shows the opinion of the coroner's jury in these cases as regards want of skill displayed, or neglect to call in medical aid sufficiently early. In one case a midwife and in another an uncertified person were censured] by the jury for neglect of a patient. The midwife who was censured by the jury was subsequently represented by the Council to the Central Midwives Board for neglect and her name was removed from the Roll. Attended by- Total Inquests. Children. No blame attached. Want of skill. Failure to call medical help sufficiently early. Censured by jury. Mothers. No blame attached. Want of skill. Failure to call medical aid Censured by jury. (a) Certified midwives 115 88 5 10 — 9 1 1 1 (b) Uncertified persons 14 6 2 3 1 2 — — — Total 129 94 7 13 1 11 1 1 1 The cause of death was given as follows :— Mothers. Puerperal fever 1 Puerperal peritonitis 3 Puerperal septicæmia 2 Acute nephritis 1 Hæmorrhage 3 Fatty degeneration of the heart 2 Heart failure 1 Epilepsy 1 14 Children. Overlaying 12 Suffocation in bed (alone) 4 Asphyxia and atelectasis 27 Accident at birth 4 Convulsions 8 Weakness due to prematurity 22 Syncope and heart disease 4 Jaundice 1 Cerebral hæmorrhage 3 Bronchitis 5 Tubercular pleurisy 1 Tetanus 1 Erysipelas 2 Want of attention at birth (born before midwife's arrival) 10 Congenital malformation 3 Hæmorrhage from cord 3 Still-birth 5 115 Full reports on all these cases were made by the Council's officers, and in the cases where blame was attributed to the midwife a letter of caution was subsequently sent to her. Puerperal Fever.—All cases of puerperal fever where there was reason to believe that a midwife had been in attendance on the patient were investigated, and full details of illness obtained. For this purpose early intimation of notified cases of puerperal fever is received from the Metropolitan Asylums Board, and weekly lists of all deaths from puerperal septic diseases are obtained from the General Register Office. During the year 1907, 254 cases of puerperal fever were notified, and 152 deaths were classed by the Registrar-General as occurring from puerperal septic diseases. The term "puerperal septic disease" as used by the Registrar-General includes, puerperal septicaemia, sapraemia, pyaemia, peritonitis and metritis, occurring in connection with parturition, but a more limited interpretation of the term puerperal fever appears to be sometimes adopted for the purposes of notification by medical men generally, and no less than 64 of the deaths registered from puerperal septic diseases related to cases which were not notified as puerperal fever. Thus of the 254 notified cases, 88 or 34.6 proved fatal. Adding the 64 unnotified cases reported by the Registrar-General to the 254 notified cases, a total of 318 known cases of the disease is obtained. As the result of enquiry, it was ascertained whether the patients in all these cases were delivered by a midwife or not, and during the latter part of the year this enquiry was extended and the cases not attended by a midwife were classed according as they were attended by medical men, confined in hospitals, etc. 18560 m 2 The following table shows the number of cases, and by whom delivered:— Delivery conducted by Cases. Deaths. (a) Certified midwives 77 21 (6) Medical practitioners 112 51 (c) Uncertified women 7 3 (d) No attendant present 12 4 (e) Confined in hospital or infirmary 15 12 ( f) Medical man called in by midwife at delivery 9 5 *(g) No midwife present 78 48 (h) Deaths in London of patients confined elsewhere 8 8 318 152 The causes of death in the 152 fatal cases, as stated on the death certificates, were as follows:— Cause of death. Total deaths. Delivered by certified midwives. Attended by certified midwives but delivered by medical practitioners. Not attended by certified midwives. Septicemia 66 13 3 50 Pyæmia 11 2 — 9 Saprpomia 5 — — 5 Puerperal peritonitis 25 1 — 24 Pelvic cellulitis 5 — 5 Puerperal fever and toxemia 21 4 1 16 Eclampsia 2 — 1 1 Puerperal mania 2 1 — 1 Phlegmasia dolens 2 — — 2 Septic phlebitis 2 — — 2 Septic pneumonia 2 — — 2 Parametritis 1 — — 1 Erysipelas after parturition 1 — — 1 Septic absorption 3 — — 3 Enteritis after parturition 2 — —' 2 Gangrene of vulva 1 — — 1 Peritoneal abscess 1 — — 1 Total 152 21 5 126 During the latter part of the year, enquiries were made from each medical practitioner who was called in by a midwife to a case subsequently notified as puerperal fever with the object of obtaining more precise information with regard to the nature of the case notified, and the following table is based upon the information thus supplied:— Disease. Recovery. Fatal. Total. Septicæmia 10 6 16 Sapræmia 11 1 12 Pyæmia 1 1 2 Parametritis 1 1 Phlegmasia dolens . 1 1 Pelvic cellulitis 2 Peritonitis 1 1 Endocarditis — 1 1 Erysipelas 1 — 1 Rheumatism 1 — 1 Sub-involution 1 — 1 Mammary abscess . 1 — 1 Mistaken diagnosis . 2 — 2 Total 32 10 42 With regard to the 77 cases delivered by certified midwives, it was found that the symptoms of fever were not observed in 13 instances during the 10 days of the midwife's attendance and that, con- *The 78 cases under (g) occurred in the early part of the year. 146 similar cases in the latter part of the year are classed under (6), (c), (d) or (e). 88 89 sequently, medical help was not advised by the midwife. A rise of temperature above 100.4° was noted by the midwife in 61 cases out of the 77 cases delivered by midwives during the course of the patient's illness and in 39 instances it was this symptom which led the midwife to seek medical help. The following table shows with regard to 77 cases delivered by midwives and 9 where a medical practitioner was called for the actual delivery, the day of the puerperium when (a) the rise of temperature was noted (b) medical aid was called (c) the case was notified as puerperal fever and (d) in fatal cases when death occurred. Day of Confinement. 2nd day. 3rd day. 4th day. 5th day. 6th day. 7th day. 8th day. 9th day. 10th day. After 10th day. Total. Rise of temperature Recovery Cases 1 7 5 12 6 1 6 3 1 42 Fatal Cases — 3 4 3 3 2 1 — 1 1 1 19 Medical help called Recovery cases 5 6 6 7 10 3 4 6 1 1 11 60 Fatal Cases 6 3 3 2 4 2 1 1 1 1 2 26 Notification as puer peral fever Recovery cases — — 2 9 3 5 6 5 4 5 21 60 Fatal cases — — 2 4 1 1 4 2 1 4 7 26 When death occurred in fatal cases — — — — 1 1 2 — 2 2 18 26 Of the 18 fatal cases where death occurred after the 10th day, 8 died within a fortnight of confinement, 6 within 2 to 3 weeks, 2 more under 4 weeks, 1 more within 5 weeks, and 1 lived for 4½ months after confinement. The age incidence of the cases of puerperal fever was as follows:— Under 15. 15-20. 20-25. 25-30. 30-35. 35-40. Over 40. All ages. Recovery cases 3 43 46 46 18 10 166 Fatal cases 1 1 29 51 31 27 12 152 The parity where ascertained of women suffering from puerperal fever and attended by a midwife is shown in the following table:— No. of cases. Recovery. Death. Primipara 20 12 8 2 Para 8 5 3 3 „ 10 6 4 45 5 5 — 5 7 5 2 6 3 3 — 7 3 2 1 8 1 1 — 9 1 1 — 10 or more 3 2 1 Multipara (no definite statement) 5 3 2 No statement 20 15 5 Total 86 60 26 The following conditions were noted with regard to 32 of these 86 cases:— Recovery cases. Fatal cases. Total. Adherent or retained placenta 5 4 9 Torn perineum 4 1 5 Ante partum hæmorrhage 1 1 2 Prolonged labour and forceps cases 6 2 8 Miscarriage or abortion 1 1 2 Placenta praevia 2 1 3 Uterus not contracting 2 1 3 90 In six cases the child was said to have been born before the midwife arrived, one of these cases proved fatal. The distribution of the cases of puerperal fever in the practices of the several midwives who had more than one case was as follows:— Two midwives, A and B, had 3 cases each during the year. A's cases were in March, June and November, and no connection could be established between them. Several other patients delivered by the same midwife in the intervals did not develop fever. B's cases were 1 in July, and 2 in August. The interval between the 1st and 2nd of these cases was more than 6 weeks, and several other patients delivered in the interval by the same midwife did not develop symptoms of puerperal fever. The 3rd case was subsequently diagnosed as "white leg." Nine midwives had two cases each as follows:—D, cases in January and April. E, cases in January and August. F, 2 cases in February. The 2nd case was delivered before the 1st case was recognised and notified—6 patients delivered in the interval between the 2 cases did not develop symptoms of puerperal fever. G, cases in February and April. H, 2 cases in August. The midwife was disinfected after the first case and delivered two other women in the evening of the day she was disinfected, neither of whom developed symptoms of puerperal fever. On the following day a patient was delivered who developed puerperal fever in a mild form. I, 2 cases in August, the 2nd being delivered before the 1st case was recognised and notified. J, cases in September and November, at an interval of 9 weeks. There were no symptoms of puerperal fever in several cases attended in the interval. K, cases in July and December. L, cases in October and November (4 weeks' interval). The midwife was disinfected after the 1st case; the 2nd case was considered to be due to decomposition of a piece of retained membrane. Ophthalmia.—In October, 1907, special attention was directed to the occurrence of ophthalmia in newly born infants, and subsequent to that date more comprehensive enquiries were made concerning cases coming to the knowledge of the inspectors of inflammation of the eyes of newly born children. The importance of seeking medical advice in such cases was pointed out to midwives by the inspectors, and as a result there was a marked increase in the last two months of the year, of notices that a doctor had been called for this reason. The figure for the whole year was 42 as against 20 in 1906. Special enquiries were made into 15 cases which occurred in the last two months of the year, and the following table shows the information obtained with regard to these cases.* Suspected cause of disease Antiseptics used for eyes at birth Interval between birth and use of antiseptic Date of onset of symptoms Date of obtaining medical aid Whether attended by private practitioner or out- or in-patient of hospital, and which hospital One or both eyes affected Duration of disease Result Evidence of spread of infection Precaution used by midwife to prevent spread of infection History of Vaginal discharge in mother 8 Boracic solution 8 Perchloride of mercury 5 Water only 2 In one case nitrate of silver was subsequently used. Immediately 8 20 minutes 2 30 „ 3 1 hour 2 Day of 2nd 3rd 4th 5th 6th 7th 8th 9th 10th After10th birth. day. day. day. day. day. day. day. day. day. day. 223121- - - 1 3 Same day as onset. 2nd day. 3rd day. 4th day. Not obtained. 6 4 1 13 Private practitioner 9 Hospital 3 Both eyes 13 One eye 2 1 week 2 2-3 months 3 1 month - over 3 months 2 2 months 3 Not known 5 Complete cure 10 Blind in one eye 1 Discharge but no corneal mischief 1 Not ascertainable, parents cannot be traced 3 No evidence 13 Conjunctivitis in other members of family 2 Disinfection with perchloride of mercury 9 Obtaining services of some other person to attend to child's eyes 3 No special precautions taken 3 *From this time onwards, these inquiries have been continued and in January, 1908, a circular letter was addressed to all midwives pointing out the necessity of advising that medical aid should be obtained " in any case of inflammation of the eyes, however slight." 91 In the case which resulted in blindness in one eye, the midwife failed to recognise any inflammation until the 8th day of life, although the mother stated that there was something wrong with the child's eyes at birth. The eyes had been washed at birth with a weak solution of perchloride of mercury. The case was subsequently recognised to be one of severe gonorrheal ophthalmia. The midwife in this case was called before the Midwives Act Committee and strongly cautioned. Lists of Births.—Midwives practising within the County were asked, in October, 1905, to send in weekly lists of the cases attended by them, forms and stamped envelopes being supplied for this purpose. A large proportion of the midwives agreed to comply with this request and have since more or less regularly forwarded these lists to the Council. The information thus obtained was distributed to the medical officers of health in London. The lists are received each week on Monday or Tuesday and the information is sent to the medical officers of health of the sanitary authorities on the following Friday. Some 185 midwives reported cases more or less regularly, and on the average 110 lists were received weekly. Lists were also received from 15 institutions employing one or more midwives, and the authorities of six lying-in hospitals supplied lists of the addresses of London mothers discharged from the hospital. The following figures obtained from these lists afford some idea of the extent of the practice of midwives — 4 midwives reported over 500 cases each in the year. 4 „ „ 400-500 „ „ 8 „ „ 300-400 6 „ „ 250-300 „ 7 „ „ 200-250 15 „ „ 150-200 26 „ „ 100-150 41 „ „ 50-100 33 „ „ 25- 50 41 „ „ less than 25 „ 185 The midwives of 15 institutions reported attending 4,454 cases in their own homes and the 6 lying-in hospitals sent information as to 2,866 patients discharged. The total number of births reported was 26,993, of which 862 were those of infants who were either still-born or died before the list was sent in. Fees charged by Midwives.—The fees charged by midwives vary in different localities from 5s. per case upwards, but as a general rule, a fee of 7s. 6d. (or 10s. if patient be a primipara) is expected. Fees of 15s. and even up to £1 Is. have been paid to a midwife on rare occasions. The charities employing midwives pay 5s. or 6s. per case and provide the necessary drugs, registers of cases, etc. It is apparent from the number of cases attended by midwives given in the above table that only a small proportion of midwives can depend solely upon their practice for their livelihood, and many supplement their incomes by other means. A few keep lying-in homes and others are registered under the Infant Life Protection Act to take charge of nurse children. Some of those midwives who have an extensive practice are approved by the Central Midwives Board as qualified to give practical instruction to pupil midwives, and receive fees from the pupils for this instruction. The lying-in hospitals in London receive into their wards some 5,000 women annually and provide for attendance on about 10,000 in their own homes. The latter cases are conducted almost exclusively by midwives and many of the cases thus attended are included in the figures obtained from the lists of births. Some of the hospitals pay the midwife a fee for each case, while others pay a fixed salary. The patients are not as a rule expected to pay for the services rendered by the district midwives attached to hospitals, and in the case of institutions there is either free attendance or a nominal fee. Having regard to the provision made for the free attendance of labour cases in London on the one hand and the low fees required by medical men in some districts, the scone for a midwife in private practice is not great, and when it is remembered that a midwife can only attend normal cases and, if any abnormality occurs, medical help must be summoned and a medical man has to be paid in addition to the midwife, it is not surprising that many midwives find great difficulty in making a living. Medical help for poor patients.—The difficulty of securing medical help for poor patients has been frequently brought to notice and the Boards of Guardians have been asked to make arrangements for the medical attendance in such cases. In July, 1907, a circular was issued by the Local Government Board calling the attention of the Board of Guardians to the powers they possess under Section II. of the Poor Law Amendment Act, 1848, of paying for medical assistance rendered in a case of midwifery, without an order from the relieving officer, and of subsequently recovering the fee if the patient be found in a position to pay. As a rule the Boards of Guardians require a midwife in the first instance to call one of the district medical officers, but in some districts the Guardians will pay a fee to any medical practitioner called in, reserving the right to recover the fee if the patient's circumstances warrant such a course.* *The Council has since issued to every midwife in London a statement showing the arrangements for this purpose in the several poor law districts so far as arrangements have been made. 92 Scholarships.—A scheme was arranged in 1905 for granting scholarships of the value of £25 to pupil midwives. The course of training is to be of 6 months duration, and to be taken at one of the lying-in hospitals selected by the Council. A condition is imposed to the effect that when qualified, the scholar must practise for two years within the County of London. Eight scholarships were granted during the year, and four scholars completed their course and passed the examination of the Central Midwives Board. Some difficulty in obtaining sufficient patients after qualification has been experienced, and in view of this, seven scholars to whom awards were made resigned their scholarships before beginning the course of training. Of twenty scholarships awarded since the inauguration of the scheme in 1905, seven scholars qualified and became certified midwives, seven resigned, three were still training, and three had not begun their course of training. Classes for Midwives.—The Education Committee has arranged classes in midwifery in connection with its scheme of technical education and some of the midwives whose training was deficient or who were trained many years ago have availed themselves of this instruction. Revised Rules of the Central Midwives Board. Revised Rules of the Central Midwives Board were approved by the Privy Council in April, 1907. A copy of the new rules was supplied by the Council to every midwife who gave notice of intention to practice during the year. The new rules differ from the old in the following particulars:— Appliances, etc.—(1) A midwife is not now obliged to carry an antiseptic lubricant. (2) The Local Supervising Authority may use their discretion in the case of untrained midwives, with regard to insisting on the carrying of a catheter and appliances for giving vaginal injections. Disinfection.—After attendance upon a case of puerperal fever or other infectious disease, the midwife must satisfy the Local Supervising Authority as to disinfection instead of the Local Sanitary Authority. Mother.—A new rule provides that the midwife must in all cases of labour examine the placenta and membranes before they are destroyed and satisfy herself that they are completely removed. Child.—As soon as the child's head is born, the eyes are to be carefully cleansed as before, but the use of an antiseptic lotion is not advised under the new rules, as it was under the old. Laying out the Dead.—Exceptions to the old rule forbidding a midwife to lay out a dead body may now be made at the discretion of the Local Super visingAuthority under the following circumstances— (a) If a midwife prepares for burial the body of a lying-in woman; a still-born child, or an infant dying within ten days. (b) If a midwife lays out a dead body in a case of non-infectious illness provided she is not attending a midwifery case at the time. Medical Help.—When medical help is advised, the notice giving the reason why such help is required, must now be handed to the husband or nearest relative or friend, in order that it may be immediately forwarded to a medical practitioner. Copies of these notices must be sent to the Local Supervising Authority within 24 hours instead of within 12 hours as heretofore. A midwife is not now forbidden to attend a case of breech presentation in a primipara. Two hours instead of one are now allowed to elapse between the birth of the child and of the placenta before a midwife is bound to advise that medical help should be obtained. A midwife is now bound to advise that medical help should be obtained in a case of dangerous feebleness in a child whether arising from prematurity or not. A form of notification of still-birth, already referred to, is now prescribed in the rules. Exemptions.—The rule exempting midwives working in hospitals under the supervision of a duly appointed medical officer from being subject to the rules, now extends only to midwives working within hospitals approved by the Central Midwives Board and the exemption is limited to certain rules only. Those working in workhouses and infirmaries under the supervision of a duly appointed medical officer are exempt from the rules as before. Designation.—A rule was added to the effect that the proper designation of a midwife was "certified midwife" and that no abbreviation in the form of letters nor any other description of the qualification was permissible. The Board has since approached the Privy Council and a modification of this rule has been effected whereby midwives enrolled as the result of examination may add the words "by examination." Water Supply. Dr. Houston, Director of Water Examinations, in his report to the Metropolitan Water Board for the twelve months ended 31st March, 1908, points out that caution is necessary in interpreting the highly useful figures which appear in the Annual Report of the Local Government Board in their relation to the quality of the supply, inasmuch as the results are averages, and he refers to his statement in a previous report "that monthly, and still more yearly, averages tend to smooth over individual results which sometimes are the reverse of satisfactory." Dr. Houston further states with reference to storage that 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 diatomaceae, cyanophyceac and protozoa. These words, quoted from the report for 1906-7, on the growth of algae, Dr. Houston remarks, "turned out to be of prophetic significance, for in the late summer and autumn months of 1907 a remarkable development of oscillaria occurred in Staines reservoir water. The growth interfered considerably with filtration at the Kempton Park, Grand Junction and West Middlesex Works. A good deal of experience, however, was gained incidentally in the successful use of copper sulphate as a remedial agent. At the commencement of the current year the 93 North and South Staines reservoirs were connected on the east side by means of a syphon, in the hope that the improved circulation of water might tend to inhibit the growth of algae. During the winter and spring months of the present year, however, growth of a different kind (chiefly asterionella, synedra and cyclotella) developed, and although the actual amount present in the water was relatively small, the blocking effect on the sand filters was serious. The film forming on the surface of the sand in the filters, although extremely thin; was of so impervious a character that the life of a filter was a question of only a few days. It was noted in connection with the growths last year, and again this year, that admixture of unstored river water with stored water prolonged the life of the filters to an extent out of all proportion to the relative volumes of the two kinds of water. Sanitary Inspectors. Among the appendices to this report is a return (Appendix IV.) showing the number of sanitary inspectors in London in June, 1908. The return also shows the numbers of men and women inspectors in the several years since 1895. It should be noted that as compared with the return published as an appendix to my last report, the total number of inspectors remains the same. The number of women inspectors, however, has increased from 38 to 40, whilst the number of men inspectors has decreased from 281 to 279. As mentioned in my last report, no woman inspector has yet been appointed in Bermondsey, Deptford, Greenwich, Hammersmith, Shoreditch, Stepney and Stoke Newington. The need for the appointment of additional sanitary inspectors or of health visitors is referred to in the annual reports of the medical officers of health of Bermondsey, Hampstead, Poplar, St. Marylebone, Shoreditch, Wandsworth and the City of London. Education (Administrative Provisions) Act, 1907. Section 13 of the Education (Administrative Provisions) Act, which became law in 1907, provides that " the powers and duties of a local education authority under Part III. of the Education Act, 1902, shall include—(b) the duty to provide for the medical inspection of children immediately before, or at the time of, or as soon as possible after their admission to a public elementary school, and on such other occasions as the Board of Education direct, and the power to make such arrangements as may be sanctioned by the Board of Education for attending to the health and physical condition of the children educated in public elementary schools ; provided that in any exercise of powers under this section, the local education authority may encourage and assist the establishment or continuance of voluntary agencies, and associate with itself representatives of voluntary associations for the purpose." In a memorandum on the Medical Inspection of Children in Elementary Schools (Circular 576) the Board of Education state that "the Board desire to emphasise that this new legislation aims not merely at a physical or anthropometric survey or at a record of defects disclosed by medical inspection, but at the physical improvement, and as a natural corollary, the mental and moral improvement of coming generations." The main principle, the recognition of which the Board regard as absolutely necessary for the development of the administration on sound lines, is that "school hygiene cannot be divorced from home hygiene, and this is in turn intimately bound up with the hygienic conditions of the community. Efficiency and economy require, therefore, an organic relationship between the daily work of the school authority and of the authority responsible for the administration of the wider branches of public health . . ."The Board add that " while it is not expected that by establishing the necessary administration on the broad basis of public health all difficulties will be avoided, the Board are convinced that this is the only practicable method and that which is most likely to promote economy, harmony and efficiency." The Board express the opinion that " in county areas the county council, which is the local education authority, should instruct their county medical officers, who will be responsible for smooth and effectual administration, to supervise the work, its actual execution being deputed wholly or partly to suitable medical colleagues or assistants (men or women), who either will be appointed specially for the purpose under him or will be local medical officers of health, and to whom groups of schools may be allocated. . . . That is to say, generally speaking, the work of inspection should be supervised by the medical officer of health of the authority which appoints the Education Committee; and when the work is obviously more than he can undertake unaided, it should be entrusted to one or more medical officers working under his supervision." The memorandum further discusses the character and degree of medical inspection and states that the Board have decided that not less than three inspections during the school life of the child will be necessary to secure the results desired. The first inspection should take place at the time of, or as soon as possible after, admission to school; the second at or about the third year (say the seventh year of age) ; and the third at or about the sixth year of school life (say the tenth year of age). The Board also discuss the subject of amelioration and physical improvement, for which a scheme has to be submitted by the local education authority for the sanction of the Board of Education, and in conclusion urge " the progressive unification of the medical services." The Medical Inspection of School Children. The Board of Education now require that the report on the work in connection with the medical inspection of school children should relate to the calendar year. Hence the forthcoming report of the Medical Officer (Education), which would otherwise have related to the year ended 31st March, 1908, will deal with the period from 1st April, 1907, to 31st December, 1908. Under these circumstances this report will be appended to the next report of the Medical Officer of Health. Shirley F. Murphy, Medical Officer of Health. To the London County Council. December, 1908. 18660 Medical Officers of Health of London Sanitary Areas, in 1907. 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 C. Porter, M.D. Fulham J. C. Jackson, L.R.C.P. Greenwich E. G. Annis, M.R.C.S. Hackney J. K. Warry, M.D. Hammersmith N. C. Collier, L.R.C.P. Hampstead G. F. McCleary, M.D. Holborn W. A. Bond, M.D. Islington A. E. Harris, L.R.C.P. Kensington T. 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. 94 APPENDIX I. APPENDIX. I. Report by Dr. Wanklyn on Cerebro-Spinal Fever in London in 1907. Advantage has been taken of the present notification period of cerebro-spinal fever to consider certain aspects of the disease which seem specially worthy of study. These are its identity, and the methods of its identification. The following notes, based on recent experience in London, deal especially with the uncertainty surrounding this disease, and with the value to be attached to the various kinds of evidence on which its diagnosis is based. The conclusion is reached that further inquiry is needed to place our knowledge upon a satisfactory footing. In London recently there has been nothing in the nature of an epidemic, and this should be borne in mind in reading what follows, for zymotic diseases have a tendency to behave differently in epidemic and non-epidemic times. Moreover, in non-epidemic times, actual cases of the malady are more apt to be obscured by cases of other maladies presenting like symptoms. The various sporadic cases, however, as they arose, have been enquired into, and certain of them have been investigated in closer detail. In these cases besides visits to patients in hospital, and to their homes to see the relatives, visits have also been paid to the various medical men in attendance on each case, and as full details as possible have been obtained from them by interviews and correspondence. Though the results are less complete than it was hoped they would be, mainly owing to the complete details of many cases being unobtainable, yet they seemed worthy of record, if only to point the way in future enquiries. In presenting what follows I have endeavoured to avoid any controversial spirit. My sole object has been to let the facts speak for themselves, and to be guided by them; so as, if possible, to add to our understanding of a disease as to which our want of precise knowledge is widely felt. In the 132 cases notified during the year 1907 the evidence of infection amounts to nil. There has been, so far as I am aware, no instance of two or more cases being associated, no case in which infection has been traced to one patient from another; no group of cases in which there has been an ascertainable common cause, and no case in which the illness appears to have been transmitted by any particular factor outside the patient. Among the cases into which I personally enquired at the patient's homes, 63 in number, there were relatively few instances of associated illness. "Common colds" have not occurred more frequently among the patient's friends than would have been expected in any other similar number of the community. Whooping cough I found to be not an uncommon coincidence, whether more than a mere coincidence I cannot say. A history of sore throats in nearly every member of the family was given in another case, and was associated with defective drainage. I was impressed in the case of more than one family of children whom I interviewed with the dirty, sore, and "running" condition of the mucous orifices, viz., ears, nose or mouth. As will be seen below (p. 5), in one case, T.T.S., such a condition appeared to be the origin of the illness. Apart from these points I cannot say that the patients' homes or surroundings presented any remarkable feature ; most of the cases came from working-class families, of which some, but by no means all, were very poor. The point which seemed to me to be of most importance, and worthy of special attention in future enquiry, was the condition of the mucous membranes of the ears, and also of the nose, mouth and throat, both of the patient, and of the children who may have been in contact with him. The problem which constantly presents itself to an enquirer into cerebro-spinal fever, and is impossible to get away from, is the identity of the disease, and its diagnosis. Judging from my experience the difficulty appears to be one which exercises the minds of the majority of the profession in London who are brought in contact with the disease, namely, to say what does, in point of fact, constitute cerebro-spinal fever. It may be illustrated by the nature of letters replying to inquiries about cases. In the returns of deaths from meningitis, some of the deaths are certified to have been caused by definite morbid processes, such as cerebral abscess. But many, especially among infants, are certified in such terms as "meningitis," or "simple meningitis," or "meningitis and coma," or "meningitis and convulsions." In a number of such cases enquiries were made by letter from the certifying physician whether there was any reason for suspecting the case to have been one of epidemic cerebrospinal meningitis. Replies took some such form as this: "The case was one of acute meningitis and not epidemic cerebro-spinal meningitis," or " it was a case of simple and not of cerebro-spinal meningitis." What was the precise distinction in the mind of the writers between these various forms of disease is not easy to say. In conversation the same thing was equally remarkable. Over and over again the question was asked: "What exactly is cerebro-spinal fever?" "And how am I to know it when I see it ? " What a remarkable fact this uncertainty is, seems hardly to be appreciated at its full import. That mystery should still surround a disease, epidemics of which have been recorded and studied for the past hundred years, and still continue to occur, seems at first sight very surprising It might have been thought that a specific disorder, so far from uncommon as this is, would have been clearly understood and recognisable by now. But with many physicians the reverse appears to be the case. The principal reason for this appears to be one of nomenclature. No definition seems to be in current general use which will readily enable cases to be placed within or without the class termed "cerebro-spinal fever." It seems almost impossible to make any real advance in knowledge until there is a common understanding as to what to include in the term. It was to assist in arriving at this result that the Public Health Committee in May, 1907, approached the President of the Royal College of Physicians, and invited his opinion as to whether cerebro-spinal fever (epidemic cerebro-spinal meningitis) should include, for notification, posterior 2 basal meningitis. The report of the Committee, which the President appointed for this purpose, seems to be so far from generally known that I will quote it in full. It is dated May 28th, 1907:— "(1) We find, clinically, that although, as regards symptomatology and duration there are some differences which might separate the most marked cases of cerebro-spinal fever (epidemic cerebrospinal meningitis) and posterior basal meningitis from one another, nevertheless intermediate cases occur in which such differentiation is impracticable. "(2) It cannot (at present) be maintained by experts, with absolute certainty that there is any demonstrable difference in the bacteriology of the two diseases. The organism which is commonly associated with each disease is microscopically the same (meningococcus, micrococcus intracellularis, diplococcus intracellulars meningitidis), such variations as may be met with being dependent on minor differences in cultural characters. "(3) It is noteworthy that, so far as has been ascertained at present, both diseases tend to occur during the earlier months of the year, and that, although the occurrence of the disease in both instances is epidemic, in neither has it the characteristics of a spreading malady. " The Committee recommend :— "(a) That, inasmuch as the season in which the disease is liable to be prevalent will not recur for 7 to 9 months, the order of notification at present issued should continue in force for a period of two years—in order to cover two possible epidemic periods. "(6) That in the order of notification distributed to practitioners it should be stated that for notification purposes the disease at present known as posterior basal meningitis is included under the term cerebro-spinal fever. "(c) That after notification further details of the cases should be obtained (i.) in hospitals through the courtesy of the medical officers in charge; (ii.) in private by a special officer available to investigate the cases bacteriologically or otherwise, if desired, in association with the practitioner in charge." The means which exist for classification of the various cases as they arise, may be conveniently placed in the three groups of (1) Clinical, (2) Bacteriological, and (3) Post-mortem evidence. The case-notes which I have obtained have been arranged under these three heads and then compared. In other words, an attempt has been made in certain cases of illness which conformed clinically to cerebro-spinal fever, to ascertain how they showed bacteriologically, and on the post-mortem table. The value to be attached to clinical evidence is indicated by Professor Osier in his Principles and Practice of Medicine, Ed. 1905, p. 163: "One has constantly to bear in mind that certain cases of typhoid fever and of pneumonia closely simulate cerebro-spinal meningitis. Long ago Stokes made the wise observation that' there is no single nervous symptom which may not and does not occur independently of any appreciable lesion of the brain, nerves, or spinal cord.'" And again, on p. 926, he says: "I have already, on several occasions, called attention to the fact that cortical meningitis is not to be recognised by any symptom or set of symptoms from a condition which may be produced by the poison of many of the specific fevers. In the cases of so-called cerebral pneumonia, unless the base is involved and the nerves affected, the disease is unrecognizable, since identical symptoms may be produced by intense engorgement of the meninges. In typhoid fever, in which meningitis is very rare, the twitchings, spasms, and retractions of the neck are almost invariably associated with cerebro-spinal congestion, not with meningitis. Actual meningitis does, however, occur in typhoid fever, and, as Ohlmacher's cases show, the typhoid bacilli may be present in the exudate." It would be unnecessary to dwell on the weakness of clinical evidence, when taken by itself, were it not for the fact that it is sometimes claimed that that class of evidence alone is sufficient for an accurate and final diagnosis to be made. The following cases form an illustration of the result of relying solely on clinical evidence:—T.N.N., aged 26 years, was certified to be suffering from epidemic cerebro-spinal meningitis, the diagnosis being made after observation for about a week. Death occurred before I could see the patient, but the account of the case was not such as to raise doubt as to the accuracy of the diagnosis, except on the general grounds of the unreliability of clinical evidence. Another case, T.N.F., age 29, was also under observation for about a week, and epidemic cerebro-spinal meningitis was confidently assigned as the cause of illness and certified as such. I saw this case in consultation, and, although it presented features which did not exactly harmonise with the diagnosis of meningitis, it was not possible to exclude that disease or even to deny its probability. Necropsies, however, were obtained in both cases, and revealed in the one case, general septicaemia, and in the other, cerebral hoemorrhage. Had no post-mortem examinations been made, both cases would have remained on record as cerebro-spinal fever. Referring now to a clinical sign which has been considered to be of special value in the diagnosis of cerebro-spinal fever, viz., Kernig's sign, it seems to me that there has been sometimes a tendency to exaggerate its importance; in point of fact it has been held to indicate not the presence of cerebrospinal fever, but merely of meningitis from any cause. Professor Osier, in an article in the "Encycloptedia Medica," Ed. 1901 (Vol. VII., p. 499), on "Epidemic Cerebro-spinal meningitis," writes: " Within the past three years we have found this (sign) of the greatest possible assistance, and I may say that it has been present in all cases of meningitis in which it has been looked for, and it has not been found in any case in which meningitis was not present." In the recent cases in London, however, the amount of assistance given by this sign has been somewhat disappointing. Of the 14 cases, for instance, alluded to below, and verified post-mortem to be meningitis, the sign was present in 9, absent in 2, and in 3 no record on the point was available. Opinion indeed appears to have changed somewhat during the last few years, for Dr. Koplik contributes the following description to "A System of Medicine " (Osier and McCrae), Ed. 1907, p. 509:— 3 "This is probably the most discussed symptom or sign in connection with meningitis of recent times. Kernig, a physician of St. Petersburg, first described it in 1882, and published his results in 1884. He observed it in various forms of meningitis and confirmed the diagnosis at autopsy. The sign consists in an inability to extend the leg fully when the thigh is placed at right angles to the trunk. Kernig observed this sign when he attempted to set the patient at the edge of the bed and straighten the legs. He noticed that this was impossible, and following up his observation he found that this was the case in all forms of meningitis. Osier simplified the sign very much by showing that it may be elicited with the patient in the recumbent posture by placing the thigh at right angles to the trunk and then attempting to extend the leg on the thigh. Kernig not only found this sign in meningitis and considered it pathognomonic, but he observed it in the convalescence from the disease when the patient was up and walking about. These observations have been confirmed with reservations. Kernig's sign is not pathognomonic of meningitis any more than rigidity of the neck. It is, however, very valuable and completes the picture of the disease. It is present in diseases of the most diverse nature where cerebral symptoms are present and toxæmia is great. The writer has seen it repeatedly in pneumonia with meningism in children, and it has been observed in adults in some diseases, such as typhoid fever. It is important to recognize what is and what is not the Kernig's sign, especially in meningitis. In some cases an attempt to straighten the leg on the thigh will be resisted at an angle of 135° and in others at an angle of 90°. It is therefore but fair to Kernig to include his sign between these two variations. Unfortunately this sign may be absent in malignant forms of cerebrospinal meningitis, especially in those with collapse symptoms, in which the patient a day or two after the onset is seized with a chill and goes into a condition of complete collapse, due, perhaps, to increase of fluid in the ventricles. In these patients the Kernig sign may be absent, although it may reappear on a subsequent day. It may be absent at the onset of an ordinary attack and appear after the disease has lasted a day or two. It is present in the majority of cases at some time in the course. As has been intimated, it may not be present at critical periods. ... As has been intimated, the Kernig sign is present in other forms of meningitis, but in tuberculous meningitis, especially in children, its presence is not so constant and in the cases studied by the writer it was absent in fully one-third. It is not to be relied on in very young infants in whom there is a muscular tonicity of both upper and lower extremities which is normal and becomes exaggerated on the onset of the least illness. Its occurrence in children below two years of age is variable for reasons which the writer cannot explain." In the light of the foregoing, Kernig's sign loses value as a pathognomonic sign even of meningitis; but further observations as to its occurrence in diseases other than meningitis seem much to be needed. The net result of taking the clinical evidence by itself in many cases of suspected cerebro-spinal fever is to leave the physician frankly baffled in his attempt to make an exact diagnosis. He finds that the ascertained signs and symptoms may be caused by, and point to a variety of diseases. He can get no further evidence, as he would in other diseases, by noting pathological changes during life. He cannot watch or feel or auscultate the working of the disordered organ. " Physical signs " are almost non-existent, and the result is that in few diseases does he find himself so baffled and so little able to make a diagnosis on clinical signs alone. Of the post-mortem findings it may be said that in meningitis the evidence gained by actual inspection and examination of the diseased organs does not differ in value from that similarly obtained in other diseases—in a word, post-mortem evidence is the most trustworthy of all, but in this connection it has the limitation, that by a mere post-mortem examination it may not be possible to differentiate cerebrospinal fever from other forms of meningitis. Bacteriology comes in, however, and offers to clear up the whole case. It claims to clinch the diagnosis beyond all shadow of doubt. Little wonder then that implicit reliance comes to be placed on the bacteriological finding; and that makes it all the more necessary to examine closely the value of this class of evidence. The causal micro-organism has been thus described:— "In 1887 W eichselbaum described an organism, the Biplococcus intracellular is meningitidis, which was probably the same as one previously found by Leichtenstern. In the tissues the organism is almost constantly within the polynuclear leucocytes. In cultures it has well characterized features, and is distinguishable from the pneumococcus. Since W eichselbaum's observations this organism has been met with in all carefully studied epidemics of the disease. In the Boston outbreak, in 35 of the cases on which post-mortem examinations were made, the diplococci were demonstrated in all but 4, in one of which they had previously been found in fluid withdrawn by spinal puncture. The other 3 cases were chronic. The recent studies, too, in Paris and Germany and in the United States have all been confirmatory of the constant association of this organism with the disease." (Osier, Principles and Practice of Medicine, Ed. 1905, p. 159.) Here at last we seem to be on safe ground. Once the meningococcus—as the organism is commonly called—is recovered, all uncertainty is at an end. If it is present, the disease is cerebrospinal fever, and it is not that disease, if the meningococcus is not recoverable. And so it comes about that the meningococcus is held to be at once the hall mark and the cause of the disease—which, indeed, is termed meningococcal meningitis. This would be very simple if it were the whole story, but is the meningococcus found exclusively in this disease ? Is it never found in any other class of case? The value of the meningococcus as a pathognomonic sign clearly turns upon these questions—some answer to which is given below. Here then are the three groups of evidence—the clinical, unreliable when taken alone; the 4 post-mortem, trustworthy as far as it goes; and the bacteriological apparently infallible. No wonder then that the bacteriological evidence is felt to be the sheet anchor in diagnosis. I will now proceed to compare the evidence in certain recent London cases. No difficulty is experienced when it all points in the same direction—when the bedside signs are confirmed by the bacteriological, and both by the post-mortem. But what of those cases in which the evidence is contradictory, and the bacteriological and post-mortem evidence is in conflict? W hich are we then to believe? I have notes of 14 cases which were originally believed to be either epidemic cerebrospinal or posterior basal meningitis, and all but one were so certified. The clinical evidence of that disease was well marked, but the post-mortem examination excluded it. In 8 of these 14 the meningococcus was absent, but in the other 6 cases the meningococcus was found, or an organism resembling it so closely as to identify the disease; and the conflict of evidence in 5 of these cases is so remarkable that I will quote them in detail. For the notes of the patients I am indebted to the courtesy of the respective physicians in whose care they were. I.R., aged 2 months.—Certified as epidemic cerebrospinal meningitis. Clinical. Bacteriological. Pathological. Had an acute illness with many Small diplococcus resembling Post-mortem examination of the signs of meningitis includ- Weichselbaum's organism. It showed pus of a thick creamy ing Kemig's sign, terminating was seen in large numbers con- character . . . scattered over the fatally at end of three days, tained within the leucocytes. It entire brain . . . and down Otorrhcea noted during life. lost the stain by Gram's method. spinal cord. Both middle ears No growth obtained: it was tried contained pus and also the R. on agar and blood. nasal fossa. There was no caries of the bone in these situations and nothing to suggest that infection started from the ears or nose. The final diagnosis by the certifying physician, was epidemic cerebrospinal meningitis, and the case was so recorded. It was considered that the inflammation in the ears was secondary to that of the brain; but it is not easy to see why suppuration should have spread from the meninges to the ears rather than from the ears to the meninges. The mother stated to me that the child had had a running of the ears before he was taken ill, and that she had syringed the ears for that reason. I. V., aged 8 months.—Certified as epidemic cerebrospinal meningitis. Clinical. Bacteriological. Pathological. Died after 50 days'illness which Diplococcus intracellularis men- Post-mortem general showed clinically many of the ingitidis of Weichselbaum re- losis. signs of meningitis including covered from the cerebrospinal Kemig's sign. fluid. T.O.V., aged 6 months.—Certified as epidemic cerebrospinal meningitis. Clinical. Bacteriological. Pathological. An acute illness lasting 3 days, Intracellular and extracellular Thin sheet of pus over vertex terminating fatally, presenting Gram-negative diplococci in fluid (of brain), 3 drachms of creamy clinically many of the signs of men- from lumbar puncture during life. pus in pericardium, ingitis, including Kemig's sign. Mucopus in both ears. The mother stated that she attended a hospital with the child when he was 6 weeks old, for a running from the ear and that she used to syringe the ear. T.T.N.B., aged 7 months.—Certified at death as posterior basal meningitis. Clinical. Bacteriological. Pathological. An illness lasting 52 days, ter- Intracellular and extracellular Creamy purulent exudate at minating fatally, presenting signs Gram—negative diplococcus re- posterior base of brain. . . . of meningitis, but not Kemig's covered from cerebrospinal fluid Lateral sinuses and fourth vensign. during life. Culture sterile. tricle contained pyolymph and were dilated. . . . Pus in left ear, mucopus in right ear. T.M.N.B., aged 20 months.—Certified at death as cerebrospinal meningitis ; considered to be posterior basal meningitis. Clinical. Bacteriological. Pathological. An illness, lasting 22 days, In cerebrospinal fluid taken Post-mortem examination terminating fatally, showing signs during life was found the diplo- Purulent meningitis. Double of meningitis, but not Kernig's coccus meningitidis intracellularis. otitis media, sign. On the relationship between otitis media and cerebrospinal fever, the following is a quotation from "A System of Medicine" (Osier and McCrae, Ed. 1907, p. 513). Dr. Koplik writes : "Otitis in its various forms is a very frequent complication. In fact, in certain forms of the affection, especially in young children, English observers have advised early puncture of the drum even with slight symptoms of myringitis as a possible measure of relief. The otitis may be catarrhal 5 or purulent and with or without mastoid complication, the latter being infrequent. Otitis is always secondary in cerebrospinal meningitis and there is no authentic case on record in which the infection began in the ear and from this spread to the meninges. The contrary is always true—the ear infection seems to be in direct extension from the brain, or an independent infection from the nose and throat. In quite a number of patients, at the very outset or in the course deafness supervenes without any lesion of the middle ear. In those there seems to be an affection of the auditory nerve apparatus. Some of these may improve in time, others remain permanently deaf." But does this explain the occurrence of such cases as I.R. and T.O.V. It is difficult to understand how, in them, the otitis was secondary to the meningitis. They both presented pre-existing otorrhœa; after an interval, a sudden onset of an acute illness, rapidly fatal; post-mortem, pus or muco-pus in both ears, and pus over the vertex of the brain. Neither in these particulars, nor in any other, so far as I am aware, did these two cases vary from suppurative meningitis, secondary to middle ear disease; and there can be little doubt but that, say 20 years ago, before Weichselbaum's diplococcus was generally known, they would have been so classed and no more thought about them. But an organism was recovered from each, solely on the strength of which they were classed as cases of a specific infectious disease, viz., cerebrospinal fever—very severe, if not fulminant cases of that disease—with a fatal termination in three days: cases essentially identical with those that go to make up epidemics. But is this classification reasonable ? Is it possible to resist what seems the obvious reading that they were, in fact, secondary suppurative meningitis with an organism occurring incidentally? Turning now to the association of tuberculous and of epidemic cerebrospinal meningitis, the following passage will be read with interest. Professor Netter writes, in his article on cerebrospinal meningitis in "Twentieth Century Practice," Ed. 1899, p. 174: "Finally the difficulty (of diagnosis) is greatly increased by the fact that in certain epidemics of cerebrospinal meningitis the cases of tuberculous meningitis are very numerous, and in such cases the cerebrospinal fluid may contain the agents of cerebrospinal meningitis. Holdheim was the first to report a case of tuberculous meningitis in which the fluid withdrawn contained the meningococcus, but he attributed the finding to an accidental impurity. Heubner, Lenharz and Netter have, however, observed similar cases in which there could be no question of contamination. This fact of the possiblity of mixed cerebrospinal meningitis is a most important one, and teaches us that in spite of apparently the best founded presumption we cannot always absolutely deny the tuberculous nature of any case of meningitis, and that the early hopes of the positive value of lumbar puncture are not fully justified." The case I.V. is an illustration; another case which I have not at present been able to trace is that of a patient who appeared to have cerebrospinal fever, and presented not only the diplococcus, but a petechial rash. Post-mortem, acute miliary tuberculosis was revealed. Consideration of such cases as these raises very important questions. The issue, of course, is this. Were these patients suffering from a dreaded epidemic disease, or from some other form of meningitis, in which an organism has been found so closely resembling Weichselbaum's diplococcus as to be indistinguishable from it? But if they are placed in the second of these classes, what becomes of Weichselbaum's diplococcus as a pathognomon of cerebrospinal fever 1 If this organism be found in meningitis of other forms, it loses its distinctive importance; and if the special criterion, as it is now generally considered, of cerebrospinal fever be common to other diseases, the foundations of the existence of that disease are assailed. These are questions which, it seems to me, cannot be lightly or summarily answered. They require to be fairly faced and thoroughly examined. It is not pretended that the data quoted are anything but entirely insufficient. Further observations are greatly needed. I should like now to quote a few cases which further illustrate the complexity of the diagnosis of this disease; and also show the desirableness of a complete examination in every case. I.M.A., aged 15 months, had an acute illness lasting three weeks, ending fatally, and showing signs of meningitis. No bacteriological examination was made. The diagnosis rested between cerebro-spinal fever and tuberculous meningitis. Opinion inclined to the latter disorder. There was no ear discharge, and on examination during life the ears appeared healthy. A postmortem was held. Purulent inflammation of the membranes of the brain was marked; there was no indication of tuberculosis. Up to this point a review of the available evidence was consistent with the diagnosis of cerebro-spinal fever. Then, however, the petrous bones were opened, and the internal ears examined; the left ear was seen to be healthy, but the right contained cheesy pus. This may be regarded as the starting point of a secondary meningitis. Of course, it will be said that such a collection of pus in the ears of young children is common, and is frequently noted to lead to no bad result; and I believe that the records of some of the Childrens' hospitals, though I have not the exact figures, show that such a condition occurs in the ears of upwards of 60 per cent. of infants dying from all causes. But because the condition is one which, in the majority of cases, leads to no bad result, can it therefore be contended that it never does? May not some of the apparently primary cases of meningitis in very young children be due to this cause? What is the proportion of cases of meningitis associated with this condition ? And what is the result of the bacteriological examination of the contents of such ears? So far as I know, without further observations, no complete answers can be given to these questions. I will quote another case illustrating the desirableness of a complete examination of a case. T.T.S., aged five years, certified as epidemic cerebro-spinal meningitis. Clinically, there was an acute illness lasting 24 hours, terminating fatally, and showing many of the signs of the illness certified. My rough note, made at the patient's house, from the mother's statement, runs: "Patient had 18560 O 6 a bit of a cold and cough 14 days before his attack, but ran about as usual; other children had had whooping cough. House infested with flies. Two children (brother and sister) seen, scalps and mucous membranes ill cared for, excoriation of the nostrils and "colds." Face of one of the children scrubbed by the mother with her apron while I was there." This was a polishing process done in such a way as to suggest that it was common. The following was the note on the post-mortem examination, by the pathologist who performed it. "Lepto meningitis with much flattening of the convolutions; a large quantity of greyish green, in some places yellowish, mucus in the nasal passages, the catarrh having spread upwards into the ethmoidal cells." Here is a case resembling, clinically, eases recorded as cerebro-spinal fever, and described as of a fulminating type. There can be little doubt but that this case would have been so recorded but for the completeness of the pathological examination. But with the evidence as it is, is there need to go beyond what seems the obvious reading of the case, that here was a child with a cold, whose nasal passages, not being attended to and kept clean, became obstructed, and filled with mucopus, from which inflammation spread to the ethmoidal cells, and thence to the membranes of the brain? While these cases emphasise the necessity of making a complete necropsy, a similar conclusion on the bacteriological side, is to be drawn from the following case:— T.N.F.D., 11 years.—Certified to have died of posterior basal meningitis. Clinical. Bacteriological. Pathological. An illness of 31 days' duration, Meningococcus not found. No evidence of tubercle. Pus ending fatally, showing many of Tubercle bacilli were found in at base of brain. Meningitis ap- the signs of meningitis, including the lymphatic glands of a guinea parently unassociated with any Kernig's sign. pig, in the neighbourhood of an other morbid condition. injection made into it of the cerebrospinal fluid from the case. Here again is a case almost certain to have been classed as cerebro-spinal fever, but placed in its proper category by the completeness of the bacteriological examination. It suggests the question as to what would be the result, if all cases of posterior basal meningitis were so tested. Evenuatlly a striking illustration of the value of additional evidence, which may be gathered about cases, is afforded by a reference to the Death Returns for the year 1907. In this period 25 persons are shown as having died in London from cerebrospinal fever. By the courtesy of the Registrar-General I have been enabled to ascertain the names of the 12 persons who were reported as having died from that disease during the second half of the year 1907. These 12 cases were among those into which I inquired, and the final result of my inquiries was as follows. Of the 12 cases in question, 2 I noted as having died from meningitis apparently associated with no other lesions, and as presenting an organism considered to be indicative of cerebrospinal fever; in 5 cases the evidence was conflicting; 2 cases were considered to be tuberculous meningitis; and the remaining 2 not meningitis at all. I will now refer more particularly to the bacteriological evidence. In his report of 18th February, 1907, to the Local Government Board, page 1, Dr. Mervyn Gordon states: "The presence within the human body of this micro-organism has been found to constitute the surest test whereby cases of epidemic cerebrospinal meningitis can be detected. Its identification, therefore, becomes a matter of no little importance with reference to that early and accurate recognition of this disease upon which a successful system of prevention of the malady must in our present state of knowledge in great part, if not wholly, depend." And on page 3: "At the present day, therefore, it is generally admitted that the Diplococcus intracellularis of Weichselbaum, or as this micro-organism is sometimes termed, Micrococcus meningitidis cerebrospinalis, or more briefly the meningococcus, is certainly the chief, and apparently the sole, bacteriological factor in epidemic cerebrospinal meningitis." The characters of the meningococcus, which Dr. Gordon appears to consider of special importance in its identification, are as follow:— 1. A coccus occurring usually as a diplococcus. 2. Occurring as intra- and extra-cellular. 3. Giving a negative result with Gram's stain. 4. Growing freely at 37°C. on a medium termed "nasgar" composed of Ascites fluid and Nutrose mixed with Peptone agar. 5. Inability to grow on nasgar between 22°C. and 25°C. Of this test he says that it "would appear to be of very great value for the purpose of distinguishing Gram-negative cocci of the normal throat from the meningococcus." Dr. Gordon mentions other reactions, which are characteristic of the meningococcus, viz., its pathogenetic, agglutinating and fermentative properties; but these, as I understand, he does not consider essential to the identification of the meningococcus; on the other hand, he would not consider the meningococcus to be identified if it did conform to character No. 5. Other bacteriologists, upon whose identification of the meningococcus recent cases have been diagnosed in London, do not wholly agree with the above-named criteria. Cases have been diagnosed as cerebrospinal fever on the bacteriological examination with the following variations. The organism in a certain case was usually Gram negative, but on one occasion was undoubtedly Gram-positive. In some cases a fermentation test has been applied, and importance attached to it; in others this test was regarded as of no value. By some observers the behaviour of the organism in milk and other media is taken into account, and, with most, the appearance of the growth, and its behaviour to drying are factors in its recognition. Not a few cases have been certified on a 7 logical examination which has not included character 5; and others again in which both characters 4 and 5 have been disregarded, no cultural tests at all having been applied. It would seem, therefore, that cases which would have been identified as cerebrospinal fever by one bacteriologist would not have been included by another. The position of the bacteriologist would appear to be this. The meningococcus is not a substance which can be exactly tested for, as a poison is, by certain delicate but definite chemical tests, but is rather to be considered as a plant which is examined and grown and observed in various ways; its recognition in some cases is simple, in others is doubtful or difficult; and recognition then turns on the general behaviour of the plant, as estimated by the acumen and experience of the observer. In such delicate and highly skilled diagnosis as this much would seem to turn on the personal equation of the bacteriologist. It does not seem possible to lay down an exact standard to which each suspected meningococcus can be fitted. I should like now to note some possible objections which may be raised to the considerations which have been advanced. Criticism is apt to take this form. If you are going to take all this time and trouble, such as waiting for a post-mortem examination, or making a long bacteriological enquiry, before identifying the various cases as they arise, it will place the recognition of the disease outside the power of all but a few specialists, and may greatly delay the adoption of preventive measures. I should reply, if this be so, it cannot be helped and we must put up with it. We must face the facts as they are and endeavour to ascertain the truth to which they lead. If we do not at once understand them we can at least refrain from constructing unnecessary hypotheses; it is better to confess ignorance than to embrace error. But I do not see what harm is done by delay in the final identification of cases. There has been in London, recently, no evidence of infection, and if such arose, there is ample means for the notification and isolation of suspected cases. On the other hand, by careful enquiry, there is the opportunity of advancing knowledge of the natural history of the disease, and the placing of it on record for the benefit of the public and of medical knowledge. It seems to me not only a waste of time, but actually harmful, to generalise from cases of secondary suppurative and tuberculous meningitis (if such they be), and record their behaviour as that of another disease, viz., cerebrospinal fever. What importance, for instance, would be attached to the records of an investigation into the natural history of primroses, let us say, when there was reason to suspect that a large number of the specimens were, in point of fact, not primroses at all, but were buttercups and daisies? I submit that articles on cerebro-spinal fever, and accounts of epidemics, would gain much in value if the reader could be referred to a detailed analysis of the cases upon which such accounts are based, and to the methods by which the cases are identified. The foregoing notes have no pretensions to completeness, nor have I any theory to press, or position to take up, in regard to the disease. I am in a state of ignorance about it. What I do feel is that further enquiry is needed, and that there is oneway, and only one, in which the obscurity of the disease is likely to be dispelled and knowledge advanced; and that is by a collective and extended investigation of cases as they occur, and by gathering together the various scraps of evidence obtainable. I have indicated above some of the points which occurred to me as being worthy of note in future enquiry. The principal requirement, however, is the adoption and general use of a definition which would facilitate the ready and accurate classification of the varieties of meningitis. W. Mc C. Wanklyn. Public Health Department. 8, St. Martin's Place, W.C. October, 1908. APPENDIX II. Lonbon County Council. NUISANCE FROM FLIES. Report by the Medical Officer of Health presenting a report by Dr. Hamer, Medical Officer (General Purposes), on the extent to which fly nuisance is produced in London by accumulations of offensive matter. (Ordered by the Public Health Committee to be printed, 23rd January, 1908. ) For many years the Sanitary Authorities of London have been engaged jin endeavouring to perfect the arrangements for removing offensive refuse from close proximity to inhabited houses. The standards laid down by the Public Health (London) Act, 1891, and by the by-laws of the London County Council, made in 1894, under sections 16 and 39 of that Act, have been gradually but steadily applied. Many difficulties were encountered at the outset, both from occupiers who claimed a right to enjoy the privilege of keeping house refuse upon their premises for indefinite periods, and from contractors who, in defiance of the by-laws, deposited house refuse, street sweepings, stable manure, etc., within the prohibited distance of houses. These have been for the most part overcome, but there still remain difficulties with regard to the depots at which refuse is manipulated. In some instances such refuse is burnt, and the furnaces employed for this purpose do not always give wholly satisfactory results; in others, it is carried away in barges or in railway trucks, and if it be transferred direct, from the cart to the barge or truck, complaint is jnuch less likely to arise than if the refuse be temporarily deposited. In a few instances, however, the refuse is deposited at the depot and allowed to remain for a time either in order to enable sorting operations to be carried on or for some other reason, and in neighbourhoods where this practice obtains, in addition to annoyance from smell and dust, fly nuisance is apt to be experienced, especially in the summer mnoths. The question of fly nuisance has been before the Committee on various occasions in the past fifteen years, but recently complaints have been more frequent, in part, no doubt, owing to the fact that attention has been pointedly called of late to the possibility that flies may act as carriers of infection. Last year a striking instance of fly nuisance came directly under the notice of the Committee, and I was instructed to have some general enquiries made. A scheme was accordingly formulated by which study could be made of the influence exerted by collections of house refuse, stable manure, cow manure, etc. Twelve sets of premises were chosen for the purposes of the experiment, and some dozen or more places of observation were selected surrounding each centre. In these places fly papers were exhibited, and careful records were made of the number of flies caught. During the hot weeks of 1907 nearly a million flies were thus captured, and Dr. Hamer's report summarises the results deduced from examination of the figures relating to the several premises under the varying conditions obtaining. One lesson clearly emerges to view. On no account should the practice of depositing manure or house dust at depots and of allowing such deposits to remain, even for a few hours, in the neighbourhood of houses, be tolerated in an urban community. Dr. Hamer, in the concluding portion of his report, deals with the evidence adduced, in this country, in support of the view that flies transmit diarrhoea and enteric fever. As to this, more information is undoubtedly needed before any definite conclusion can be arrived at. In the meantime, the facts ascertained indicate that, even apart from any question of disease-transmission, the physical discomfort extending even to loss of sleep, caused by flies, is sufficiently great to warrant further effort being made to deal effectively with fly nuisance. Moreover, even in the absence of direct proof of disease dissemination the well-known habits of flies justify their being regarded with disfavour. A visitor in an hotel at an American health resort, in which the dry method of disposal of excreta was adopted, is said to have complained of the plague of flies in the sanitary offices. He was advised that experience showed the condition of the offices was less open to objection during hours when meals were being served, as the flies were then attracted to the hotel tables. Considerations of this sort suffice in themselves to carry conviction as to the need of dealing with fly nuisance. SHIRLEY F. MURPHY, Medical Officer of Health. To the Public Health Committee, January, 1908. 16292 s.s.,1362 2 Dr. HAMER'S REPORT. In January, 1905 the Education Committee communicated with the Public Health Committee concerning the use by one of the borough councils, as a shoot for street sweepings, of land adjoining an Elementary School. Enquiry was made and it was found that stable manure was deposited for the purpose of mixing with road slop in a position some fifty yards from the school in question. Inasmuch as this action appeared to involve a breach of the Council's by-laws, made under section 16 (2) of the Public Health (London) Act, 1891, the Public Health Committee drew the attention of the Borough Council to the subject. Correspondence ensued, and in September, 1905, the practice was discontinued. Early in the following year, it was found that a destructor-furnace and a machine for separating houserefuse had been installed on the site, and that large quantities of "breeze" and "fine ash," were there awaiting removal by barge. The practice of depositing road slop and manure had been resumed, and a large square basin had been formed by banks of manure; road-slop was from time to time poured into the hollow thus made. There was, moreover, evidence of nuisance caused by smoke and dust emanating from the chimney of the destructor-furnace. The Borough Council had made application to the County Council for a loan of £3,025 in respect of the newly erected apparatus at the site, and the Medical Officer was therefore instructed to report whether any nuisance caused by working the apparatus or by any operations carried on by the Borough Council existed at the school. As a result of the Medical Officer's enquiries the Council entered into communication with the Borough Council on the question of nuisance. The depot was kept under observation throughout the ensuing summer, during which period correspondence between the Borough Council and the Council was being carried on, and it was found that the requirement of the by-law was not strictly complied with; indeed, it was admitted that the barge intended to remove deposits, only came to the wharf three times a week; this fact of course made it apparent that the deposits of refuse material at the depot were allowed to remain for periods exceeding 24 hours. An inspection on 27th July, 1906, showed the presence of myriads of flies in the neighbourhood of the heaps, and one of the men working at the depot exhibited a shovel full of "gentles," which he had collected from the deposits, for use as bait when fishing in the canal. At houses in the immediate neighbourhood, the fly nuisance was very pronounced. Complaint was made about this time by several persons to the Council's inspector of their inability even to sleep at night by reason of the plague of flies. Trouble was also experienced at the school, though it appeared that the dust from the destructor chimney was there a cause of even greater evil than the flies, for, with certain winds, there was liability to deposit of layers of fine ash on the walls of the class rooms. The borough council was unwilling to discontinue the use of the site, and, it was indeed urged by some of those who advocated the continuance of the manipulations that there was no reasonable cause for complaint. On November 23rd, 1906, the County Council's Public Health Committee, in view of the conflicting evidence on this question, decided to view the premises. At this time, the hot weather being over, the number of flies was far less than it had been some weeks previously, but an inspection of neighbouring houses satisfied the Committee that very serious nuisance had been experienced. At a small general shop, food materials exposed for sale were seen to be thickly covered with fly marks, dead flies were found in the milk on the counter, and the occupier of the shop exhibited in a box many thousands of flies which had been collected during the day or two preceding the Committee's visit. The outcome of the inspection was to raise question whether it was practicable on a site such as that visited, even if every possible care were taken to avoid any infringement of the Council's by-laws, to conduct operations of the kind carried out without causing considerable annoyance to neighbours. It was felt, therefore, that further enquiry should be made with regard to this question of fly nuisance, thus demonstrated to be almost necessarily experienced in association with manipulation on a large scale of refuse materials of this sort. During the winter of 1906, and the early part of 1907, the question of granting a loan in respect of works carried out at the depot was on several occasions before the Council's Committees, and, at length, on February 26th, it was resolved to grant the loan, on the understanding that this action should not be held to prejudice any step the Council might deem it necessary to take in the event of nuisance being caused. The continued use of the premises during the summer of 1907 thus became inevitable and it was, therefore, seen that at least an opportunity presented itself of studying in a comprehensive manner the whole question of fly nuisance. The Medical Officer was instructed to choose some dozen premises—dust yards, etc.—at which accumulations of refuse were known to esist, for purposes of comparison with this particular depot, and to estimate the amount of fly nuisance existing under differing circumstances. To carry out the scheme involved the selection first of a number of centres, and then of some half-dozen or more places of observation at varying distances from each centre. So far as the centres themselves were concerned no difficulty presented itself, but in the case of the places of observation it was of course necessary to obtain the co-operation of the occupiers of the premises in the work of testing day by day the extent of prevalence of flies. With a view to conducting the operations on an uniform plan, it was decided to endeavour to secure as places of observation kitchens or living rooms occupied by poor people. The rule was laid down that each room should be fairly lighted and, if possible, have a southern aspect, and that it should be on the ground floor where practicable. The house selected was preferably to be one not exceptionally clean, and a rough guiding principle was adopted that the room should not have been "done up" within the last six months. On the other hand it was thought undesirable to select houses which were exceedingly dirty, or where there was any local disturbing cause likely to attract flies—such as a manure heap, or a large accumulation of house refuse. It was of course felt to be important that the house chosen for observation should not be close to a 3 baker's, butcher's or grocer's shop, or a marine store dealer's or other premises likely, by forming a subsidiary centre of attraction for flies to interfere with the observations* The method of determining the extent of the fly nuisance in a particular house was to hang up a fly paper from the ceiling or gas bracket of one of the rooms, to allow it to remain exposed for a definite period of 24, 48 or 72 hours (as the case might be), and then to count the number of flies on the paper. The papers used were smeared over with a sticky compound known as " honey-gum " and were about 12 inches by 8 inches in size. Experience acquired with regard to other papers of somewhat similar character seemed to show that there were no great variations in the number of flies caught under the different circumstances; but, for the sake of uniformity in all the observations, the numbers referred to in this report were obtained by use of fly papers of one particular type. It would, no doubt, have been advantageous, had it been possible, in place of the fly papers to have used fly traps, as has been done by Dr. Niven of Manchester, but inasmuch as it was desired to carry out experiments on a considerable scale the question of cost assumed large importance and indeed made it necessary to have recourse to the cheapest method of catching flies which could be relied upon to give fairly accurate results. The papers were in no instance placed in a dark part of a room, on the other hand they were not exposed to direct sunlight. They were, as a rule, collected on Mondays, Wednesdays and Fridays, and special effort was made to secure their being renewed at the same hour in the case of each particular room. The endeavour was made, as far as this was practicable, to obtain for purposes of observation at least two houses as near as possible to the centre of investigation, at least two houses 50 yards away, and two houses about 100 yards away, were also, when possible fixed upon. In the case of premises with large accumulations of refuse and manure, a few houses were chosen, where this could be done, at greater distances; the two houses selected at each particular distance were if practicable situated at opposite points of the compass—one of them, when possible, to the North East and the other to the SouthWest of the centre. At first, considerable difficulty was experienced in gaining the co-operation of occupiers of the houses, but, as time went on, and when the benefit resulting from ridding the rooms of numbers of flies became appreciated, the difficulty, instead of being one of obtaining permission to use a particular room, became rather one of obviating the necessity of making use of more rooms than were really essential for the purpose of the experiment,—occupiers of rooms who were already exhibiting papers being anxious that friends and relations should also be given the opportunity of doing so. With regard to the character of the premises chosen as centres, the main idea kept in view was to select places to, or at, which large quantities of house refuse, manure, etc., were brought, or were allowed to accumulate. Thus depots used by borough councils, or by contractors, for the purpose of dealing with refuse, and large stabling premises and cowsheds were naturally selected in the first instance. For the purposes of contrast, two premises at which offensive trades were carried on, and further a jam factory and a cattle market, were included in the list. The following is a brief description of the twelve sets of premises chosen as centres. (1) Borough Council Depot (No. 1).—This depot adjoins a railway siding, with lines of trucks into which horse manure and stable refuse are loaded for removal from London. Boughly speaking some twelve truck loads of horse manure and twenty-four of house refuse were removed daily during the summer of 1907 from this depot. The material brought in during the day was, speaking generally, removed the same night, and this rule, with some exceptions, was fairly well adhered to throughout the summer. On particular occasions, however, considerable accumulations of road slop, etc., were observed. (2) Borough Council Depot (No. 2).—This is the depot referred to in the early part of this report. It is situated on the banks of a canal, and covers an area of nearly two acres. Between 55 and 65 cart-loads of house refuse are brought to this depot from various parts of the borough daily. The refuse is passed over a screen, through which heavy matter falls, while the lighter particles are picked up and burnt in the furnace. The refuse which has passed through is lifted by an elevator into a revolving screen divided into three sections. The soft core derived from this screen is carted away to a "tip" on the outskirts of the county; the ash and breeze are barged away, some three barge loads being removed each week. Accumulations of ash and breeze were frequently noted, but the soft core was fairly regularly removed. Boad-slop, but no manure, is deposited at the depot. There are some stables, but no cowhouses in the neighbourhood. (3) Borough Council's and Contractors' Dust Wharves.—The centre chosen in this case was a point midway between two wharves, situated on the North bank of a canal, each covering an area of about half an acre. Befuse is brought to the one on the East from neighbouring districts and dealt with by a contractor, who causes it to be screened by machinery and allows no accumulation to collect. To the other wharf house refuse is brought by the borough council and dealt with in a similar manner. From these two wharves more than 20 barge loads of house refuse are removed *The selection of the rooms in which the number of flies was to be computed was entrusted to the Council's Inspectors, Messsrs. Tuck, Lewis, Harrison, Perry, Swinson, Mernagh and Powell, and these officers undertook the work of securing the co-operation of the occupiers of the premises ; each officer moreover, kept the record for one or more of the twelve areas. The special knowledge of the inspectors concerning these p irticular centres and the surrounding localities thus became available for the purposes of the enquiry. It was hoped that the work could be done without material interference with the inspectors' ordinary duties; it was found, however, that no light task had been entered upon,and some strain was especially experienced when, in order to maintain continuity of the observations during August and September, the duties were necessarily performed by a more limited staff, Inspectors Lightfoot and Hitchmough rendered assistance during this period. The two photographs reproduced were taken by Messrs. Lightfoot and Swinson, and the calculations, and the preparation of the charts were undertaken by Messrs. Avery and O'Carroll. 16292 A 2 4 each week. No manure is taken to these wharves, but at adjoining wharves large quantities of roadslop and some manure are dealt with. There are some stables but no cowhouses in the vicinity. (4) Manure Bepol—This depot adjoins a railway siding at which manure is loaded directly from carts into railway trucks, and sent to the country. Fish refuse and horse manure are also received here. The railway yard is a very extensive one, having a width of 120 yards and a length of a quarter of a mile. About 50 trucks are loaded per diem on an average, and these, as a rule, are sent away each night to the country. (5) Stable Premises No 1.—At these premises several hundred horses are accommodated. The stabling is of modern brick construction, well lighted and ventilated. The manure is stored in the covered yard in front of the stable, and is said to be removed daily. No other stables or cowhouses are in the immediate vicinity. (6) Stable Premises No. 2.—There are two large stables here in close proximity to one another. Several hundred horses are kept. The manure is removed daily, and no considerable quantity of manure was found at any time on the premises. Peat-moss litter was used instead of straw. No cowhouses or noxious trade premises are in the vicinity, but there are some smaller stables, and a fried fish shop is situated nearly opposite the house at which the largest number of flies was caught.* (7) Cattle Market.—The places of observation were all situated on the North side of the Islington Cattle Market. The market days for the sale of cattle here are Mondays and Thursdays. Lairs are provided on the South and West sides of the market-place and cattle are kept at these lairs before the market is open ; while, if any of the cattle are not sold they are again placed in the lairs until the next market day, or until they are slaughtered. There are slaughter-houses on the East side of the market-place. The manure is swept up and removed on the day following each market-day, the pens and alleys being washed down. Some small stables are in the vicinity. (8) Cowhouse Premises.—These premises are licensed for the keeping of 20 cows in two sheds. There is a dwelling-house adjoining, and a small open yard in which are receptacles for the storage of grain and dung, and a milkstore. The cowsheds are brick buildings, but they are not of modern construction. They are fairly well ventilated, but not well lighted. The dung is removed from the premises twice a week. A railway line carried on an embankment lies a few yards to the South, a bakehouse abuts partly on the South side of the premises. The neighbourhood is thickly populated and lies a little way to the East of a market street. (9) Centre situated midway between two Cowshed Premises.—One of the cowsheds is licensed for the keeping of 12 cows, the other for 20. On the West side of the smaller cowshed there are several stables with living and sleeping rooms over them. The cowshed premises are old and very ill-adapted for the purpose for which they are used. Many complaints have been received as to nuisance from accumulations of manure, and especially as to offensive smells experienced when manure is removed. (10) Offensive Trade Premises No. 1.—This centre is a knacker's yard in which about 70 horses a week are dealt with. It consists of several buildings open at the ends and having openings in the roof; also, an open fronted shed, and hauling ways. On the West side it abuts upon a public school and play-ground, on the East partly upon a public street and partly upon several small cottages, on the North and South it adjoins buildings used as manufactories. With the exception of the immediately surrounding locality, which has recently been cleared under a housing scheme, the neighbourhood is thickly populated by persons of the poorer classes, occupying small cottages and tenement blocks—public and private. There are a number of manufactories of various kinds, including premises once used by a Gut manufacturer, one cowshed and a few small Stables, within the area under observation. There is, moreover, a small stable on the knacker's premises for Police and other emergency work. The dung receptacle measures 7 ft. 6 in. by 7 ft. in area. The front wall is about 3 ft. high. The dung is cleared away daily by a contractor. It was observed that the receptacle was thoroughly cleansed with water after having been emptied. (11) Offensive Trade Premises No. 2.—These premises are in the occupation of a Cat-gut manufacturer. In the immediate neighbourhood are two permanent school buildings; there is also a building temporarily used as a school. No stables or cowsheds are in the immediate neighbourhood, but there are premises upon which fish-curing is carried on. The Gut-scraping premises consist of a brick building and a small open yard, and the offensive processes of the business are conducted in closed chambers ventilated by extraction and propulsion fans, and the offensive vapours are cremated in a furnace. (12) Jam Factory.—During the season, a large quantity of fruit is received at the premises, and, while the jam is being made, a characteristic odour is noticeable in the vicinity. Stables, in which ten horses are kept, are situated in the rear of the factory. While the intervals of time during which the fly papers were exposed were, as a rule, periods of 72 and 48 hours, in certain exceptional cases, (bank-holidays, etc.), the interval was a somewhat longer one. The numbers corresponding to each interval have been divided by three, in the case of the 72 hours, and by two in that of the 48 hours intervals, so that figures representing, so to speak, the "daily number of flies," for each period, at each particular centre were obtained. Diagram I., which is based upon these crude figures, suggests at once that the premises at which there are accumulations of house refuse and stable manure tend to attract to their neighbourhood, if not to produce, exceptionally large numbers of flies. Inasmuch, however, as the number of places of observation around the twelve centres *The figures in the case of this centre have been obtained by dealing sep arately with houses surrounding the two stables, and then adding the totals together. 5 was not uniform, but varied from some six or seven places to as many as twenty-nine : and as furthermore the distances from the centres, of the places of observation chosen, were not precisely the same, it is clear that some method of applying correction to the crude figures must be made, if it is desired to compare results relating to the different centres. It was felt to be necessary in making such correction to have regard both to the number of places of observation and to the degree of concentration of these places about the centres chosen, for obviously if they cluster closely around the centre, any influence the centre may exert would be likely to be more manifest than if they were widely scattered. The plan adopted was to determine for each centre of observation a particular number, to be used as a divisor and applied to the crude figures representing flies caught. This number it was on consideration decided should be obtained by adding together the places of observation at less than 100 yards multiplied by 4, those between 100 and 150 yards multiplied by 3, those between 150 and 200 yards multiplied by 2, and, finally adding the number distant more than 200 yards.* The gross figures for each centre were then divided by the divisors thus obtained, with the result that the twelve curves shown in Diagram II. have been plotted out: these curves, it is claimed, fairly admit of comparison one with another. A study of this diagram shows at once that the two offensive trade premises, the Knacker's Yard and Gut Scraper's premises,† chosen as centres for observation, yielded only a small number of flies in comparison with other centres. The places of observation around the Jam Factory showed an excessive number of flies during the latter part of August and early part of September, and, again, during the early part of October. These increases did not correspond with the general increase in the number of flies throughout London, for the former precedes, and the latter follows after, it. It is probable, though it has not been possible to definitely ascertain the fact, that the prevalences in the neighbourhood of the Jam Factory were to some extent influenced by variations in the amount of work being done there. In the neighbourhood of the two cowshed premises the evidence of fly nuisance was pronounced. There were a number of stables in the immediate vicinity of one of these centres, and this disturbing influence was no doubt not without effect. The increase in the number of flies in the case of the Cattle Market is somewhat more marked than in the case of the cowshed premises. A like increase is also quite apparent in the case of both stable centres. The four centres, however, in which the evidence of fly nuisance stands out in a most striking way are the four depots. At Centre No. 4, where there were no accumulations other than those in the trucks (the manure being removed direct from the cart to truck), and at Centre No. 3, at which there were no accumulations save those in barges, the nuisance was not quite so great as at Centres Nos. 1 and 2, where the rule of not allowing deposits was not so strictly enforced; it may be further observed that at Centre No. 1, where considerable quantities of horse manure were dealt with, the numbers of flies were more excessive than at No. 2, to which centre nothing but house refuse and road-sweepings were brought. Indeed the Centre No. 1 stands out pre-eminently as a defaulter upon the evidence obtained. The main outcome of the enquiry undoubtedly is that accumulations of horse manure and in less degree of house dust and other refuse, promote fly nuisance in their immediate neighbourhood, their influence being manifested in marked degree at a distance of 100 to 150 yards, and still distinctly appreciable as far away as 200 yards, or even at greater distances. While the collection of refuse material at a depot necessarily therefore involves production of nuisance, the observations made show that this nuisance is doubled or trebled in intensity if the most strict adherence to the rule that deposits should not be allowed to accumulate at the premises be not observed. The value of the Council's by-law, which prohibits the deposit near houses of offensive refuse for more than twenty-four hours, is thus apparent; although it is at the same time obvious that, even when the by-law is strictly complied with, fly nuisance must none the less be experienced. Study has further been made of the extent to which other and less potent influences than collections of stable manure or house refuse have been operative in determining increase in the number of flies. (1) Domestic Cleanliness.—A dirty condition of rooms, walls and ceilings appears to favour invasion by flies ; though, when the rooms have been " done up," it has not been found to reduce but rather, momentarily, at any rate, to increase the number caught. The presence of crumbs and of particles of food on floors, in crevices and upon rugs and coverings, seems to attract flies to a much greater extent than does the mere existence of dirty walls and ceilings. It is a noteworthy fact that where there are a number of children in a house, flies appear, other things being equal, in larger numbers ; and, in the case of one house, the inspector found that, when during the course of the summer the children went away, the number of flies showed a marked reduction. That the association is indirectly caused is shown by the freedom from flies of occupied class-rooms of schools, a fact confirmed by experiment during this enquiry. *The number of flies caught per place of observation for places situated at differing distances from the several centres are as follows: at more than 200 yards, 4,300; between 150 and 200 yards away, ],900; between 100 and 150 yards away, 5,400; at less than 100 yards, 6,700. A more precise gradation is obtained if 210 yards be taken as the highest limit instead of 200. The figures then are: 3,500 at more than 210; 3,000 at from 150 to 210; 5,400 at from 100 to 150 each; 6,700 at less than 100. The corresponding figures for eleven of the centres (omitting a centre at which the conditions were somewhat exceptional) were 2,200, 2,600, 4,800, and 5,700. These figures justify some such method of computation as that above adopted. †The Knacker's Yard showing, however, a larger number than the Gut Scraper's: this may be accounted for by the fact that a few horses were kept, and that there was thus some accumulation of stable manure at the former premises. 6 (2) Temperature of Booms.—Warmth and Cooking.—A warmroom greatly favours flies, and ihis is especially the case in Autumn, when cold nights begin to prevail. Numbers of observations 1 ave been made in this connection with regard to use of coal fires and to the amount of cooking carried on. Thus the influence of the "week end" is very apparent in the figures which the inspectors have recorded. This point has been noticed by all the inspectors; one of them, Mr. Lewis, has worked out the daily average number of flies, at a particular place of observation, for the week end (Friday to Monday) throughout the summer and found it was 26; the corresponding daily averages for other divisions of the week were, 14 (Monday to Wednesday) and 8 (Wednesday to Friday). Doubtless the cooking operations of the week-end and perhaps to some extent also the larger use of rooms on Saturday and Sunday are in the main responsible for this phenomenon. Washing-days exert also a distinct influence, and, in one instance, the preparations for a wedding appreciably increased the number of flies. Premises such as bakehouses and cowhouses, which are always at a comparatively high temperature, are favoured places of refuge for flies during the Autumn and Winter months.* Cold and rain, needless to say, have an opposite effect to atmospheric warmth, and their influence is mainly rendered apparent in causing flies to have resort to houses when the temperature falls, or when it is wet. (3) The improper storage and insufficiently frequent removal of house refuse exercise marked influence. For example, in the back yard of a house not far from one of the cowsheds (Centre 9) there were always far more flies than in the cowshed itself—a fact no doubt attributable to the presence of an old dust-bin, in which considerable quantities of refuse were allowed to accumulate. A similar experience was forthcoming from the neighbourhood of the Knacker's Yard. The clearing of roadways, channels and street gullies near houses also exerted appreciable influence. It was found, moreover, that houses in streets down which dust-carts or manure carts passed were especially infested with flies ; in numerous instances it was clear that this constituted an important factor in the promotion and maintenance of fly nuisance. (4) Aspect and Elevation of Room.—A sunny aspect exercised great influence on the number of flies, wnile very dark rooms were comparatively free from them. Ground floor rooms yielded more flies, cateris parilun, than rooms on higher floors. Thus around Centre 10 the daily average for 12 ground floor rooms was 25.5, for 13 first-floor rooms it was 12.7 and for 12 rooms on the 3rd and 4th floors it was 12. Several of the places of observation around this centre were in County Council Dwellings, and the number of flies obtained in rooms in those dwellings compared, it was found, very favourably with the numbers caught in other premises in the neighbourhood. The superiority of the Council's dwellings as regards sanitary conditions and the better supervision exercised, by tenants and by superintendents and caretakers, no doubt accounts in large measure for the small number of flies found in them. (4) Position of Fly Paper.—As was of course foreseen, the position of the fly paper materially influenced the number of flies caught. The numbers were larger when the papers were hung in places where the light was good, especially, if the spot chosen happened to be near the centre of the room. One of the inspectors was told that the smell of gas attracts flies, and the number of flies found near a gas-house was certainly larger than might have been expected, but the opportunity of further investigating the matter did not present itself. (6) Open Windows.—A factor of importance proved to be the influence of open windows. In premises where the doors and windows were kept closed during the greater part of the day, comparatively few flies were caught. This was especially noticeable in certain cases in which the family were at work all day, or went "hopping" for a few days in the country. On the other hand, when it chanced, owing to the desire of the occupiers for fresh air, that windows were left widely open, the rooms were especially infested with flies. The fact that flies were continually invading a room from without was rendered particularly clear in the case of a barber's shop used as a place of observation. The shop was clean and no cooking was carried on ; there was indeed no ascertainable special source of attraction for flies, except the presence of apparatus for providing hot water and the fact that the shop front consisted almost entirely of glass. The shop was, however, on the ground floor of a block of high buildings and was just opposite the opening of a street leading .to some stables. Flies travelling westwards from the stables would impinge upon the block of buildings and the barber's shop constituted in fact a sort of fly trap. Although many thousands of flies were caught, day by day, the supply was continually renewed, presumably from the stables; this process of renewal, according to the occupier, was especially in evidence each morning when he threw open the doors and windows of the shop. Attempt was made in connection with some of the centres to study the influence exerted by prevailing winds. This was found to be less marked than might perhaps have been expected. At one centre the places of observation to the North East suffered less than those to the South West, but the former were separated from the centre by a canal, and there were other reasons for the observed differences. Yet even here it was found that the places of observation to the North East of the centre especially suffered when the wind was in the South West. (7) The influence of certain special sources of attraction in determining quantity and character of flies.—The study made of the conditions obtaining in places of observation surrounding the Jam Factory seems to suggest that numbers of flies, in excess of those ordinarily present, were observed in the neighbourhood, when the characteristic smell of jam making was specially pronounced. On the whole, however, the influence exerted by the Jam Factory was less considerable than it had been anticipated would prove to be the case. Early in the enquiry a disturbing influence was found to *Even in the depth of winter (January, 1908) considerable numbers of flies were found in the cowsheds at Centre 9. 7 be at work rendering the number of flies unusually large at a particular place of observation, and this was, it appeared, exerted by some neighbouring premises at which muslin wrappings of frozen carcases of meat were cleansed ; the operation in question produced a characteristic odour. From the outset the attempt was made to determine the species of flies caught. More than nine-tenths were examples of the common-house fly—Musca domestica. Some hundreds were identified as belonging, and doubtless some thousands actually belonged, to the less common species— Homolomyia camcularis—which closely resembles Musca domestica, but is rather smaller. A third species—Stomoxys calcitrans—is said to be not uncommonly met with in houses; the inspectors were on the look out for this fly, which is a stinging fly and should be readily distinguished by reason of the appearance of its proboscis, but no examples of this species were detected. A similar experience is recorded by Mr. Newstead from Liverpool. A considerable number, some 3,000 specimens, of the common blue-bottle—Cattiphora vomvtoria—were secured. There was a marked tendency for blue-bottles to appear in some numbers when they appeared at all; at two places of observation in the neighbourhood of stables the number was noted as considerable; the centre with the largest total number of blue-bottles was the depot No. 2, from which over 1,000 were reported; 360 were captured at the places of observation surrounding one of the offensive trade centres (centre 11), but only 115 were counted on the papers from houses surrounding the other (centre 10). The observations with regard to blue-bottles are no doubt less reliable than those relating to smaller flies, for in numerous, instances blue-bottles were found to be able to effect escape after first alighting and adhering to the paper. In addition to the insects mentioned, a number of "gnats" and " midges," and a few " green flies," " moths," "crane flies and "bed bugs " were enumerated. While these various subsidiary causes each, no doubt, exert more or less effect, the preponderating influence is unquestionably shown by the enquiry to be proximity to collections of horse manure and, in less degree, of house dust and other refuse. In a report by Mr. Robert Newstead, A.L.S., F.E.S., prepared by the direction of the Liverpool Corporation, the result is given "of enquiry (December, 1906, to October, 1907) as to the breeding places of house flies, and it is shown that horse manure and spent hops and ash-pits, containing fermentative material, are especially to be regarded in towns in this country as "permanent breeding places." In addition to the foregoing, certain other collections of material may serve as "temporary breeding places," collections of fermenting vegetable refuse, accumulations of manure at wharves, and bedding in poultry pens are particularly mentioned. The reporter writes, with reference to stable middens containing horse manure, " The larval stages of the house fly occurred in countless thousands, revelling in the heat produced by fermentation. The adjacent Walls often swarmed with newly hatched flies, and occasionally one also found enormous masses of their eggs, while deep down at the sides, in the cooler portions of the receptacles, the pupa or chrysalis stage occurred in enormous numbers, looking like small heaps or collections of reddish berries. Middens containing a mixture of horse and cow dung were also infected, though to a less extent than those receptacles containing horse manure only."* The belief that horse manure especially serves as the breeding place for house flies is found expressed in most books which deal with the house fly and its habits, though a somewhat different experience Was obtained in India by Major Smith.† This observer studied the ways of house flies under tropical conditions at Benares, and there found Musca domestica and Musca entceniata mainly represented in barrack rooms, etc., the former apparently breeding chiefly in cow dung, the latter in human ordure and in dog excrement. Horse and donkey dung in single deposits only yielded flies which are not domestic in habit. In London, horse manure pre-eminently stands out as the chosen breeding ground for house flies, but it appears clear that the ordinary house refuse deposited in dust-receptacles also possesses great attractions for them. An interesting demonstration of the influence of horse manure is afforded if the curve showing the prevalence of flies throughout the summer, in the places of observation surrounding the four centres at which horse manure mainly came into question, be contrasted with the corresponding curve for the remaining eight centres (see Diagram III.). It transpires that in the case of the four centres, following upon the rise coincident with the development of hot weather in July and August, there ensued a further and, as it were, super-added wave of prevalence, covering the latter part of September and early October. This second wave is much less conspicuous in the curve for the other eight centres. At several of these, however, some influence is known to have been exercised by collections of horse manure, and if this influence could be eliminated altogether the superadded wave would no doubt disappear from that curve. On the other hand, the presence of the superadded wave in the general curve of prevalence for the twelve centres may be safely attributed to the breeding of batches of flies in horse manure during the close of the summer and early autumn. A detailed examination of the figures recorded at houses surrounding the several centres confirms in a very striking manner the conclusion that collections of horse manure exercise an altogether exceptionally important influence. Thus persistently high figures were recorded at two places of observation situated some distance from the dust wharf (Centre 3), and this exceptional incidence was found to be associated with the proximity of the houses in question to some stables, which constituted a subsidiary disturbing influence. A similar phenomenon was observable in the case of Centre 9, where *"It is important to note, however," he adds, "that in all cases where fowls (not ducks or geese) were kept and allowed freedom in the yards, relatively few of the earlier stages of the house fly were found, and whenever present were invariably located in places inaccessible to the fowls." †See Journal of the Royal Army Medical Corps, Vol. ix., No. 2. 8 it was found that a room situated between one of the cowsheds and some stables invariably yielded far more flies than did the cowshed itself. A like experience, moreover, is recorded in respect of Centre 12, where the occurrence of an exceptional degree of fly nuisance in a particular room was undoubtedly due to a large collection of stable manure in the near neighbourhood.‡ The importance of securing speedy removal of horse manure from near proximity to inhabited houses is, it will therefore be seen, particularly emphasised by the experience gained during this enquiry. Diagram III. shows the relation of temperature conditions and diarrhœa mortality to the fly curve. A study of the amount of diarrhœa sickness occurring in the several areas surrounding the twelve centres was contemplated when the enquiry was commenced, and the co-operation of the medical officers of health of the boroughs in which the centres are situated was sought in making this investigation. It soon, however, became apparent that the coolness of the summer would cause the diarrhœal mortality to be considerably below the normal amount, and, as a matter of fact, it proved to be exceptionally low. The number of deaths recorded from diarrhceal disease, during the thirteen summer weeks ending with the close of the first week in September was less than one-seventh of the mortality recorded during the corresponding period of the year 1906—334 deaths in 1907 as compared with 2,588 deaths in the preceding year. Enquiries were instituted on a comprehensive scale by Dr. Brown in Bermondsey, and Dr. Millson in Southwark, with a view to ascertaining the number of cases of diarrhœa occurring in the areas surrounding two of the twelve centres already referred to, for it was recognised, of course, that the number of cases constitutes a far more precise test of the amount of diarrhœa than does the number of deaths. The small degree of prevalence of the disease will be sufficiently indicated when it is stated that in a considerable area, surrounding Centre 10 in Southwark, with a population of between 8,000 and 9,000 persons, the result of the house to house enquiry instituted by Dr. Millson showed that only 50 cases of diarrhœa occurred during the hottest months of the summer. Among these 50 cases there were only six in infants less than one year of age, and the six babies all recovered. The fact that among nearly 9,000 persons, occupying one of the poorest areas in London, not a single death from infantile diarrhoea occurred during the four hottest weeks of the summer of 1907, is sufficiently indicative of very exceptional meteorological conditions. The question of the relation of enteric fever and summer diarrhœa to fly prevalence has during the last few years been made the subject of some study.§ It has been shown by several investigators that the temperature curve, fly curve, and diarrhœa curve stand in remarkable relationship one with another. The fact that during the hot weeks of the year the temperature curve and the diarrhoea curve show a rough correspondence, and that the similarity of the variations of the curves is exhibited in a marked manner when the figures for a number of years are passed in review, has, of course, been long well known. Dr. Ballard showed that this correspondence was more precise if, instead of dealing with the ordinary air temperature, that of the earth four feet below the surface be used in plotting out the temperature curve, and he was disposed to think this fact meets its explanation in an hypothesis that the cause of diarrhoea is some living organism finding specially favourable conditions for growth in the superficial layers of the earth. It has been pointed out, however, that the curve of "earth temperature " of necessity lags a little behind that of "atmospheric temperature," for heat takes time to penetrate three or four feet beneath the surface; and it has been urged that in like manner the rise of diarrhceal mortality of necessity lags a little behind the rise in the total amount of diarrhœal disease. It may well be argued, therefore, that the correspondence noted by Dr. Ballard is, after all, no more than a chance coincidence, the rises in the "earth temperature "curve and in the "diarrhœal curve" being merely due to one common cause—"hot weather." In the same way, it is open to argument that the correspondence between the fly curve and the diarrhœa curve is a mere coincidence; in other words, that both simply result from the influence of temperature, and that there is not, in point of fact, any causal connection between flies and diarrhœa. Thus Dr. Niven, of Manchester, who was one of the first to devote attention to the subject, wrote, in 1903, "So far, not a shadow of evidence has been adduced, unless it be the absence of other ascertainable means of transport. Yet the proposition is not one that we can positively reject. Warm weather brings flies and warm weather brings diarrhœa about the same time." Dr. Niven hass hown, on the other hand, that the correspondence in the two curves is of a fairly precise character, and has urged that when the "dates of onset of fatal illness" are used for plotting out the diarrhœa curve, the fly curve is found to ante-date, by a few days, the rise and fall of the diarrhœa curve in Manchester (see Annual Report for 1905); further, he finds, when the number of flies caught day by day in different parts of Manchester is studied, that there appears in the several localities "a tendency for an increased number of flies to precede an increase in the commencement of fatal cases by a period of three or four days " (loc. cit. p. 150). The difference in dates was so small in 1904 and 1905 (see Diagram III.) that These three examples are all taken from places of observation surrounding centres belonging to the group not pre-eminently associated with collections of horse manure. §Dr. Niven, of Manchester,who has been a pioneer in these investigations, has, moreover, iu his annual report, 1905, drawn attention to the need of enquiry as to whether there is an excessive incidence of diarrhœal mortality upon infants living in close proximity to stables. It had been intended to investigate this subject in the twelve areas with which this report deals, but the coolness of the summer effectually prevented this being done. Dr. Harris, of Islington, has, indeed, made some enquiry as to the extent to which diarrhœal mortality prevailed during the third quarters of 1903-07 in the neighbourhood of stables in his borough, but his results are, on the whole, negative. As long ago as the year 1900, Dr. F. J. Waldo, in his Milroy Lectures on Summer Diarrhœa, raised question as to whether horse dung was answerable to any extent for the causation of the disease. The trend of his argument was in favour of acceptance of this view, but he notes that there does not, so far as can be ascertained, appear to be excessive incidence of diarrhœa upon the families of stablemen who live in mews. He quotes, moreover, Dr. Orme Dudfield's opinion to a like effect. 9 the possibility is perhaps not wholly precluded that there may be some mistake about its existence' There was, however, a distinct interval in 1906. As Dr. Niven says, "The impression produced by the two sets of figures in 1905 is rather one of simultaneity than of cause and effect, and if we take the figures as indicating that flies do cause rise in the number of cases, we must also assume that their action is very rapid." (Annual Report, 1905.) In 1906 it was clear that the increase of flies commenced "before the increase in fatal cases." Dr. Niven says, "It is probable, therefore, that the relation is one of cause and effect. These observations, however, fall far short of absolute proof." (Annual Report, 1906.) It should be pointed out that there are certain difficulties in the way of accepting the thesis that the correspondence exhibited in the curves affords reason for concluding that flies and diarrhœa stand to one another in relation of cause and effect At the commencement of the hot summer weeks, when the number of flies has begun to show marked increase, the diarrhoea curve is rapidly rising. After some weeks the number of flies reaches the maximum, and then diminishes, and so, in almost precise correspondence, does the amount of diarrhœa. A period is later reached, towards the close of the hot weeks, at which the number of flies is still as markedly excessive as at the earlier period when the amount of diarrhœa was increasing, but at the later period the amount of diarrhœa is declining; it even anticipates decline in the number of flies. If the fly is to be regarded as the carrier of the organism which causes diarrhœa, it might perhaps have been anticipated that at the later period—the number of flies still being excessive and infective material being then presumably more widely distributed than ever before—the amount of diarrhœa, instead of showing early and rapid decline, would still be increasing. It would almost appear that the advocate of the "fly-borne diarrhoea hypothesis" must necessarily fall back in support of his theory upon the hypothetical organism, conveyed by the fly, which he may claim is affected by temperature in such a way as to bring about correspondence between the diarrhœa curve and the fly curve. The very closeness of the correspondence between these curves may indeed from this point of view be thought of as constituting a difficulty rather than a point in favour of the hypothesis that summer diarrhœa is caused by flies. The attempt has, however, been made to explain the fact that the diarrhœal curve has already begun to decline, while the number of flies still remains excessive, by the hypothesis that so many persons have at that time been attacked by diarrhœa that then at length, the "susceptible material" having all been exhausted, a decline in the diarrhœal curve has become inevitable. Thus Dr. Niven writes (Annual Report for 1904), " It is noticeable that the descent in the number of deaths precedes the diminution in the number of flies. It is possible that this is due to exhaustion of material." Against this exhaustion hypothesis two considerations must be set. First, that the comparatively early fall in the amount of diarrhœa is observed not only in years of excessively high mortality, but also, as, for example, in London last year, in years of very low mortality. In the case of the former, an hypothesis of" exhaustion of susceptible material" may hold good, but it fails to explain the phenomena in the latter instance. The second consideration is that the "exhaustion of susceptible material" hypothesis does not adequately account for the almost identically similar behaviour of the two curves—for even small variations in the one, the fly curve, are generally accurately reflected in the other, the diarrhœa curve—and this not only in their ascent but also in their descent. This close correspondence of the variations in these curves better accords with the view that both are dependent on temperature variations than with the hypothesis that diarrhœa stands in direct causal relation to fly prevalence. The difficulty caused by the fact that the diarrhœa curve follows so closely upon the fly curve may perhaps be in part met by an assumption that only the newly fledged fly can transmit diarrhœa— the disease being an infantile disorder, so to speak, in the fly—and by further assuming that immediately upon its becoming a perfect insect the fly is infected, and in its turn infects; for the exigencies of time, having in view the close correspondence of the fly and diarrhœal curves, admit of little delay. Even in the event of no time whatever being lost, it is, however, difficult to understand why, despite the large increase in the amount of infective material which presumably occurs during the hot weeks, the fall in the diarrhœa curve so closely corresponds with arrest of increase of flies. It might be thought that a comparatively small number of flies would serve to maintain a high level of diarrhœa prevalence at this period, if it be legitimate to assume that there is then especially widespread distribution of infective matter. But, on turning from the left-hand side of the curves, i.e., from the ascending side, to the righthand side, i.e. to the descending curves, it will be seen that the time difficulties are now greater than before, for Die descent of the diarrhœal curve actually precedes that of the fly curve (see Diagram III.). On the whole, therefore, while it is not easy to reconcile the behaviour of the curves with an hypothesis that flies transmit diarrhoea, it must be admitted that the phenomena accord quite well with the supposition that both flies and diarrhœa stand in close relation with temperature. On this latter hypothesis the delayed fall of the fly curve, as compared with that of the diarrhœal curve, presents no difficulty. In North America and South Africa it has been pointed out that enteric fever outbreaks have a tendency to occur at times when there are large numbers of flies in an affected locality. It is impossible here to enter into detailed discussion of this subject. A brief reference may, however, be made to a carefully studied outbreak in this country in which question arose as to whether the spread of enteric fever had been caused by fly prevalence. The circumstances of this outbreak, which occurred near London, were investigated by the Medical Officer of Health (Dr. Ransome) and by Dr. Young (County Medical Officer of Middlesex), and are briefly recounted by the latter in his Annual Report for 1906. I have had the opportunity of fully discussing the circumstances with Dr. Young. Into the possible causes of the outbreak, other than flies, it is here unnecessary to enter. The only point of present interest is whether this strictly localised explosive outbreak of some 50 or 60 cases of enteric fever was attributable to flies bred in deposits of house refuse situated some 200 or 300 yards to the south-west of the affected 16292 B 10 area. Curiously enough almost, but not quite, coincidently with the enteric fever epidemic an outbreak of dysentery occurred in one of the Council's asylums, some 500 or 600 yards to the northwest of the place of deposit of the house refuse. The outbreak of dysentery was attributed at the time to the presence of an excessive number of flies in the asylum. Now, consideration seems to make it clear that whatever value be at first sight attached to explanation by a fly hypothesis of the localised outbreak of enteric fever, 300 yards to the north-east of the refuse deposit, and to a similar explanation of the dysentery outbreak, 500 yards to the north-west of the refuse deposit, there must arise some question as to accepting these two hypotheses in the light ofthe fact, that during the same hot weeks, the two outbreaks occurred in areas so differently situated with regard to the source of origin of the flies. The strict localisation of the enteric fever outbreak, and, in less degree, of the dysentery outbreak, might perhaps, on a first study of the circumstances of either outbreak, be defended by reason of the somewhat partial distribution of habitations in the locality, but the ground of such defence is cut away by the occurrence of the two outbreaks. In order to explain the circumstances on the fly hypotheses, it becomes, in fact, necessary to imagine that a cloud of flies was transferred 200 or 300 yards in a north-easterly direction from the refuse heap, and, confining operations to a certain circumscribed area, assisted in spreading of enteric fever; and that a second cloud of flies was transferred some 500 or 600 yards to the north-west to the asylum, and there keeping strictly within the limits of that institution, or rather, within the limits of a particular portion of that institution, disseminated dysentery. For such cloud transmissions, the direction of the winds prevalent during the summer affords no sufficient explanation, nor is it easy to frame a hypothesis to account for such localised distribution of fly swarms ; and further, the absence of recognition of the existence of enteric fever or dysentery in the inhabited areas lying around and between the area of dysentery prevalence and that of enteric fever prevalence (for, despite the suburban character of the locality, there are such inhabited areas) is a fact which militates very strongly against the view that flies were responsible for either of these outbreaks. In summary of this matter, it may be stated that the facts at present ascertained, as to the influence of flies in spreading disease under conditions obtaining in this country, are not such as to enable any positive opinion to be expressed. There can be no question, however, as to the extent of the evil caused by flies in the twelve centres studied during the past summer. The contamination of food material, the irritation and annoyance and even loss of sleep caused to residents in the neighbourhood of these centres, constitute injurious influences of the most serious character. The extent of this annoyance in a particular instance will be appreciated by a glance at the photograph on the opposite page, which shows the number of flies caught in a small general shop during a period of 72 hours during the hottest part of last summer. Fig. 1 depicts seven papers covered with flies, representing a total of upwards of 5,000 flies caught in that period, in one room and doubtless more could have been caught had more papers been exposed, for experience shows that comparatively little relief is afforded by these fly-catching operations. The room in question was a small one, about 800 cubic feet in capacity, and as fast as the flies were caught others streamed in to renew the supply; so that had fresh fly-papers been continuously available, there can be no doubt it would have been possible in 72 hours to collect a solid mass of flies of no inconsiderable dimensions; indeed, the catch for the entire summer, given an unlimited supply of fly papers, may not unreasonably be thought of as constituting in total bulk quite an appreciable percentage of the cubic capacity of the room. Even when successive detachments of invading flies are persistently removed, this does not altogether dispose of the difficulty associated with contamination by fly marks. In rooms which had not been "done up" for some time, the evidence of the extent of fly nuisance during the past summer was strikingly afforded by the dense accumulations of fly marks upon the walls and ceilings. Fig. 2 represents a portion of the ceiling of a room which had been infested with flies for several summers and shows the extent of material which gradually collects, as the result of the deposit of excreta by swarm after swarm of flies. While the mildness of the summer has rendered it one in which the amount of fly nuisance has been, presumably, at a minimum, the extent of this nuisance in the neighbourhood of collections of refuse, even under the exceptional conditions which obtained, is made quite obvious by this enquiry. No doubt, a great deal could be accomplished by further perfecting the system of removal of house refuse and stable manure, but the evidence obtained clearly teaches the lesson that premises closely surrounded by houses should not be used for the purpose of collection of refuse material; further, within a town no manipulations of refuse should be permitted, the material should be transferred direct from the cart to the canal barge or railway truck, and should on no account be deposited in proximity to dwellings, even for a short period. W. H. HAMER, Medical Officer (General Purposes). FIGURE 1. Photograph of seven fly papers exposed for a period of 72 hours in a small general shop in the neighbourhood of Centre No. 2. FIGURE 2. Photograph of the ceiling of a room in the neighbourhood of Centre No. 3, showing deposits of fly-excreta. It will be noticed that the excreta are most thickly deposited along the margin of a newly-plastered patch in the ceiling shown at the top of the photograph. APPENDIX III. London County 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:— Men. Women. Couples. Authorised accommodation 25,599 2,436½ 245 Number of persons on night of 8th February 20,438 1,598 207 Number of vacant beds 5,161 838½ 38 Number of persons turned away—unable to pay, etc 658 21 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 free 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. Tabic 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. 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 made use of on the night of 8th February. In some few cases where the precise figures were not available the average number of residents has been inserted. (Signed) Shirley F. Murphy, 8, St. Martin 's-place, W.C. Medical Officer of Health. 21st February, 1907. 13092—1250—23.4.07 s.s./17316 2 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, Lillieroad to River 11 3 1 *3. City West, Embankment, Westminster, Soho, St. James's Park, Marble Arch 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 +6. Spitalfields, Whitechapel-road, Bethnal-green-road, Cambridge-road, Bishopsgate 246 90 7. City East, Shadwell, Poplar, Limehouse 148 28 3 8. Borough, Southwark, Lambeth, Kennington, Clapham 118 61 9. Bermondsey, Elephant, Old Kent-road, Camberwell, Peckham, Albert-embankment, Westminster-bridge-road, Vauxhall 4 1 — Totals 1,998 402 4 ♦Including 862 men and 30 women on Embankment for free food and 156 men at the Church Army tents, flncluding 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—91 h 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 16 — 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 9 406 — 4 333 3 133 1 — — — Hampstead — — — — — — — — — — — Holborn 30 1,807 1G2 — 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 5,034 754 180 4,496 563 172 1,138 191 8 202 4 8 Stoke Newington 1 37 — — 35 — — 2 — — 1 — — Wandsworth 9 176 5½ 20 159 5 14 17 ½ 6 2 - — Westminster 19 1,759 75 — 1,490 00 — 269 15 — 43 - — Woolwich 24 548 44 — 470 3 3 — 78 11 — 10 1 — Totals 403 25,599 2,4364 245 20,438 1,59 8 207 5,161 838J 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 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 TABLE IV. Number of beds in 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 of census — 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. 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 homo Free. (4) 10 8 Rescue homo 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 homo. 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 we»lf (2) 6 6 Shelter Free (3) 9 59 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. Holborn. (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) (5) 60 36 Clerks, teachers, etc 8/6-12'6 a week. 19 18 Do. 10/6 a week. (6) 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 homo 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 homo Free. (5) 13 in 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 (lay 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, teacher's 10/6 to 12/6 a week. (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 Refuge 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 home, 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 Free 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 home Free. (4) 112 108 Shelter Free. (5) 63 60 Working girls 3/6 a week board and lodging. Stoke Newinoton. (1) 90 82 Training home Free. Wandsworth. (1) 20 8 Laundry hands and servants 7/- aweek. (2) 8 5 Servants 10/6''a week. 13092 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 9 Rescue home 5/- or 7/- a week. (11) 12 10 Rescue home 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. Awiting 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-place, W.C. 21 st February, 1907. Shirley F. Murphy, Medical Officer of Health. APPENDIX IV. 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, 18th June, 1908). During the past fifteen years I have from time to time presented returns based upon information supplied by the medical officers of health of the metropolitan boroughs and the cities of London and Westminster showing the sanitary staff in the several districts of London. This is the ninth return, and it is worthy of note that the return shows that there has been no alteration in the number of inspectors since 1906, whereas previous returns have shown a steady increase in successive years of the number of sanitary inspectors employed. The total number of inspectors now is 319, and reference to the following table will show that this number has been maintained only by the increased employment of women:— Inspectors. Inspectors. Inspectors. Year. Men. Women. Year. Men. Women. Year. Men. Women. 1893 188 — 1898 250 6 1904 285 28 1894 219 — 1901 264 11 1906 281 38 1895 227 1 1903 281 20 1908 279 40 The number of men inspectors reached a maximum of 285 in 1904, it fell to 281 in 1906, and to 279 in 1908. In the same years the number of women inspectors was 28, 38 and 40 respectively. As compared with 1904, four districts, Bethnal Green, Lewisham, Woolwich and the City of London, had in 1906 each replaced one of their men inspectors by a woman inspector, and three Borough Councils, viz., Camberwell, Deptford and Greenwich, had reduced their staff of men inspectors bv one, each. Since 1906 the staff of Deptford has been still further reduced by one, and Bermondsey and St. Pancras also show a reduction in staff. The first woman inspector in London was appointed by the Kensington Vestry in 1895. There are now 40 women inspectors, or two more than in 1906, though now, as then, no woman inspector has been appointed in Bermondsey, Deptford, Greenwich, Hammersmith, Shoreditch, Stepney and Stoke Newington. The following table shows the number of inspectors in the several sanitary districts in the years 1904, 1906 and 1908:— District. No. of Inspectors. District. No. of Inspectors. 1904. 1906. 1908. 1904. 1906. 1908. M. W. M. W. M. W. M. W. M. W. M. W. Battersea 11 2 11 2 11 2 Paddington 10 2 10 2 10 2 Bermondsey 9 — 9 — 8 — Poplar 7 1 8 1 8 1 Bethnal Green 10 — 9 1 9 1 St. Marylebone 7 1 7 2 7 3 Camberwell 13 1 12 1 12 1 St. Pancras 15 1 15 2 14 2 Chelsea 3 1 3 1 3 1 Shoreditch 6 6 6 Deptford 8 — 7 — 6 — South wark 13 3 13 3 13 3 Finsbury 9 1 9 2 9 2 Stepney 18 — 18 — 18 — Fulham 6 1 6 1 7 1 Stoke Newington 3 — 3 — 3 — Greenwich 6 — 5 — 5 — Wandsworth 10 1 10 2 10 2 Hackney 15 2 15 2 15 2 Westminster 10 2 10 2 10 2 Hammersmith 9 — 9 — 9 — Woolwich 9 1 8 2 8 2 Hampstead 6 1 6 1 6 1 City of London 18 1 17 2 17 3 Holborn 3 1 Q 1 3 1 Islington 19 1 20 2 20 2 London 285 28 281 38 279 40 Kensington 11 2 11 2 11 2 Lambeth 12 1 13 2 13 2 M = Men. 313 319 319 Lewisham 9 1 8 2 8 2 W = Women. On the basis of the figures of the 1901 census there is in London one sanitary inspector to every 1,792 inhabited houses and to every 14,221 persons. Of this average population more than half, or 7,680 persons, live in tenements of less than five rooms, and of these persons 2,276 are living more than two in a room. Public Health Department, 8, St. Martin's-place, July, 1908. Shirley F. Murphy, Medical Officer of Health. printed for THE LONDON COUNTY COUNCIL by soothwood, smith and co., ltd. And may be purchased, either directly or through any Bookseller, from P. S. KING AND SON, 2 and 4, Great Smith-street, Victoria-street, Westminster, S.W., Agents for the sale of the Publications of the London County Council. No. 1182.—Price 3d.; post free, 3½d. 17422—2,000 -11.8.08. S.S./3884 2 3 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 males. Inhabits houses. Tenements. Tenements under 5 rooms. Overc row dec tenements. Population Population in tenements under & rooms. Population in overcrowded tenements. Battersea 11 2 23,462 38,987 24,089 3,032 168,907 88,999 18,381 1,805 2,999 1,853 233 12,993 6,846 1,414 118 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 an additional £10 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 instructions to mothers in the feeding and care of infants. Part of her salary is wholly payable by the borough council. (a) 9 disinfecting assistants. (b) 5 drain-testing assistants. (c) 1 mortuary keeper and 1 temporary assistant. 6 Bermondsey 8 15,817 29,073 22,064 4,307 130,760 86,156 25,726 1,977 3,634 2,758 538 16,345 10,769 3,216 , 223 at end of 1907. 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. Each inspector has an assigned district, in which he carries out all the duties arising under the Public Health Act, Factory and Workshop, and Food and Drugs Acts. The inspectors also supervise drainage work reconstruction. (а) 6 disinfecting assistants. (б) 1 mortuary keeper. (c) 1 shelter caretaker (female). 4 and 1 office youth. green 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 Twice in each year. One superintends, and in conjunction with the 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 measles and 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. (b) 4 disinfectors (c) mortuary keeper 5 Camberwell 12 1 V 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 with work under the 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 on occasions under the Food and Drugs Act. One (female) is chiefly concerned with laundries, factories and workshops employing female labour. (a) 1 superintendent and 7 disinfecting assistants. (b) 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) with the disinfection of 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. (b) 2 disinfecting and draintesting assistants. None. » For the purposes of this report the term “overcrowded tenements" is applied to those tenements of less thin 5 rooms which at the date of the 1901 census were occnpied vo.the extent of more than two persons per room. * 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 n 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 6 rooms. Population in overcrowded tenements. Deptford 6 - 15,823 24,615 13,956 1,667 110,398 51,861 9,999 2,637 4,102 2,326 278 18,400 8,643 1,666 269 Once. Four have each an assigned district in which they perform the general duties of a sanitary inspector. One is charged with the duties under the Dairies and Milksliops Order, Factory and Workshop Act, Canal Boats Acts, and with the administration of the regulations as to slaughterhouses, knackers' yards, offensive businesses, throughout the borough. One is concerned with infectious disease. All inspectors arc qualified to act under the Food and Drugs Act. (a) 3 disinfecting assistants. 1 Finsbury 9 2 9,280 24,097 20,515 6,373 101,463 78,346 35,723 844 2,191 1,865 579 9,224 / 7,122 3,248 1,233 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 the portion of the Kegent's Canal within the borough and the 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, outworkers' homes, etc., and then make special inquiries into infantile deaths and cases of measles. In certain cases they also visit homes of newly-born infants. (a) 2 d i s i n fectors. (b) 2 mortuary keepers, one of whom also disinfects rooms, and the other also works steam disinfector. (c) 1 van driver, who also assists with disinfection. 2 and 1 office youth. Fulham 7 1 18,534 32,137 21,681 2,341 137,289 81,364 14,892 2,317 4,017 2,710 293 17,161 10,170 1,861 329 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 births. One is employed in the supervision of the drains of new houses, a proportion of his salary being allotted for this work. He also inspects houses let in lodgings and does other special work. (a) 2 drainage inspectors. (b) 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 2,848 3,940 2,175 240 19,154 8,252 1,589 13 - 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 Workshop Acts. (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 re-construction and alterations 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. (b) 9 assistants for disinfecting. (c) 1 mortuary keeper, 1 temporary shelter caretaker (and wife). (d) 1 drain-testing assistant, 1 smoke nuisance assistant. (e) varying number of dustmen. 4 and 1 messenger. Hammersmith 9 15,198 25,810 15,505 2,185 112,239 55,259 13,192 1,689 2,868 1,723 243 12,471 6,140 1,466 3,027 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 London County Council and also with smoke nuisances. One is concerned with factories and workshops. (а) 2 assistants for disinfection. (б) 1 mortuary keeper. (c) 2 drainage inspectors. (d) 1 lady health visitor. 2 6 7 SANITARY OFFICERS. Metropolitan borough. Number of sanitary inspectoi s. 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 6 roon.s. Overcrowded tenements. Population Population in tenements under 5 rooms. Population in overcrowded tenement*. stead 6 1 11,294 16,998 7,178 864 81,942 24,211 5,215 1,613 2,428 1,025 123 11,706 3,459 745 315 No fixed number of times. Frequency ol inspection is governed by character oi 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 Act. One (female) is engaged in the inspection of premises where females are employed, and makes special investigations. (а) 3 disinfecting assistants. (b) 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 3,719 686 All houses inspected once. Many more frequently, and in some cases 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 Drug Acts. One (female) is engaged on special inspections under the direction oi the medical officer, such as factories and workshops, restaurants where females are employed, outworkers' homes, in connection with the prevention of consumption, the non-notifiable infectious diseases, and infantile mortality. She also carries out duties under the sale of Food and Drugs Acts. (a) 2 disinfecting assistants. (b) 1 mortuary keeper. 2 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 2,589 Under new, bylaws no register is kept. The number oi times varies. 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 2 temporary disinfectors. 7 Kensing ton 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 2052 » Variable, according to requirement of 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 Acts. 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 oi disinfection oi houses and infected articles, and 3 disinfectors, including one man who acts as engineer. (b) mortuary keeper. (c) sanitary labourer for assisting in testing drains. (d) 2 female health visitors for the prevention of infant mortality in connection with the Notification of Births Act. 5 8 9 SANITARY Metropolitan borough. Number of sanitary inspectors. Census, 1901. Houses let in lodgings. Assistants. Clerical staff*• Inhabited houses. Total tenements. Tenements undor 5 rooms. • Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Average per sanitary inspector. , Duties of sanitary inspector. Males. Fenales. labited houses. Tenen. outs. Tenements under 6 rooms. Orerjrowded tenements. Population Population in tenements under 6 rooma. Population in overcrowded tenements. No. of houses let in lodgings on the register. No. of times a year these houses are inspected. Lambeth 13 2 41,511 70,887 44,495 6,548 301,895 153,184 36,904 2,767 4,726 2,966 437 20,126 10,212 2,460 372 Visited regularly once a year. Twelve have each an allotted district, in which they are concernec with all duties arising under the Public Health and Factory anc 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 (female) carry out duties under the Factory and Workshop Act, inspect underground conveniences and perform duties of a general character. (а) 11 disinfecting assistants. (б) 2 mortuary keepers and a deputy. (c) 1 temporary caretaker of shelter(female). (d) 1 lady health visitor who deals with the notification and registration of births. (e) 1 manageress of milk depot. 3 and 2 boy clerks (one temporary). Lewishani t 8 2 22,750 27,701 8,561 535 127,495 28,928 3,416 2,275 2,770 856 53 12,749 2,893 342 15 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, work places, &c., where females are employed, and make special investigations into cases of infectious disease, infantile mortality, etc. (a) 6 disinfecting assistants. (b) 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 under 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 duties under the Canal Boats Act, for which a separate salary is assigned. (N.B.—Drainage works in new buildings are under the direction of the surveyor.) One has supervision of workshops and work-places and is concerned with the enforcement of the Factory and Workshop Acts. Two attend to houses let in lodgings and the enforcement of by-laws under section 94 of the Public Health (London) Act, 1891. One has to watch food supplies, and inspect slaughterhouses, cowsheds, dairies, refreshment houses, etc. Ice-cream inspection is also carried out by him. Two (female) inspect all workplaces where women are employed and make inquiries into infectious diseases not scheduled for notification. (a) inspector under the Food and Drugs Act. (b) mortuary keeper. (c) 4 navvies (employed for opening defective drains, etc.). (d) 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 11,722 3,078 1025 A large number very frequently and many also at night. Seven have each an assigned duty in which they carry out duties under the Public Health, Metropolis Management, Factory and Workshop, Food and Drugs and Canal Boats Acts. ")ne visits houses let in lodgings. Dne (female) inspects all places where female labour is employed and sanitary offices of schools for girls. Also makes enquiries under London County Council General Powers Act asto verminous clothing. (a) 1 chief and 4 disinfecting o assistants. (b) 5 labourers (who assist inspectors). (c) 1 female attendant at the Grlaucus - street shelter. 4 and 1 fice youth. St. Marylebone *7 *3 13,536 31,623 22,947 5,180 133,301 74,153 28,147 1,354 3,162 2,295 518 13,330 7,415 2,815 758 Bye-laws sent to L.G.B. for approval. I'hree have each an allotted district in which they are concerned with all duties arising under the Public Health and Food and Drugs Acts, etc. Two other inspectors supervise all drainage work, both as regards new premises and reconstruction, and are to some extent engaged in work of a more general character. Jne is concerned with duties arising under the Factory and Workshop Act and also deals with smoke nuisances. 3ne (temporary) acts as dust inspector. Two (female) are concerned with duties arising under the Factory and Workshop Act, the Cleansing of Persons Act, and the Notification of Births Act. They also deal with cases of phthisis and inspect schools. Due (female, temporary) has duties in connection with infant feeding and the prevention of infantile mortality. [Note.—The revision of the duties of the sanitary staff is at present under the consideration of the borough council.] (a) 3 disinfecting assistants. (b) mortuary keeper. (c) caretaker of shelter(female). (d) 1 bath attendant. (e) 1 female attendant (part time). chief and 2 assistant clerks. • Including one temporary inspector. 17422 B 10 11 SANITARY OFFICERS. Metropolitan borough. Number of sanitary in.spector. Census, 1901. Houses let in lodgings. Duties of sanitary inspector, Assistants. Clerical stall. Inhabited houses. Total tenements. Tenements under 5 rooms. * Overcrowded tenements- Population. Population n 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. St. Pan- eras 14 2 23,715 57,045 45,023 10,158 235,317 155,790 56,423 1,482 3,565 2,814 635 14,707 9,737 3,526 2296 at end of 1906. Twice a year. Twelve inspectors have each an assigned district in which they deal with infectious diseases, complaints, drainage and nuisances generally. One of the inspectors also carries out duties under the Food and Drugs Act and the by-laws regulating slaughterhouses and dairies in his own district. Two inspectors carry out solely the duties under the Food and Drugs Act and the by-laws regulating slaughterhouses and dairies. One of these inspectors also carries out duties under the Canal Boats 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. (a) 3 disinfecting assistants and 1 general assistant. (ft) caretaker of mortuary and coroner's court and 1 contact shelter attendant and attend an t at cleansing station and children's baths. 1 chief clerk, 7 assistant clerks. ditch 6 - 12,743 27,031 22,940 6,269 118,637 89,580 35,529 2,124 4,505 3,823 1,045 19,773 14,930 5,921 i 272 k If found on inspection to be kept in a satisfactory sanitary condition once a year only. If not, the houses are inspected as often as may be necessary to secure improvement. Some houses have required frequent visits at short intervals. 419 visits in 1907. One chief inspector who is not restricted to a district is concerned with duties under the Public Health and Factory and Workshop Acts, and generally superintends and assists other inspectors. Also attends to the registration of houses let in lodgings. Each of the five other inspectors has an allotted district in which he performs the various duties arising under the Public Health and Factory and Workshop Acts, including the abatement of smoke nuisances, the supervision of drainage work, both in new and existing houses, and the testing of drains. Each inspector is required to take four samples per fortnight under the Food and Drugs Act, and from time to time to be on duty in the street markets on Saturday evenings and Sundays with a view to taking samples and watching the quality 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. One of the district inspectors is on duty for the purposes of food inspection and for taking samples under the Food and Drugs Act on each evening of the week between 6 and 10 p.m. Two inspectors are on duty on Saturday evenings and Sunday mornings. (a) 1 general assistant, (b) 1 disinfector and 2 assistants. (c) 1 mortuary keeper. (d) caretaker(female)of shelter. 3 wark 13 3 20,878 47,808 39,612 8,133 206,180 147,923 46,073 1,305 2,988 2,476 508 12,886 9,245 2,880 1241 At least four times a year. Many monthly, some weekly. One (male) chief inspector supervises generally the work of the other male inspectors. One acts as a Food and Drugs inspector. Ten 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 inspector examines food at the wharves and at other places in the borough where it is stored. One (female) chief inspector visits workshops and does special work. Two female inspectors visit houses let in lodgings. (a) 11 disinfecting assistants, (b) 2 mortuary keepers, and a superintendent and his wife at receptionhouse. 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 2784 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 the food stuffs landed there. (a) 14 disinfecting and general assistants. 7 Stoke Newington 3 — 7,717 11,824 5,813 497 51,247 18,611 2,835 2,572 3,941 1,938 166 17,082 6,204 945 243 All once, some twice annually. The three inspectors have each an assigned district in which they cany out general sanitary duties. (a) 1 disinfecting assistant. 1 12 13 OFFICERS. SANITARY Metropolitan borough. Number of sanitary inspectors. Census, 1901. Houses let in lodgings. Duties of sanitary inspector. Assistants. Clerical staff. No. of houses let in lodgings on the register. No. of times a year these houses are inspected. lnhabitet houses. Total tenements. Tenements under 5 rooms. * Overcrowded tenements Population. Population in tenements under 5 rooms. Population in overcrowded tenements Average per sanitary inspector. Males Females Inhabited houses. Tenements. Tenements under 5 rooms. Overcrowded tenements. Population Population in tenements under 5 rooms. Population in overcrowded tenements. 222 Twice and more frequently if there be 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 tako samples under the Food .and Drugs Act if required. Three have additional duties under the Canal Boats Act for which a separate allowance 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 a birth. Note.—The drainage work in both old and new houses is performed by five inspectors under the control of the surveyor. (a) 10 disinfecting assistants. (b) 3 mortuary keepers. 4 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 6,361 861 Westminster, City of 10 2 18,366 41,214 26,668 4,346 183,011 83,624 23,856 1,530 3,437 2,222 362 15,251 6,969 1,988 1572 2237 inspections were made in 1907. Seven 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. One inspects hotels and restaurants, ice-cream shops, and places where food is prepared for sale. Two (female) are engaged in the inspection of workshops, workplaces, etc., where female labour is employed, and also they inspect houses let in lodgings. (a) 10 disinfecting and other assistants. (b) 2 mortuary keepers and 1 assistants. (c) 2 women in charge of shelter and 1 cleaner. 5 Woolwich 8 2 18,086 24,585 14,017 1,243 117,178 50,985 7,727 1,809 2,458 1,402 124 11,718 5,098 773 330 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 they inspect dairies and milk shops. One is inspector for the market, slaughterhouses and principal butcliers'sliops. One inspects workshops where women are not employed, and is also 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.); she also visits houses where births have occurred, and acts as health visitor. (a) 3 disinfectors. (b) 3 drainage workmen. (c) 1 mortuary keeper. (d) 1 manager and 4 assistants at milk depot. 4 City of London 17† 3 3,865 5,339 3,307 504 26,923 10,625 2,921 193 267 165 25 1,346 531 146 305 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. Three 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 with infantile mortality. (a) 3 assistant inspectors of meat (on probation). (b) 1 disinfecting assistant. (c) 1 mortuary keeper. (d) 1 matron at shelter. 4 of London; 279 40 571,768 1,019,546 672,030 124,773 4,536,541 2,449,789 726,096 1,792 3,196 2,107 391 14,221 7,680 2,276 • There are also five inspectors concerned with drains and sanitary fitting in old and new houses under the control of the Surveyors. † Includes eight meat inspectors. - 4 . -