LCC18 London County Council PUBLIC HEALTH-COUNTY OF LONDON. REPORT of the PUBLIC HEALTH COMMITTEE of the LONDON COUNTY COUNCIL, Submitting the REPORT of the MEDICAL OFFICER OF HEALTH OF THE COUNTY FOR THE YEAR 1909. (Printed by order of the Council.) SOUTHWOOD, SMITH & CO., PRINTERS, 93 and 94, LONG ACRE, W.O. 2057 a London County Council. Report of the Public Health Committee of the London County Council submitting the Report of the Medical Officer of Health for the year 1909. 24t'h November, 1910. The Council has from time to time authorised the circulation of the annual report of the Medical Officer of Health. A report for the year 1909 has now been submitted to us, and the Council, on our recommendation, has decided that the report shall be circulated and placed on sale. W. Freeman Barrett, Chairman of the Public Health Committee 2057 a 2 EIGHTEENTH ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH OF THE ADMINISTRATIVE COUNTY OF LONDON TABLE OF CONTENTS. PART I. Vital Statistics. page Population 5 Natural increase 5 Marriages 6 Of minors, per cent.of total marriages 7 Births 7 Rates per 1,000 persons living and legitimate births per 100 married females (aged 15-45) in sanitary areas 9 Fertility of married women in relation to social condition 9 Notification of Births 10 Deaths 11 London mortality in the year 1909 compared with the mortality in the decennium 1891-1900 12 Deaths from certain diseases and groups of diseases (increased or diminished incidence 1909) 14 Crude and corrected rates in sanitary areas 15 Deaths at the several age-periods in sanitary areas 17 Death-rates at certain age-periods in relation to social conditon, 1905-9 17 Rates from all causes and from specified causes in sanitary areas 18 Infantile mortality 18 In sanitary areas 19 Deaths from stated causes 20 Life-table for the first 12 months of life in London 1909 23 Deaths in sanitary areas at months of age under one year 25 In relation to overcrowding 25 Principal Epidemic Diseases 27 Smallpox and Vaccination 29 London vaccination returns 31 Number of children for whom certificates of conscientious objection were obtained, together with the number of children not finally accounted for per cent, of births 31 Measles 32 Mortality among children at ages 0-5 in sanitary areas 33 In relation to overcrowding 34 Deaths at the several age-periods in sanitary areas 35 In schools 35 Scarlet Fever 36 Age and sex distribution 38 Scarlet fever and elementary schools 38 Source of infection 39 Diphtheria 40 Comparative case-rates in sanitary areas 42 Age and sex distribution 43 Diphtheria and elementary schools 43 Bacteriological diagnosis in 1909 44 Whooping-cough 45 In relation to overcrowding 47 In schools 47 Typhus 47 Enteric Fever 48 Age and sex distribution 49 Bateriological diagnosis in 1909 50 Diarrhoea 51 Erysipelas 52 Puerperal Fever 54 Influenza, Bronchitis and Pneumonia 55 Phthisis 55 Crude and corrected death-rates in sanitary areas 57 Deaths at the several age-periods in sanitary areas 57 In relation to overcrowding 58 Age incidence on males and females in relation to social condition 58 Notification 60 Bacteriological diagnosis in 1909 63 Cancer 64 Crude and corrected death-rates in sanitary areas 64 Deaths from sarcoma, carcinoma, and cancer (otherwise undefined) at the several age-periods in sanitary areas 65 In relation to overcrowding 67 Cerebro-spinal Fever 67 Anthrax 68 Glanders 68 Meteorology 68 PART II. Public Health Administration. Dairies, Cowsheds and Milk shops 69 Tuberculosis of the udder in cows 70 Tuberculous milk supply in London 71 TABLE OF CONTENTS—continued. page Offensive Businesses 73 Nuisances 74 Smoke nuisance 74 Nuisance from stable manure 75 Removal of refuse 76 Nuisance from flies 76 Housing of the Working Classes Act, 1890 76 Proceedings under Part III. of the Act 76 Death-rates among persons resident in the County Council's dwellings 77 Proceedings in respect of houses represented under Part II. of the Act as unfit for human habitation 77 Sousing and Town Planning Act, 1909 78 Common Lodging-houses 78 Death-rates of inmates of common lodging-houses 79 Homeless persons 80 Seamen's lodging-houses 80 Houses let in Lodgings 81 Furnished rooms 82 Water supply to tenement houses 83 Storage and cooking of food in tenement houses 84 Houses infested with Vermin 85 Revenue Act, 1903 85 Underground Rooms 86 Overcrowding 87 Factory and Workshop Act, 1901 87 Table showing proceedings of sanitary authorities under the Factory and Workshop Act 88 Places where Food is Prepared for Sale 90 Sale of Ice Cream Inspection of Food 92 Disinfection 93 Shelters 93 Mortuaries 94 Cleansing of Persons Act, 1897 94 London Equalisation of Rates Act, 1894 95 Water Supply 96 Health Visitors 96 Sanitary Inspectors 96 Midwives Act, 1902 97 Infectious diseases in schools—closure of, and exclusion from school 106 Medical Officers of Health of London Sanitary Areas 108 Appendices— I.—Report on an outbreak of Scarlet Fever in London and Surrey in June, 1909. II.—Report on Pulmorary Tuberculosis. III.—Report on Cerebro-spinal Fever. IV.—Report on Nuisance from Flies and Vermin. V.—Report on Homeless Persons in London. VI.—Report on the Sanitary Staffs of the Metropolitan Sanitary Authorities. LIST OF DIAGRAMS. facing page Diagram I.—Marriages, 1851-1909 7 „ II.—Births, 1851-1909 7 ,, III.—Deaths (all causes) 1841-1909 11 „ IV.—Mortality- and Birth-rates in relation to social condition 17 „ V.—Infantile Mortality, 1858-l909 18 VI.—Smallpox (mortality) 1841-1909 29 „ VII.—Measles (mortality) 1841-1909 32 n VIII.—Measles and Whooping-cough (monthly deaths) 1891-1909 33 IX.—Scarlet Fever (mortality) 1859-1909 36 X.—Scarlet Fever (admissions to hospitals of Metropolitan Asylums Board, per cent, of total notified cases in london) 1890-1909 36 ,, XI.—Scarlet Fever (monthly no titled cases and case-mortality) 1891-1909 37 „ XII.—Diphtheria and Croup {mortality) 1859-1909 40 ,, XIII.—Diphtheria (admissions to hospitals of Metropolitan Asylums Board, per cent, of total notified cases in london) 1890-1909 40 ,, XIV.—Diphtheria (monthly notified eases and case-mortality) 1891-1909 41 ,, XV.—Whooping-cough (mortality) 1841-1909 45 „ XVI.—Typhus (mortality) 1869-1909 48 „ XVII.—Enteric Fever (mortality) 1869-1909 48 „ XVIII.—Enteric Fever (weekly notified casts, 1909, and mean weekly notified cases, 1890-1909) 48 ,, XIX.—Enteric Fever (monthly notified cases and case-mortality) 1891-1909 49 „ XX.—DiarrhoBa, Dysentery and Cholera (mortality) 1841-1909 51 XXI.—Phthisis (mortality—males and females) 1851-1909 56 , XXII.—Phthisis (mortality at ages in relation to social condition, 1906-8, and in successive decemia since 1861) 58 REPORT OF THE MEDICAL OFFICER OF HEALTH, 1909- PART I. The mean temperature of the air during 1909 was somewhat below the average of the preceding 65 years. The monthly average was exceeded in October, April, December and January, while in June the temperature was markedly below the average, the deficiency being also considerable in September, March, February and July. The rainfall during the year, as a whole, was above the average, the excess being most marked in the months of June, March and October: the deficiency was greatest in November and January, the other months below the average being February, May, and August. The marriage rate (15 8) was below the marriage rate of the preceding year (15.9), and was the lowest rate recorded in London since complete marriage statistics have been available. The birth-rate (24.2) was the lowest on record in London since the institution of civil registration, as was also the infantile mortality (108). The death-rate (14.0) was, however, slightly higher than in the preceding year. The deaths from pneumonia, influenza, cancer and measles were above the annual average of the preceding 10 years, and the deaths from small-pox, whooping-cough, scarlet fever, diphtheria, enteric fever, diarrhoea, and phthisis were below the average. If the death-rate in 1909 be compared with that of the decennium 1891-1900, the result expressed in terms of lives and "life-capital," shows a saving of 24,902 lives, representing a gain to the community of 1,080,784 years of " life-capital." Population. The population of the Administrative County of London, estimated to the middle of the year 1909, was 4,833,938. The population of the City of London and of each metropolitan borough, as constituted by the London Government Act of 1899, estimated to the middle of 1909, is shown in the following table— Sanitary areas.—Population (middle of 1909). Sanitary area. Estimated population (middle of 1909). Sanitary area. Estimated population (middlo of 1909). Paddington 151,955 Shoreditch 114,802 Kensington 183,683 Bethnal Green 131,316 Hammersmith 125,704 Stepney 312,525 Fulham 176,406 Poplar 171,965 Chelsea 75,249 South wark 211,125 Westminster, City of 168,883 Bermondsey 127,569 St. Marylebone 126,027 Lambeth 324,188 Hampstead 94,185 Battersea 186,036 St. Pancras 237,422 Wandsworth 297,646 Islington 351,202 Camberwell 283,022 Stoke Newington 54,423 Deptford 118,583 Hackney 237,601 Greenwich 111,014 Holborn 53,802 Lewisham 160,749 Finsbury 95,289 Woolwich 133,374 London, City of 18,193 In the consideration of these estimates and of the rates which in this report are based upon them, it is necessary to bear in mind that 1909 is the eighth year which has elapsed since the enumeration of the population in 1901. Natural Increase (Excess of births over deaths). The natural increase of the population is the amount by which the number of births exceeds the number of deaths annually. It is a convenient measure for comparing the vitality of one community or section of a community with another. Immigration and emigration to some extent affect the comparison of the natural increase of various towns, but their effect upon the natural increase rate is partially compensated for by the fact that if the emigration exceeds the immigration, both the deaths and the births are reduced, while if immigration exceeds emigration, both are increased, thus these factors need not influence greatly the difference between the birth-rate and death-rate (i.e., the rate of natural increase) except so far as the age and sex of the immigrants differs widely from that of the emigrants. A comparison of the rates of natural increase in different localities is also affected by the differences in the age- and sex-constitution of the populations compared. The combined effect of all these disturbing factors, however, will probably not be so great as to vitiate general comparison of the crude natural increase rates. The following table shows the mean annual rate of natural increase of the population per 1,000 living in certain periods from 1876-80 to 1909:— 2067 B 6 Natural Increase Rates.—London and England and Wales. Period. Mean of annual birth-rates per 1,000 living. Mean of annual death-rates per 1,000 living. Mean of annual rate of natural increase per 1,000 living. London. England and Wales. London. England and Wales. London England and Wales. 1876-1880 35.55 35.35 22.17 20.79 13.38 14.56 1881-1885 34.29 33.51 20.95 19.40 13.34 14.11 1886-1890 32.10 31.44 19.69 18.89 12.41 12.55 1891-1895 30.761 30.48 19.822 18.71 10.94 11.77 1896-1900 29.661 29.27 18.512 17.69 11.15 11.58 1901-1905 28.061 28.10 16.132 16.00 11.93 1210 1906 26.521 27.07 15.112 15.38 11.41 11.69 1907 25*59' 26.27 14.602 15.00 10.99 11.27 1908 25.211 26.53 13.822 14.68 11.39 11.85 1909 24.181 25.58 14.03 14.49 10.15 11.09 The rate of natural increase prior to 1876 is probably understated owing to the fact that the registration of births was not made compulsory until the beginning of 1875. The following table enables comparison to be made of the rates of natural increase of the London population with those of the principal towns of England. It will be observed that in 1909 the rates are below those of the quinquennium 1904.8 in all towns except Hull:— Rate of natural increase per 1,000 living. Town. 1904.8. 1909. Town. 1904.8. 1909. London 11.3 10.2 Bradford 5.0 4.3 Liverpool 12.4 12.1 West Ham 15.1 13.2 Manchester 10.6 9.9 Newcastle.on.Tyne 13.5 12.5 Birmingham 12.4 11.2 Hull 13.2 14.5 Leeds 10.3 8.7 Nottingham 10.2 9.4 Sheffield 14.0 13.1 Salford 11.9 9.9 Bristol 11.1 9.9 Leicester 11.3 9.0 The factors affecting the rates of natural increase in different localities to which reference is made above, probably tend more to vitiate accurate comparison when the populations concerned are of different nationalities, and this should be borne in mind in connection with the following table3:— Rate of natural increase per 1,000 living. Town. 1904.8. 1909. Town. 1904.8. 1909. London 11.3 10.2 Stockholm 9.7 9.5 Greater London 12.5 11.1 St. Petersburg 3.2 3.2 Paris 1.3 •3 Berlin 8.3 6.5 Brussels 4.0 2.9 Vienna 7.9 5.3 Amsterdam 11.9 10.8 Rome 5.1 3.4 Copenhagen 12.3 12.8 New York 8.9 10.7 The natural increase during the period 1904.8 in New York is probably understated, owing to incomplete registration of births prior to 1908. It will be noticed that the excess of births over deaths in 1909 is below the average of the preceding five years in all these towns except Copenhagen, New York and St. Petersburg. Marriages. The number of marriages in the Administrative County of London in 1909 was 38,170 (52 weeks), giving an annual rate of 15.8 persons married per 1,000 living. This, as previously stated, is the lowest rate recorded in London since complete marriage statistics have been available. 1 For the purposes of these rates the births in the principal lying-in institutions have been distributed to (he district to which they belong. 2 These death-rates are fully corrected for institutions, by the exclusion of deaths of persons not ing to, but occurring in, institutions situated within London, and by the inclusion of deaths of persons belonging to London, but occurring in London institutions situated outside the Administrative County. s All death-rates in this report relating to foreign towns are calculated upon figures published by the Registrar - General. Diagram I marriages.- Diagram II BIRTHS. 7 The marriage-rate in successive periods has been as follows— Marriage-rates. Period. Marriage-rate per 1,000 persons living. Period. Marriage-rate per 1,000 persons living. 1851-60 20.6 1903 17.5 1861-70 20.3 1904 17.0 1871-80 19.1 1905 16.9 1881-90 17.6 1906 17.1 1891-1900 17.8 1907 17.0 1901 17.6 1908 15.9 1902 17.8 1909 15.8 The accompanying diagram (I.) shows the marriage-rate in each year since 1850, in relation to the mean marriage-rate of the period 1851-1909. In the year 1909 among the males 31 per cent, married were under 21 years of age, and among the females 11.1 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 20.4 1871-80 4.7 169 8.0 22.0 1881-90 5.5 189 6.8 20.8 1891-1900 4.7 16.5 5.4 17.5 1901 4.4 15.0 5.0 16.0 1902 4.0 14.0 4.7 15.4 1903 3.8 13.7 4'6 15.2 1904 3.7 139 4.6 15.3 1905 36 130 4.4 14.7 1906 3.5 12.9 4.3 14.6 1907 3.2 11.8 41 14.2 1908 2.9 11.3 4.0 140 The decline in the marriage-rate of London is discussed in the Annual Summary of the RegistrarGeneral, who shows that if the marriage-rate of 1909 be compared with the marriage-rate of 1870-72, it has decreased by about 19 per cent., if based on the total population, and by 27 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 1909 (52 weeks) was 116,559, giving a birth-rate of 24.2 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 1909 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 1903 28.31 1861-70 35.4 1904 27.71 1871-80 35.4 1905 27.01 1881-90 33.2 1906 26.51 1891-1900 30.21 1907 25.61 1901 28.81 1908 25.21 1902 28.41 1909 24.21 2057 1 See footnote (1) page 6. b 2 8 The corresponding figures for England and Wales are as follows:— England and Wales—Birth-rates. Period. Birth-rate per 1,000 persons living. Period. Birth-rate per 1,000 persons living 1851-60 34.1 1903 28.4 1861-70 35.2 1904 27.9 1871-80 35.4 1905 27.2 1881-90 32.4 1906 27.1 1891-1900 29.9 1907 26.3 1901 28.5 1908 26.5 1902 28.5 1909 25.6 The following table enables comparison to be made of the birth-rate in London with that of the chief towns of England. It should be borne in mind, however, in contrasting the decrease of the rate in 1909 in different towns, that these rates, being calculated per 1,000 persons living, depend to a large extent upon the accuracy of the estimate of population, which may vary considerably. Birth-rates per 1,000 persons living. Town. 1904-8. 1909. Town. 1904-8. 1909. London 26.51 24.21 Bradford 20.8 18 8 Liverpool 32.6 31.1 West Ham 30 2 27.2 Manchester 29.6 27.8 Newcastle.on.Tyne 30.5 27.3 Birmingham 29.4 26.6 Hull 30.0 29.4 Leeds 26.2 22.8 Nottingham 26.8 25.7 Sheffield 30.7 28.2 Salford 30.3 27.9 Bristol 25.4 22.6 Leicester 24.9 21.9 It will be seen from the following table that the decrease in birth-rate apparent in London is shared by all the chief foreign capitals, and that the London birth-rate compares not unfavourably with that of all the largest continental and capital towns. Birth-rates per 1,000 persons living. Town. 1904-8. 1809. Town. 1904-8. 1909. London 26.51 24.21 St. Petersburg 29.5 27.8 Paris 19.0 17.7 Berlin 24.4 21.6 Brussels 18.3 16.8 Vienna 26.0 22.1 Amsterdam 25.7 23.9 Rome 24.0 22.7 Copenhagen 28.1 27.3 New York 27.7 26.9 Stockholm 24.2 23.8 The accompanying diagram (II.) shows the London birth-rate in each year since 1850, in relation to the mean birth-rate of the period 1851-1909. In connection with this diagram it should be noted that the registration of births was not made compulsory until the beginning of 1875; before that year many births were probably unregistered. From the year 1885 onwards the births have been corrected as far as possible by the exclusion of those which occurred in the chief lying-in institutions in cases where the mother resided outside the County of London. See footnote (1) page 6. 9 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 1904-8 and in the year 1909:— Birth-rates in sanitary areas. Sanitary area. Births,1 1909 (52 weeks). Birth-rate1 per 1,000 persons living. Legitimate births1 per 100 married females aged 15-45. 1904-8. 1909. 1904-8. 1909. Paddington 3,120 22.6 20.6 18.6 17.0 Kensington 3,362 19.5 18.4 179 17.0 Hammersmith 2,995 26.4 23.9 20.1 18.3 Fulham 4,307 29.5 24.5 19.5 162 Chelsea 1,391 21.2 18.5 18.4 161 Westminster, City of 2,730 17.3 16.2 15.5 14.4 St. Marylebone 2,595 21.0 20.6 17.7 17.3 Hampstead 1,328 16.0 14.1 14.9 13.1 St. Pancras 5,609 25.8 23.7 193 17.9 Islington 8,320 25.6 23.8 19.5 18.0 Stoke Newington 1,025 20.8 18.9 17.3 15.8 Hackney 5,416 24.8 22.9 200 18.5 Holborn 976 21.2 18.2 169 14.7 Finsbury 2,810 31.1 29.6 237 22.5 London, City of 247 14.9 13.6 16.6 15.5 Shoreditch 3,632 33 .0 31.7 25.4 24.5 Bethnal Green 4,132 33.7 31.6 26.5 24.7 Stepney 9,506 34.5 30.5 26.8 23.7 Poplar 5,192 32.0 30.3 25.2 23.8 Southwark 5,969 30.4 28.3 22.2 20.8 Bermondsey 4,104 32.5 32.3 25.7 25.5 Lambeth 7,578 25.8 23.4 19.6 17.8 Battersea 4,447 26.8 240 19.3 17.3 Wandsworth 7,005 26.0 23.6 20.6 18.7 Camberwell 6,689 25.5 23.7 20.4 19.0 Deptford 3,117 28.6 26.4 21.5 19.9 Greenwich 2,481 24.7 22.4 20.4 18.5 Lewisham 3,529 24.2 22.0 19.3 17.5 Woolwich 2,947 26.9 22.2 19.8 16.2 London 116,559 26.4 24.2 20.8 19.0 It will be seen from the above table that the birth-rates of the several sanitary districts vary greatly, ranging from 13.1 in Hampstead to 25.5 in Bermondsey, when the rates for the year 1909, based on the number of married females, are compared. It will be seen on reference to Diagram IV. that the birth-rate per 1,000 persons living varies directly with the social condition of the population. The diagram is based upon the number of births per 1,000 living, without any correction for such disturbing factors as differences in the age and sex constitution of the population ; in the proportion of women married ; and in the fertility of marriage. The Registrar-General has compared the birth-rate of London, in 1870-2 with that of subsequent periods, showing these rates calculated on the total population, and also on the female population aged 15-45 years, and further has compared the rates, for 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 1909 has decreased by 31.2 per cent. when calculated on the total population, and 34.1 per cent. when calculated on the female population aged 15-45 years; the legitimate birth-rate has declined 29.5 per cent. when calculated on the married female population aged 15-45 years; and the illegitimate birth-rate has declined 46.6 per cent. when calculated on the unmarried and widowed female population of that age period. Fertility and social condition. It is a generally accepted fact that the fertility of married women decreases with age, and a comparison of the fertility rates of different sections of a community is affected to some extent by the differences in the age-constitution of the married women populations. Among married women in 1 See footnote (1) page 6. 10 poorer districts of London the percentage at younger ages is higher than in the better-class districts, as will be seen from the following table:— Group. Percentage of children aged 5-14 scheduled for education purposes. Proportion of married women at census 1901 at ages. Under 18. 18- 19- 20- 21- 25- 35- 15-45. I. Under 79% 4 14 37 87 921 4,732 4,205 10,000 II. 79% to 85% 4 18 44 107 1,037 4,710 4,080 10,000 III. 85% to 91% 4 17 47 116 1,123 4,767 3,926 10,000 IV. 91% to 97% 3 16 57 134 1,190 4,735 3,865 10,000 V. 97% and over 3 23 62 174 1,424 4,687 3,627 10,000 4 17 48 120 1,125 4,735 3,951 10,000 With a view to correcting these differences as far as possible, a factor has been calculated, based upon observations made in Sweden during the period 1891-1900 of the number of accouchements at certain periods of life occurring among all married women aged 15—45. No statistics relating to the United Kingdom of this kind are available for recent years, but the Swedish figures do not differ very widely from those relating to Edinburgh and Glasgow for the year 1855. The results of the application of the corrective factor to the figures of the quinquennium 1905-9 are as follows:— Fertility-rate of married women in London, 1905-9. (Annual legitimate births' per 100 married women aged 15-45.) Group. Crude fertility rate. Corrective factor. Corrected fertility rate. Corrected fertility rate. (London, 1000.) I. 17.48 1.02522 17.92 873 II. 18.55 1.01135 18.77 914 III. 19.87 .99931 19.85 967 IV. 23.03 .99151 22.83 1,112 V. 26.84 .96723 25.96 1,264 20.54 1.00000 20.54 1,000 With regard to the standard adopted here and elsewhere in this report in connection with the grouping of the sanitary districts in order of "social condition," it may be stated that in tables dealing with figures going back to 1901, or tables which have appeared in previous reports, the grouping of the London boroughs in five groups of different social condition is based upon the percentage of persons living in overcrowded tenements of less than five rooms in each borough, as shown by the 1901 census. In tables prepared this year for the first time, or tables dealing with figures for recent years only, however, the grouping is based upon the percentage of children aged 5—14 in each borough scheduled by the London County Council for education in its schools. The scheduling of children for this purpose is conducted annually by the Council and the question whether or not a child is to be scheduled depends upon various circumstances which, it is thought, taken together form a general measure of " social condition." The children scheduled are:— Those residing in houses rated at £28 or less; in houses at a higher rating for which the landlord is rated; in houses let in lodgings to monthly or weekly tenants; in servants' dwellings, such as gardeners' cottages, stables with living rooms, etc.; in houses containing a child on the roll of a public elementary school; in other houses ascertained to contain or likely to contain children of a similar class or any children of a higher class whose education it is supposed has been neglected; and, lastly, in canal boats registered in the Administrative County of London. It should be noted, however, that we can only arrive at the percentage of children thus scheduled by relying upon an estimated total children between the ages of 5 and 14 in each borough. These estimates are based upon the population in 1907 as calculated for the purposes of rate.equalisation (see page 95). If there has been a movement of the population peculiar to persons of one social status, the comparisons made in the tables referred to will be to some extent affected. In this connection, reference may be made to Diagram IV., from which it will be seen that the " all causes " and phthisis death-rates, which it is common knowledge vary closely with social condition, show a very regular gradation from the first to the fifth group ; it is, therefore, reasonable to assume that the somewhat less regular gradation exhibited in other rates cannot result merely from error in the population estimates upon which the rates are based. Notification of births. In the last annual report it was stated that the Notification of Births Act had been adopted by all but eight of the London sanitary authorities. On the 23rd March, 1909, the Council resolved to ask the Local Government Board to declare by Order that the Act shall be in force in the areas of See footnote (1) page 6. Diagram III DEATHS (all Causes). 11 those metropolitan borough councils which had not yet adopted the Act, and in October the Board made an Order declaring the Act in force from and after the 30th November, 1909, in the area of each of the councils of the metropolitan boroughs of Bethnal Green, Camberwell, Chelsea, Hammersmith, Lewisham. and Wandsworth. Under this Act the London County Council receives particulars of the births which have been notified to the medical officers of health of the several sanitary areas in London, and from the information thus received the following table has been prepared; the figures for those districts in which the Act had been in operation for the whole of the year have alone been included: Sanitary area. Total births notified (corrected for institutions). Stillbirths (corrected). Births, less stillbirths (corrected). Births registered (corrected). Excess of registered over notified births (corrected). Paddington 2,535 61 2,474 3,120 646 Kensington 2,330 37 2,293 3,362 1,069 Fulham 3,327 69 3,258 4,307 1,049 St. Marylebone 2,084 34 2,050 2,595 545 Hampstead 1,238 27 1,211 1,328 117 St. Pancras 4,291 128 4,163 5,609 1,446 Islington 7,301 257 7,044 8,320 1,276 Stoke Newington 634 10 624 1,025 401 Holborn 873 22 851 976 125 Finsbury 2,909 59 2,850 2,810 — London, City of 229 5 224 247 23 Poplar 4,379 96 4,283 5,192 909 Southwark 6,168 179 5,989 5,969 — Bermondsey 4,077 78 3,999 4,104 105 Lambeth 5,140 57 5,083 7,578 2,495 Battersea 2,938 74 2,864 4,447 1,583 Woolwich 2,627 61 2,566 2,947 381 Comparison of the number of births notified, after deduction of still births, in districts in which the Notification of Births Act has been in operation during the whole year, with the number of births registered after correction for births occurring in institutions indicates that in some districts the requirement of the Notification Act has not yet been fully complied with, notwithstanding the efforts of sanitary authorities to make that requirement known. In Southwark and Finsbury the number of births notified slightly exceeds the number of births registered, due to the fact that the average interval between birth and registration is much longer than that between birth and notification. The numbers relating to births registered and notified shown in the table have been corrected by distribution, to the districts to which they belong, of births occurring in lying-in hospitals. Deaths. The number of deaths in the Administrative County of London in 1909 (52 weeks) was 67,632, giving an annual death rate of 14 0 per 1,000 of the estimated population. ' The death-rate in successive periods has been as follows:— All Causes—Death-rates. Period. Death-rate (All Causes) per 1,000 persons living. Period. Death-rate (All Causes) per 1,000 persons living. 1841-50 24.8 1903 15.21 1851-60 23.7 1904 16.11 1861-70 24.4 1905 15.11 1871-80 22.5 1906 15.11 1881-90 20.3 1907 14.61 1891-1900 19.21 1908 13.81 1901 17.11 1909 14.01 1902 17.21 The death-rate in each year since 1840 in relation to the mean death-rate of the period 1841-1909 is shown in diagram III. The following table has been prepared for the purpose of comparing the death-rate of London with those of other English towns having populations which exceeded 200,000 persons at the census 1 See footnote (2) page 6. 12 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 1909. All Causes—Death-rates per 1,000 persons living. Town. Estimated Population (middle of 1909). Crude death-rate per 1,000 persons living. Death-rate per 1,000 persons living (corrected for age and sex distribution). Comparative mortality figure. 1904-8. 1909. 1904-8. 1909. 1909. England & Wales 35,756,615 15.3 14.5 15.3 14.5 1,000 London 4,833,938 14.91 14.01 15.71 14.71 1,018 Liverpool 760,357 20.2 19.0 21.6 20.4 1,406 Manchester 655,435 18.9 17.9 21.1 20.0 1,379 Birmingham 563,629 17.0 15.4 18.3 16.6 1,145 Leeds 484,012 15.9 14.1 17.3 15.3 1,058 Sheffield 470,958 16.6 15.1 17.9 16.2 1,121 Bristol 377,642 14.3 12.7 14.7 13.1 901 West Ham 321,767 15.1 14.0 16.1 15.0 1,037 Bradford 293,983 15.9 14.5 17.5 16.0 1,106 Newcastle-on-Tyne 281,584 17.0 14.8 18.4 16.0 1,104 Hull 275,552 16.8 14.9 17.2 15.3 1,057 Nottingham 263,443 16.6 16.3 17.5 17.2 1,184 Salford 241,950 18.4 18.0 20.3 19.9 1,372 Leicester 244,255 13.5 12.9 14.4 13.8 949 London had therefore (comparing the corrected death-rates) both in the quinquennium 1904-8 and in the year 1909 a lower death-rate than any of these towns except Bristol and Leicester. The following table enables comparison to be made of the crude death-rate of London with that of several foreign towns:— All Causes—Death-rates per 1,000 persons living. Town. 1904-8. 1909. Town. 1904-8. 1909. London 15.11 14.01 St. Petersburg 25.5 24.6 Paris 17.7 17.4 Berlin 16.1 15.1 Brussels 14.4 13.9 Vienna 18.0 16.8 Amsterdam 13.8 13.1 Rome l8.9 19.3 Copenhagen 15.9 14.5 New York 18.8 16.2 Stockholm 14.5 14.3 It will be seen from the foregoing table that in the quinquennium 1904-8 the London death-rate was exceeded by the death-rates of Paris, Copenhagen, St. Petersburg, Berlin, Vienna, Rome and New York, and in 1909 was lower than that of any except Brussels and Amsterdam. London mortality in 1909 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 1909. The figures for the year 1909 are fully corrected for institution deaths (see footnote (2), page 6), and the rates for the decennium 1891-1900 are based upon figures which have been corrected for institution deaths on the basis of the experience of the four years 1897-1900; a fuller discussion of this point will be found in the London Life Table appended to my report for the year 1901. 1 See footnote (2) page 6. 13 Death-rates per 1,000 living at the several age-periods in 1909 as compared with those of the decennium 1891-1900. Age-period. Males. Females. Mean deathrate 1891-1900. Death-rate 1909. Difference per cent. Mean deathrate 1891-1900. Death-rate 1909. Difference per cent. 0— 71.97 40.58 —43.6 61.99 35.01 —43.5 5— 4.97 3.14 —36.8 5.17 2.98 —42.4 10— 2.46 1.68 —31.7 2.48 1.75 —29.4 15— 3.47 2.53 —27.1 2.94 1.80 —38.8 20— 4.59 3.15 —31.4 3.46 2.31 —33.2 25— 7.36 5.06 —31.2 5.65 3.65 —35.4 35— 14.22 9.95 —30.0 10.68 7.36 —31.1 45— 23.14 19.11 —17.4 17.12 13.42 —21.6 55— 40.68 35.61 —12.5 31.01 26.34 —15.1 65— 77.78 79.54 + 2.3 63.44 60.47 — 4.7 75— 154.13 154.26 + 0.1 134.56 133.89 — 0.5 85 and upwards 284.10 358.84 +26.3 265.77 318.42 + 19.8 All ages 20.88 15.21 —27.2 17.88 13.05 —27.0 It will be seen from this table that the rate of mortality in 1909 was considerably lower than that of the period 1891-1900 at each age-period of life and for each sex, except at the period 65 and upwards for males and 85 and upwards for females. 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 1909 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 1909. 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 c— 2057 c 14 Table II. Lives and "Life-capital" gained or lost in 1909, as compared with the decennium 1891-1900. Age-group. Deaths calculated according to mean death-rates of 1891-1900. Deaths occurring in the year 1909. Gain (+) or loss (-) of lives in the year 1909, by fluctuations of mortality. Gain (+) or loss (-) of "life capital" in the year 1909 by fluctuations of mortality. Males. Years. 0— 19,012 10,720 + 8,292 + 415,927 5— 1,167 736 + 431 + 21,503 10— 545 373 + 172 + 7,845 15— 772 563 + 209 + 8,623 20— 1,063 730 + 333 + 12,338 25— 2,913 2,004 + 909 + 28,224 35— 4,253 2,975 + 1,278 + 30,646 45— 4,814 3,976 + 838 + 14,874 55— 5,146 4,504 + 642 + 7,929 65— 4,559 4,662 - 103 - 822 75— 2,798 2,800 - 2 - 10 85 and upwards 527 666 - 139 - 420 All Ages—Males 47,569 34,709 + 12,860 + 546,657 Females: 0— 16,361 9,239 + 7,122 +382,167 5— 1,225 705 + 520 + 27,810 10— 560 394 + 166 + 8,184 15— 730 446 + 284 + 12,763 20— 961 641 + 320 + 12,998 25— 2,636 1,703 + 933 + 32,086 35— 3,532 2,433 + 1,099 + 29,552 45— 3,982 3,122 + 860 + 17,234 55— 4,658 3,957 + 701 + 9,765 65— 5,257 5,011 + 246 + 2,189 75— 4,274 4,253 + 21 + 113 85 and upwards 1,158 1,388 - 230 - 734 All Ages—Females 45,334 33,292 + 12,042 +534,127 Total—Persons 92,903 68,001 + 24,902 + 1,080,784 It will be seen from the preceding table that during the year 1909, compared with the decennium 1891-1900, there has been a saving of 24,902 lives, representing a gain to the community of 1,080,784 years of " life-capital." Deaths at All Ages from certain Diseases and Groups of Diseases. The following table shows the diminution or excess in the number of deaths from certain diseases and groups of diseases during the year 1909, compared with the mean of the annual deaths in the preceding 10 years, corrected for increase of population. Number of deaths, 1909, compared with the mean of the annual deaths of the preceding decennium, 1899-1908. Cause of Death. Diminution in 1909. Excess in 1909. Smallpox 167 Measles - 290 Scarlet Fever 125 — Typhus 1 — Influenza - 93 Whooping-Cough 391 - Diphtheria 468 - Pyrexia (origin uncertain) 3 - Enteric Fever 301 - Diarrhœa 1,954 - Pneumonia - 625 Erysipelas 26 - (Continued on next page.) 15 Cause of Death. Diminution in 1909. Excess in 1909. Tuberculous Phthisis 1,203 - Phthisis Tuberculous Meningitis 199 - Tuberculous Peritonitis 244 - Tabes Mesenterica Other Tuberculous Diseases (including Scrofula) 194 - Cancer - 350 Premature Birth 439 - Diseases of Nervous system 1,871 - Diseases of Circulatory system1 Diseases of Respiratory system 1,125 - Diseases of Digestive system 1,042 - Diseases of Urinary system 61 - Childbirth and Puerperal Septic Diseases 37 - Accident 638 - Homicide 23 - Suicide 30 - All other Causes 1,048 - Net diminution 10,232 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 1909; the mean death-rates for the period 1904-8 are also shown for the purposes of comparison. Crude and corrected death-rates2 (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. Corrected comparative mortality figure (London, 1,000), 1904-8. 1909. 1904-8. 1909. 1904-8. 1909. England and Wales 18.19 1.0000 — — — — — — London 17.31 1. 0511 14.9 14.0 15.7 14.7 1,000 1,000 Paddington 17.04 1.0677 13.1 12.9 14.0 13.8 890 934 Kensington 16.88 1.0778 13.7 13.3 14.8 14.4 943 973 Hammersmith 17.47 1.0414 14.5 14.3 1.51 14.9 963 1,009 Fulham 17.39 1.0462 14.0 12.0 14.6 12.6 930 851 Chelsea 17.56 1.0361 15.3 14.4 15.9 15.0 1,009 1,015 Westminster, City of 16.22 1.1217 13.1 13.1 14.7 14.7 938 999 St. Marylebone 17.08 1.0652 15.2 14.6 16.2 15.6 1,029 1,055 Hampstead 16.13 1.1280 9.3 8.9 10.5 10.1 668 683 St. Pancras 17.40 1.0456 15.8 14.8 16.5 15.5 1,049 1,051 Islington 17.51 1.0391 14.5 14.0 15.1 14.6 960 988 Stoke Newington 17.43 1.0438 12.3 11.3 12.8 11.8 819 798 Hackney 17.46 1.0420 13.8 12.6 14.4 13.1 916 891 Holborn 16.90 1.0766 17.5 15.6 18.9 16.8 1,203 1,137 Finsbury 17.57 1.0355 19.7 19.2 20.4 19.9 1,298 1,351 London, City of 16.55 1.0993 17.2 20.3 18.9 22.3 1,204 1,511 Shored itch 17.34 1.0493 19.5 19.0 20.5 20.0 1,305 1,353 Bethnal Green 18.01 1.0102 18.3 16.8 18.4 17.0 1,175 1,151 Stepney 17.41 1.0450 17.4 15.3 18.2 16.0 1,159 1,082 Poplar 17.64 1.0314 17.3 16.3 17.9 16.8 1,137 1,136 South wark 17.41 1.0450 18.2 16.8 19.0 17.5 1,211 1,187 Bermondsey 17.76 1.0244 19.1 18.8 19.6 19.2 1,246 1,304 Lambeth 17.63 1.0320 14.7 14.1 15.2 14.5 967 984 Battersea 16.96 1.0728 13.6 13.0 14.5 14.0 927 947 Wandsworth 17.25 1.0547 12.5 11.9 13.2 12.5 841 849 Camberwell 17.54 1.0373 14.0 13.4 14.5 13.9 921 941 Deptford 17.31 1.0511 14.9 13.6 15.6 14.3 995 971 Greenwich 17.82 1.0210 13.3 12.2 13.6 12.4 865 844 Lewisham 17.46 1.0420 11.6 10.3 12.1 10.8 772 730 Woolwich 17.02 1.0690 12.8 11.9 13.7 12.8 874 864 1 For the purpose 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 (2), page 6. 2057 c 2 16 It will be seen from the foregoing table (comparing the corrected death-rates) that in the quinquennium 1904-8, Shoreditch (20.5) had the highest rate and Hampstead (10.5) the lowest; in the year 1909, City of London (22'3) had the highest, the lowest again obtaining in Hampstead (10.1). For the purposes of the calculation of the death-rates in the above table the populations of the metropolitan boroughs have been estimated on the assumption that the rate of increase in the last intercensal period has been since maintained. The correctness of this assumption is open to doubt, especially in view of the fact that eight years have elapsed since the census of 1901, and the estimates of population used need to be checked by figures obtained on some other assumption. The only official figures available are the populations calculated by the Registrar-General for the purposes of the Equalisation of Rates Act, these populations being based upon the number of rated houses in each borough. The following table shows the populations estimated by the two methods referred to, and the resulting death-rates for the year 1909. It will be noticed that the deathrate of the County of London is only slightly affected, but the difference in some districts is considerable. It should, however, be noted that migration and the declining birth-rate of recent years in addition to affecting the total number of the population may have considerably altered its age constitution since the date of the last census, and no reliable correction can be made for this effect until the figures of the next census are available. Death-rates in sanitary areas per 1,000 persons living in 1909, calculated (a) on Registrar-General's Annual Summary population and (b) on Equalisation of Rates population. Sanitary area. Population (estimated to the middle of the year). Crude Death-rate.1 Amount by which the death-rate based on estimate (b) differs from that based on (a). (a) Annual Summary estimate. (b) . Equalisation of Rates estimate. Calculated on (a). Calculated on (b). Paddington 151,955 145,292 12.9 13.5 +0.6 Kensington 183,683 184,383 13.3 13.3 - Hammersmith 125,704 121,851 14.3 14.7 +0.4 Fulham 176,406 158,245 12.0 13.4 +1.4 Chelsea 75,249 71,080 14.4 15.3 +0.9 Westminster, City of 168,883 174,919 13.1 12.7 -0.4 St. Marylebone 126,027 125,425 14.6 14.7 +0.1 Hampstead 94,185 88,806 8.9 9.5 +0.6 St. Pancras 237,422 228,161 14.8 15.4 +0.6 Islington 351,202 337,094 14.0 14.6 +0.6 Stoke Newington 54,423 52,549 11.3 11.7 +0.4 Hackney 237,601 220,674 12.6 13.6 +1.0 Holborn 53,802 53,685 15.6 15.6 - Finsbury 95,289 102,219 19.2 17.9 -1.3 London, City of 18,193 21,729 20.3 17.0 -3.3 Shoreditch 114,802 116,667 19.0 18.7 -0.3 Bethnal Green 131,316 128,600 16.8 17.2 +0.3 Stepney 312,525 285,534 15.3 16.7 +1.4 Poplar 171,965 167,319 16.3 16.7 +0.4 Southwark 211,125 198,397 16.8 17.8 +1.0 Bermondsey 127,569 128,714 18.8 18.6 -0.2 Lambeth 324,188 310,299 14.1 14.7 +0.6 Battersea 186,036 173,223 13.0 14.0 +1.0 Wandsworth 297,646 328,623 11.9 10.8 -1.1 Camberwell 283,022 270,215 13.4 14.0 +0.6 Deptford 118,583 112,669 13.6 14.3 +0.7 Greenwich 111,014 104,770 12.2 12.9 +0.7 Lewisham 160,749 171,135 10.3 9.7 -0.6 Woolwich 133,374 138,679 11.9 11.5 -0.4 London 4,833,938 4,720,956 14.0 14.4 +0.4 It will be noticed that the highest death-rate on the basis of the Annual Summary estimate, namely, that of the City of London (20.3) becomes reduced to 17.0 on the Equalisation of Rates estimate, the highest rate on the latter basis being that of Shoreditch (18.7). 1 See footnote (2), page 6. Diagram IV MORTALITY-AND BIRTH-RATES IN LONDON 1905-1909 IN RELATION TO "SOCIAL CONDITION." For the purposes of this diagram the proportion of the child population in each Metropolitan Borough scheduled for compulsory attendance at the Council's Schools has been used as an index of "Social Condition," and the 29 Boroughs have been arranged in Five Groups as under:— Group I. Boroughs in which less than 79% of the child population were scheduled in 1907. „ II. „ „ „ from 79-85 „ „ „ „ „ „ „ „ „ III. „ „ „ „ 85-91 „ „ „ „ „ „ „ „ „ IV. „ „ „ „ 91-97 „ „ „ „ „ „ „ „ „ V. „ „ „ more than 97 „ „ „ „ „ „ „ „ 17 The following table shows the number of deaths1 (All Causes) occurring at the several age periods in each of the sanitary areas of the Administrative County of London during the year 1909 (365 days)— All Causes—Deaths at the several age-periods in sanitary areas—1909 (365 days). Age-period. 0- 1- 2- 3- 4- Under 5. 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 & upwards All Ages. Paddington 314 77 36 17 19 463 40 13 26 30 138 151 194 274 310 244 83 1,966 Kensington 376 132 51 32 16 607 31 21 38 58 111 188 268 333 380 307 107 2,449 Hammersmith 361 123 39 26 17 566 37 12 27 40 99 125 183 182 264 201 62 1,798 Fulham 468 130 67 40 23 728 39 29 30 50 119 182 206 250 248 185 45 2,111 Chelsea 148 46 12 14 13 233 22 11 12 21 45 78 123 148 212 153 40 1,098 Westminster, Gity of 263 58 24 15 15 375 24 17 29 42 120 210 318 332 400 287 76 2,230 St. Marylebone 263 80 18 10 14 385 32 7 27 42 85 148 218 292 325 214 79 1,854 Hampstead 99 28 10 4 5 146 17 8 16 17 52 70 71 118 146 132 48 841 St. Pancras 571 174 57 49 26 877 74 36 48 78 199 313 395 463 562 375 119 3,539 Islington 849 302 132 61 55 1,399 89 55 56 86 273 420 545 605 691 548 173 4,940 Stoke Newington 81 23 9 6 4 123 9 5 9 15 26 45 62 97 115 85 27 618 Hackney 552 144 58 30 28 812 64 34 40 72 157 219 323 415 394 370 103 3,003 Holborn 101 32 18 5 1 157 5 7 5 16 41 93 103 155 163 72 26 843 Finsbury 369 145 51 32 16 613 38 26 35 24 93 146 200 239 251 154 29 1,848 London; City of 27 8 3 4 5 47 1 3 6 5 16 36 52 61 57 66 14 364 Shoreditch 514 189 84 52 30 869 46 33 31 49 102 178 224 237 225 149 41 2,184 Bethnal Green 536 182 58 37 27 840 48 26 36 38 115 164 208 239 276 175 54 2,219 Stepney 1,134 396 148 68 53 1,799 101 58 78 75 264 409 496 568 547 297 79 4,771 Poplar 671 247 106 46 26 1,096 72 37 42 58 134 205 263 289 337 226 34 2,793 Southwark 718 265 115 44 38 1,180 81 43 55 61 224 281 387 448 439 286 62 3,547 Bermondsey 573 219 94 34 37 957 55 31 42 43 120 176 254 255 252 182 44 2,411 Lambeth 820 225 104 60 38 1,247 97 47 62 92 252 389 475 566 690 507 141 4,565 Battersea 479 153 68 37 23 760 58 28 43 59 126 172 228 319 347 229 59 2,428 Wandsworth 608 187 84 51 27 957 97 39 51 86 206 283 312 427 549 412 140 3,559 Camberwell 672 212 90 46 35 1,055 107 51 62 78 225 282 360 431 560 446 138 3,795 Deptford 321 119 52 25 10 527 36 23 21 29 95 115 171 172 229 158 43 1,619 Greenwich 248 60 30 25 13 376 29 22 18 40 84 94 154 144 179 166 56 1,362 Lewisham 261 44 21 14 22 362 40 25 24 29 95 105 142 218 279 259 82 1,660 Woolwich 242 80 35 21 25 403 52 20 40 38 91 131 163 184 246 168 50 1,586 London 12,639 4,080 1,674 905 661 19,959 1,441 767 1,009 1,371 3,707 5,408 7,098 8,461 9,673 7,053 2,054 68,001 The following table enables comparison to be made of the death-rates from all causes at certain age-periods in five groups of London sanitary districts arranged in order of the "social condition" of their population (see page 10 ante). The table shows generally a progressive increase in the deathrates at each period of life and for each sex coincident with the graduation of the population with regard to social condition as thus measured:— All causes—Death-rates1 at certain age-periods in relation to " social condition2"—1905-9. Males. Group. Age-period. 0- 5- 15- 25- 45- 65 + All ages. I. 37.21 2.14 2.55 5.98 20.79 86.07 13.44 II. 44.38 2.36 2.75 7.24 25.92 99.12 15.99 III. 44.93 2.53 3.00 7.29 24.74 101.20 16.06 IV. 54.62 2.75 3.49 8.56 27.15 105.66 18.19 V. 60.21 3.00 3.36 9.57 31.56 103.85 19.71 Females. Group. Age-period. 0- 5- 15- 25- 45- 65 + All ages. I. 31.16 2.10 1.57 4.06 14.68 75.68 10.65 II. 36.68 2.55 1.98 4.88 17.79 85.79 12.55 III. 37.75 2.59 2.54 5.62 18.50 87.04 13.17 IV. 47.15 2.74 2.99 6.67 21.87 94.10 15.43 V. 52.33 3.03 2.87 7.71 24.70 89.40 16.57 In Diagram IV. the death-rate from "all causes" at "all-ages" during the quinquennium 1905-9 is shown in relation to social condition. 1 See footnote (2) page 6. 2 For the purposes of this table the proportion of the child population in each metropolitan borough scheduled for compulsory attendance at the Council's schools has been used as an index of "social condition." See Diagram IV. 18 Comparison can be made of death-rates from certain causes of death in sanitary areas by reference to the following table. The death-rates shown are fully corrected for deaths in institutions (see footnote (2) page 6) 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, and these factors and the corrected death-rates are shown on pages 56 and 64 respectively. Death-rates per 100,000 living from All Causes, and from Specified Causes, in each of the several sanitary areas, 1909 (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 Respiratory Diseases. All other Causes. All Causes. Paddington 24 6 65 8 28 5 12 110 11 122 160 743 1,294 Kensington 32 2 70 8 40 7 17 93 16 146 156 746 1,333 Hammersmith 64 7 52 5 34 9 17 109 10 172 136 815 1,430 Fulham 43 5 57 5 20 5 18 116 16 141 95 676 1,197 Chelsea 33 7 68 3 44 3 28 146 16 169 166 776 1,459 Westminster, City of 15 4 72 7 40 7 12 134 15 131 149 734 1,320 St. Marylebone 27 4 70 6 55 8 8 133 14 145 173 828 1,471 Hampstead 14 5 63 10 19 2 11 62 11 82 91 523 893 St. Pancras 45 9 69 6 27 8 13 160 16 192 141 805 1,491 Islington 58 6 54 6 41 12 23 123 13 159 154 758 1,407 Stoke Newington 18 4 62 4 48 15 11 86 13 108 140 627 1,136 Hackney 24 4 56 5 31 16 16 121 13 127 117 734 1,264 Holborn 26 6 69 13 41 7 11 210 19 175 188 802 1,567 Finsbury 91 10 68 5 22 6 24 225 19 230 239 1,000 1,939 London, City of 33 5 71 16 60 16 16 192 22 231 253 1,086 2,001 Shoreditch 114 6 49 3 31 13 31 174 30 266 179 1,006 1,902 Bethnal Green 61 4 40 7 44 16 21 155 21 206 221 894 1,690 Stepney 77 2 41 6 20 9 21 167 20 201 171 792 1,527 Poplar 90 5 65 5 17 8 17 128 21 176 172 920 1,624 Southwark 61 7 69 4 15 12 19 179 21 222 185 886 1,680 Bermondsey 157 6 78 6 27 31 27 178 36 220 195 929 1,890 Lambeth 32 6 85 7 26 11 11 139 14 159 148 770 1,408 Battersea 48 6 50 3 45 6 18 121 12 131 157 708 1,305 Wandsworth 38 4 46 7 39 5 15 94 10 114 110 714 1,196 Camberwell 38 8 43 6 45 6 21 120 22 121 142 769 1,341 Deptford 57 6 54 7 28 6 20 126 14 116 163 768 1,365 Greenwich 37 4 51 8 19 3 16 99 14 113 124 739 1,227 Lewisham 4 6 65 5 27 5 12 78 6 62 110 653 1,033 Woolwich 41 4 52 5 33 7 21 118 14 93 92 709 1,189 London 49 5 59 6 32 9 18 131 16 154 150 778 1,407 Infantile Mortality. The deaths of children under one year of age in the Administrative County of London during 1909 (52 weeks) numbered 12,582, being in the proportion of 108 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* 1903 1301 1851-60 155* 1904 1451 1861-70 162* 1905 1301 1871-80 158* 1906 1311 1881-90 152 1907 1161 1891-1900 1591 1908 1131 1901 1481 1909 1081 1902 1401 The accompanying diagram (V.) shows the infantile mortality in each year since 1857 in relation to the mean infantile mortality of the period 1858-1909, and also the infantile 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. It is thus seen that the rates of 1909 are the lowest recorded in this period. The following table enables comparison to be made of the infantile mortality in London and other large English towns. * The registration of births was not made compulsory until the beginning of 1875; before that year many births were probably unregistered. 1 See footnotes (1) and (2) page 6. Diagram V. INFANTILE MORTALITY. (Deaths under one year of age per 1000 births). 19 Deaths under one year of age per 1,000 births. Town. 1904-8. 1900. Town. 1904-8. 1909. London 1271 1081 Bradford 146 116 Liverpool 161 144 West Ham 145 124 Manchester 162 134 Newcastle-on-Tyne 140 119 Birmingham 162 134 Hull 152 114 Leeds 149 122 Nottingham 162 150 Sheffield 154 118 Salford 158 141 Bristol 122 100 Leicester 149 127 London had therefore both in the period 1904-8 and in the year 1909 a lower infantile mortality than any of these towns except Bristol. The rates are uncorrected (except in the case of London) for births and deaths in institutions. The uncorrected London rate for 1909 was 110. The comparison of the infantile mortality rates of towns in different countries is undoubtedly affected by differences in the practice with regard to the registration of births. The rates shown in the following table, which are calculated on the number of living births registered, can only be taken as approximately correct. The rate for New York is somewhat overstated for the period 1904-8, owing to the incomplete registration of births prior to 1908. Deaths under one year of age for 1,000 births. Town. 1904-8. 1909. Town. 1904-8. 1909. London 1271 1081 St. Petersburg 258 249 Paris 1082 962 Berlin 183 158 Brussels (1906-8) 149 141 Vienna 177 172 Amsterdam 105 82 Rome 142 140 Copenhagen 1443 1093 New York 149 130 Stockholm 103 85 The following table shows the deaths of infants 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 1904-8 and for the year 1909:— Sanitary areas—Deaths under one year of age per 1,000 births. Sanitary area. Deaths under one year of age, 1909 (52 weeks). Deaths under one year of age per 1,000 births. 1904-8. 1909. Paddington 312 113 100 Kensington 379 132 113 Hammersmith 360 130 120 Fulham 466 134 108 Chelsea 149 125 107 Westminster, City of 260 107 95 St. Marylebone 258 116 99 Hampstead 99 83 75 St. Pancras 570 121 102 Islington 843 118 101 Stoke Newington 82 104 80 Hackney 550 125 102 Holborn 100 124 102 Finsbury 367 144 131 London, City of 28 106 113 Shoreditch 510 161 140 Bethnal Green 535 145 129 Stepney 1,130 136 119 Poplar 669 140 129 Southwark 711 146 119 Bermondsey 567 147 138 Lambeth 823 125 109 Battersea 477 123 107 Wandsworth 601 112 86 Camberwell 666 123 100 Deptford 317 126 102 Greenwich 249 121 100 Lewisham 262 101 74 Woolwich 242 110 82 London 12,582 127 108 1 See footnotes (1) and (2), page 6. 2 The infantile mortality rate here shown for Paris is not comparable with that of other towns owing to the practice largely prevailing among residents within the city of putting infants out to nurse in the suburbs. 3 In Copenhagen, about one-fifth of the total births occur in the Lying-in Hospital, and in respect of these no deduction is made for births to mothers not resident within the city. 20 It will be seen from the foregoing table that in the period 1904-8 and the year 1909 Shoreditch (161 and 140 respectively) and Bermondsey (147 and 138 respectively) had the highest infantile death-rates and Hampstead (83 and 75 respectively) and Lewisham (101 and 74 respectively) had the lowest. The deaths under one year of age per 1000 births, during each of the four quarters of the year, were as follows:— First quarter 112; second quarter 92; third quarter 109; fourth quarter 116. The reports of Medical Officers of Health of the several sanitary areas of the Administrative County for the year 1909 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 age-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. Infantile mortality during the year 1909 (52 weeks). Deaths from stated causes in the first four weeks of life and in months under one year of age. Cause of death. Under 1 Week. 1-2 Weeks. 2-3 Weeks. 3-4 Weeks. Total under 1 Month. 1-2 Months. 2-3 Months. 3-4 Months. 4-5 Months. 5-6 Months. 6-7 Months. 7-8 Months. 8-9 Months. 9-10 Months. 10-11 Months. 11-12 Months. Total Deaths under one year. Common Infectious Diseases— Small-pox — — — — — — — — — — — — — — — — — Chicken-pox — — — — — — 1 — — 1 4 1 — 1 1 1 10 Measles — — 1 — 1 4 5 4 7 17 33 60 63 83 108 118 503 Scarlet Fever — — 1 — 1 1 — — 2 — 1 2 — 2 6 5 20 Diphtheria and Croup — 1 — — 1 2 — 1 1 5 5 5 9 10 9 12 60 Whooping-cough 1 — 4 5 10 33 32 48 32 40 45 54 53 56 62 59 524 Diarrhal Diseases— Diarrhœa, all forms 1 9 7 15 32 112 146 144 145 105 97 90 75 65 54 52 1,117 Enteritis (not tuberculous) 3 14 16 11 44 70 97 81 70 71 41 35 32 29 22 20 612 Gastritis, Gastrointestinal Catarrh 2 6 6 3 17 22 16 19 8 10 7 5 8 5 2 1 120 Wasting Diseases— Premature Birth 1,473 190 151 107 1,921 121 37 16 10 5 3 3 4 — 1 1 2,122 Congenital Defects 325 67 37 36 465 69 37 24 15 13 5 7 11 11 5 5 667 Injury at Birth 106 2 4 1 113 — — — — — — — — — — 113 Want of Breast-milk 6 11 3 6 26 14 8 8 3 5 2 2 1 69 Atrophy, Debility, Marasmus 259 126 116 115 616 285 223 179 138 78 66 54 32 29 30 26 1,756 Tuberculous Diseases— Tuberculous Meningitis — 1 — — 1 8 3 12 18 22 24 18 17 28 23 29 203 Tuberculous Peritonitis : Tabes Mesenterica 2 2 12 17 23 18 13 12 8 17 6 8 9 145 Other Tuberculous 1 1 2 4 12 11 19 17 12 19 19 27 19 14 15 188 Diseases Erysipelas — 1 5 1 7 6 3 3 8 5 2 3 5 1 2 3 48 Syphilis 10 20 13 14 57 58 39 18 14 6 7 5 6 1 4 1 216 Rickets — 1 — 1 2 2 2 2 2 4 2 5 7 4 8 5 45 Meningitis (not Tuberculous) — 5 4 1 10 2 9 12 12 20 20 23 16 20 14 12 170 Convulsions 86 59 29 21 195 72 44 35 30 31 20 19 10 7 17 15 495 Bronchitis 13 19 38 47 117 141 100 69 60 81 66 67 78 69 57 55 960 Laryngitis — — — — — 1 1 — 1 — 2 3 4 — — 3 15 Pneumonia 14 18 29 32 93 131 111 96 94 81 87 101 139 121 138 142 1,334 Suffocation, overlaying 55 11 20 21 107 75 60 40 12 12 3 3 3 3 4 — 322 Other causes 181 50 55 30 316 93 58 59 47 39 51 35 43 41 36 34 852 Total (All Causes) 2,535 612 540 471 4,158 1,346 1,060 912 764 676 624 625 661 611 626 623 12,686 21 Comparison may be made between the number of deaths from the several causes in the above table with those of the four antecedent years by reference to the following table:— Cause of death. 1905. 52 weeks. 1906. 52 weeks. 1907. 52 weeks. 1908. 53 weeks. 1909. 52 weeks. Small-pox - Chicken-pox 3 3 5 3 10 Measles 389 420 400 333 503 Scarlet Fever 34 18 35 24 20 Diphtheria and Croup 52 59 53 67 60 Whooping-cough 623 502 746 469 524 Diarrhoea 3,423 4,468 1,790 2,709 1,849 Enteritis (not tuberculous) Gastritis, Gastro-intestinal Catarrh Premature Birth 2,423 2,208 2,299 2,197 2,122 Congenital Defects 547 613 645 705 667 Injury at Birth 99 113 117 110 113 Want of Breast-milk 2,281 2,130 1,922 1,843 1,825 Atrophy, Debility, Marasmus Tuberculous Meningitis 273 241 239 259 203 Tuberculous Peritonitis : Tabes Mesenterica 192 225 153 168 145 Other Tuberculous Diseases 284 246 264 255 188 Erysipelas 64 50 52 35 48 Syphilis 271 233 226 229 216 Rickets 79 67 58 51 45 Meningitis (not tuberculous) 300 302 210 246 170 Convulsions 803 660 603 520 495 Bronchitis 1,276 1,043 1,284 982 960 Laryngitis 25 23 15 18 15 Pneumonia 1,490 1,335 1,629 1,431 1,334 Suffocation, overlaying 462 417 421 417 322 Other causes 1,004 1,009 979 885 852 Total 16,397 16,385 14,145 13,956 12,686 Number of births 125,989 124,880 121,408 122,898 116,559 22 of infants surviving to the age in question. The table shows that the greatest decrease per cent. has been experienced in the sixth and seventh months of life, and the smallest decrease in the first and twelfth months of life:— Infantile Mortality at ages in London during 1909 compared with 1905. Age-period. Death-rate per 1,000 living at commencement of each age-period. Decrease in death- rate in 1909 as compared with 1905. Decrease per cent. 1905. 1909. Weeks. 0— 22.92 21.75 1.17 5.1 1— 6.57 5.37 1.20 18.3 2— 5.46 4.76 0.70 12.7 3— 4.64 4.17 0.47 10.0 Months. 0— 39.11 35.67 3.44 8.8 1— 14.84 11.97 2.87 19.3 2— 11.84 9.54 2.30 19.3 3— 10.28 8.29 1.99 19.3 4— 8.86 7.00 1.86 20.9 5— 8.51 6.24 2.27 26.6 6— 813 5.80 2.33 28.7 7— 7.51 5.84 1.67 22.2 8— 7.80 6.21 1.59 20.4 9— 7.56 5.78 1.78 23.6 10— 7.39 5.95 1.44 19.4 11— 6.40 5.96 0.44 6.9 With a view to comparing the rates of mortality from the several groups of diseases in the years 1905.9 the following table has been prepared. It will be seen that in 1909 the greatest decrease has occurred in deaths from diarrhceal diseases, and inasmuch as deaths from these diseases constitute an especially large proportion of the infant deaths from all causes, to this decrease is due in the main the comparatively low infantile mortality of that year. This decrease is chiefly due to the favourable meteorological conditions of 1909. in. London—Deaths, per 1,000 births, of infants under one year of age, from all causes and certain specified causes. Year. All causes. Measles. Whooping. cough. Diarrhceal diseases. Wasting diseases. Tuberculous diseases. Meningitis and convulsions. Bronchitis. Pneumonia. Other causes. 1905 130.2 31 4.9 27.2 42.5 6.0 8.8 10.1 11.8 15.8 1906 131.2 3.4 4.0 35.8 40.5 5.7 7.7 8.4 10.7 15.0 1907 116.5 3.3 6.2 14.7 41.0 5.4 67 10.6 13.4 152 1908 113.61 2.7 3.8 22.0 39.5 5.6 6.2 8.0 11.7 14.1 1909 108.81 4.3 4.5 15.9 40.6 4.6 5.7 8.2 11.4 13.6 The decrease in the death.rate from tubercular diseases is less easy of explanation than that from diarrhceal diseases. The table shows that the former death.rate has conspicuously fallen in 1909. Comparison of the death-rates in past years from tubercular diseases with those from diarrhceal diseases does not indicate parallel variations, and therefore there is no reason for thinking that climatic conditions have determined the decline; further, there is no evidence that transference to other headings, such as meningitis (not tubercular) and convulsions affords sufficient explanation of the decrease in the death-rate from tubercular diseases. Even if due allowance is made for the uncertainty which must attach to diagnosis of disease in infancy, it is difficult to find explanation of the decrease in this circumstance. Reference to the following table shows that the decrease of mortality from these diseases has not been limited to infants in the first year of life, children in the second year of life largely sharing 1 These rates differ slightly from those shown on page 18, the latter being based upon figures in the RegistrarGeneral's Annual Summary, whilst the rates shown above are based upon the totals of the births and deaths as corrected for each borough by the respective Medical Officers of Health. 23 in the decrease. The experience of farther years is obviously needed before reliable reference can be drawn from the behaviour of the figures, but so far as they go they suggest that explanation may possibly be found eventually in improved powers of resistance or in diminished exposure to infection. Mortality in London from tubercular diseases, 1901-1909. Death-rate per 1,000 living at each year of life among children under 5 years of age. Year. 0— 1— 2— 3— 4— 1901 7.36 1902 7.36 4.95 1903 6.99 4.92 2.59 1904 6.68 4.72 2.60 1.54 1905 5.81 4.19 241 1.72 110 1906 5.69 4.79 2.72 1.49 1.44 1907 5.26 4.35 2.40 1.62 1.04 1908 5.48 4.71 2.25 1.51 1.30 1909 4.47 3.75 2.38 1.43 0.97 The following life table, which is based upon the figures shown in the table on page 20, shows the probability of living for one month from the commencement of each month in 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 in the year 1909. In the last four columns of the table the similar figures for the preceding four years are shown; these differ slightly from those contained in the life tables published in former reports owing to their being recalculated upon the more fully corrected figures which have become available since the life table was first introduced into these reports. London—1909. Life Table1 for the first 12 months of life (based on the mortality of the year 1909). Ago-period. X/12 Registered deaths. 1909. 1909. Probability of living for one month. Px/12 1909. Number living at the beginning of each month of age. lx/12 1908. Number living at the beginning of each month of age. lx/12 1907. Number living at the beginning of each month of age. lx/12 1906. Number living at the beginning of each month of age. lx/12 1905. Number living at the beginning of each month of age. lx/12 0—1 mth. 4,158 .96567 100,000 100,000 100,000 100,000 100,000 1—2 mths. 1,346 .98843 96,567 96,437 96,219 96,320 96,188 2—3 ,, 1,060 .99076 95,450 95,173 94,953 94,983 94,795 3-4 „ 912 .99198 94,568 94,196 93,990 93,859 93,701 4—5 „ 764 .99321 93,809 93,360 93,137 92,845 92,761 5—6 ,, 676 .99391 93,172 92,633 92,475 91,988 91,958 6-7 „ 624 .99430 92,605 91,985 91,910 91,130 91,194 7-8 „ 625 .99423 92,077 91,391 91,326 90,360 90,466 8-9 „ 661 .99385 91,546 90,847 90,774 89,631 89,799 9-10 „ 611 .99427 90,983 90,295 90,217 88,956 89,110 10-11 „ 626 .99409 90,461 89,779 89,670 88,254 88,444 11-12 „ 623 .99408 89,927 89,259 89,153 87,639 87,797 0—1 year 12,686 — 89,395 88,730 88,598 87,012 87,238 It will be seen from the figures in the third column of the table that while there is generally a progressive increase in the probability of living one month, the increase is not continued into the later months. The depression in the probability curve in the vicinity of the ninth month of life is a feature of similar tables published in previous annual reports. In the report for 1905, giving the first table of the series, the possibility of the diminished viability of children of this age being due to the change from natural to artificial food was suggested. It was pointed out, however, that the experience of further years was necessary to ascertain whether the probability depression referred to was a constant feature of the figures relating to London infantile mortality. The figures for five successive years are now available, and a composite probability curve for these years shows that with a generally rising probability curve, there is a slightly diminished probability of living during the ninth month of life. 1 See footnotes (1) and (2), page 6. 2067 D 2 24 The persistency of this feature of the probability curve for the first year of life has led me to make further analysis of the monthly mortality figures, and the following table has, therefore, been prepared, which shows, for the quinquennium 1905-9, the deaths per thousand living in London at the commencement of each month of life from certain groups of causes of death, and from " all causes":— Infantile Mortality in London, 1905-9. Deaths,1 per 1,000 living at commencement of each month of life, from certain groups of causes of death, and from all causes. Cause of death. 0— 1— 2 — 3— 4— 0— 6— 7— 8— 9— 10— 11— Common infectious diseases 0.14 0.44 0.43 0.40 0.40 0.57 0.74 0.95 110 1.32 1.51 1.63 Diarrhceal diseases 1.25 2.45 2.82 304 2.80 2.61 2.25 1.99 1.79 1.55 1.33 119 Premature birth, congenital defects, injury at birth 21.19 1.75 0.62 0.33 0.21 0.14 0.08 010 0.10 0.05 006 0.04 Want of breast.milk, atrophy, debility, marasmus 5.91 2.92 2.25 1.75 117 0.77 0.63 0.44 0.41 0.30 0.26 0.23 Tubercular diseases 0.13 0.34 0.45 0.57 0.56 0.60 0.54 0.54 0.53 0.55 0.55 0.58 Respiratory diseases (pneumonia, laryngitis, bronchitis) 1.99 2.73 2.18 1.78 1.52 1.64 1.67 1.66 1.94 1.88 1.81 1.87 All other causes 6.80 2.92 2.10 1.69 1.42 1.19 1.20 1.06 0.94 0.99 0.89 0.82 All causes 37.40 13.55 10.84 9.57 8.08 7.52 7.12 6.74 6.80 6.65 6.41 6.36 An examination of this table shows that with regard to the common infectious diseases, there is an almost uninterrupted increase in the rate of incidence from the first to the twelfth month of life, while the reverse is practically true for premature birth, want of breast milk, etc., and "all other causes." The rates shown for tubercular diseases exhibit remarkable constancy from the fourth month of life onwards, while the age-incidence curve of diarrhœal diseases rises to a maximum in the fourth month of life, and then progressively declines. The age-incidence curve for respiratory diseases is, however, much less regular, and further analysis of the figures is necessary to ascertain the cause or causes which determine the shape of the curve, a shape which is suggestive of increasing susceptibility to some forms of respiratory diseases and increasing resistance to others as the age of the child advances. It will be seen that the marked increase in the incidence of these diseases during the ninth month is sufficient alone to account for the depression in the probability curve at this point in the London infant life tables. The figures for the whole of England and Wales for the same period relating to respiratory diseases show a maximum incidence at the ninth month, but the excess over the eighth month is not nearly so great proportionately as in London. It seems, therefore, reasonable to conclude that an average over a greater number of years in London will somewhat reduce the disparity between the respiratory-diseases deaths at the eighth and ninth months of life. It is, however, clear from an examination of the death-rates from all causes in England and Wales over a series of years that the influences operating in the first year of life are such as to produce normally a flattening, hardly amounting to a depression, of the probability curve about the eighth month, this being the natural result of the rapid decrease, down to this point, of the deaths from pre-natal and natal influences on the one hand, and the increase from the sixth month onwards in the deaths from infectious diseases and, to some extent, respiratory diseases on the other hand. Broadly speaking, the table shows that the causes of infantile mortality can be roughly grouped into three classes:—(a) those causes increasing in incidence with progressive age, such as the common infectious diseases; (b) those causes showing little or no variation in age incidence, such as tuberculous diseases; and (c) those causes exhibiting diminished incidence as age advances, such as premature birth, want of breast milk, etc. It will thus be seen that the composite "all ages" curve is, in the main, a blending of two curves, one approaching, the other receding from, the base-line, and an approximately straight line. The contour of the "all ages" curve, therefore, will depend upon the relative steepness and distance from the base-line of the auxiliary curves, which qualities must obviously vary with variations iu the prevalence of the causes of mortality thus graphically represented. On these grounds alone, it is easy to conceive of irregularities in the contour of the "all ages" curve similar to that to which attention has been directed in connection with the probability curve. The expiration of a longer period than that under review, and the consequent elimination of "epidemic influence," is necessary to demonstrate whether the irregularity in the curve is of a purely arithmetical character, in which case the irregularity will be smoothed out when a curve is constructed on a larger number of observations 1 See footnote (1), page 22. 25 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:— Deaths1 at each interval of age (under one year) from All Causes in sanitary areas in 1909. 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 75 16 6 11 108 39 24 23 11 19 13 21 17 7 22 7 311 Kensington 80 16 18 12 126 32 36 34 27 17 15 13 30 18 13 18 379 Hammersmith 58 22 19 14 113 33 32 21 25 25 23 23 16 20 13 17 361 Fulham 92 19 23 14 148 54 45 27 29 29 27 19 30 23 13 22 466 Chelsea 35 3 9 9 56 18 8 8 9 10 10 5 5 12 3 6 150 Westminster,Gity of 57 20 12 10 99 17 27 15 22 16 19 5 12 12 10 4 258 St. Marylebone 65 13 11 9 98 32 22 10 15 11 12 11 12 11 14 11 259 Hampstead '27 2 5 7 41 10 3 7 6 2 9 3 4 4 5 5 99 St. Pancras 142 20 23 14 199 58 50 47 30 27 17 31 32 27 33 19 570 Islington 156 52 26 35 269 83 64 44 58 46 55 34 55 45 40 48 841 Stoke Newington 15 3 7 1 26 8 12 8 3 1 2 4 4 4 9 3 84 Hackney 143 30 24 32 229 75 56 51 34 28 21 29 22 20 24 27 616 Holborn 24 3 7 1 35 6 12 11 4 2 9 2 1 2 11 5 100 Finsbury 57 15 16 12 100 42 33 31 16 20 18 21 23 22 12 28 366 London, Gity of 13 — — — 13 3 3 1 — 1 — 1 3 1 26 Shoreditch 92 11 24 23 150 46 39 33 39 28 27 33 22 31 36 28 512 Bethnal Green 93 20 14 16 143 64 50 38 36 31 25 29 28 32 27 31 534 Stepney 199 39 44 37 319 123 103 87 73 62 59 61 59 66 61 57 1,130 Poplar 122 25 35 21 203 74 53 55 35 35 29 35 37 38 38 38 670 Southwark 131 45 27 32 235 61 63 61 46 41 35 30 45 37 38 19 711 Bermondsey 89 30 25 21 165 45 35 43 38 39 25 38 33 32 36 44 573 Lambeth 166 34 38 27 265 94 67 69 56 38 41 54 40 30 38 38 830 Battersea 95 24 19 17 155 51 48 28 31 28 31 14 22 18 24 28 478 Wandsworth 135 39 27 24 225 59 43 57 30 25 28 31 34 25 24 20 601 Camberwell 129 43 39 24 235 88 56 40 32 34 27 27 35 30 28 55 687 Deptford 66 22 13 9 110 39 23 18 14 24 18 15 11 18 13 18 321 Greenwich 52 12 10 9 83 33 16 17 21 12 11 14 13 11 13 7 251 Lewisham 72 18 13 20 123 26 22 15 14 16 6 10 7 4 12 7 262 Woolwich 55 16 6 10 87 33 15 14 10 9 12 12 12 11 13 12 240 London 2,535 612 540 471 4,158 1,346 1,060 912 764 676 624 625 661 611 626 623 12,686 With a view to the consideration of the effect of social condition, as indicated by the extent of " overcrowding," on the rates of infantile mortality at different periods during the first year of life, the following table has been prepared, in which the rates of infantile mortality obtaining for groups of districts (arranged on the basis of the amount of "overcrowding" shown by the census of 1901) can be compared:— Infantile mortality and overcrowding2—1909. [###period. Proportion of overcrowding in groups of sanitary districts. I. Under 7.5 per cent. II. 7.5 to 12.0 per cent. III. 12. to 20.1 per cent. IV. 20. to 27. per cent. V. Over 27.5 pe cent.[/##p Under 1 week 19.2 21.8 21.8 23.9 22.0 1-2 weeks 4.9 5.5 5.7 5.3 4.2 2-3 „ 3.7 5.0 4.7 4.5 4.9 3-4 „ 3.9 3.9 4.2 3.7 4.4 Under 1 month 31.7 36.2 36.4 37.4 35.5 1.2 months 8.6 12.6 10.9 10.4 13.7 2-3 60 9.3 8.7 9.7 11.2 3-4 6.4 7.3 7.9 8.5 9.4 4-5 4.0 6.5 7.1 6.3 8.2 5-6 3.3 5.9 6.4 5.3 7.0 6-7 3.6 5.3 5.9 4.8 6.4 7-8 3.8 5.3 5.4 4.9 7.2 8-9 3.8 51 6.7 6.0 6.6 9-10 „ 3.0 4.6 5.8 5.1 7.5 10-11 „ 4.0 4.5 5.7 6.3 6.8 11-12 „ 3.0 5.7 5.9 3.6 7.1 0-3 months 46.3 58.1 56.0 57.5 60.4 3-6 „ 13.7 19.7 21.4 20.1 24.6 6-9 „ 11.2 15.7 18.0 15.7 20.2 9-12 „ 10.0 14.8 17.4 15.0 21.4 0-12 months 812 108 3 1128 108 3 126 6 1 Eefer to footnote (1), page 22. ' 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. 26 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 c— Infantile mortality and. overcrowding1—1909. 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. Children under 1 year. 1905-8. 1909. 1905-8. 1909. 1905-8. 1909. 1905-8. 1909. 1905-8. 1909. I. 100 100 100 100 100 100 100 100 100 100 II. 110 126 122 143 132 139 145 149 119 133 III. 112 121 123 156 134 160 146 174 122 139 IV. 112 124 124 147 124 139 153 150 121 133 V. 116 130 145 180 160 179 184 215 136 156 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. The figures for 1909 are in general agreement with those for the period 1905-8. Similar results are obtained if the grouping of districts is based upon the percentage of children, aged 5-14 years, scheduled for education purposes. Thus:— Infantile Mortality, all causes, at ages (trimesters), 1909. Group. 0- 3- 6- 9- I. 100 100 100 100 II. 112 121 131 118 III. 114 117 129 143 IV. 121 148 157 174 V. 121 156 166 198 In this table the rates are calculated upon the number of survivors at the commencement of each trimester. Reference may here be made to diagram IV., which shows the infantile mortality rate for the quinquennium 1905-9 in relation to social condition. The improvement in the death-rate in 1909 has not been shared equally by all classes of the population, but has been experienced in greater degree by the population of districts better circumstanced than by those not so well circumstanced. If the districts be grouped on the basis of the percentage of population " overcrowded as before and the infant mortality rates of 1909 be compared with those of 1905, the following results are obtained:— Group. Amount of decline in 1909 per ceut. of rates (per 1,000 births) in 1905. I 24.7 II 15.6 Ill 15.5 IV 14.2 V 12.8 London 16.4 Comparing Group I. and Group V., with regard to certain groups of causes of death, it is found that the decline per cent. in 1909 as compared with 1905 has been as follows:— Group I. Group V. Diarrhoeal diseases 55 28 Wasting diseases 17 4 Tubercular diseases 34 20 Respiratory diseases (including pneumonia) 16 13 The death-rates in the more favoured group of districts have, therefore, responded in greater degree in respect of all these classes of disease to the more favourable conditions of 1909 than the rates of the groups of less favoured districts, and this difference manifests itself even in the deaths from suffocation, which in Group I. had declined 40 per cent., and in Group V. 27 per cent. Most of the annual reports of medical officers of health give account of the action which is being taken in their districts to reduce infantile mortality. For this purpose the homes in which births have occurred are visited and advice is given as to the immediate and future care of the infants. In See footnote (2), page 25. 27 some districts, the services of health visitors employed by the sanitary authorities are supplemented by aid given by local health societies. At the present time, the majority of the local authorities have arranged that the services of one or more health visitors or female inspectors shall be available for this purpose. Thus health visitors are included in the staff of the following districts:— Kensington (2), Hammersmith (1), Finsbury (2), Shoreditch (1), Stepney (1), Poplar (1), Bermondsey (1), Lambeth (1), Battersea (1), Deptford (1), Westminster (1 unpaid) and part of the time of one or more female sanitary inspectors is devoted to this work in Paddington, Fulham, Chelsea, St. Marylebone, Hampstead, St. Pancras, Stoke Newington, Holborn, the City, Bethnal Green, Southward, Wandsworth, Lewisham, and Woolwich. The recommendation of the medical officer of health of Islington that three health visitors should be appointed for that borough has not yet been adopted. The local health societies are evidently doing useful work in districts where they exist. In Woolwich, Dr. Davies states such service cannot be obtained and the women inspectors are unable adequately to cope with the work. "Consultative centres," to which mothers can take their infants for advice, have been instituted in Paddington, Kensington, Fulham, Westminster, St. Marylebone, Hampstead, St. Pancras, Finsbury, Poplar, and Greenwich. In Battersea, Lambeth and Woolwich milk depots have been established where specially prepared milk is supplied for infants who cannot be fed from the breast. In Holborn arrangements have been made with a dairy company, by which such milk is supplied on the order of the medical officer of health. Arrangements had formerly existed in Finsbury, by which the sanitary authority supplied milk from a country farm, but these were discontinued in March, 1909. In Kensington, Fulham, Chelsea, Westminster, Hampstead, and St. Pancras, necessitous nursing and expectant mothers are able to avail themselves of the opportunity of obtaining meals at trivial cost, such meals being provided by philanthropic bodies. Thus in various directions effort is being made in many districts to safeguard infant life, and it may be anticipated that in the remaining districts the necessity of making similar effort will soon be recognised by the sanitary authorities. Many of the annual reports contain information of interest and value in connection with the prevention of infantile mortality, and the experience of 1909 emphasises the great advantage which breast-fed children have over those which are wholly or in part artificially fed. Among other matters which are discussed in a few of the reports, is the effect of employment away from home upon nursing mothers. Larger figures are necessary for reliable inferences than are as yet available, but inquiry into 1,030 cases in the northern part of Westminster by Dr. Allan points to advantage in respect of their health to infants of mothers who have no occupation. Figures published by Dr. Sykes concerning a smaller number of cases in St. Pancras point in the same direction. In a report on infant and child mortality recently issued, the medical officer of the Local Government Board (Dr. Arthur Newsholme) discusses inter alia the possibility that the variations in infantile mortality, owing to varying environment, may exercise a selective influence on the children surviving beyond the first year of life. The conclusions arrived at by Mr. G. Udny Yule, who made a statistical study of the subject, are thus stated by Dr. Newsholme :—"There is little definite evidence of such selection beyond the second year of life, and after the third year the environmental influences even of infancy alone appear to preponderate over any possible selective influence." 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 1909 (52 weeks) was 6,285, giving an annual death-rate of 130 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 1903 1.76 1 1851-60 5.13 1904 2.14 2 1861-70 5.23 1905 1.69 2 1871-80 3.86 1906 1.92 2 1881-90 3.02 1907 1.42 2 1891-1900 2.66 2 1908 1.35 1901 2.23 2 1909 1.30 1902 2.212 It will be seen from the following table that in the quinquennium 1904-8, London had a lower death-rate from these diseases than any of the undermentioned English towns, except Bristol, Bradford, Newcastle-on-Tyne and Leicester, and in 1909 had a lower death-rate than any, except Leeds, Bristol, Bradford, Newcastle-on-Tyne and Leicester. 1 Origin uncertain. Originally described as simple continued fever. 2 See footnote (2), page 6. 28 Principal Epidemic Diseases—Death.rates per 1,000 persons living. Town. 1904.8. 1909. Town. 1904.8. 1909. London 1.70 1.30 West Ham 2.83 2.24 Liverpool 3.01 2.11 Bradford 1.63 0.68 Manchester 2.47 1.81 Newcastle.on.Tyne 1.7.9 1.22 Birmingham 2.34 2.03 Hull 2.55 1.38 Leeds 1.83 0.80 Nottingham 2.08 1.67 Sheffield 2.57 1.78 Salford 3.07 2.45 Bristol 1.33 0.87 Leicester 1.67 1.22 The following table shows that the London death.rate from six of these principal epidemic diseases, viz.: smallpox, measles, scarlet fever, diphtheria (including croup), whooping.cough and enteric fever was, in the quinquennium 1904.8, higher than the death.rates of all the undermentioned foreign towns except St. Petersburg and New York, and in 1909, was higher than that of all except St. Petersburg, Berlin, Rome and New York. Six Principal Epidemic Diseases—Death.rates per 1,000 persons living. Town. 1904.8. 1909. Town. 1904.8. 1909. London 1.011 0.981 St. Petersburg 3.20 2.46 Paris 0.55 0.50 Berlin 0.80 1.03 Brussels 0.48 0.46 Vienna 0.82 0.69 Amsterdam 0.96 0.79 Rome 0.97 0.99 Copenhagen 0.66 0.79 New York 1.10 0.98 Stockholm 0.56 0.54 The following table shows the deaths from the principal epidemic diseases and the death.rates per 1,000 persons living in each of the sanitary areas of the County in 1909, and the death.rates for the eriod 1904.8:— Principal Epidemic Diseases.—Death.rates in sanitary areas. Sanitary area. Deaths, 1909 (52 weeks). Death.rate per 1,000 persona living. 1904.8. 1909. Paddington 136 1.26 091 Kensington 183 1.28 1.00 Hammersmith 210 1.73 1.67 Fulham 276 2.18 1.57 Chelsea 75 1.44 1.00 Westminster, City of 104 0.76 0.63 St. Marylebone 105 1.14 0.83 Hampstead 50 0.55 0.52 St. Pancras 230 1.47 0.97 Islington 423 1.41 1.22 Stoke Newington 34 1.04 0.63 Hackney 220 1.71 0.93 Holborn 45 1.34 0.85 Finsbury 224 2.45 2.36 London, City of 13 0.70 0.72 Shoreditch 328 2.88 2.87 Bethnal Green 260 2.44 1.99 Stepney 526 2.53 1.68 Poplar 405 2.66 2.37 South wark 350 2.29 1.67 Bermondsey 348 2.52 2.74 Lambeth 387 1.56 1.19 Battersea 239 1.67 1.29 Wandsworth 286 1.37 0.96 Camberwell 306 1.51 1.08 Deptford 178 1.83 1.51 Greenwich 114 1.63 1.03 Lewisham 93 1.18 0.57 Woolwich 137 1.46 1.02 London 6,285 1.70 1.30 1 See footnote (1), page 6. Diagram VI SMALLPOX. 29 It will be seen from the foregoing table that the death.rate from the principal epidemic diseases in the period 1904.8 and in the year 1909, was highest in Shoreditch (2.88 and 2.87 respectively) and lowest in Hampstead (0.55 and 0.52 respectively). The death.rates from these diseases during each of the four quarters of the year were as follows : First quarter, 1.73 ; second quarter, 1.38 ; third quarter, 133; and fourth quarter, 0.77 per 1,000 persons living. The extent to which the death.rate from the principal epidemic diseases (excluding diarrhoea) and from diarrhoeal diseases, varies with social condition, will be seen on reference to Diagram IV. Smallpox and Vaccination. Fifteen cases of smallpox are known to have occurred in the Administrative County of London during the year 1909, and of these two terminated fatally; two deaths were attributed to cowpox. The death-rates from smallpox in successive periods have been as follows:— Smallpox. Period. Death.rate per 1,000 persons living. Period. Death.rate per 1,000 persons living. 1841-50 0.402 1903 0.0031 1851-60 0.280 1904 0.0051 1861-70 0.276 1905 0.0021 1871-80 0.457 1906 — 1881-90 0.142 1907 — 1891-1900 0.0091 1908 — 1901 0.051 1909 0.0001 1902 0.2821 The smallpox death-rate in each year since 1840 in relation to the mean death.rate during the period 1841.1909 is shown in diagram VI. 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.— Cases notified and case.rates per 1,000 living. Year. Cases notified. Case-rato 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 1908 4 0.001 1909 21 0.004 It will be seen from the following table that in the quinquennium 1904.8 only four of the undermentioned towns, namely Bradford, Newcastle-on-Tyne, Hull and Nottingham, had a rate exceeding 0.005 per 1,000, while in 1909 deaths occurred in London, Bristol and Hull only. 2057 1 See footnote (1), page 6. e 30 Smallpox—Death-rates per 1,000 persons living. Town. 1904-1908. 1909. Town. 1904-1908. 1909. London 0.00 o.oo1 West Ham 0.00 Liverpool 0.00 — Bradford 0.01 — Manchester 0.00 — Newcastle-on-Tyne 0.02 — Birmingham 0.00 — Hull 0.01 0.01 Leeds 0.00 — Nottingham 0.01 — Sheffield 0.00 — Salford 0.00 — Bristol 0.00 0.02 Leicester 0.00 — In this table 0.00 indicates that the deaths were too few to give a rate of 0.005 ; where no death occurred—is inserted. The following table shows that of the undermentioned towns, St. Petersburg is the only one which had an appreciable death-rate from smallpox during the year 1909. Smallpox—Death-rates per 1,000 persons living. Town. 1904-1908. 1909. Town. 1904-1908. 1909. London 0.001 0.001 St. Petersburg 0.06 0.17 Paris 0.02 0.00 Berlin 0.00 0.00 Brussels 0.00 0.00 Vienna 0.00 — Amsterdam 0.00 — Rome 0.00 0.00 Copenhagen — — New York 0.00 0.00 Stockholm — — In this table 0.00 indicates that the deaths were too few to give a rate of 0.00; where no death occurred — is inserted. The actual occurrences of cases of smallpox in 1909 were the following:— February.—Camberwell.—P. W., a male, aged 20, was associated on the journey from Alexandria to London with a man who complained of being unwell, and on whose face an eruption had appeared. Smallpox eruption appeared on P.W. about eleven days after his arrival in London— i.e., on 1st February. He was removed to hospital on the 5th February. March.—Westminster.—L. C., a male, aged 26, was employed as a sculleryman in a hotel, but lived at home. Smallpox eruption appeared on the 5th March, and he was removed to hospital on the 8th. The source of infection was not discovered. Hackney.—C. C., a male, aged 54, was employed as a salesman in a warehouse in the City. Smallpox eruption appeared on the 10th March, and he was removed to hospital on the 13th. The source of infection was not discovered. Holbom.— H. S., a male, aged 22, had been travelling in the Mediterranean and Riviera. Smallpox eruption appeared on March 16th, two days after his return to England, and he was removed to hospital on the following day. October—Stepney.—J. G., a male, aged 40, a stoker on board a ship. He went into hospital at Algiers with four other men, two of whom died. He was himself only detained a few days and travelled to London, where he arrived on the 28th September. After calling in London at the rooms of his sister and her husband (M. M. and J. M.), he proceeded at once to Capel, near Tonbridge, where they were hop-picking. The three returned to Royal Mint-square on the 30th September. On this or the following day, a smallpox eruption appeared on J. G., and he was removed to hospital on the 4th October. M. M. and J. M. were removed to the shelter of the borough council, and both sickened with smallpox on the 13th October, the eruption appearing in each case on the 15th, on which day they were both removed to hospital from the shelter. E. G., a female, aged 40, who lived in a tenement adjoining that of the above, sickened with smallpox on the 19th October. Her eruption appeared on the 21st, but the patient was not removed to hospital until the 1st November, as the nature of the disease was not before recognised. 'November.—Stepney.—Four other cases occurred in neighbouring tenements during November, viz., J. O'B., male, aged 49, whose eruption appeared on the 8th November, and who was removed to hospital the same day. K. C., female, aged 51, whose eruption also appeared on the 8th November, and who was removed to hospital the same day. S. K., female, aged 35, whose eruption appeared on the 10th November, and who was removed to hospital the same day ; and P. O'B., female, aged 34 (wife of J. O'B.), whose eruption appeared on November 19th, and who was removed to hospital the same day. December.—Islington.—-W. C., a male, aged 29, member of a theatrical company, was exposed to infection of smallpox in Dantzig, and suffered from an eruption, which, on his arrival in London on the 28th November, was thought to be that of chickenpox. He lodged in a house in Islington, and attention was directed to his case by the occurrence of smallpox in W. F., male, aged 1 See footnote (2) page 6. 31 7 years, living in the same house. W. F.'s eruption appeared on the 13th December, and he wa removed to hospital on the 18th December. W. C. was removed to hospital on the 20th December as he was not entirely free from eruption. E. F., female, aged 28, the mother of W. F., fell ill with smallpox on the 30th December, and was removed to hospital on the 31st. Another person developed smallpox at Tottenham in December, through visiting W. C. during his convalescence, and from this case three other cases resulted in the same house in Tottenham, and a further case in Friern Barnet. A further case, C. S., a male, aged 26, occurred in the house in Islington which had been occupied by W. C. His eruption appeared on the 5th January, 1910, and he was removed to hospital the following day. The limitation of this outbreak was largely due to the persistent inquiries made by the medical officer of health of Islington, as to the persons with whom W. C. had been in contact, and to the steps which were able to be taken on the information thus gained. Poplar.—T. M., male, aged 56, a casual labourer, developed smallpox in Aberfeldy.street, Poplar. He sickened on the 30th December, eruption appeared on the 2nd January, 1910, and he was removed to hospital the following day. Four cases of smallpox occurred on vessels in the Port of London, and were removed by the Port medical officer of health to the Corporation's hospital at Denton. Of the fifteen patients admitted into the hospital of the Metropolitan Asylums Board, twelve were vaccinated and three unvaccinated. One death occurred among the unvaccinated and one among the vaccinated. 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. 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 1890 13.9 1873 8.7 1891 16.4 1874 8.8 1892 18.4 1875 9.3 1893 18.2 1876 6.5 1894 20.6 1877 7.1 1895 24.9 1878 7.1 1896 26.4 1879 7.8 1897 29.1 1880 7.0 1898 33.0 1881 5.7 1899 27.7 1882 6.6 1900 25.8 1883 6.5 1901 24.1 1884 6.8 1902 21.3 1885 7.0 1903 20.7 1886 7.8 1904 19.1 1887 9.0 1905 18.9 1888 10.3 1906 21.2 1889 11.6 1907 22.7 The percentage of children born who were exempted by "conscientious objection" certificates since and including 1898 has been as follows:—1898, 1.4; 1899, 1.0; 1900, 1.0; 1901, 1.1; 1902, 0.8; 1903, 10; 1904, 1 1; 1905, 1 2; 1906, 15; 1907, 3 1. During these years, the proportion of children exempted by certificate of conscientious objection, together with the proportion of children not finally accounted for in the several Unions, has been as follows:— Number of children for whom certificates of conscientious objection were obtained together with the number of children not finally accounted for (including cases postponed) per cent, of births. Metropolitan Union. 1898. 1899. 1900. 1901. 1902. 1903. 1904. 1905. 1906. 1907 Bermondsey 32.5 23.6 21.8 18.0 17.5 16.3 16.6 15.7 17.2 18.0 Bethnal Green 67.0 48.2 49.2 52.2 44.1 44.9 42.8 42.0 48.3 55.1 Camberwell 41.2 29.7 23.0 20.0 21.4 21.8 23.6 23.4 26.8 34.0 Chelsea 17.3 14.9 16.0 13.4 14.9 13.9 10.0 8.9 13.0 14.3 Fulham 15.4 12.6 13.7 120 11.8 12.7 11.5 10.8 14.6 18.1 George's, St., Hanover.square 11.1 9.0 7.1 5.8 7.5 5.1 4.9 4.4 4.3 7.2 George, St., in.the. East 34.6 35.0 33.5 30.6 29.7 27.7 15.7 17.3 16.8 17.7 Giles, St., and St. George 32.5 33.0 33.6 30.7 27.1 24.9 17.9 20.4 20.8 28.1 Greenwich 17.2 14.2 13.8 12.6 11.1 11.1 10.4 9.7 9.8 13.1 (Continued on next page). 2057 E 2 32 Metropolitan Union. 1898. 1899. 1900. 1901. 1902. 1903. 1904. 1905. 1906. 1907. Hackney 49.0 38.6 40.4 38.5 26.1 25.5 26.9 28.2 36.8 33.2 Hammersmith 13.8 11.7 9.1 8.3 9.4 7.2 7.4 8.0 10.1 13.1 Hampstead 15.4 10.3 11.0 10.0 9.2 9.5 9.2 9.2 10.4 12.3 Holborn 43.8 31.8 28.5 27.6 23.2 20.7 20.4 20.6 24.5 26.7 Islington 31.1 29.2 26.2 21.6 17.7 17.0 15.9 17.5 18.2 21.2 Kensington 13.5 10.2 9.2 9.0 7.2 6.6 6.6 5.5 7.2 8.0 Lambeth 30.6 25.2 20.6 22.2 20.4 21.0 16.9 17.3 19.6 23.4 Lewisham 27.8 22.6 20.7 15.7 135 15.4 14.0 13.8 16.2 21.4 London, City of 25.4 18.3 14.2 11.3 11.3 11.8 13.0 15.3 16.8 17.5 Marylebone, St. 18.0 20.9 17.7 14.6 12.5 10.8 10.4 10.8 12.1 12.7 Mile End Old Town 68.9 69.9 68.0 66.1 58.8 59.8 47.3 47.1 48.4 52.3 Paddington 14.7 14.6 13.5 11.0 10.1 11.7 12.7 13.3 13.3 15.5 Pancras, St. 36.7 36.1 32.9 32.8 26.2 25.3 23.1 22.1 260 31.1 Poplar 63.6 50.1 49.0 491 44.2 46.9 45.4 45.3 49.3 53.9 Shoreditch 68.8 52.4 53.0 44.7 36.4 36.6 34.8 36.7 33.3 33.3 Southwark 32.6 30.3 27.6 26.8 25.4 24.9 24.3 24.2 28.4 31.1 Stepney 48.6 46.9 44.4 44.3 37.2 35.8 32.9 32.9 32.9 38.1 Strand 25.2 19.7 19.2 16.1 19.0 18.6 150 11.8 11.7 14.2 Wandsworth and Clapham 32.2 25.1 23.0 20.5 19.2 17.2 16.3 14.8 18.0 22.8 Westminster 17.4 14.8 12.2 13.3 13.4 12.1 11.0 8.2 9.4 10.1 Whitechapel 11.8 14.5 13.1 10.5 9.5 10.1 9.1 10.6 11.5 14.1 Woolwich. 10.2 8.3 7.5 9.8 9.7 7.1 7.2 6.6 9.3 15.0 London 34.4 28.7 26.8 25.2 22.1 21.7 20.2 20.1 22.7 25.8 Measles. The deaths from measles in the Administrative County of London during 1909 (52 weeks) numbered 2,324, as compared with 1,524 in 1908 (53 weeks). The death.rates from this disease per 1,000 persons living in 1909 and preceding periods haye been as follows:— Measles. Period. Death.rate per 1,000 persons living. Period. Death.rate per 1,000 persons living. 1841.50 0.62 1903 0.44 1 1851.60 0.53 1904 0.49 1 1861.70 0.58 1905 0.37 1 1871.80 0.51 1906 0.41 1 1881.90 0.64 1907 0.38 1 1891.190 0.58 1 1908 0.31 1 1901 0.431 1909 0.481 1902 0.511 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 1903 3.901 1861.70 4.18 1904 4.301 1871.80 3.65 1905 3.191 1881.90 4.74 1906 3.571 1891.1900 4.82 1907 3.29 1 1901 3.701 1908 2.711 1902 4.421 1909 4.18 1 1 See footnote (1) page 6. MEASLES Diagram VII MEASLES & WHOOPING-COUGH. (Deaths 1891-1909). Diagram VIII 33 The death.rate in each year since 1840 in relation to the mean death.rate of the period 1841.1909, calculated on the population at all ages, is shown in diagram "VII. The monthly deaths from measles in relation to the mean of the period 1891.1909 is shown in diagram VIII. The following table shows the deaths and death.rates from measles in 1909 (52 weeks) in each of the sanitary areas of the County :— Measles—Death.rates1 in sanitary areas. Sanitary area. Deaths, 1909 (52 weeks). Death.rate per 1,000 persons living. 1904.8. 1909. Paddington 36 0.26 0.24 Kensington 58 0.30 0.32 Hammersmith 80 0.44 0.64 Fulham 74 0.42 0.42 Chelsea 24 0.38 0.32 Westminster, City of 25 0.13 0.15 St. Marylebone 33 0.27 0.26 Hampstead 14 0.12 0.15 St. Pancras 105 0.37 0.44 Islington 199 0.41 0.57 Stoke Newington 10 0.18 0.18 Hackney 57 0.31 0.24 Holborn 14 0.36 0.26 Finsbury 85 0.65 0.89 London, City of 6 0.08 0.33 Shoreditch 130 0.67 1.14 Bethnal Green 79 0.57 0.60 Stepney 236 0.60 0.76 Poplar 156 0.53 0.91 Southwark 127 0.60 0.60 Bermondsey 200 0.70 1.57 Lambeth 104 0.35 0.32 Battersea 90 0.38 0.49 Wandsworth 111 0.27 0.37 Camberwell 105 0.35 0.37 Deptford 67 0.43 0.57 Greenwich 38 031 0.34 Lewisham 6 0.20 0.04 Woolwich 55 0.24 0.41 London 2,325 0.39 0.48 In the distribution of measles mortality throughout the year 1909, the highest death.rate obtained in Bermondsey (1.57) and the lowest in Lewisham (0.04). There was in 1909, as compared with 1908, increased mortality in every district except Hackney, Bethnal Green, Stepney, Lewisham and Stoke Newington, and an exceptionally high mortality in 1908 was maintained in Bermondsey and Stepney in 1909. For the period 1904.8, Bermondsey (0'70) had the highest measles death.rate, and the City of London (0.08) the lowest. The death.rates from this disease in each of the four quarters of the year 1909 were as follows—first quarter, 0'95 ; second quarter, 0.69 ; third quarter, 017 ; and fourth quarter, 011 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 1909. Measles1—Mortality among children at ages 0.5 in sanitary areas—1909. Sanitary area. Death.rate per 1,000 children living aged 0.5, 1909. Sanitary area. Death.rate per 1,000 children living aged 0.5, 1909. Sanitary area . Death.rate per 1,000 children living aged 0.5, 1909. Paddington 2.74 Stoke Newington 1.60 Bermondsey 11.43 Kensington 3.87 Hackney 2.06 Lambeth 2.87 Hammersmith 5.90 Holborn 3.22 Battersea 3.70 Fulham 3.23 Finsbury 7.29 Wandsworth 3.27 Chelsea 3.45 London, City of 5.80 Camberwell 311 Westminster, City of 1.95 Shoreditch 8.54 Deptford 4.40 St. Marylebone 2.97 Bethnal Green 435 Greenwich 2.97 Hampstead 1.62 Stepney 5.62 Lewisham 0.35 St. Pancras 411 Poplar 6.89 Woolwich 3.18 Islington 5.09 Southwark 4.81 London 423 1 See footnote (2) page 6. 34 The mortality from measles in the several districts is in a large degree determined by the social condition of the population. If London districts be grouped in relation to overcrowding, it is found that the groups having the largest proportion of their population "overcrowded" have the highest death.rates from measles. The following table shows the measles mortality under five years of age in five groups of districts, arranged in order, according to the proportion of their population living more than two in a room in tenements of less than five rooms :— Measles and overcrowding,1 1901.9. Proportion of overcrowding1 in groups of sanitary areas. Measles death-rate 2 at ages 0.5 per 1,000 living 1901.9. Under 7.5 per cent. 2.14 7.5 to 12.5 per cent. 3.34 12.5 to 20.0 per cent. 4.02 20.0 to 27.5 per cent. 4.29 Over 27.5 per cent. 4.74 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 quinquennium 1904.8, the London death.rate was exceeded by the death.rates of Liverpool, Manchester, Leeds, Sheffield, West Ham, Hull, Nottingham and Salford, and in the year 1909 was lower than that of any except Leeds, Bristol, Bradford, Newcastle, Hull and Leicester. Measles—Death.rates per 1,000 persons living. Town. 1904.8. 1909. Town. 1904.8. 1909. London 0 392 0.482 West Ham 0.52 0.69 Liverpool 0.55 0.61 Bradford 0.28 0.08 Manchester 0.56 0.62 Newcastle.on.Tyne 0.31 0.40 Birmingham 0.38 0.93 Hull 0.41 0.31 Leeds 0.44 0.16 Nottingham 0.40 0.54 Sheffield 0.46 0.88 Salford 0.67 0.80 Bristol 0.31 0.24 Leicester 0.34 0.41 The following table shows that the London measles death.rate, in the quinquennium 1904.8, was higher than that of any of the undermentioned foreign towns except Amsterdam, St. Petersburg, Vienna and Rome. In 1909 it was only exceeded by that of St. Petersburg. Measles—Death.rates per 1,000 persons living. Town. 1904.8. 1909. Town. 1904.8. 1909. London 0.392 0.482 St. Petersburg 0.83 0.82 Paris 0.19 0.18 Berlin 0.20 0.19 Brussels 0.14 0.15 Vienna 0.39 0.25 Amsterdam 0.46 0.36 Rome 0.45 0.43 Copenhagen 0.15 0.22 New York 0.21 0.22 Stockholm 0.07 0.04 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 (2), page 6). 1 See footnote (2), page 25. 2 See footnote (2), page 6. 35 Measles '—Deaths at the several age-periods in sanitary areas—1909 (365 days). Age-period. 0— l— 2— 3— 4— Under 5. 5— 10— 15 and upwards. All Ages. Paddington 10 19 5 2 1 37 37 Kensington 12 28 11 5 1 57 1 — — 58 Hammersmith 17 38 12 8 5 80 — — — 80 Fulham 14 36 11 7 6 74 1 — — 75 Chelsea 3 11 2 4 2 22 2 — 1 25 Westminster, City of 5 10 5 2 1 23 1 — 2 26 St. Marylebone 7 19 4 — 1 31 3 — — 34 Hampstead 4 3 3 — 2 12 1 — — 13 St. Pancras 29 41 21 5 4 100 6 — 1 107 Islington 32 90 40 17 13 192 10 — 1 203 Stoke Newington 2 2 2 1 1 8 2 — — 10 Hackney 9 19 12 6 8 54 2 — 1 57 Holborn 2 5 4 2 1 14 — — — 14 Finsbury 22 46 9 5 2 84 3 — — 87 London, City of — 2 1 2 1 6 — — — 6 Shoreditch 35 54 18 11 5 123 8 — — 131 Bethnal Green 17 34 13 7 7 78 2 — — 80 Stepney 78 106 28 14 8 234 6 — — 240 Poplar 33 69 33 13 3 151 4 — — 155 Southwark 28 51 27 10 9 125 4 — — 129 Bermondsey 31 91 35 13 17 187 13 — — 200 Lambeth 21 41 27 7 4 100 4 — — 104 Battersea 14 33 22 10 4 83 6 — — 89 Wandsworth 22 41 19 15 6 103 9 1 — 113 Camberwell 21 45 19 9 6 100 7 — — 107 Deptford 16 26 15 4 2 63 4 — — 67 Greenwich 10 15 8 3 2 38 3 — — 41 Lewisham — 2 4 — — 6 — — — 6 Woolwich 14 20 9 5 2 50 5 — — 55 London 508 997 419 187 124 2,235 107 1 6 2,349 Medical officers of health derive their information as to the occurrence 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, 1909. Sanitary area. No. of cases of measles, 1909. Sanitary area. No. of cases of measles, 1909. Paddington 709 Hackney 911 Lambeth 1,616 Kensington 542 Holborn 139 Battersea 811 Hammersmith 847 Finsbury 436 Wandsworth 1,670 Fulham 740 Shoreditch 365* Deptford 467 Chelsea 332 Bethnal Green 599 Greenwich 795 Westminster 529 Poplar 789 Lewisham 383 Hampstead 283 Southwark 833 Woolwich 768 Islington 1,667 Bermondsey 755 * Houses invaded. The age distribution of the cases made known to the medical officer of health is shown in the report relating to Paddington, thus : Measles—Age incidence of cases. Sanitary area. 0— 1— 2— 3— 4— 5— 13- 15— Paddington i. 40 95 96 85 102 277 2 12 The majority of the reports of medical officers of health give account of steps taken to limit measles prevalence in their districts. The general rule is for the invaded house to be visited, and advice, 1 See footnote (2) page 6. 36 printed or verbal, to be given concerning the precautions which should be taken. In measles, especially, difficulty is experienced from the fact that the disease often occurs without the patient being under medical treatment or supervision. Thus, in Hampstead, of 283 cases brought to the knowledge of the medical officer of health, no medical practitioner was in attendance in 51. In Holborn the same fact was observed in 17 out of 124 cases, and in Bethnal Green in 137 out of 599 cases, or some 20 per cent, of the cases in the three districts. Many of the reports show the steps taken in the schools to prevent extension of measles, through school attendance, either by way of closure of schools or classes, by exclusion from school of children from invaded houses, or by the more recent method of exclusion from school in some cases of children who are not known to be protected by previous attack. In Woolwich it was deemed necessary to exclude from attendance at most of the schools all children under five years of age for some weeks during the year, and this course was adopted iu Lewisham in the case of three schools. Reference will be found on page 106 to a memorandum issued in 1909 by Dr. Newsholme and Dr. Newman, medical officers of the Local Government Board and Board of Education respectively, dealing with the administrative measures necessary for the prevention of the spread of infectious diseases among children attending elementary schools. As in previous years, the medical officers of health of Paddington and Hampstead shew the number of houses in which there occurred during the year more than one case of measles, thus : Measles—Single and multiple cases, 1909 Sanitary area. Number of houses in which one or more cases occurred. One case, Two cases. Three cases. Four cases. Five cases. Six cases. seven cases. Paddington 200 104 55 21 9 — 1 Hampstead 128 42 15 5 1 — Thus of 581 houses invaded in these districts multiple cases occurred in 253. Scarlet Fever. The cases of scarlet fever notified in the Administrative County of London during 1909 (52 weeks) numbered 17,254, compared with 22,072 in 1908 (53 weeks). The number of deaths registered from this cause was 383 in the year 1909 (52 weeks), compared with 548 in 1908 (53 weeks). The scarlet fever case.rates, death.rates and case.mortality for 1909 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. Case. mortality per cent. 1861.70 1.13 1 1 1871.80 0.60 I 1 1881.90 0.33 1 l 1891.1900 0.192 4.8 3.8 1901 0.132 41 3.2 1902 0.122 3.9 31 1903 0.082 2.7 2.9 1904 0.082 2.9 2.7 1905 0.122 4.2 2.8 1906 0.112 4.3 2.6 1907 0.142 5.5 2.5 1908 0.112 4.5 2.5 1909 0.082 3.6 2.2 The death.rate in each year since 1858 in relation to the mean death.rate of the period 1859. 1909 will be seen on reference to diagram IX. It will be observed that the death.rate of 1909 was the same as in 1900, 1903 and 1904, the lowest death.rate recorded in London. The monthly case.rate and case.mortality in each of the years 1891.1909 in relation to the mean of the whole period is shown in diagram XI. It will be seen from the following table that in the peiiod 1904.8 the London scarlet fever death. rate was exceeded by that of Liverpool, Manchester, Birmingham, Sheffield, West Ham, Salford and Leicester, and in 1909 was in addition exceeded by that of Newcastle.on.Tyne. 1 The Infectious Disease (Notification) Act came into force iu 1889. 2 See footnote (2), page 6. SCARLET FEVER: Diagram IX. Diagram X Number of admissions to Hospitals of the Metropolitan Aeylums Board percent, of total cases notified in London. 1890-1909 SCARLET FEVER. Diagram XI. 37 Scarlet Fever—Death.rates per 1,000 persons living. Town. 1904.8. 1900. Town. 1904.8. 1909. London 0.11 1 0.081 West Ham 0.15 0.17 Liverpool 0.26 0.28 Bradford 011 0.07 Manchester 0.15 0.26 Newcastle.on.Tyne 0.07 0.11 Birmingham 0.12 0.19 Hull 0.05 0.04 Leeds 0.09 0.02 Nottingham 0.06 0.04 Sheffield 0.24 0.09 Salford 0.25 0.34 Bristol 0.08 0.03 Leicester 0.13 0.09 The following tabic shows that in the year 1909 the London scarlet fever death.rate was higher than that of Paris, Brussels, Amsterdam and Rome, and in the quinquennium 1904.8 was exceeded by the death.rates of Stockholm, St. Petersburg, Berlin and New York. Scarlet Fever—Death.rates per 1,000 persons living. Town. 1904.8. 1909. Town. 1904.8. 1909. London 0.111 0.08 1 St. Petersburg 0.56 0.48 Paris 0.06 006 Berlin 0.16 0.30 Brussels 0.05 0.07 Vienna 0.10 0.17 Amsterdam 0.05 0.03 Rome 0.02 0.05 Copenhagen 0.05 0.17 New York 0.20 0.17 Stockholm 0.15 0.17 The following table shows the scarlet fever cases, deaths, case.rates, and death.rates for the year 1909 and the case.rates and death.rates for the period 1904.8 in the several sanitary districts of the County:— Scarlet Fever—Case.rates and death.rates in sanitary areas. Sanitary area. Notified cases, 1909 (52 weeks). Case.rate per 1,000 persons living. Deaths, 1909 (52 weeks). Death.rate per 1,000 persons living. 1904.8. 1909. 1904.8. 1909. Paddington 630 3.50 4.16 14 0.09 0.09 Kensington 420 2.26 2.29 9 0.06 0.05 Hammersmith 389 3.39 3.10 11 0.09 0.09 Fulham 511 3.71 2.90 10 0.09 0.06 Chelsea 307 2.68 4.09 6 0.09 0.08 Westminster, City of 590 2.60 3.50 18 0.07 0.11 St. Marylebone 458 2.82 3.64 8 0.11 0.06 Hampstead 259 2.97 2.76 4 0.06 0.04 St. Pancras 771 3.74 3.26 17 0.11 0.07 Islington 1,285 3.68 3.67 26 0.09 0.07 Stoke Newington 110 3.45 2.03 3 0.08 0.06 Hackney 784 5.23 3.31 10 0.12 0.04 Holborn 97 2.67 1.81 3 0.06 0.06 Finsbury 240 4.45 2.53 11 0.17 0.12 London, City of 38 3.51 2.09 — 0.09 — Shoreditch 340 5.58 2'97 9 0.20 0.08 Bethnal Green 566 673 4.32 25 0.23 0.19 Stepney 1,038 6.36 3.33 26 0.17 0.08 Poplar 731 5.46 4.26 23 0.17 0.13 Southwark 590 5.50 2.80 14 014 0.07 Bermondsey 459 6.00 3.61 15 0.19 0.12 Lambeth 1,171 3.70 3.62 27 o.10 0.08 Battersea 733 4.88 3.95 8 0.11 0.04 Wandsworth 997 4.31 3.36 14 0.08 0.05 Camberwell 1,022 4.34 3.62 17 0.09 0.06 Deptford 374 5.45 316 12 o.io 0.10 Greenwich 390 4.06 3.52 9 0.08 0.08 Lewisham 927 3.60 5.78 15 0.06 0.09 Woolwich 1,027 4.90 7.72 19 0.09 0.14 Port of London London 17,254 4.27 3.58 383 0.ll 0.08 2057 1 See footnote (2) page 6. 38 It will be seen from the foregoing table that the scarlet fever death-rate was, in the period 1904-8, highest in Bethnal Green (0.23) and lowest in Kensington, Hampstead, Holborn and Lewisham (0-06); in the year 1909, Bethnal Green (0.19) had the highest death-rate, and Hampstead, Hackney and Battersea (0.04) the lowest, exclusive of the City of London, where no deaths occurred. The scarlet fever death-rates obtaining in London in the four quarters of the year 1909 were as follows : first quarter, 0.09; second quarter, 0.09; third quarter, 0.07; and fourth quarter, 0.07 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 1909. It will be seen that at " all ages ' the case-rate, death-rate and fatality were higher among males than among females. In the age-groups adopted for the purposes of this table the greatest incidence of attack was upon both males and females of four years of age. The greatest incidence of death was upon males of three and females of one year of age. The fatality, it will be observed, was highest among male children under one year of age and among female children of one year of age. The fatahty shown foi males aged 45— is obviously abnormal, and occasioned by the smallness of the figures. Scarlet Fever1—1909. Age-period. Males. Females. Notified cases. Deaths.2 Casemortaiity per cent. Rates por 100,000 living. Notified cases. Deaths.2 Casemortality per cent. Kates per 100,000 living. Cases. Deaths. Cases. Deaths. All Ages 8,238 210 25 362 9 9,016 184 24 354 7 0— 111 15 135 190 26 88 6 6.8 152 10 ]— 305 26 8.5 589 50 290 31 10.7 560 60 2— 593 26 4.4 1,133 50 549 18 3.3 1,053 35 3— 739 29 3.9 1,450 57 734 29 4.0 1,423 56 4— 795 28 3.5 1,594 56 819 23 2.8 1,650 46 5— 3,342 57 1.7 1,428 24 3,836 54 1.4 1,623 23 10— 1,416 14 1.0 641 6 1,485 16 1.1 660 7 15— 461 8 1.7 208 4 411 2 0.5 166 1 20— 220 3 1.4 95 1 311 3 1.0 112 1 25— 197 3 1.5 50 1 378 2 0.5 81 0 35— 50 — — 17 — 78 — — 24 — 45— 5 1 20.0 2 0 22 — — 9 — 55 & upwards 4 — — 2 — 15 — — 6 — , [_J 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 Council schools began in 1909 on Thursday, the 22nd July, i.e., the latter part of the 29th week, and the schools re-opened on Monday, the 23rd August, i.e., at the beginning of the 34th week. If the number of cases notified in the four weeks which would be most subject to holiday influence be compared with the number of cases notified in the four preceding and four subsequent weeks, ;the results shown in the following table are obtained:— 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 (27th to 30th) Four weeks of holiday influence (31st to 34th) Four weeks following weeks of holiday influence (35th to 38th) 187 148 174 1,100 812 1,238 215 169 222 -20.9 + 17.6 -26.2 +52.5 -21.4 + 31.4 The only outbreak of scarlet fever during the year which was attributed to milk occurred in the month of June, the milk being derived from a dairy farm in Wiltshire. Prevalence of scarlet fever resulted in several districts of London, and in greater degree in Surrey. The occurrence of this outbreak was first brought to my knowledge by Dr. Allan, after investigations of cases of scarlet fever in Westminster, and its circumstances in the various localities invaded were subsequently investigated by Dr. W. H. Hamer, on behalf of the London County Council, and by Dr. T. Henry Jones, on behalf of the Surrey County Council, and a detailed report by these officers is appended. (See appendix I.) 1 See footnote (2) page 6. 2 The cases are those notified during the year, but, as is the case in similar tables published in previous reports, the deaths relate to a period of one year commencing somewhat later, in order that they may correspond more closely to the cases upon which the case-mortality is calculated. 39 In this report it is clearly demonstrated that the milk from this dairy farm was the cause of the occurrences of scarlet fever, and the question is discussed as to how the milk became infected. In this outbreak, as in many others which have been investigated, there was absence of evidence that the milk was infected by human agency. Scarlet fever certainly occurred in the family of a man engaged in the work of the dairy, but in one distant area cases of sore throat, and in other distant areas cases of definite scarlet fever occurred among the consumers of the milk antecedent to its occurrence in this family. It is impossible to reconcile with the facts of the occurrences the view that the milk owed its infection to this family. There appeared to be interruptions to the continued infectivity of the milk as judged by the dates of attack of the different consumers, and again, the milk appeared on one day to have been especially operative in causing scarlet fever. These variations find explanation when the details of treatment and distribution of the milk from the depot come to be studied. Varying amounts of the infected milk were pasteurised on different days, and on the day when the most mischief was done the whole of the infected milk was sent out unpasteurised. The report shows, as in some other outbreaks, that a vesicular disease was found on the teats and udders of some of the cows and the property of infectivity of the milk was first manifested when the milk of one of these cows, which had recently calved, was brought into use after the death of the calf. In a few of the annual reports information is supplied as to the number of cases in which a probable source of infection was ascertained. Thus :— Scarlet fever—Sources of injection. Sanitary area. Cases notified. Source of infection discovered. Total. Previous case in family or house. Infection by friends or neighbours. School. Return cases. Visiting hospitals. Other sources. St. Marylebone 458 194 99 55 25 15 Finsbury 240 81 27 29 12 6 7 — Bermondsey 459 85 53 9 11 12 — — Woolwich 1,027 244 124 36 15 58 8 3 The difficulty of identifying the source of infection is obvious when the mildness of the prevailing type of scarlet fever is considered, prevalence being no doubt maintained in the main by unrecognized and probably often unrecognizable cases. The number of houses in which there were multiple cases is shown in some of the reports as follows:— Scarlet fever—Single and multiple cases, 1909. Sanitary area. Number of houses in which one or more cases occurred. One case. Two cases. Three cases. Four cases. Five cases. Six cases. Paddington 388 59 22 3 1 Fulham 335 52 10 6 — 3 Westminster 421 57 10 5 1 — Holborn 86 6 — — — — Thus of 1,465 houses invaded in these districts, multiple cases occurred in '235. A number of reports give account of the steps taken by way of closure of school departments or classes, or disinfection of schoolrooms, to limit the spread of infection through school attendance. Outbreaks in residential institutions are reported in Chelsea, where scarlet fever occurred among the pupils of the Duke of York School; in Lambeth, where 18 cases occurred in the Lambeth Workhouse and Infirmary, and in a general hospital where cases occurred among the nurses, the attacks being due to the infected milk supply already referred to ; the patients of this institution who had pasteurised milk from the same source escaped. Reference will be found on page 106 to a memorandum issued in 1909 by Dr. Newsholme and Dr. Newman, medical officers of the Local Government Board and Board of Education respectively, dealing with the administrative measures necessary for the prevention of the spread of infectious diseases among children attending elementary schools. Return cases are mentioned in the reports relating to Paddington 40 cases, Kensington 6, Fulham 14, Chelsea 5, Stoke Newington 4, Holborn 1, Finsbury 6, Shoreditch 2, Stepney 16, Bermondsey 12, Wandsworth 46, Camberwell 2, Greenwich 10, and Woolwich 58. Concerning the Wandsworth cases, Dr. Caldwell Smith states that there has been a decrease of return cases since 1908, when parents were advised to prevent the early association of the returning child with others; and with reference to the cases in Bermondsey, Dr. Brown writes that the facts concerning them do not support the view that 2067 f 2 40 they are due to premature discharge of the first patients from the hospitals. In Woolwich, of 996 cases, 81 were retained at home and, as Dr. Davies states, without a second case occurring in the house. Proportion of cases of scarlet fever removed to hospital. It will be seen from diagram X 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. Proportion of cases erroneously certified. Cases certified to be those of scarlet fever and admitted into the hospitals of the Metropolitan Asylums Board in which the diagnosis was not subsequently confirmed, constitute in successive years the following percentage of the total cases admitted :— Scarlet fever—Percentage of total cases admitted concerning which the diagnosis was not subsequently confirmed 1901-1909. Year. Percentage. Year. Percentage. 1901 5.6 1906 4.9 1902 4.7 1907 6.8 1903 6.4 1908 5.8 1904 6.7 1909 6.9 1905 5.4 Diphtheria. The cases of diphtheria (including membranous croup) notified in the Administrative County of London in 1909 (52 weeks) numbered 6,679, compared with 8,002 in 1908 (53 weeks). The number of deaths was 605 in 1909 (52 weeks) compared with 724 in 1908 (53 weeks;. It is well to bear in mind that the case-rate and case-mortality may be affected by variations in the extent of use of bacteriological methods of diagnosis, the effect of which is to increase the notified number of clinically mild cases of the disease. The diphtheria case-rates, death-rates, and case-mortality in 1909, 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-inortality per cent. 1861-70 0.18 l 1871-80 0.12 l i 1881-90 0.26 l l 1891-1900 0.492 2.6 18.8 1901 0.29 2 2.7 10.9 1902 0.25 2 23 10.8 1903 0.16 2 1.7 9.6 1904 0.168 1.6 10.0 1905 0.12 3 1.4 8.4 1906 0.152 1.7 8.6 1907 0.16 2 1.8 8.9 1908 0.15 2 1.6 9.0 1909 0.13 2 1.4 9.1 The death-rate in each year since 1858 in relation to the mean death-rate of the period 18591909 is shown for diphtheria and also for diphtheria and croup combined in diagram XII. It will be observed that the death-rate from diphtheria and croup of 1909 was almost identical with that of 1905, which was the lowest recorded in London. The case rate was the same as in 1905, in which year the rate was the lowest recorded in London. The monthly case-rate and case-mortality in each of the years 1891-1909 in relation to the mean of the period is shown in diagram XIV. 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 quinquennium 1904-8 the London rate was exceeded by that of all except that of Leeds, Sheffield and Leicester, and in 1909 was exceeded by the rates of all except Leeds, Sheffield, West Ham, Nottingham and Leicester. 1 The Infectious Disease (Notification) Act came into force in 1889. 2 See footnote (J), page 6. DIPHTHERIA: Diagram XII Number of admissions to Hospitals of the metropolitan Asylums Board percent, of-Mai casts notified in London. 1890 - 1909 Diagram XIII DIPHTHERIA. Diagram XIV 41 Diphtheria—Death.rates per 1,000 persons living. Town. 1904-8. 1909. Town. 1901-8. 1909. London 0.151 0.131 West'Ham 0.22 0.13 Liverpool 0.20 0.15 Bradford 0.27 0.17 Manchester 0.18 0.17 Newcastle.on.Tyne 0.19 0.19 Birmingham 0.19 0.16 Hull 0.30 0.23 Leeds 0.12 0.13 Nottingham 0.18 o.1o Sheffield 0.13 0.08 Salford 0.41 0.44 Bristol 0.20 0.14 Leicester 0.06 0.06 The following table shows that in the quinquennium 1904.8 the London diphtheria death.rate exceeded that of any of the undermentioned foreign towns except Dtockholm, St. Petersburg, Berlin, Vienna, and New York, and in 1909 was higher than that of any except Stockholm, St. Petersburg, Berlin, Vienna, Rome and New York :— Diphtheria-—Death-rates per 1,000 persons living. Town. 1904-8. 1909. Town. 1904-8.  London 0.151 0.13 St. Petersburg 0.59 0.46 Paris 0.08 0.09 Berlin 0.20 0.32 Brussels 0.09 0.11 Vienna 0.21 0.16 Amsterdam 0.10 0.07 Rome 0.12 0.15 Copenhagen 0.08 0.11 New York 0.45 0.38 Stockholm 0.16 0.17 The following table shows the diphtheria cases, deaths, case.rates, and death.rates foi the year 1909, and the case.rates and death.rates for the period 1904.8, in the several sanitary districts:— Diphtheria.—Case.rates and death.rates in sanitary areas. Sanitary area. Notified Oases, 1909 (52 weeks). Case.rate per 1,000 persons living. Deaths, 1909 (52 weeks). Death.rate per 1,000 persons living. 1901.8. 1909. 1904.8. 1909. Paddington 184 1.00 1.21 10 0.10 0.07 Kensington 177 1.08 0.97 19 0.11 0.10 Hammersmith 192 1.89 1.53 23 0.17 0.18 Fulham 322 2.44 1.83 40 0.18 0.23 Chelsea 98 1.53 1.31 15 0.12 0.20 Westminster, City of 225 0.92 1.34 18 0.07 0.11 St. Marylebone 113 0.99 0.90 9 0.09 0.07 Hampstead 47 0.89 0.50 5 _ 0.06 0.05 St. Pancras 320 1.33 1.35 27 0.12 0*11 Islington 432 1.24 1.23 30 0.11 0*09 Stoke Newington 28 1.39 0.52 2 0.09 0.04 Hackney 264 1.98 1.11 19 0.17 0.08 Holborn 47 0.98 0.88 3 0.10 0.06 Finsbury 167 1.66 1.76 14 0.17 0.15 London, City of 19 1.23 1.05 — 0.12 — Shoreditch 186 1.63 1.62 22 0.14 0.19 Bethnal Green 184 2.37 1.41 17 0.22 0.13 Stepney 583 2.26 1.87 51 0.25 0.16 Poplar 213 2.44 1.24 20 0.28 0.12 South wark 256 1.60 1.22 33 0.16 0.16 Bermondsey 197 1.97 1.55 9 0.17 0.07 Lambeth 378 1.19 1.17 58 0.14 0.18 Battersea 288 1.57 1.55 22 0.12 0.12 Wandsworth 371 1.84 1.25 27 0.14 0.09 Camberwell 374 1.22 1.33 43 0.12 0.15 Deptford 195 2.03 1.65 15 0.14 0.13 Greenwich 163 2.24 1.47 7 0.18 0.06 Lewisham 388 1.75 2.42 21 0.14 0.13 Woolwich 267 2.29 2.01 26 0.17 0.20 Port of London 1 | London 6,679 1.63 1.39 605 0.15 0.13 1 See footnote (2), page 6. 2 The death.rates in this table relate to diphtheria including croup. 42 It will be seen from the foregoing table that in the period 1904-8 the diphtheria death-rate was highest in Poplar (0.28) and lowest in Hampstead (0.06); in the year 1909 Fulham (0.23) had the highest death-rate, and Stoke Newington (0.04) the lowest, exclusive of the City of London, where no death occurred. The diphtheria death-rates in each of the four quarters of the year 1909 were as follows : first quarter, 0.19; second quarter, 0.11 ; third quarter, 0.09 ; and fourth qaarter, 0.11 per 1,000 persons living. To enable the variations in diphtheria prevalence in the several sanitary areas to be more clearly appreciated, the following table has been prepared. This table shows the comparative case-rates of each area in each of the years 1891-1909 inclusive, i.e., the case-rates of each area are shown in relation to the London case-rate of the same year, the London rate being taken as 100 — Diphtheria.1 Sanitary areas.— Comparative case-rates (London taken as 100). Sanitary area. Comparative case-rate (London case-rate taken as 100). 1891. 1892. 1893. 1894. 1895. 1896. 1897. 1898. 1S99. 1900. 1901. 1902. 1903. 1904. 1905. j 1906. 1907. 1908. 1909. Paddington 104 77 73 117 74 66 91 98 68 44 89 65 59 63 50 71 61 60 88 Kensington 78 60 68 63 86 70 67 49 51 74 52 43 59 63 50 59 78 78 70 Hammersmith 195 164 87 72 77 67 49 58 58 85 74 70 82 106 143 135 100 99 111 Fulham 61 58 78 126 139 99 109 145 135 178 174 126 118 125 129 147 200 140 132 Chelsea 138 110 83 107 143 184 107 79 61 74 56 78 76 50 50 129 117 113 94 Westminster, City of 58 91 57 53 61 53 59 67 50 59 52 70 59 50 50 71 44 66 96 StMarylebone 70 81 88 78 64 66 53 64 47 59 74 78 100 56 71 65 56 56 65 Hampstead 105 96 73 53 61 84 47 65 48 74 70 52 59 44 57 65 67 41 36 St. Pancras 89 95 103 83 90 64 76 78 79 93 148 152 129 94 86 71 83 78 98 Islington 152 119 86 103 70 106 73 60 68 70 100 113 82 63 71 76 78 91 89 Stoke Newington 83 113 97 77 70 70 52 59 34 111 104 83 47 75 107 53 122 72 37 Hackney 131 147 135 108 93 89 122 152 106 107 167 139 141 156 121 100 128 99 80 Holborn 52 89 79 61 66 61 104 102 46 70 104 87 53 50 57 71 67 55 63 Fnsbury 118 82 130 81 86 112 170 163 93 74 107 100 76 94 100 118 89 106 127 London, City of 59 130 60 49 51 74 71 60 68 89 96 161 65 106 50 47 78 90 76 Shoreditch 124 89 131 95 80 97 103 80 103 111 104 83 76 100 114 71 106 109 117 BethnalGreen 154 230 181 168 143 114 144 100 89 115 133 104 112 206 164 112 122 127 101 Stepney 106 132 112 123 157 150 128 93 89 107 104 113 106 169 150 118 133 127 135 Poplar 191 148 214 159 179 133 141 105 83 141 137 117 147 250 207 88 117 110 90 Southwark 71 72 116 113 86 106 102 151 207 141 100 113 100 87 107 112 HI 77 88 Bermondsey 68 60 84 126 80 99 97 90 177 133 93 91 76 94 93 153 139 118 112 Lambeth 88 97 91 83 88 74 83 103 121 104 63 70 65 69 100 76 56 65 84 Battersea 144 123 132 122 97 81 125 178 116 70 59 74 106 81 79 88 111 120 112 Wandsworth 74 83 84 79 60 51 100 114 99 74 74 135 124 100 93 118 128 123 90 Camberwell 69 65 67 112 140 180 154 102 156 130 122 113 82 63 64 76 83 85 96 Deptford 72 68 86 153 225 113 141 132 121 111 144 104 241 106 93 153 150 106 119 Greenwich 60 43 84 85 137 189 82 105 122 89 74 78 124 94 100 229 133 123 106 Lewisham 48 74 82 70 57 122 85 127 170 126 85 130 118 56 79 106 111 180 175 Woolwich 32 68 66 66 81 96 91 86 100 115 67 91 88 81 157 176 122 168 145 London 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 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 1909. 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 males of 3— and females of 4— years of age; the greatest incidence of death was upon males and females of one year of age. The fatality was greatest among males and females under two years of age 1 See footnote (!) page 6. 43 Diphtheria1—1909. Age-period. Males. Females. Notified Cases. Deaths. Case mortality per cent. Bates per 100,000 living. Notified Cases. Deaths. Case mortality per cent. Bates per 100,000 living. Cases. Deaths. Cases. Deaths. All Ages 3,110 313 10.1 137 14 3,569 314 88 140 12 0— 124 34 27.4 212 58 99 26 26.3 170 45 1— 259 72 27.8 500 139 212 55 25.9 409 106 2— 341 55 16.1 652 105 282 45 16.0 541 86 3— 390 40 11.8 765 90 367 44 12.0 712 85 4— 361 30 8.3 724 60 369 39 10.6 743 79 5— 1,004 71 7.1 429 30 1,249 89 7.1 529 38 10— 304 1 0.3 138 0 417 10 2.4 185 4 15— 125 2 1.6 56 1 161 1 0.6 65 0 20— 75 — — 32 — 141 1 0.7 51 0 25— 78 1 1.3 20 0 187 1 0.5 40 0 35— 32 — — 11 — 55 1 1.8 17 0 45— 13 1 7.7 6 0 20 — — 9 — 55 & upwards 4 — — 2 — 10 2 20-0 4 1 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 22nd July, i.e., the latter part of the 29th week, and the schools re-opened on Monday, the 23rd August, i.e., at the beginning of the 34th 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. Diphtheria—Notified cases—1909. Notified cases—Age periods. Increase (+) or decrease (-) per cent. Period. 0—3. 3—13. 13 and upwards. 0—3. 3—13. 13 and upwards. Four weeks preceding weeks of holiday influence (27th to 30th) 92 333 89 — — — Four weeks of holiday influence (31st to 34th) 69 211 71 —25.0 -36.6 —20-2 Four weeks following weeks of holiday influence (35tli to 38tli) 78 339 89 + 13.0 + 60.7 + 25.4 The distribution of cases of diphtheria in houses is shown in the reports relating to Paddington, Fulham and Westminster, thus :— Diphtheria—Single and multiple cases, 1909. Sanitary area. Number of houses in which one or more cases occurred. One case. Two cases. Three cases. Four cases. Five cases. Six cases. Paddington 131 7 1 — — — Fulham 232 27 6 3 — 1 Westminster 186 12 2 1 1 — Thus of 610 houses invaded, multiple cases occurred in 61. The reports relating to Finsbury, Woolwich and Stoke Newington show the probable source of infection of those cases for which explanation could be found. In Finsbury, of 152 cases occurring in the district, in 12 instances infection appeared to be due to previous cases occurring in other members 1 See footnotes (2), page 6, and (2) page 38. 44 of the family, in 15 others to previous cases in the same house or its immediate vicinity, and in 3 cases to infection at school; inWoolwich, of 240 cases occurring in the district, in 31 instances the disease appears to have been due to infection from other inmates of the house, in 8 instances from neighbours and friends, and in 4 from schoolmates. Two cases in Finsbury and four in Woolwich were attributed to visiting at general hospitals. Of 29 cases occurring in Stoke Newington, infection was in 3 instances attributed to a known antecedent case. Cases due to infection from a patient discharged from hospital are mentioned in the reports relating to Holborn, 2 ; Finsbury, 5, of which 3 followed the return of the same patient from hospital, the original case being subsequently sent back to hospital; Wandsworth 4 cases ; and Woolwich 3 cases. Particular prevalences of diphtheria are discussed in some of the reports. Dr. Allan mentions that in connection with one school in Westminster " 18 persons proved to have the specific organism in their throats, and two of them had been ill some weeks previously, and were probably acting as sources of infection in the school; after they were excluded, no further cases were detected." In connection with the ability of bacillus " carriers " to give rise to infection, Dr. Annis refers to the case of a boy (G.C.) who, on account of an attack of scarlet fever, was removed from the Royal Hospital School in Greenwich to the Brook Hospital. The occurrence of a case of diphtheria in the convalescent ward where this boy was, led to the bacteriological examination of material from the patients, and this boy was found during June to be harbouring diphtheria bacilli, but not to be suffering from any symptoms of the disease. No diphtheria bacilli were found as the result of two examinations early in July. He was discharged on July 7th, and after his return to the Royal Hospital School, he was isolated for a few days and then allowed to mix with the other boys. No case of diphtheria occurred before the summer vacation, but one boy on reaching home developed diphtheria, from which he died. G.C. went home to a somewhat isolated part of Ireland on July 30th, and after his return five members of the family speedily developed diphtheria, the first commencing to be ill about three days after G.C.'s arrival. Two of the cases proved fatal. Dr. Annis states that there had been no case of diphtheria in that part of Ireland for the previous fifteen years. In a few reports mention is made of special incidence of diphtheria in particular schools, and of the steps taken for limitation of disease, by way of exclusion from school of children found to be harbouring diphtheria bacilli or by closure of classrooms. Information is much needed concerning the evidence found, in the homes, of the infectiveness of the children thus excluded, as manifested by subsequent attack of other members of the family, and as to the circumstances which determine the pathogenicity of such cases as that described by Dr. Annis. With the present state of knowledge, the bacillus carrier must be regarded as a very possible source of danger to other children. Dr. Davies writes that in Woolwich, " after a case has been notified in a house, no children from that house are allowed to return to school until they have been certified free from infection after a bacteriological examination." Dr. Caldwell Smith states in his annual report " At no period of the year was there any outbreak to call for special notice, and this is due, as was stated in my report for last year, largely to the methods adopted for dealing with cases in elementary schools." He notes, moreover, that with decline of diphtheria from 527 cases in the borough in 1908 to 335 in 1909, the number of cases among school attending children constituted 40 per cent, of the total cases in 1908, and 49'2 per cent, of the total cases in 1909, a relatively increased incidence on school attending children. Reference will be found on page 106 to a memorandum issued in 1909 by Dr. Newsholme and Dr. Newman, medical officers of the Local Government Board and Board of Education respectively, dealing with the administrative measures necessary for the prevention of the spread of infectious diseases among children attending elementary schools. Information concerning the number of specimens examined for diphtheria bacilli by the sanitary authorities is contained in the reports relating to the following districts :— Diphtheria—Bacteriological diagnosis, 1909. Sanitary area. Number of specimens examined. Number found positive. Sanitary area. Number of specimens examined. N umber found positive. Paddington 122 37 Shoreditch 13 7 Kensington 30 18 Bethnal Green 23 8 Fulham 349 90 Stepney 51 12 Chelsea 93 20 Poplar 124 35 Westminster, City of 177 46 Southwark 145 31 St. Ivlarylebone 73 16 Bermondsey 134 13 St. Pancras 90 29 Lambeth 551 20 Islington 300 64 Wandsworth 372 97 Stoke Newington 56 8 Deptford 190 68 Hackney 153 40 Greenwich 891 137 Finsbury 98 25 Lewisham 550 146 London, City of .. 4 3 Woolwich 768 90 The action taken in connection with this work is thus stated by the medical officer of health of Woolwich: " Positive cases with any symptoms were notified and sent to hospital, or strictly isolated; positive cases without any symptoms were excluded from school and from mixing with other children outside the house." Diagram XV —whooping-cough.— 45 In three reports, viz., those relating to Stoke Newington, Lambeth and Greenwich, reference is made to the fact that the medical officers keep a supply of antitoxic serum for the use of medical practitioners. The importance of making antitoxic serum available so that it may be used without delay is emphasised by the experience of the Metropolitan Asylums Board, gained in the treatment of cases of diphtheria in the hospitals of that Board. Of cases treated with this serum in those hospitals in 1908, the mortality was as follows:—Cases in which the treatment was begun on the first day of the illness 30 per cent.; on the second day of the illness, 6.5 per cent.; on the third day, 10.6 per cent. ; on the fourth day, 12 9 per cent; and on the fifth day and later, 14.8 per cent. Proportion of cases of diphtheria removed to hospital. It will be seen from diagram XIII. that the proportion of cases of diphtheria removed to the hospitals of the Metropolitan Asylums Board was about the same as in the preceding year. Proportion of cases erroneously certified. Cases certified to be those of diphtheria and admitted into the hospitals of the Metropolitan Asylums Board, but in which the diagnosis was not subsequently confirmed, constituted the following percentage of total cases admitted in successive years:— Diphtheria—Percentage of total cases admitted concerning which the diagnosis was not subsequently confirmed, 1901-1909. Year. Percentage. Year. Percentage. 1901 12.8 1906 15.5 1902 13.5 1907 17.0 1903 14.7 1908 18.1 1904 16.1 1909 16.8 1905 18.0 Whooping-cough. The deaths from whooping-cough in the Administrative County of London during the year 1909 (52 weeks) numbered 1.246, as compared with 984 in 1908 (53 weeks). The death-rates from this disease in 1909 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 1903 0.351 1851-60 0.88 1904 0.321 1861-70 0.88 1905 0.321 1871-80 0.81 1906 0.261 1881-90 0.69 1907 0.381 1891-1900 0.50 1908 0.201 1901 0.351 1909 0.261 1902 0.40 The following are the death-rates of children under five years of age. 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 1903 3.162 1861-70 6.53 1904 2.912 1871-80 6.02 1905 2.872 1881-90 5.34 1906 2.332 1891-1900 4.212 1907 3.372 1901 3.132 1908 1.842 1902 3.562 1909 2.402 The death-rate in each year since 1840 in relation to the mean of the period 1841-1909 is shown in diagram XV., while the deaths in each month since 1890 in relation to the mean monthly deaths of the period 1891-1909 are shown in diagram VIII., page 33. 1 See footnote (2), page 6. 2 Including deaths of Londoners in the Metropolitan Workhouses, Hospitals, and Lunatic Asylums outside the County, but excluding those of non-Londoners in the London Fever Hospital, the West Ham Union Workhouse at Hackney, the Metropolitan Asylums Hospitals and the Middlesex County Asylum, within the County of London. 2067 G 46 It will be seen from the following table that in the quinquennium 1904-8 the London whoopingcough death-rate was exceeded by that of all except Bristol, Bradford, Nottingham and Leicester, but in the year 1909, was only exceeded by that of Liverpool and West Ham:— Whooping-cough—Death-rates per 1,000 persons living. Town. 1904-1908. 1909. Town. 1904-1908. 1909. London 0.301 0.261 West Ham 0.39 0.58 Liverpool 0.43 0.30 Bradford 0.22 0.15 Manchester 0.39 0.19 Newcastle-on-Tyne 0.42 0.26 Birmingham 0.49 0.26 Hull 0.32 0.18 Leeds 0.33 0.17 Nottingham 0.30 0.22 Sheffield 0.35 0.11 Salford 0.42 0.19 Bristol 0.28 0.14 Leicester 0.26 0.21 The following table shows that the London whooping-cough death-rate was, in the quinquennium 1904-8, higher than that of any of the undermentioned foreign towns except Copenhagen, and in the year 1909, higher than that of all except Amsterdam, Copenhagen, and St. Petersburg. Whooping-cough—Death-rates per 1,000 persons living. Town. 1904-1908. 1909. Town. 1904-1908. 1909. London 0.301 0.261 St. Petersburg 0.23 0.27 Paris 0.10 0.08 Berlin 0.20 0.18 Brussels 0.10 0.05 Vienna 0.08 0.08 Amsterdam 0.24 0.29 Rome 0.08 0.13 Copenhagen 0.35 0.27 New York 0.08 0.09 Stockholm 0.15 0.15 The following table shows the whooping-cough deaths and death-rates for the year 1909 and the death-rates for the period 1904-8 in the several metropolitan sanitary districts:— Whooping-cough—Death-rates in sanitary areas. Sanitary area. Deaths, 1909 (52 weeks). Death-rate per 1,000 persons living. 1904-8. 1909. Paddington 36 0.19 0.24 Kensington 40 0.21 0.22 Hammersmith 47 0.27 0.37 Fulham 49 0.35 0.28 Chelsea 13 0.29 0.17 Westminster, City of 19 0.12 0.11 St. Marylebone 25 0.17 0.20 Hampstead 18 0.10 0.19 St. Pancras 30 0.32 0.13 Islington 86 0.26 0.25 Stoke Newington 14 0.24 0.26 Hackney 51 0.23 0.22 Holborn 15 0.26 0.28 Finsbury 51 0.39 0.54 London, City of 4 0.20 0.22 Shoreditch 72 0.58 0.63 Bethnal Green 40 0.42 0.31 Stepney 69 0.39 0.22 Poplar 84 0.43 0.49 Southwark 57 0.39 0.27 Bermondsey 55 0.36 0.43 Lambeth 85 0.27 0.26 Battersea 63 0.33 0.34 Wandsworth 69 0.26 0.23 Camberwell 52 0.30 0.18 Deptford 47 0.33 0.40 Greenwich 20 0.32 0.18 Lewisham 20 0.23 0.12 Woolwich 15 0.26 0.11 London 1246 0.30 0.26 See footnote (2), page 6. 47 It will be seen from the foregoing table that in the period 1904-8 the highest whoopingcough death-rate obtained in Shoreditch (0.58), and the lowest in Hampstead (0.10); in the year 1909 Shoreditch (0.63) had the highest death-rate and Westminster and Woolwich (0.11) the lowest. The whooping-cough death-rates in each of the four quarters of the year 1909 were as follows: first quarter, 0.30; second quarter, 0.35; third quarter, 0.19; and the fourth quarter, 0.20 per 1,000 persons living. The following table shows that when the London sanitary districts are grouped according to the proportion of the population living more than two in a room, in tenements of less than five rooms, the incidence of whooping-cough mortality progressively increases from the least to the most overcrowded groups of districts. Whooping-cough1 mortality and overcrowding 2 1901-9. Proportion of overcrowding in groups of sanitary areas. Whooping-cough death-rates at ages 0-5 per 1,000 living. 1901-9. Under 7.5 per cent. 2.22 7.5 to 12.5 per cent. 2.69 12.5 to 20.0 per cent. 2.88 20.0 to 27.5 per cent. 3.04 Over 27.5 per cent. 3.23 The annual reports supply but little information concerning whooping-cough, but reference is made in a few to the need for better recognition by the public of the dangerous nature of this disease. As pointed out by Dr. Davies, medical officer of health of Woolwich, much could be done by health visitors in this direction, but he adds "to do so, however, would require an increase of staff." Such information as medical officers of health obtain concerning the occurrence of attacks of whooping-cough is derived, in the main, from school teachers. The number of cases reported, so far as stated in the annual reports, was as follows:— Whooping cough—Cases notified to medical officers of health by school teachers, etc., 1909. Sanitary area. Number of cases. Sanitary area. Number of cases. Paddington 589 Shoreditch 335* Kensington 292 Southwark 438 Hammersmith 281 Bermondsey 346 Westminster 228 Lambeth 763 St. Pancras 205 Wandsworth 538 Islington 708 Lewisham 459 Hackney 285 Woolwich 361 Finsbury 257 * Houses invaded. Whooping-cough among school attending children is dealt with much on the same lines as measles In Woolwich all children under five years of age were excluded from attendance at a number of schools for several weeks, and the same course was adopted in Lewisham in the case of two schools. The medical officer of health of Islington reports that some schools were disinfected on account of prevalence of whooping-cough among the children, and the medical officer of health of Lambeth states that the homes of children so suffering were disinfected. Reference will be found on page 106 to a memorandum issued in 1909 by Dr. Newsholme and Dr. Newman, medical officers of the Local Government Board and Board of Education respectively, dealing with the administrative measures necessary for the prevention of the spread of infectious diseases among children attending elementary schools. Typhus. There were no deaths from typhus registered in the Administrative County of London during the year 1909. 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 — 1903 .001 1 1904 - 1905 - 1906 - 1907 — 1908 - 1909 — In this table -000 indicates that the deaths were too few to give a rate of .0005; where — is inserted no death occurred. 3 See footnote (2), page 25. 2057 G 2 48 The death-rate in each period since 1868 in relation to the mean death-rate of the period 1869-1909 is shown in diagram XVI. The actual cases of typhus which are known to have occurred in London are the following:— February A.V., male aged 29, living in Christian-street, Whitechapel, sickened on the 24th February and removed to hospital on the 27th A.V. was an actor at music halls, and had lived for four months at the above address. The source of his infection could not be ascertained. June E.H., female, aged 29; died at Guy's hospital, on the 27th June. Her illness was suspected to be typhus. Her son, W.H., aged 9, was removed to the fever hospital on the 28th June. His malady was undoubtedly typhus. Both had been living in Marine-street, Bermondsey, for four years. The source of their infection could not be ascertained. July A third case, E.B., a woman aged 28, occurred later in this house. She began to be ill on the 15th July and was removed the same day to the fever hospital. August P.C., a male aged 52, a tailor, sickened with typhus on the 16th August, and was removed to the fever hospital on the 23rd August. He had been living for a considerable time in a somewhat overcrowded house in Underwood-street, Whitechapel, when he was taken ill. Enteric Fever. The number of cases of enteric fever notified in the Administrative County of London during 1909 (52 weeks) was 1,043, compared with 1,357 in the year 1908 (53 weeks). The deaths from this disease numbered 146 in 1909 (52 weeks), compared with 225 in 1908 (53 weeks). The case-rates and death-rates per 1,000 persons living and the case-mortality per cent. in 1909 and proceding 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 2 2 1891.1900 0.14 1 0.8 17.4 1901 0.111 0.7 15.6 1902 0.12 1 0.7 15.8 1903 0.08 1 0.5 15.7 1904 0.06 1 0.4 15.1 1905 0.05 1 0.3 15.1 1906 0.06 1 0.3 16.3 1907 0.04 1 0.3 13.9 1908 0.05 1 0.3 16.6 1909 0.03 1 0.2 14.0 The death-rate in each year since 1868 in relation to the mean death-rate of the period 1869-1909 is shown in diagram XVII. The death-rate in 1909 was the lowest on record. The notified cases in each week of 1909 may be compared with the average weekly notifications of the period 1890-1909 on reference to diagram XVIII. The distribution of the cases of enteric fever throughout the year was somewhat exceptional, the usual autumnal increase being absent, as will be seen by reference to diagram XVIII. Owing to this fact the incidence in the early part of the year appears unduly prominent in the diagram, but it should be noted that this is relative only, the curve for the early part of the year being merely the normal continuation of the curve of the preceding year. This will be better seen on reference to diagram XIX., which shows the monthly case-rate and case-mortality in each of the years 1891-1909 in relation to the mean of the whole period. This diagram shows that, except for the absence of the autumnal increase already noted, the behaviour of enteric fever in 1909 was not conspicuously different from the normal. The following table shows the enteric fever cases, deaths, case-rates and death-rates for the year 1909, and the case-rates and death-rates for the period 1904-8 in the several sanitary districts— Enteric Fever—Case-rates and death-rates in sanitary areas. Sanitary area. Notified cases, 1909 (52 weeks). Case-rate per 1,000 persons living. Deaths, 1909 (52 weeks). Death-rate per 1,000 persons living. 1904-8. 1909. 1904-8. 1909. Paddington 29 0.26 0.19 4 0.04 0.03 Kensington 48 0.25 0.26 8 0.04 0.04 Hammersmith 16 0.31 0.13 5 0.05 0.04 Fulham 41 0.29 0.23 4 0.06 0.02 Chelsea 12 0.23 0.16 2 0.04 0.03 Westminster, City of 25 0.27 0.15 7 0.04 0.04 1 See footnote (2), page 6. Continued on next page. 2 The Infectious Disease (Notification) Act came into force in 1889. Diagram XVI —typhus.— Diagram XVII enteric fever. Diagram XVIII enteric feyer. Diagram XIX —enteric fever.— 49 Sanitary area. Notified cases, 1909 (52 weeks). Case-rate per 1,000 persons living. 1904-8. 1909. Deaths, 1909 (52 weeks). Death-rate per 1,000 persons living. 1904-8. 1909. St. Marylebone Hampstead St. Pancras Islington Stoke Newington Hackney Holborn Finsbury London, City of Shoreditch Bethnal Green Stepney Poplar Southwark Bermondsey Lambeth Battersea Wandsworth Camberwell Deptford Greenwich Lewisham Woolwich Port of London London 21 16 50 94 11 59 16 13 4 51 33 71 54 35 30 50 54 66 47 33 30 18 12 4 1,043 0.32 0.25 0.35 0.33 0.23 0.54 0.41 0.43 0.40 0.45 0.48 0.43 0.46 0.39 0.40 0.24 0.25 0.29 0.23 0.29 0.33 0.21 0.22 033 0.17 0.17 0.21 0.27 0.20 0.25 0.30 0.14 0.22 0.45 0.25 0.23 0.31 0.17 0.24 0.15 0.29 0.22 0.17 0.28 0.27 0.11 0.09 0.22 1 5 6 13 1 6 1 3 1 6 4 6 13 6 2 9 7 6 5 6 4 2 3 146 0.03 0.04 0.04 0.05 0.04 0.08 0.06 0.09 0.03 0.06 0.07 0.07 0.07 0.06 0.07 0.04 0.04 0.04 0.04 0.05 0.06 0.02 0.05 005 0.01 0.05 0.03 0.04 0.02 0.03 0.02 0.03 0.06 0.05 0.03 0.02 0.08 0.03 0.02 0.03 0.04 0.02 0.02 0.05 0.04 0.01 0.02 0.03 It will be seen from the foregoing table that among the several sanitary areas in the period 1904-8 the enteric fever death-rate was highest in Finsbury (0.09), and lowest in Lewisham (0 02); in the year 1909, Poplar (0-08) had the highest enteric fever death-rate, while St. Marylebone and Lewisham (0.01) had the lowest. The death-rates from enteric fever in London, in each of the four quarters of the year 1909, were as follows: first quarter, 0.05; second quarter, 002; third quarter, 0 02; and fourth quarter, 0 03 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 1909. 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 and females aged 10-15, the greatest incidence of death was upon males aged 25-35 and upon females aged 15-20 and 25-35. The fatality was greatest among males of 45-55 and females aged 55 and upwards. Enteric Fever1—1909. 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 540 99 18 3 24 4 503 57 11.3 20 2 0— 2 - 8.1 14 1 5 - 9.4 12 1 1— 2 1 4 1 2— 9 1 3 _- 3— 10 1 11 2 4— 14 9 5— 69 5 7-2 29 2 54 _ 23 10— 74 3 41 34 1 69 5 7.2 31 2 15— 54 7 130 24 3 57 11 19.3 23 4 20— 64 14 21.9 28 6 78 4 5.1 28 1 25— 106 32 30.2 27 8 119 20 16.8 26 4 35— 86 19 22.1 29 6 58 8 13.8 18 2 45— 36 12 33.3 17 6 25 2 8.0 11 1 55 & upwards 14 4 286 7 2 11 4 36.4 4 1 1 See footnotes (2), page 6 and (2), page 38. 50 The results of inquiry into the source of infection are stated in about half of the annual reports. Dr. Caldwell Smith gives account of the occurrence in Wandsworth of nine cases in the early part of the year, due to infection from a milk supply derived from Wiltshire, and supplied by a Wandsworth dairyman to the invaded houses. Other five cases among persons supplied from the same source occurred in Barnes. Dr. Caldwell Smith's inquiries elicited the fact that a case of enteric fever had occurred on the farm from which the milk was derived, and he urges the need for notice of cases occurring on dairy farms to be sent to the medical officer of health of the district in which the milk consumers are resident. Some of the reports give information as to the number of cases in which articles of food, usually coming under suspicion as a cause, have been consumed at a time which would suggest that they may have been operative in the cases in question. In summary it may be stated that in ten districts in which 276 cases of enteric fever occurred, mussels had been consumed in 12 instances, oysters in 10 instances, periwinkles in 2 instances, cockles in 1 instance, shell-fish unspecified in 11 instances, and ice-cream in 1 instance. Both mussels and watercress had been consumed in one instance and "fish" is mentioned in two instances. Dr. Alexander records that three cases occurred in one family in Poplar and two in another, in both of which a hearty meal of mussels had been eaten. In a number of instances infection derived from an antecedent case is mentioned as explanation of the attack. Dr. Stevens' report, relating to Camberwell, contains the following paragraphs illustrative of such cases:— Two outbreaks of enteric fever which occurrcd in two distinct localities in Dulwich, and apparently unconnected one with the other, are remarkable in the way of showing how this disease, while not, to use a popular term, catching, may under certain conditions be passed on from one person to another. In the first outbreak, a child was attacked by some obscure form of illness, and was nursed by her mother, who, a few weeks later, started to be ill. When she became incapable of looking after the first patient, a daughter returned from service to take charge of affairs, and she too was attacked, and down to February of this year, cases kept on cropping up at this house With the gradual disablement of the members of the household, a married daughter came to the rescue, her husband meanwhile staying at home. The daughter escaped the disease, but the husband was attacked, and that fatally. Careful questioning brought out the fact that he had occasionally taken his meals at the infected house, so that there was little doubt about the origin of infection. The food, milk and water supply were all reviewed, but nothing could be found in any way likely to suggest that they were at fault. The second set of cases occurred only a short distance away from the first, but were apparently unconnected with it. The cases occurred in two adjoining houses occupied by two sisters, each of them married and having a family Here again no question of food arose ; but the policy of exclusion led to the same conclusion as in the first series: for there was a lengthy and undiagnosed illness of one man followed by attack of other members of the same family. Proportion of cases erroneously certified. Cases certified to be those of enteric fever admitted into the hospitals of the Metropolitan Asylums Board, but in which the diagnosis was not subsequently confirmed, constituted the following percentage of total cases admitted in successive years:— Enteric fever—Percentaqe of total cases admitted concerninq which the diagnosis was not subsequently confirmed, 1900-1909. Year. Percentage. Year. Percentage. 1900 18.3 1905 29.7 1901 25.4 1906 25.2 1902 21.2 1907 29.1 1903 24.2 1908 28.1 1904 26.3 1909 37.9 The number of cases in which blood was examined by the Widal test at the expense of the sanitary authority is shown in the reports relating to the following districts:— Enteric fever—Bacteriological diagnosis, 1909. Sanitary area. Number of specimens examined. Number found positive. Sanitary area. Number of specimens examined. Number found positive. Paddington 27 7 Shoreditch 20 5 Fulham 42 14 Bethnal Green 13 8 Chelsea 1 — Stepney 8 3 Westminster, City of 7 2 Poplar 40 14 St. Marylebone 8 — Southwark 12 3 St. Pancras 24 9 Bermondsey 13 4 Islington 55 20 Lambeth 32 11 Stoke Newington 15 7 Wandsworth 25 10 Hackney 21 6 Deptford 15 6 Holborn 2 1 Greenwich 21 4 London, City of 2 1 Lewieham 23 2 Woolwich 15 4 Diagram XX. — DIARRHœA. DYSENTERY & CHOLERA- 51* Diarrhœa. The deaths within the Administrative County of London during 1909 (52 weeks) attributed to epidemic diarrhoea and infective enteritis numbered 941, while 8321 deaths were attributed to diarrhœa and dysentery. The corresponding figures for 1908 (53 weeks) were 1,577 and 1,081 respectively. The age-distribution of the fully corrected deaths in 1909 was as follows:— Diarrhœa—Deaths2 at the several age-periods—1909. Disease. Under 1 year. 1-5. 5-20. 20-40. 40-60. 60-80. 80 and upwards All ages Epidemic diarrhoea, infective enteritis 602 140 14 7 12 5 1 781 Diarrhœ and dysentery 562 110 7 14 36 46 21 796 Total 1,164 250 21 21 48 51 22 1,577 No accurate comparison can be made of the deaths from epidemic diarrhoea for a long series of years in London, owing to changes made in methods of classification; diagram XX., however, shows the death-rate from cholera, dysentery and diarrhoea combined, in each year since 1840 in relation to the mean death-rate of the period 1841-1909. The following table shows that the London diarrhoea death-rate was in the quinquennium 1904-8 lower than the death-rate of any of the undermentioned large English towns, except Bristol, Bradford and Newcastle-on-Tyne, and in 1909 was lower than that of any except Leeds, Bristol, Bradford and Newcastle-on-Tyne. Diarrhœ—Death-rates per 1,000 persons living. Town. 1904-8. 1909. Town. 1904-8. 1909. London 0.713 0.332 West Ham 1.44 0.65 Liverpool 1.45 0.70 Bradford 0.62 0.16 Manchester 1.09 0.43 Newcastle-on-Tyne 0.54 0.20 Birmingham 1.08 0.45 Hul 1.34 0.57 Leeds 0.76 0.23 Nottingham 0.98 0.69 Sheffield 1.29 0.55 Salford 1.15 0.50 Bristol 0.41 0.27 Leicester 0.84 0.43 The deaths and death-rates from diarrhoea for the year 1909, and the death-rates for the period 1904-8 in each of the sanitary areas of London, are shown in the following table:— Diarrhœa—Death-rates in sanitary areas. Sanitary area. Deaths, 1909 (52 weeks). Death-rate per 1,000 persons liying. 1904-8. 1909. Paddington 36 0.58 0.24 Kensington 49 0.56 0.27 Hammersmith 44 0.71 0.35 Fulham 99 1.08 0.56 Chelsea 15 0.52 0.20 Westminster, City of 16 0.33 0.10 St. Marylebone 29 0.47 0.23 Hampstead 4 0.17 0.04 St. Pancras 45 0.51 0.19 Islington 69 0.49 0.20 Stoke Newington 4 0.41 0.07 Hackney 77 0.80 0.32 Holborn 9 0.49 0.17 Finsbury 60 0.97 0.63 London, City of 2 0.18 0.11 Shoreditch 89 1.22 0.78 Bethnal Green 95 0.92 0.73 Stepney 137 1.05 0.44 Poplar 109 1.18 0.64 Southwark 113 094 0.54 Bermondsey 67 1.03 0.53 Lambeth 103 0.66 0.32 Battersea 49 0.69 0.26 Wandsworth 58 0.58 0.20 Camberwell 84 0.61 0.30 Deptford 31 0.78 0.26 Greenwich 36 0.68 0.33 Lewisham 29 0.52 0.18 Woolwich 19 0.65 0.14 London 1,577 0.71 0.33 1 See footnote (2), page 45. ? See footnote (2), page 6. 52 It will be seen from the foregoing table that the diarrhoea death-rate was, both in the period 1904-8 and in the year 1909, highest in Shoreditch (1.22 and 0"78 respectively) and lowest in Hampstead (0.17 and 0.04 respectively). The diarrhœa death-rates in London in each of the four quarters of the year 1909, were as follows: first quarter, 0.14; second quarter, 0.12; third quarter, 0.79; and fourth quarter, 0.25, per 1,000 persons living. As previously stated, the meteorological conditions of 1909 were favourable to a low death-rate from diarrhœal diseases. It is not unlikely that the action of sanitary authorities, through the visits of their health officers to the homes where births have occurred, may already in some degree be contributing to the prevention of diarrhoea mortality; for there is abundant evidence that the probability of attack in infancy is governed in considerable degree by the care of the child. The work of the health visitor in encouraging the better feeding of infants and conditions of cleanliness in the homes cannot fail to be effective in this direction. In the last annual report reference was made to the results obtained in Woolwich by the system of voluntary notification of cases of diarrhoea, which had been instituted during the summer months in that district. Dr. Davies now reports that the results were so encouraging that in February, 1909, the borough council resolved to continue voluntary notification indefinitely, and to extend the period of notification to June and October, thus making the disease notifiable during five months, instead of three. Dr. Davies finds reason for thinking that a proportion of the cases which were notified were due to a previous case in the same or a neighbouring house. The reports of the medical officers of health of Paddington and Kensington give account of multiple attacks in houses and in certain instances give reasons for thinking that the disease had been communicated from person to person. In several annual reports reference is made to the largely accepted view that flies play an important part in the causation of diarrhoea. The need for further study of this subject is obvious, and hence observations have been continued in London on the seasonal distribution of the different genera of flies in the neighbourhood of certain localities where refuse is accumulated. Dr. Hamer's report on this subject is appended (see Appendix IV). Two special outbreaks of diarrhoea are recorded in the annual reports. The first occurred in a rescue home in Chelsea where, Dr. Parkes states, 23 persons out of 31 inmates were attacked with severe diarrhœa and sickness. The staff numbered eight, all of whom remained well. The evidence pointed to infection on a particular day in September on which cold mutton and cold gammon of bacon were eaten at the mid-day meal. One death occurred and bacteriological investigation of the blood and internal organs of the deceased showed the presence of large numbers of the bacillus of Gaertner. The other outbreak occurred among the waitresses of a restaurant in Holborn, ten of whom, together with two men, were attacked with severe vomiting, diarrhoea and fever. Inquiry by Dr. Bond showed that all of them, with one doubtful exception, had consumed milk in the form of junket, or custard, or both, and these were the only articles eaten in common. It was impossible to ascertain the farm from which the milk was derived. Erysipelas. The deaths from erysipelas in the Administrative County of London during 1909 (52 weeks) numbered 1801, as compared with 160 in 1908 (53 weeks). The age-distribution of such of these deaths as belong to London was as follows — Erysipelas2—Deaths at the several age-periods—1909. Under 1 Year. 1-5. 5-20. 20-40. 40-60. 60-80. 80 and upwards. All ages. 46 7 2 12 34 65 10 176 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 1 Bee footnote (2), page 45. The fully corrected deaths during 1909 number 176, but the corresponding figures for previous years are not available. 2 See footnote (2), page 6. (Continued on next page). 53 Year. Notified cases. Case-rate per 1,000 persons living. Deaths.1 Death-rate per 1,000 persons living. 1900 4,762 1.06 182 0.04 1901 4,604 1.02 171 0.04 1902 5,536 1.19 183 0.04 1903 4,372 0.95 183 0.04 1904 4,943 1.08 232 0.05 1905 4,972 1.06 226 0.05 1906 5,019 1.07 245 0.05 1907 4,497 0.95 189 0.04 1908 4,203 0.86 160 0.03 1909 4,192 0.87 180 0.04 The number of cases of erysipelas notified and the case-rate for the year 1909, together with the case-rate for the period 1904-8, in the several sanitary areas are shown in the following table:— Erysipelas.—Case-rates in sanitary areas. Sanitary area. Notified Cases, 1909 (52 weeks). Case-rate per 1,000 persons living. 1904-1908. 1909. Paddington 106 0.84 0.70 Kensington 135 0.78 0.74 Hammersmith 76 0.86 0.61 Fulham 115 0.83 0.65 Chelsea 40 0.75 0.53 Westminster, City of 102 0.64 0.61 St. Marylebone 134 1.17 1.07 Hampstead 30 0.54 0.32 St. Pancras 155 0.90 0.65 Islington 220 0.75 0.63 Stoke Newington 27 0.69 0.50 Hackney 271 1.22 1.14 Holborn 41 0.91 0.76 Finsbury 132 1.15 1.39 London, City of 10 0.81 0.55 Shoreditch 144 1.26 1.26 Bethnal Green 164 1.78 1.25 Stepney 487 1.49 1.56 Poplar 177 1.17 1.03 Southwark 224 1.35 1.06 Bermondsey 142 1.32 1.12 Lambeth 191 0.80 0.59 Battersea 156 0.91 0.84 Wandsworth 193 0.89 0.65 Camberwell 234 1.08 0.83 Deptford 181 1.34 1.53 Greenwich 95 0.90 0.86 Lewisham 105 0.63 0.65 Woolwich 101 0.72 0.76 Port of London 4 London 4,192 1.00 0.87 The following table shows the age and sex distribution of the notified cases of erysipelas in 1909— Age-period. All Ages. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75 and upwards. Males 1,855 178 75 78 70 79 228 331 361 245 154 56 Females 2,337 183 81 91 128 148 274 400 422 317 214 79 Persons 4,192 361 156 169 198 227 502 731 783 562 368 135 The table shows, so far as the figures relating to notified cases of this disease can be trusted in this connection, that the number of females attacked exceeds the number of males attacked, and this is true, even when allowance is made for the excess of females in the total population. 2057 1 See footnote (2), page 45. H 54 Puerperal Fever. The deaths in the Administrative County of London during the year 1909 (52 weeks) attributed to puerneral fever1 numbered 1802. as compared with 137 in 1908 (53 weeks). 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 1908 228 137 1909 287 180 If these cases and deaths are considered in relation to the total population and total births the following rates are obtained— Puerperal Fever.—Case-rates and death-rates. Year. Case-rate per 1,000 living. Case-rate per 1,000 births. Death-rate2 per 1,000 living. Death-rate2 per 1,000 births. 1891 0.05 1.64 0.05 1.65 1892 0.08 2.55 0.07 2.37 1893 0.09 2.98 0.08 2.65 1894 0.06 1.92 0.05 1.60 1895 0.05 1.76 0.05 1.56 1896 0.06 2.04 0.05 1.66 1897 0.06 1.98 0.05 1.61 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 1908 0.05 1.86 0.03 1.11 1909 0.06 2.46 0.04 1.54 The number of deaths in the several divisions of London was in 1907, 1908 and 1909, as follows:— Puerperal Fever.2—Deaths of Londoners 1907-9. District. Total number of deaths. 1907. 1908. 1909. West 29 26 36 North 36 26 39 Central 3 8 7 East.. 25 17 27 South 51 52 61 Total 144 129 170 1 Including deaths from puerperal septicaemia and puerperal pyaemia. 2 See footnote (2), p. 45. 3 See footnote (2) page 6. 55 It is thus seen that the increase was not manifested in one area only, and the distribution suggests that the figures are in some degree governed by a condition widely operative. In this connection it may be pointed out that the number of cases of erysipelas notified and the number of deaths attributed to this cause were in 1909 greater than in 1908, recalling to memory the observations of Dr. G. B. Longstaff in 1880 of the similarity in the behaviour of puerperal fever and erysipelas. An account of puerperal fever occurring in the practice of midwives is referred to later in connection with the administration of the Midwives Act, 1902, pp. 97, et seq. Influenza, Bronchitis and Pneumonia. The deaths attributed to influenza, which in 1908 numbered 1,350 (53 weeks), fell to 1,2161 in 1909 (52 weeks). The deaths from bronchitis numbered 6,1281 in 1909, as compared with 5,342 in 1908. In 1909 there were 7,591' deaths attributed to pneumonia, as compared with 6,751 in 1908. The deaths from these diseases since 1889 have been as follows:— Influenza, Bronchitis and Pneumonia. Year. Deaths1 from Influenza. Deaths1 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 6,801 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 1908 1,350 5,342 6,751 1909 1,216 6,128 7,591 Ths distribution of deaths from influenza throughout the year for each of the years 1890 to 1909 is shown in the following table:— Influnza—Deaths1 registered in London in four-weekly periods—1890-1909. Number of weeks. 1890 1891 1892 1893 1894 1895 1896 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1—4 303 9 1,308 52 272 59 37 40 244 66 1,016 57 77 141 67 94 56 291 87 61 5—8 167 7 637 96 96 164 58 55 368 259 298 75 224 103 62 119 44 186 276 90 9—12 75 8 119 162 69 1,343 61 94 193 430 130 134 298 89 74 119 98 104 424 430 13—16 39 29 42 180 56 257 50 121 140 302 172 102 89 54 62 75 129 81 209 257 17—20 13 770 33 125 32 106 50 96 61 121 105 81 58 46 40 56 105 48 94 85 21—24 5 1,044 22 72 27 35 33 54 51 82 57 30 35 37 21 38 40 41 36 46 25—28 6 242 15 49 19 28 17 26 25 42 16 21 20 25 17 16 21 25 28 34 29—32 6 51 7 23 17 14 15 18 27 27 12 18 7 18 5 4 20 14 15 15 33—36 3 32 9 23 20 17 10 13 10 11 11 11 16 6 9 11 15 18 12 10 37—40 6 13 6 18 14 15 12 19 17 19 15 12 13 17 24 22 18 19 21 15 41—44 5 15 20 28 29 22 27 29 46 55 17 23 35 13 92 39 35 42 30 31 45—48 13 35 18 152 41 47 56 35 49 61 55 44 65 44 98 44 86 39 45 56 49—522 6 81 28 546 58 49 56 71 52 342 46 56 99 51 138 52 228 59 57 86 Phthisis. The deaths from phthisis in the Administrative County of London during 1909 (52 weeks) numbered 6,337, as compared with 6,419 in 1908 (53 weeks). 1 See footnote (2), p. 45. The fully corrected deaths during 1909 from Influenza, Bronchitis and Pneumonia were 1,202, 6,084 and 7,383 respectively, but the corresponding figures for previous years are not available. 2 The deaths occurring in the 53rd week of the years 1890, 1896, 1902 and 1908 which are not shown, numbered 1, 14, 37 and 16 respectively. 2057 H 2 56 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 1903 1.551 1861-70 2.84 1904 1.621 1871-80 2.51 1905 1.421 1881-90 2.08 1906 1.441 1891-1900 1.79 1907 1.401 1901 l.661 1908 1.321 1902 1.601 1909 1.311 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 1851-1909 (males and females) is shown in diagram XXI. This diagram shows the marked decline of phthisis mortality in both sexes, the greater incidence of such mortality on males than on females, and the fact that until the last seven years the decline has been more manifest in females than in males. This alteration in the relative decline in the deathrate of the two sexes in recent years may, however, be an apparent alteration only inasmuch as it would be explicable if there has been change in the relative proportions of the two sexes in the population since the last census. The following table shows the crude phthisis death-rate, and the rate corrected for differences in the age and sex constitution of the population 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.2 Factor for correction for age and sex distribution. Crude death-rate. Corrected death-rate. Comparative mortality figure. (London 1,000.) 1904-8. 1909. 1904-8. 1909. 1904-8. 1909. London 1.74 1.00000 1.44 1.31 1.44 1.31 1,000 1,000 Paddington 1.80 0.96659 1.08 1.08 1.04 1.04 722 791 Kensington 1.78 0.97419 1.17 0.96 1.14 0.94 792 715 Hammersmith 1.74 0.99600 1.25 1.09 1.24 1.09 861 829 Fulham 1.69 1.02786 1.22 1.17 1.25 1.20 868 913 Chelsea 1.83 0.95018 1.53 1.45 1.45 1.38 1,007 1,050 Westminster, City of 1.95 0.89205 1.40 1.34 1.25 1.20 868 913 St. Marylebone 1.85 0.93836 1.47 1.35 1.38 1.27 958 966 Hampstead 1.75 0.98862 0.76 0.61 0.75 0.60 521 456 St. Pancras 1.80 0.96551 1.68 1.61 1.62 1.55 1,125 1,179 Islington 1.75 0.99145 1.32 1.23 1.31 1.22 910 928 Stoke Newington 1.77 0.97914 1.22 0.83 1.19 0.81 826 616 Hackney 1.68 1.02969 1.25 1.22 1.29 1.27 896 966 Holborn 1.97 0.87894 2.55 2.05 2.24 1.80 1,556 1,369 Finsbury 1.72 1.01050 2.21 2.22 2.23 2.24 1,549 1,704 London, City of 1.89 0.91946 1.69 2.15 1.55 1.98 1,076 1,506 Shoreditch 1.66 1.04206 2.05 1.75 2.14 1.82 1,486 1,385 Bethnal Green 1.59 1.08984 1.99 1.54 2.17 1.68 1,507 1,278 Stepney 1.65 1.05281 1.74 1.67 1.83 1.76 1,271 1,339 Poplar 1.66 1.04772 1.50 1.29 1.57 1.35 1,090 1,027 Southwark 1.74 0.99829 2.09 1.79 2.09 1.79 1,451 1,362 Bermondsey 1.65 1.05026 1.94 1.78 2.04 1.87 1,417 1,423 Lambeth 1.75 0.99258 1.44 1.41 1.43 1.40 993 1,065 Battersea 1.69 1.02483 1.30 1.22 1.33 1.25 924 951 Wandsworth 1.72 1.01050 1.01 0.93 1.02 0.94 708 715 Camberwell 1.68 1.03522 1.25 1.19 1.29 1.23 896 936 Deptford 1.69 1.02969 1.28 1.25 1.32 1.29 917 981 Greenwich 1.67 1.04143 1.19 0.99 1.24 1.03 861 784 Lewisham 1.69 1.02543 0.87 0.80 0.89 0.82 618 624 Woolwich 1.70 1.01881 1.39 1.20 1.42 1.22 986 928 1 See footnote (2) page 6 2 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. Diagram XXI — PHTHISIS MORTALITY IN LONDON — 1851-1900 Annual Death-rate among males and females per 1000 living, corrected for differences in age-constitution of the population, 57 It will be seen from the foregoing table (comparing the corrected death-rates) that among the several sanitary areas in the quinquennium 1904-8, Holborn (2.24) had the highest phthisis death-rate and Hampstead (0 75) the lowest; in the year 1909 Finsbury (2.24) had the highest death-rate, the lowest again obtaining in Hampstead (0.60). The death-rates from phthisis in each of the four quarters of the year 1909 were as follows: first quarter, 1.65; second quarter, l.20.; third quarter, 1.06; and fourth quarter, 1.34, 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 1901-1909, 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; in the later years, however, the rates may in some districts be subject to considerable modification when further corrections can be made for the intercensal changes in the sex-age constitution of the populations. 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. Phthisis.—Corrected death-rates per 1,000 persons living (1901-1909). Sanitary area. 1901. 1902. 1903. 1904. 1905. 1906. 1907. 1908. 1909. Hampstead 0.90 0.84 0.73 0.82 0.82 0.66 0.69 0.77 0.60 Lewisham 0.92 1.09 0.86 0.92 0.87 0.84 0.95 0.87 0.82 Paddington 1.06 1.01 1.02 1.16 0.93 1.08 1.05 0.98 1.04 Wandsworth 1.15 0.91 0.96 1.13 1.03 1.02 0.96 0.97 0.94 Greenwich 1.20 1.24 1.17 1.39 1.31 1.24 1.12 1.15 1.03 Deptford 1.22 1.15 1.39 1.46 1.26 1.32 1.38 1.19 1.29 Stoke Newington 1.32 1.23 1.20 1.68 1.30 1.02 0.92 1.05 0.81 Kensington 1.33 1.26 1.22 1.40 1.11 1.24 1.00 0.95 0.94 Hammersmith 1.41 1.42 1.46 1.37 1.16 1.24 1.20 1.25 1.09 Fulham 1.41 1.42 1.42 1.47 1.25 1.16 1.22 1.17 1.20 Battersea 1.49 1.34 1.32 1.46 1.37 1.31 1.28 1.22 1.25 Islington 1.50 1.49 1.39 1.54 1.25 1.22 1.31 1.23 1.22 Camberwell 1.53 1.56 1.26 1.42 1.25 1.30 1.36 1.16 1.23 Hackney 1.57 1.47 1.31 1.43 1.18 1.34 1.20 1.26 1.27 Chelsea 1.59 1.38 1.49 1.73 1.43 1.49 1.43 1.21 1.38 Lambeth 1.64 1.69 1.39 1.44 1.37 1.36 1.52 1.44 1.40 Westminster, City of 1.68 1.59 1.51 1.36 1.35 1.24 1.22 1.10 1.20 St. Marylebone 1.77 1.80 1.72 1.58 1.37 1.46 1.39 1.09 1.27 Woolwich 1.79 1.52 1.48 1.70 1.55 1.36 1.27 1.22 1.22 St. Pancras 1.80 1.82 1.76 1.82 1.47 1.75 1.60 1.46 1.55 Poplar 1.87 1.78 1.82 1.82 1.60 1.62 1.39 1.40 1.35 Bermondsey 1.88 1.97 1.83 2.23 1.88 2.11 1.97 1.98 1.87 London, City of 2.10 1.55 1.46 1.45 1.23 1.60 1.87 1.65 1.98 Stepney 2.20 2.00 2.21 2.23 1.81 1.81 1.64 1.64 1.76 Finsbury 2.21 2.30 2.30 2.42 2.04 2.20 2.35 2.17 2.24 Shoreditch 2.32 1.89 2.42 2.27 2.04 2.09 2.19 2.08 1.82 Bethnal Green.. 2.35 2.15 2.29 2.35 2.22 2.45 2.07 1.75 1.68 Holborn 2.47 2.65 2.76 2.51 2.50 2.08 2.27 1.85 1.80 Southwark 2.51 2.62 2.40 2.36 2.13 2.06 2.03 1.88 1.79 The following table shows the number of deaths from phthisis at several age-periods in each of the sanitary areas. Phthisis—Deaths at the several age-periods in sanitary areas.—1909 (365 days). Age-period. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 and upwards All Ages. Paddington 2 3 - 5 9 44 42 37 14 11 - - 167 Kensington 3 1 1 7 19 29 49 26 20 14 2 - 171 Hammersmith 7 — 1 10 15 30 28 31 11 4 — - 137 Fulham 8 1 8 15 17 44 39 30 28 11 3 - 204 Chelsea 3 - - 4 8 19 25 23 15 11 2 - 110 Westminster, City of 3 1 2 8 17 33 49 56 39 16 3 - 227 St. Marylebone 4 2 2 2 13 27 41 36 25 14 2 - 168 Hampstead 2 - 1 5 8 14 15 9 3 1 — - 58 St. Pancras 17 2 3 15 24 79 108 79 37 12 3 - 379 Islington 13 4 5 6 39 96 114 80 50 20 6 - 433 Stoke Newington - - - 3 3 10 9 9 10 3 - 47 Hackney 4 3 1 15 30 61 56 55 38 18 6 - 287 Continued on next page. 58 Age-period. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 and upwards All Ages. Holborn — — 1 2 5 19 30 25 20 10 1 - 113 Finsbury 8 2 5 13 6 37 49 46 29 16 3 - 214 London, City of — 1 1 3 1 5 10 7 3 2 2 - 35 Shoreditch 6 3 3 11 15 38 47 46 23 8 - - 200 Bethnal Green 8 1 2 11 18 47 47 41 17 10 1 - 203 Stepney 14 2 3 27 27 98 142 95 75 32 6 1 522 Poplar 3 3 2 10 22 58 57 41 17 7 — - 220 Southwark 6 6 7 21 22 85 114 69 41 4 3 - 378 Bermondsey 7 2 4 17 15 56 53 48 19 6 — -- 227 Lambeth 14 8 6 22 34 88 120 87 42 25 5 1 452 Battersea 9 4 4 16 23 41 33 51 29 14 2 - 226 Wandsworth 10 2 8 13 25 67 57 48 34 15 1 - 280 Camberwell 7 5 4 17 31 80 75 67 36 17 1 1 341 Deptford 1 3 6 6 15 36 30 34 14 5 - - 150 Greenwich 3 — 4 8 11 28 16 29 8 3 — - 110 Lewisham 2 2 2 9 9 31 26 22 16 6 1 - 126 Woolwich 4 2 5 6 15 32 37 34 15 6 1 - 157 London 168 63 91 307 496 1332 1518 1261 728 321 54 3 6342 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, 1901-9. Phthisis death-rates in relation to overcrowding. Proportion 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. 1.034 1.718 1.00991 1.044 709 7.5 to 12.5 per cent. 1.320 1.705 1.01761 1.343 912 12.5 to 20 per cent. 1.413 1.771 0.97969 1.385 941 20.0 to 27.5 per cent. 1.924 1.805 0.96124 1.850 1,256 Over 27.5 per cent. 1.953 1.651 1.05090 2.052 1,394 London 1.472 1.735 1.00000 1.472 1,000 Tables similar to the above have been published in several previous annual reports, and the close relationship existing between "social condition" as measured by "overcrowding" and phthisis mortality is conspicuous. It will be seen that in the group of most overcrowded districts the death rate from phthisis is approximately twice that in the group least overcrowded. For the purpose of comparison of the phthisis death-rate at ages, male and female, in relation to social condition, as measured by the percentage of children scheduled for compulsory education2, the figures in the following table have been calculated on the deaths for the three years 1906-8. Deaths occurring in institutions of persons whose last known address was a common lodging-house have been excluded. Diagram XXII. is based on these figures. Males. Group. 15- 20- 25- 35- 45- 55- 65- 75 + All ages. I. 0.53 1.20 1.51 2.30 2.73 2.67 2.11 1.26 1.24 II. 0.57 0.95 1.79 3.26 4.04 3.67 3.28 1.95 1.65 III. 0.72 1.41 2.06 3.17 4.10 3.39 2.54 1.39 1.70 IV. 0.83 1.77 2.32 3.93 4.51 4.01 2.65 1.62 1.99 V. 0.92 1.26 2.87 4.34 5.24 4.80 3.97 1.57 2.24 Females. Group. 15- 20- 25- 35- 45- 55- 65- 75 + All ages. I. 0.54 0.50 0.95 1.19 1.32 0.97 0.86 0.26 0.68 II. 0.52 0.67 0.99 1.41 1.53 1.43 1.33 1.15 0.83 III. 0.78 1.07 1.35 1.78 1.91 1.63 1.16 0.55 1.04 IV. 1.06 1.12 1.67 2.46 2.27 1.52 1.24 0.30 1.25 V. 0.72 1.27 1.70 3.06 2.58 2.09 1.48 0.52 1.39 1 See footnotes (2) page 6 and (2) page 25. 2 See heading to diagram IV. Diagram XXII †The index of "Social Condition" for the purpose of this diagram is the same as that described in the heading to Diagram IV. 59 The figures show that the male rate is greatest in each group of districts at age 45—; but the female rate, while greatest at that age in groups I., II. and III., is greatest in groups IV. and V. at age'35—and this fact appears to hold good whether the deaths among inmates of common lodging houses are included or excluded, as will be seen from the following table:— Phthisis.'—Comparative male and female death-rates at age 45— (death-rates at age 35— being taken as 100) 1906-8. Group. Comparative death-rates of age 45— (death-rates of age 35— taken as 100). Excluding deaths among inmates of common lodging-houses. Including deaths among inmates of common lodging-houses. Males. Females. Males. Females. I. 118 111 119 107 II 124 108 124 107 III. 129 108 131 107 IV. 115 92 115 91 V. 121 84 122 85 It appears, therefore, that as between age 35— and age 45— there is a tendency in the female rates for the greater incidence to occur in the earlier age as the social condition becomes less favourable. This tendency is not exhibited by the male rates. There is one factor which should be borne in mind in this connection as possibly concerned in producing this result, viz., that the employment of servants occurs in greater proportion in the better circumstanced districts than in those less well circumstanced, and in so far as young women suffering from phthisis would die in their own homes, instead of where they are employed, this would tend to diminish the incidence of mortality from phthisis in the better circumstanced districts and to increase that in the less favoured districts. It should, however, be pointed out that the reliability of any conclusions drawn from these figures is largely dependent on the accuracy of the assumption that the age and sex constitution of the population has remained constant since the date of the last census, and a fuller discussion of the behaviour of phthisis in this respect must obviously be deferred until more reliable estimates of population are provided by the forthcoming census. Phthisis death-rates at ages, male and female, in successive intercensal periods, calculated on a standard population to eliminate the effect of differences in age-constitutionof the several populations, are shown in the following table:— Males. Period. 15- 20- 25- 35- 45- 55- 65- 75 + All ages. 1861-70 1.99 3.83 4.81 6.21 6.40 5.33 3.21 1.50 3.466 1871-80 1.58 3.03 4.52 6.08 6.15 4.99 2.75 0.90 3.141 1881-90 1.17 2.27 3.81 5.32 5.49 4.65 2.71 1.14 2.661 1891-1900 0.96 1.96 3.00 4.78 5.11 4.34 2.75 1.10 2.320 1901-09 0.76 1.48 2.27 3.70 4.55 3.99 2.98 1.21 1.904 Females. Period. 15- 20- 25- 35- 45- 55- 65- 75 + All ages. 1861-70 1.97 2.68 3.71 4.11 3.22 2.31 1.36 0.67 2.398 1871-80 1.63 2.25 3.26 3.88 3.03 2.08 1.18 0.44 2.102 1881-90 1.20 1.62 2.60 3.25 2.59 1.83 1.06 0.53 1.680 1891-1900 0.96 1.17 1.84 2.73 2.28 1.58 1.04 0.55 1.334 1901-09 0.74 0.90 1.31 1.95 1.86 1.42 1.09 0.63 1.023 The table shows that at every age-period almost without exception there has been since 1861-70 a decline in the mortality attributed to phthisis. The annual summary of the Registrar-General contains tables which supply information of much value concerning the place of death of persons dying from phthisis in London during 1909, 1 See footnote (2) page 17. 60 from which it is seen that the proportions of deaths in public institutions among males and females were as follows :— Phthisis'—Percentage of total deaths occurring at home and in institutions, 1909. Place of death. Per cent, of total deaths. Males. Females. At home 44.1 55.4 In workhouse establishments 44.0 31.8 In hospitals 7.3 6.4 In lunatic and imbecile asylums 4.6 6.4 Thus nearly half the deaths among males and over 30 per cent, of the deaths among females occurred in workhouse establishments. The figures provide striking evidence of the intimate association of this disease with poverty. It is seen also that a larger proportion of the deaths of males occur in public institutions, and especially in workhouse establishments, than of the deaths of females, no doubt for the reason that destitution especially occurs when the male fails in health. In some degree in females and more markedly in males these proportions follow the grouping of districts when arranged according to social condition. Thus, if the proportions of deaths among persons from 25—55 years of age occurring at home, in workhouse establishments and hospitals, are studied in respect of the several groups the following results are obtained :— Phthisis1—Place of death in relation to " social condition" 2—1909. Group. Males. Females. At home. In workhouse. In hospital. At home. In workhouse. In hospital. I. 48.5 39.8 11.7 55.4 32.2 12.4 II. 44.5 44.3 11.2 55.4 33.6 11.0 III. 45.3 42.0 12.7 56.1 32.9 11.0 IV. 39.9 51.8 8.3 55.5 36.6 7.9 V. 36.6 52.5 10.9 51.8 351 13.1 That the effect of social condition on the proportion of deaths occurring in institutions is not more strongly marked in the above figures is no doubt due to the fact that this disease occurs especially among the poor, and that in the main comparison is being made between deaths in very similar populations. Administrative effort in connection with the notification of phthisis. As stated in previous annual reports, a system of voluntary notification of phthisis has for some years been in operation in some of the London sanitary areas, and in the present year this system has been supplemented by an Order of the Local Government Board requiring the notification of cases of phthisis occurring in poor law practices and empowering local authorities to adopt measures for the prevention of the disease. The steps which sanitary authorities are empowered to take in respect of persons notified under this Order are contained in Article IX., which reads as follows :— (1) Nothing in these Regulations shall have effect so as to apply, or so as to authorise or require a medical officer of health or a council, or any other person or authority, directly or indirectly, to put in force with respect to any poor person, in relation to whom a notification in pursuance of these Regulations has been posted to a medical officer of health, any enactment which renders the poor person, or a person in charge of the poor person, or any other person, liable to a penalty, or subjects the poor person to any restriction, prohibition, or disability affecting himself, or his employment, occupation, means of livelihood, or residence, on the ground of his suffering from pulmonary tuberculosis. (2) Subject as aforesaid, a council, on the advice of their medical officer of health, in the case of a poor person in relation to whom a notification in pursuance of these Regulations has been posted to the medical officer of health, may, for the purpose of preventing the spread of infection from pulmonary tuberculosis— (i.) take all such measures, or do all such things as are authorised, in any case of infectious disease, or of dangerous infectious disease, by any enactment relating to public health, and as have reference to the destruction and disinfection of infected articles, or the cleansing or disinfecting of premises ; (ii.) take all such measures, or do all such things as are appropriate and necessary for the safe disposal or destruction of infectious material, produced and discharged, as a result of pulmonary tuberculosis; and otherwise for the prevention of the spread of infection from any such material; (iii.) afford or supply all such assistance, facilities, or articles as, within such reasonable limits as the circumstances of the case require and allow, will obviate, or remove, or diminish the risk of infection arising 1 See footnote (2) page 6. 2 See footnote (2) page 17. 61 from the conditions affecting the use or occupation of any room, when used or occupied by the poor person as a sleeping apartment; and (iv.) furnish, for the use of the poor person on loan, or otherwise, any appliance, apparatus, or utensil which will be of assistance for the purpose of any precaution against the spread of infection. (3) A council, on the advice of their medical officer of health, may provide and publish, or distribute in the form of placards, handbills, or leaflets, suitable summaries of information and instruction respecting pulmonary tuberculosis, and the precautions to be taken against the spread of infection from that disease. The Order therefore provides for pulmonary tuberculosis to be dealt with as an infectious disease, and this view and the steps which should be taken in connection therewith are clearly expressed in a memorandum by the Medical Officer of the Local Government Board, which points out the several measures, educational and administrative, deemed to be necessary in respect of persons so suffering. The provision (2) (iii.) of Article IX. of the Order quoted above appears to enable sanitary authorities to exercise very wide powers in respect of the most necessitous class of the community; such, indeed, as would tend to amelioration of the conditions under which such persons suffering from pulmonary phthisis are now living. It would, for instance, probably be competent for these authorities to provide hospital and sanatorium accommodation for such cases, or to give assistance which would ensure that a separate sleeping room were provided for their use. In such way, if the removal of the sick person to hospital or the infirmary were not feasible, the assistance might take the form of provision of an additional room so as to prevent in future such conditions as those mentioned in the annual reports relating to Hackney, Finsbury and Chelsea, which are referred to later. The London County Council was not included in the Order of the Local Government Board, and such information as is available is contained in the annual reports of medical officers of health, which has been supplemented by periodical returns kindly supplied by the medical officers of health of the following nineteen districts, viz., Kensington, Hammersmith, Fulham, Chelsea, St. Marylebone, Hampstead, Islington, Stoke Newington, Hackney, Shoreditch, Bethnal Green, Stepney, Poplar, South. wark, Bermondsey, Battersea, Camberwell, Lewisham and Woolwich. The following table shows the number of cases of phthisis notified in the several districts of London and the number of deaths occurring in workhouse institutions, the latter obtained from tables contained in the annual summary of the Registrar-General:— Phthisis—Notifications, 1909. Sanitary area. No. of persons notified under the Order. Voluntary. Deaths1 in Workhouse Establishments. Paddington 176 19 49 Kensington 230 14 76 Hammersmith 174 25 34 Fulham 279 51 78 Chelsea 272 31 52 Westminster, City of 279 159 104 St. Marylebone 236 98 79 Hampstead 55 12 10 St. Pancras 237 99 146 Islington 574 64 130 Stoke Newington 25 44 10 Hackney 354 58 121 Holborn 319 16 61 Finsbury 316 43 114 London, City of 72 6 17 Shoreditch 313 None 88 Bethnal Green 296 None 86 Stepney 800 29 258 Poplar 330 None 89 Southwark 479 165 182 Bermondsey 346 102 98 Lambeth 601 148 173 Battersea 257 130 72 Wandsworth 317 74 76 Camberwell 509 None 138 Deptford 172 None 51 Greenwich 103 193 26 Lewisham 164 26 43 Woolwich 97 109 34 London 8,382 1,715 2,495 It must be remembered that the deaths in workhouse establishments shown in the table stand in relation to a much larger number of sick persons than those whose illness had been notified in 1909, nevertheless the number of cases notified in that year is probably larger than that which will be notified in subsequent years, unless efforts are made to search in the homes of the poor for those who are affected. The cases notified are, indeed, the majority of those poor persons whose illness has so far advanced that they are driven by stress of sickness to seek the aid of the poor law medical officer. The figures of 2057 1 See footnote (2), page 6. I 62 future years will be more closely limited to the annual accessions to this class.* In this connection evidence of the period of time which elapses between admission to the workhouse infirmary and the death of some of the patients is of interest. Thus, Dr. Dudfield gives account of 46 persons who died from phthisis in the Paddington Workhouse and Infirmary. As many as 37 of these persons had not on any previous occasion been inmates of either of these institutions. The average interval between notification and death was for 25 males 67'4 days, and for 12 females 19 days : of the remaining 9 patients 1 had been in the workhouse for 7 years and 6 had been " ins and outs " between the times of recognition of their illness and their death ; the information with regard to the remaining two persons was incomplete. As already stated, the medical officers of health of nineteen sanitary areas have supplied the Council with certain particulars of the cases notified to them. In these districts since 14th August 2,300 persons were notified, of which 1,589 were males and 711 females. Thus the number of males notified was more than twice the number of females. Exclusive of 23 cases for which the age was not stated, the age-distribution of the persons notified was as follows :— Phthisis—Age-distribution of persons notified under the Poor Law Order, 1909. Age. 0— 5— 10— 15— 20— 25— 35— 45— 00— 65— ###] Males 16 34 27 42 101 321 430 349 203 52 5 Females 17 33 36 43 68 140 154 108 69 24 5 Persons 33 67 63 85 169 461 584 457 272 76 10 Although the persons notified in these districts numbered 2,300, the number of notifications received was, in consequence of duplicate notification, 3,010. Thus 398 persons were notified twice, 96 persons 3 times, 19 persons 4 times, 9 persons 5 times, 3 persons 6 times, and 2 persons 7 times. The character of the homes from which the patients come is shown in some of the reports. Thus, Dr. Sandilands found in Kensington and Dr. Thomas found in Finsbury, that the home accommodation of patients was as follows :— Phthisis—Home Accommodation of phthisis patients. Number of rooms. 1. 2. 3. 4 or more. Cases in Common Lodging Houses. Number of cases—Kensington 100 83 55 43 19 „ „ Finsbury 91 88 23 15 188 In Hackney, Dr. Warry found that of 135 cases concerning which information could be obtained 93 shared the bedroom and 64 of these shared the bed with other members of the family. Dr. Thomas gives the following cases illustrative of the conditions found on visiting the homes of poor persons. " (1) A mother and six children ranging from six months to 13 years live and sleep in one room. Two of the children are consumptive. (2) A man, wife and one adult child, and six little children occupy two rooms. Two children have already died from consumption. The mother and one child of 12 years are now consumptive." Dr. Parkes mentions the following—" (1) Mother (a widow) in the last and most infectious stage of phthisis found sleeping in the same bed with three sons aged 17,11 and 7 years. The family occupied two rooms. (2) Child of 9 years, suffering from tuberculosis and sleeping in the same bed with both parents and three young brothers and sisters—the family occupying a single room." The extent to which tuberculosis exists in the London population is unknown, and indeed the proportion which would be called tuberculous would depend in large degree on the standard which is adopted for determination whether the persons examined are to be regarded as subjects of this disease. Dr. Dudfield gives the results of the examination of persons living with others who were patients attending the Paddington Dispensary for the Prevention of Tuberculosis. He writes as follows: "The medical officer of the dispensary reports that after examining 472 patients resident in the borough and finding 184 ' definite ' and 154 ' suspect' cases of consumption, and 8 cases of tuberculosis of other forms than the pulmonary, he examined 228 ' contacts,' of whom 50 were found to be suffering with the disease, 98 suspected to be so suffering and 3 had other forms of tuberculosis." The true significance of these figures could of course only be rightly understood if similar inquiry were made into the health of persons of the same class not known to be associated with other persons suffering from this disease. *In some districts the number notified includes all the cases of this disease in poor-law practices under treatment during the year. Where, however, under a system of voluntary notification a proportion of these cases had already been notified, it does not appear that they havo been again notified under the Order. 63 Notified cases in common lodging-houses.—Inquiry has been made with regard to 272 persons notified under the order and giving addresses at common lodging-houses licensed by the Council, viz. : 259 males and 13 females. The age-distribution of 262 of these cases was— 0— 5— 10— 15— 20— 25— 35— 45— 55— 65+ 1 2 1 2 8 38 70 91 39 10 As the result of inquiry information was obtained in respect of 149 of the patients as to whether their illness began before or after they had resorted to this mode of living. Of the total (149) the onset of the illness was stated in 52 cases to date from a time prior to that when resort was made to common lodging-houses, while in 10 other cases it was practically coincident with entry. As regards cases developing after commencement of this mode of life—in 30 cases the illness was first manifested before the expiration of three years ; in 16 cases in from three to five years ; in 22 cases between five and ten years ; in 14 cases between ten and twenty years; in five cases the illness developed after more than twenty years of common lodging-house life. Voluntary notification by hospital authorities.—During 1909 the Brompton Hospital supplied the Council's medical officer with particulars of cases attending that hospital, where the patient gives consent for this course to be adopted, and this information is communicated to the medical officers of health concerned. This hospital included among its patients persons from all parts of London. The age-distribution of 730 patients concerning whom information was thus received was as follows :— Phthisis—Age and sex distribution of 730 patients notified by Brompton Hospital, 1909. Age. 0— 15— 20— 25— 35— 45— 55— 65+ Males 13 41 76 150 106 39 8 1 Females 19 36 46 94 70 25 6 — The maximum incidence of the disease among patients thus notified was upon age 25—, whereas that among cases occurring in poor law practices was upon age 35—. The 730 Brompton Hospital cases are, of course, but a sample of the whole of the cases treated by that institution, but the comparison between their age-distribution and that of the cases occurring in poor law practices appears to give indications that under the stress of poverty resort to poor-law medical assistance occurs at a later stage of the disease, and hence the need for enquiry in the homes if any substantial effort is to be made for the detection of cases in the early stage of the disease. It is unnecessary to state here in any detail the steps which are taken in the London sanitary districts for the prevention of this disease, as a full report on this subject by Dr. Wanklyn is appended (see Appendix II.). Sanitary authorities are rendering useful service in undertaking the examination of sputum for tubercle bacilli and in a number of reports information is given as to the number of specimens examined and the results of the examination thus— Phthisis—Bacteriological diagnosis, 1909. Sanitary area. No. of Specimens Examined. No. found to be Tuberculous. Sanitary area. No. of Specimens Examined. No. found to be Tuberculous. Paddington 26 7 Shoreditch 2 1 Fulham 308 48 Bethnal Green 10 1 Westminster, City of 61 22 Stepney 49 12 St. Marylebone 77 26 Southwark 139 38 St Pancras 80 16 Bermondsey 229 61 Islington 222 60 Lambeth 186 71 Stoke Newington 51 17 Battersea .. 151 34 Hackney 104 28 Wandsworth 105 35 Holborn 7 1 Greenwich 30 5 Finsbury 42 12 Lewisham 74 26 London, City of 5 2 Woolwich 179 55 In reviewing the facts stated in the appended report, it cannot be said that in London as a whole, any material effort was made to deal with this disease ; and especially was effort wanting to detect early cases of phthisis and to provide for their subsequent treatment. It needs to be noted that in Paddington, as the result of philanthropic effort, a dispensary has been instituted which is rendering useful service in these directions and that in one or two other districts the provision of such an institution is being undertaken ; but in the districts generally little was done to exercise the powers conferred by the Order of the Local Government Board. *During the current yearseven other London hospitals have agreed to adopt a similar course. 2057 I 2 64 Cancer. The deaths1 from cancer in the Administrative County of London during 1909 (365 days), numbered 4,706, as compared with 4,628 for the 366 davs of 1908. The death-rates from this disease in successive periods have been as follows:— Cancer. Period. Death-rate per 1,000 persons living. Period. Death-rate per 1,000 persons living. 1851-60 0.42 1903 0.961 1861-70 0.48 1904 0.921 1871-80 0.55 1905 0.931 1881-90 0.68 1906 0.981 1891-1900 0.85 1907 0.95l 1901 0.881 1908 0.961 1902 0.931 1909 0.971 For the purpose of enabling the incidence of cancer on the several populations of the sanitary areas to be more precisely stated, factors have been calculated for correcting the death-rates, as far as possible, for differences in the age and sex constitution of the several populations concerned. These factors are shown in the following table, together with the death-rates for each sanitary area, corrected by their application. Cancer. Crude and corrected death-rates1 per 1,000 persons living in the County of London and the several sanitary districts. Sanitary area. Standard deathrate.8 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). 1904-8 1909. 1904-8. 1909. 1904-8. 1909. London 0.87 1.00000 0.95 0.97 0.95 0.97 1,000 1,000 Paddington 0.98 0.89478 1.14 1.01 1.02 0.91 1,072 930 Kensington 1.02 0.85622 1.04 1.18 0.89 1.01 936 1,034 Hammersmith 0.90 0.96811 1.06 0.91 1.03 0.88 1,086 901 Fulham 0.77 1.13828 0.84 0.82 0.96 0.93 1,011 954 Chelsea 1.03 0.84874 1.07 1.14 0.90 0.97 954 996 Westminster, City of 0.96 0.91348 1.05 1.19 0.96 1.09 1,008 1,116 St. Marylebone 0.99 0.88571 1.20 1.30 1.06 1.15 1,117 1,183 Hampstead 092 0.94816 0.91 0.91 0.86 0.87 910 889 St. Pancras 0.92 0.95229 1.03 1.03 0.98 0.98 1,039 1,005 Islington 0.90 0.96704 1.02 101 0.99 0.98 1,042 1,007 Stoke Newington 0.98 0.89387 1.11 1.14 1.00 1.02 1,051 1,045 Hackney 0.88 0.99341 0.88 0.92 0.87 0.91 918 936 Holborn 0.95 0.91924 0.95 1.23 0.88 1.13 925 1,158 Finsbury 0.84 1.04071 0.84 0.95 0.87 0.99 917 1,020 London, City of 1.06 0.82316 1.39 1.48 1.14 1.22 1,204 1,254 Shoreditch 0.79 1.10518 0.82 0.84 0.91 0.92 961 948 Bethnal Green 0.78 1.12077 0.87 0.91 0.98 1.02 1,034 1,052 Stepney 0.74 1.17976 0.78 0.67 0.92 0.79 965 807 Poplar 0.81 1.08327 0.78 0.87 0.85 0.94 895 '970 Southwark 0.82 1.06350 0.91 0.89 0.97 0.94 1,025 967 Bermondsey 0.81 1.08462 0.88 1.12 0.96 1.22 1,009 1,248 Lambeth 0.92 0.95333 1.04 1.18 1.00 1.13 1,050 1,156 Battersea 0.79 1.10798 0.92 0.98 1.02 1.09 1,080 1,119 Wandsworth 0.88 0.99116 0.95 0.92 0.95 0.92 998 940 Camberwell 0.87 1.00483 0.90 0.93 0.91 0.94 958 963 Deptford 0.81 1.07396 0:86 0.89 0.93 0.95 977 975 Greenwich 0.87 1.01064 0.84 0.78 0.85 0.79 900 813 Lewisham 0.92 0.95333 0.92 0.97 0.88 0.92 929 949 Woolwich 0.78 1.11933 0.81 0.90 0.90 1.01 951 1,034 It will be seen from the foregoing table (comparing the corrected death.rates) that in the quinquennium 1904-8 among the several sanitary areas the City of London (1.14) had the highest cancer death.rate and Greenwich and Poplar (0.85) the lowest; in the year 1909, the City of London and Bermondsey (1.22) had the highest, the lowest obtaining in Stepney and Greenwich (0.79). See footnote (2), page 6. 2 See footnote (2), page 56. 65 The following table shows the corrected death.rate from cancer in each of the sanitary districts of London, annually for the last nine years:— Cancer—Corrected death-rates per 1,000 persons living (1901-1909). Sanitary area. 1901. 1902. 1903. 1904. 1905. 1906. 1907. 1908. 1909. Paddington 0.92 0.86 1.00 0.98 0.91 101 1.07 1.11 0.91 Kensington 0.96 0.76 0.92 0.87 0.82 0.84 1.01 0.89 1.01 Hammersmith 0.81 0.82 0.83 0.98 0.99 1.15 1.08 0.95 0.88 Fulham 1.00 0.85 0.91 0.97 0.98 0.98 1.08 0.79 0.93 Chelsea 0.77 0.90 1.06 1.04 0.87 0.98 0.81 0.83 0.97 Westminster, City of 0.76 0.98 0.94 0.93 0.97 0.91 0.89 1.08 1.09 St. Marylebone 0.92 0.97 1.19 0.97 1.16 0.94 1.06 1.16 1.15 Hampstead 0.91 1.05 1.20 0.93 0.67 1.03 0.76 0.92 0.87 St. Pancras 0.84 0.98 1.02 0.92 0.95 1.01 0.87 1.17 0.98 Islington 0.88 0.95 1.05 0.93 0.96 1.05 0.98 1.03 0.98 Stoke Newington 0.82 0.76 0.97 0.92 0.93 0.92 1.08 1.13 1.02 Hackney 0.79 0.87 0.88 0.83 0.88 0.80 0.87 0.95 0.91 Holborn 0.92 0.99 0.92 0.86 0.85 1.07 0.75 0.85 1.13 Finsbury 0.81 0.84 0.95 0 86 0.73 0.90 0.93 0.94 0.99 London, City of 1.05 1.28 0.84 1.16 1.18 1.12 1.09 1.15 1.22 Shoreditch 0.90 1.15 0.94 0.86 0.97 0.80 1.04 0.88 0.92 Bethnal Green 0.96 0.93 0.96 0.98 0.91 1.09 0.95 0.98 1.02 Stepney 0.86 0.79 0.92 0.90 0.86 1.10 0.85 0.87 0.79 Poplar 0.79 0.92 0.90 0.77 0.89 0.82 0.84 0.92 0.94 Southwark 0.91 0.89 1.04 0.90 1.12 0.94 0 98 0.93 0.94 Bermondsey 0.73 1.03 0.93 0.79 0.91 1.05 1.08 0.94 1.22 Lambeth 0.94 0.96 0.97 0.98 1.01 0.95 1.02 1.01 1.13 Battersea 0.90 0.95 0.94 1.05 1.10 1.06 0.98 0.93 1.09 Wandsworth 0.88 0.92 1.02 0.98 0.85 0.97 0.98 0.94 0.92 Camberwell.. 0.97 0.95 0.86 0.88 0.85 0.98 0.87 0.94 0.94 Deptford 0.87 1.03 0.99 1.01 0.97 1.03 0.73 0.89 0.95 Greenwich 0.70 0.86 0.76 0.87 0.96 0.77 0.78 0.89 0.79 Lewisham 0.91 0.93 0.83 0.81 0.86 0.91 0.92 0.91 0.92 Woolwich 0.79 0.96 0.87 0.93 0.76 1.04 0.97 0.81 1.01 London 0.88 0.93 0.96 0.92 0.93 0.98 0.95 0.96 0.97 The following tables (a), (b), and (c) show the deaths during 1909 (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 distinguish them further for purposes of classification. (a) Sarcoma.—Deaths at the several age.periods in sanitary areas.—1909 (365 days). Age-period. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 and upwards ges Paddington — — — 1 2 4 1 — 3 1 — — 12 Kensington 1 — — 1 — — 2 6 3 1 — — 14 Hammersmith — — — — 1 — 2 1 2 — — — 6 Fulham 1 3 3 1 1 — — 9 Chelsea — — — — 1 — — — — — 1 — 2 Westminster, City of — — — — — 2 2 1 1 4 2 — 12 St. Marylebone 2 — 1 — — — 1 — 1 1 1 — 7 Hampstead — — — — 1 1 1 2 — 2 1 1 9 St. Pancras 1 — 1 — — o u 2 3 2 3 1 — 15 Islington — 2 — — 2 1 — 4 6 4 2 — 21 Stoke Newington — — — — — — — 1 — — 1 — 2 12 Hackney 1 — 1 2 1 — 1 2 3 — 1 — Holborn — — — 1 — 2 1 1 — 2 — — 7 Fin3bury — — — 1 — ] 1 1 — 1 — — 5 London, City of — — — — — — — 1 2 — — — 3 Shoreditch 1 — — — — 1 — 1 1 — — — 4 Bethnal Green 2 — — — — 2 — 3 2 — — — 9 Stepney 2 — — — 1 3 4 5 — 5 — — 20 Poplar — 1 — 1 — 1 2 1 2 — 1 — 9 SouthwaTk 2 1 — — — 1 1 1 1 2 — — 9 Bermondsey — — 1 — — 1 — 3 1 1 1 — 8 Lambeth 2 1 — 1 2 2 4 2 3 7 — — 24 Battersea — 1 — — — 1 — 3 — 1 — — 6 Wandsworth 1 — — 1 — 1 1 4 8 3 1 — 20 Camberwell — — 2 2 1 — 3 3 2 3 — — 16 Deptford — — — — — 2 1 2 — 1 1 1 8 Greenwich — 1 — — 1 2 2 1 — — 1 1 9 Lewisham — — — — — 1 1 1 3 2 — — 8 Woolwich 1 — — 2 — 3 — 1 — — — — 7 London 17 7 6 13 13 34 36 57 47 45 15 3 293 66 (b) Carcinoma.—Deaths at the several age-periods in sanitary areas.—1909 (365 days). Age-period. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 and upwards All Ages. Paddington — — — — — 2 8 17 34 24 13 1 99 Kensington — — — — — 3 13 27 34 31 20 1 129 Hammersmith — — — — — 2 7 19 20 15 1 1 65 Fulham — — — — 1 2 11 25 31 23 6 1 100 Chelsea — — — — — 7 10 14 15 3 — 51 Westminster, City of — — — — — 1 8 24 37 37 10 4 121 St. Marylebone — — — — — 3 3 12 33 21 15 1 88 Hampstead — — — — — 2 7 8 20 16 5 — 59 St. Pancras — — — 1 — 3 8 35 42 52 22 2 165 Islington — — — — — 4 16 50 49 51 14 6 190 Stoke Newington — — — — — — 2 6 10 11 5 — 34 Hackney — — — — — 4 8 29 50 27 13 2 133 Holborn — — — — — — 2 8 14 9 4 — 37 Finsbury — — — — — 1 8 13 26 15 2 — 65 London, City of — — — — — — 1 5 1 4 2 — 13 Shoreditch — — — — — — 9 15 15 10 6 1 56 Bethnal Green — — — — — 1 4 15 12 17 3 1 53 Stepney — — — — — 1 17 28 42 28 10 1 127 Poplar — — — — — 3 16 23 33 29 6 1 111 Southwark — — — — 1 2 11 37 45 34 15 1 146 Bermondsey 1 12 25 30 22 10 — 100 Lambeth — — — — — 8 14 54 78 81 33 6 274 Battersea — — — — 1 — 9 15 35 22 10 1 93 Wandsworth — — — — 1 1 13 28 37 32 21 5 138 Camberwell — — — — 1 1 12 28 25 33 19 3 122 Deptford — — — — — 1 2 13 18 23 7 — 64 Greenwich — — — — — 1 7 10 20 12 6 1 57 Lewisham — — — — — 1 9 18 32 25 16 4 105 Woolwich — — — — — — 7 19 19 12 10 2 69 London — — — 1 5 48 521 616 856 731 307 49 2864 (c) Cancer (otherwise undistinguished).—Deaths at the several age-periods in sanitary areas.—1909 (365 days). Age-period. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 and upwards All Ages. Paddington — — — — — — 6 12 9 9 5 2 43 Kensington — — — — — 3 3 15 25 12 13 2 73 Hammersmith — — — — — 3 3 5 7 20 5 — 43 Fulham — — — — — — 4 10 9 9 3 — 35 Chelsea — — — — — 2 1 12 6 7 5 — 33 Westminster, City of — — — — 1 — 4 21 14 13 14 1 68 St. Marylebone — 1 — — — 3 3 17 17 20 8 — 69 Hampstead — — — — — 1 — 1 7 8 1 — 18 St. Pancras — — — — — 3 4 15 18 16 7 1 64 Islington — — — — 1 4 12 27 41 40 19 1 145 Stoke Newington — — — — — — 1 10 8 4 3 — 26 Hackney — — — — — 2 7 14 23 17 9 1 73 Holborn — — — — — — 1 5 9 7 — — 22 Finsbury .. — — — — — — 1 4 9 6 1 — 21 London, City of — 1 1 4 2 3 — — 11 Shoreditch — — — — — — 3 8 10 11 4 — 36 Bethnal Green — — — — — i 3 11 20 16 6 1 58 Stepney — — — — 1 2 2 15 18 19 4 — 61 Poplar — — — — — — 1 7 8 9 5 — 30 Southwark — — — — — — 2 6 5 14 5 — 32 Bermondsey — — — — — — 4 14 10 5 2 — 35 Lambeth — — — — — 2 10 12 20 25 13 3 85 Battersea — — — — 1 2 5 24 21 25 5 1 84 Wandsworth — 2 — — 2 7 16 17 28 27 17 1 117 Camberwell 1 1 — — 1 1 12 25 35 35 14 1 126 Deptford 1 — — — — — 3 7 14 6 2 — 33 Greenwich — — — — — — — 5 9 5 2 — 21 Lewisham — — — — — — 5 6 11 10 10 1 43 Woolwich — — — — — — 1 9 11 17 5 1 44 London 2 4 — — 7 37 118 338 424 415 187 17 1549 67 The following table shows the proportional age-distribution of the deaths in London during 1909 (365 days) classified under the three headings— Cancer—Deaths1 at each age-period per 1,000 deaths at All Ages—1909 (365 days). Type of cancer. All ages. Under 35. 35- 45- 55- 65- 75- 85 and upwards. Sarcoma 1,000 307 123 195 160 154 51 10 Carcinoma 1,000 19 88 215 299 255 107 17 Cancer (not otherwise defined) 1,000 32 76 218 274 268 121 11 Total 1,000 41 86 215 282 253 108 15 In the report for the year 1908 a table was included showing the cancer death-rates in the period 1901-8 in areas presenting different degrees of overcrowding,2 the object being to compare the death-rates of populations differently circumstanced in respect of "social condition." The following table shows the corresponding death-rates for the period 1901- 9:— London, 1901-9. Cancer death-rates1 in relation to overcrowding' Proportion of overcrowding in each group of sanitary areas. Crude cancer death-rate per 1,000 persons living. Standard deathrate. 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. 0.933 0.883 0.99003 0.923 982 7.5 to 12.5 per cent. 0.928 0.864 1.01180 0.939 998 12.5 to 20 per cent. 0.992 0.921 0.94919 0.942 1,001 20. to 27.5 per cent. 1.017 0.904 0.96704 0.983 1,045 Over 27.5 per cent. 0.807 0.774 1.12946 0.911 969 London 0.940 0.874 1.00000 0.940 1,000 I he 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 58). Cerebro.spinal Fever. During 1909, 111 persons were certified to be suffering from cerebro-spinal fever and 15 deaths were attributed to this disease. The number of deaths in each year since 190] has been as follows :— Deaths.3 s.3 1902 4 1906 4 1903 6 1907 25 1904 6 1908 12 1905 5 1909 15 As stated in the last annual report, the larger number of deaths attributed to this cause in 1907 was probably an indirect effect of the Council making an Order requiring cases of this disease to be notified. The number of cases notified and the number of deaths were higher in 1909 than in 1908. The requirement of notification did not become operative until the 12th of March, 1907, and during the remainder of that year 135 cases were notified, or 50 more than in the whole of the year 1908. In 1909 there w6r6 111 notified cb-sbs. The age distribution of the 111 cases notified in 1909 was as follows:— Cerebrospinal fever—Age-distribution of notified cases, 1909. Sex. All ages. 0- 1- 2- 3- 4- 5- 6- 7- 8- 9- 10- 13- 15+ Males 51 19 8 6 4 2 2 1 — — — — 3 6 Females GO 24 7 3 5 2 2 — 2 1 1 8 1 6 Persons 111 43 15 9 9 4 4 1 2 1 1 6 4 12 1 See footnote (2), page 6. 2 See footnote (2), page 25. 3 See footnote (2), page 45. 68 A report by Dr. "Wanklyn on cerebro-spinal fever in London during 1909 is appended. (See Appendix III.) Anthrax. On the 6th April, 1909, the Council made an Order requiring the notification of cases of glanders, anthrax and hydrophobia in man; the Order came into force on the 26th April. Four persons during the year were certified under this Order to be suffering from anthrax. The cases of this disease which came under observation during the year were the following :— 1. February—A cats' meat man in Lambeth. 2. March—A lime jobber in Bermondsey, infected from Chinese hides. 3. March—A lime jobber in Bermondsey, infected from Chinese hides. 4. April—A dock labourer in Bow, engaged in unloading jute and wool. 5. May—A labourer in Bethnal Green, engaged in opening and disinfecting bales of Siberian horsehair. 6. June—A house-keeper in Water-lane, City, who had swept up horsehair and bristles. 7. June—A wharf labourer in Bermondsey, infected from Cape goat-skins. 8. June—A labourer at a tannery in Bermondsey, infected from foreign hides. 9. December—A man employed on a barge in "VVapping. He had been stung by a fly on the barge, but otherwise the source of infection was unknown as the barge was exclusively used for carrying waste paper. Of these cases Nos. 8 and 9 proved fatal. Glanders. The following is the history of human glanders in London during 1909 :— A horse-keeper, (Pi. 41, died on 2nd March in St. Thomas's Hospital. His right knee had been swollen and there were swellings on the leg, ankle, and forehead. The diagnosis was confirmed by bacteriological examination. The mallein test was applied to the stud of horses, among which he had worked, with result that several were found to be affected with glanders. In April two supposed cases, one in Islington and one admitted to the Eastern Hospital, Homerton, were notified in error. The latter proved to be a case of erythema multiforme. In September a case was notified as farcy in Poplar ; this case proved to be one of impetigo contagiosum. In October a death occurred in Kensington (the case had been notified in July). The man, a carman, had been in Charing Cross Hospital and the Throat Hospital, Golden-square, suffering with sore throat. The presence of the bacillus mallei was demonstrated in the throat lesions. In October there occurred the death of a member of the staff in the inoculation department of a London hospital. His fatal illness was contracted in 1906 while working in the inoculation department. The nature of the disease was at first obscure, but was later identified as internal glanders. Two other cases in which a suspicion of glanders arose occurred during the year, but in neither case was the diagnosis confirmed. 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 1909 was 48-9 deg. Fahrenheit, which is 12 degrees below the average of the pieceding 65 years. The rainfall during the year amounted to 25"72 inches, an excess of 1'60 inches on the average of the preceding 65 years. The temperature and rainfall in each month of the year 1909 are shown in the following table :— Temperature and Rainfall—1909. Month. Temperature of the air. Departure of mean monthly temperature from average of preceding 65 years. Rain and other forms of precipitation. Departure of mean monthly rainfall from average of preceding 65 years. Absolute maximum. Absolute minimum. Mean for the month. Number of days it fell. Amount collected. deg. F. deg. F. deg. F. deg. F. Inches. Inches. January 50 21 38.5 +01 12 0.77 —1.11 February 56 19 37.2 —2.6 9 0.63 —0.85 March 62 14 39.6 —2.9 22 3.08 + 1.56 April 71 29 49.6 + 1.5 16 1.64 +0.07 May 84 33 53.2 —0.6 10 1.24 —0.68 June 74 38 54.8 —5.5 16 3.67 + 1.63 July 78 46 61.3 —2.4 18 3.16 +0.76 August 86 45 62.7 —0.2 11 1.80 —0.54 September 71 37 55.2 —3.0 17 2.48 + 0.33 October 68 28 52.5 +2.1 19 4.06 + 1.28 November 57 28 41.7 —1.7 14 0.79 — 1.43 December 54 22 40.1 +0.5 22 2.40 + 0.57 69 PART II. Dairies, Cowsheds and Milkshops. The County Council received during the year 216 applications for cowhouse licences, of which 214 were granted. The number of applications for licences received during the last sixteen years and the number granted are shown in the following table. It will be seen that the number of these premises in London is continually decreasing. Cowshed.premises—Number of licences granted. Year. No. of applications received. No. of premises for which licences were granted. 1894 456 446 1895 427 416 1896 405 393 1897 379 374 1898 357 354 1899 338 330 1900 323 321 1901 306 295 1902 294 291 1903 282 277 1904 266 259 1905 257 255 1906 244 240 1907 234 233 1908 229 225 1909 216 214 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 or specially furnished by them. The following table relating to cowsheds has been thus prepared:— Cowshed-premises. Sanitary area. Number of cowshed premises. Number of inspections by the sanitary authority, 1909. Number of prosecutions by sanitary authority, 1909. On register at end of 1908. Added in 1909. Removed in 1909. On register at end of 1909. Battersea 3 — — 3 — Bermondsey 6 — 1 5 49 1 Bethnal Green 15 — — 15 77 — Camberwell 14 — — 14 217 — Chelsea 2 — — 2 36 — Deptford 3 — — 3 38 — Finsbury 5 — 2 3 26 — Fulham 2 — — 2 30 — Greenwich 4 — — 4 16 — Hackney, 21 — — 21 269 — Ilolborn 1 — — 1 52 — Islington 7 — — 7 68 — Kensington 1 — — 1 47 — Lambeth 14 — 1 13 26 — Lewisham 14 — 1 13 126 — Paddington 1 — — 1 4 — Poplar 15 — — 15 63 — St- Marylebone 6 — 1 5 121 — St. Pancras 7 — — 7 — Shoreditch 7 — — 7 83 — South wark 5 — 1 4 69 — Stepney 38 — 2 36 71 — Stoke Newington 2 — — 2 2 — Wandsworth 13 — 1 12 61 — Westminster, City of 2 — 1 1 29 — Woolwich 17 — 1 17 68 — 2057 K 70 Milhshop premises. In 1908 the London County Council obtained the sanction of Parliament to a provision, contained in the General Powers Act of that year, authorising any sanitary authority to remove from the register of milk vendors, or to refuse to register the name of any person carrying on or proposing to carry on the business of a dairyman or purveyor of milk upon premises which, in the opinion of the sanitary authority, are unsuitable for the sale of milk. The Act provides an appeal to a Court of Summary Jurisdiction. The following table shows the number of milkshop premises at the end of 1908 and 1909 in the several sanitary districts of London, the number of inspections and the proceedings taken. The table has mainly been compiled from information contained in the annual reports:— Sanitary area. Number of premises.* Number of inspections, 1909. Number of notices, 1909. Number of prosecutions, 1909. On register at end of 1908. Added in 1909. Removed in 1909. On register at end of 1909. City of London 612 38 48 602 2 Battersea 241 50 113 178 852 65 — Bermondsey 263 25 15 273 1,112 26 1 Bethnal Green 342 31 46 327 1,320 155 — Camberwell 616 43 55 604 1,341 34 1 Chelsea 121 16 24 113 196 8 — Deptford 200 48 49 199 484 13 1 Finsbury 243 66 84 265 258 56 — Fulham 249 25 81 193 715 48 — Greenwich 210 10 14 206 272 12 — Hackney 362 27 27 362 1,218 7 — Hammersmith 300 36 2 334 678 34 — Hampstead 113 4 2 115 310 21 — Holborn 178 27 37 168 542 22 — Islington 573 38 24 587 2,231 355 — Kensington 284 14 108 190 1,574 36 — Lambeth 544 11 — 555 555 48 Lewisham 178 57 49 186 530 16 — Padding-ton 176 14 7 183 . 245 — — Poplar 341 20 20 341 1,442 5 — St. Marylebone 247 28 11 264 7 St. Pancras 413 — — 413 1,141 2 1 Shoreditch 292 28 18 302 3,404 9 1 Southwark 400 134 113 421 690 35 — Stepney 970 244 238 976 2,664 203 31 Stoke Newington 63 — — 53 91 6 — Wandsworth 367 58 94 331 1,365 57 7 Westminster, City of 344 43 37 350 690 4 1 Woolwich 134 37 43 128 217 9 — *Figures in italics refer to persons registered. Tuberculosis of the udder in London cows. London County Council (General Powers) Act, 1904 (Part F.). The Dairies, Cowsheds and Milkshops Order, 1899, provides that the milk from cows certified by a veterinary surgeon to be affected with tubercular disease of the udder, shall not be (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 1904, however, the Council obtained powers, as incorporated in the above-named Act, to remove any cow from any dairy, farm or cowshed in the County (elsewhere than in the City), if such cow is suspected to be suffering from tuberculosis of the udder, and if, upon slaughter, these suspicions are verified, a sum equal to three-quarters of the agreed value of the animal (not exceeding £22 10s.) is payable by the Council. If, however, the cow is proved to be free from tuberculosis of the udder, the full agreed value (not exceeding £30), together with a further sum of £1, is payable by the Council. 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 1909 there were five inspections of 71 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 1909. Details of Examination. 1st period, 5th Dec., 1908 to 4th Feb., 1909. 2nd period, 5th Feb. to 20th April, 1909. 3rd period, 21st Apil to 10th July, 1909. 4th period, 11th July to 4th Sept., 1909. 5th period, 5th Sept. to 30th Nov., 1909. Total number of cows examined 3,557 3,465 3,328 3,434 3,386 Affected with disease or defects of the udder 205 159 191 214 190 A fleeted with tubercular disease of the udder 5 5 6 6 6 Suspected cases of tubercular disease — 1 3 — — Subjects of acute mastitis 35 30 32 41 31 Affected with chronic induration of the udder 10 6 12 12 13 Atrophy of one or more quarters 124 94 95 116 90 Injuries, abscesses, simple eruptions, strictures and obliterations of milk ducts 11 12 31 24 30 Hypertrophied udders without induration 1 1 1 2 2 Giving milk of poor quality (dried-off cows) 19 10 11 13 18 The 28 cows suffering from tubercular disease of the udder were slaughtered, and the carcases destroyed, compensation being paid by the Council to the owners in accordance with the provisions of the London County Council (General Powers) Act of 1904. During the year the President of the Local Government Board introduced a bill into Parliament providing for the supervision of dairies and of the conduct of the milk business. The bill was not proceeded with. A circular letter was issued by the Board of Agriculture to Local Authorities on 27th May, 1909, enclosing copy of an Order to come into operation on 1st January, 1910, providing for the notification and slaughter of tuberculous cattle subject to compensation; the Order was, however, subsequently withdrawn. London County Council (General Powers) Act, 1907.—Part IV. Milk Supply (Tuberculosis). Part IV. of the Act of 1907 empowers the County Medical Officer of Health or other duly authorised person to take, within and without the County, samples of milk produced or sold or intended for sale within the County ; and, having obtained a justice's order, in company with a veterinary surgeon, to enter any dairy from which milk is being sold or suffered to be sold or used within the County, and to inspect the cows kept therein, and if the Medical Officer or such authorised person has reason to suspect that any cow is suffering from tuberculosis of the udder he may take samples of the milk of such cow. If it appears to the Council that tuberculosis is caused, or is likely to be caused, to persons residing in the County from the consumption of milk from any dairy, or from any cow kept therein, the Council may make an order prohibiting the supply of such milk in the County until the order has been withdrawn, and any person contravening the order is liable to a penalty not exceeding £5, and for a continuing offence to a daily penalty not exceeding 40s. Appeal may be made against the Council's order. On 11th February, 1908, the Council delegated to the Public Health Committee, the authority conferred by Part IV. of this Act, dealing with tuberculous milk and fixed the 1st July, 1908, as the date upon which the Act should become operative. During the year under review, the method of procedure adopted was as follows : Samples were taken by the Council's inspectors from churns of milk consigned from the country to the various London railway termini, and submitted to the Lister Institute for bacteriological examination. In the case of those samples in respect to which the examination proved that there was evidence of the presence of tubercle bacilli, a clinical examination of the cows at the dairy farm from which the milk had been consigned was made by a veterinary inspector, appointed for the purpose under the Act, and cows found to have tuberculous udders were certified for the purposes of the Dairies and Cowsheds Orders and copies of the certificates were forwarded to the local sanitary authorities concerned. During the year under review 2,325 samples of milk were taken. The milk had been sent to London from the following counties : Bedfordshire, Berkshire, Buckinghamshire, Cambridgeshire, Derbyshire, Dorsetshire, Essex, Gloucestershire, Hampshire, Hertfordshire, Huntingdonshire, Kent, Leicestershire, Lincolnshire, Middlesex, Norfolk, Northamptonshire, Nottinghamshire, Oxfordshire, Rutlandshire, Somersetshire, Staffordshire, Suffolk, Surrey, Sussex, Warwickshire, Wiltshire and Worcestershire, and the samples were taken principally from churns at stations of the Great Western, the Great Eastern, the Great Northern, the Great Central, the Midland, the Metropolitan, the London, Brighton and South Coast, and the London and North Western and South Western Railwav ComDanies. The following table shows the number of samples taken during the period under review, 18th January to 31st December, 1909, the counties from which they were derived, and the results of the bacteriological examination at the Lister Institute. 2057 k 2 72 County. No. of samples taken, from churns for examination. No. of samples found to be tuberculous. No. of samples found not to be tuberculous. No. of Bamples the examination of which was not completed owing to accident and other causes. Bedfordshire 37 3 29 5 Berkshire 162 11 134 17 Buckinghamshire 117 7 103 7 Cambridgeshire 28 2 19 7 Derbyshire 113 27 79 7 Dorsetshire 20 3 16 1 Essex 324 27 173 124 Gloucestershire 29 28 1 Hampshire 160 16 136 8 Hertfordshire 89 10 56 23 Huntingdonshire 3 1 2 — Kent 29 1 21 7 Leicestershire 200 22 152 26 Lincolnshire 12 — 11 1 Middlesex 4 1 2 1 Norfolk 3 1 1 1 Northamptonshire 124 6 111 7 Nottinghamshire 17 2 14 1 Oxfordshire 114 4 101 9 Kutlandshire 2 — 2 — Somersetshire 36 3 24 9 Staffordshire 98 7 78 13 Suffolk 17 6 8 3 Surrey 53 8 39 9 Sussex 227 12 169 46 Warwickshire 42 1 39 2 Wiltshire 260 24 212 24 Worcestershire 2 — 2 — Total 2,325 205 1,761 359 This table shows that out of 1,966 completed examinations of samples taken from churns consigned to London, 205 proved to be tuberculous, i.e., 10"4 per cent. Some of the samples were derived from the milk of more than one farm. The last annual report gave a similar account of 528 samples of milk examined in the period 1st July. 1908. to 16th Januarv. 1909. of which 61. or ll.fi nrr cent,., were found to be tuberculous. The following table shows the number of farms visited, the number of cows inspected and the number of cows certified to have tuberculosis of the udder during this period : County. No. of farms inspected. No. of cows inspected. No. of cows with tuberculous udders. Bedfordshire 2 103 4 Berkshire 9 354 8 Buckinghamshire 7 201 5 Derbyshire 181 2,828 47 Essex 34 1,952 36 Hampshire 18 765 18 Hertfordshire 8 333 11 Leicestershire 14 319 8 Nottinghamshire 1 17 1 Somersetshire 42 826 5 Staffordshire 9 265 7 Suffolk 3 124 4 Surrey 9 442 14 Sussex (East) 30 458 2 Sussex (West) 23 312 11 Wiltshire 49 1,705 38 Totals 439 11,004 219 This table shows that 2 per cent, of the cows examined were found to have clinical symptoms of tubercular disease of the udder. The supply of milk for human consumption from the cows thus a fleeted was immediately stopped. 73 In the last annual report it was stated that 4,997 cows had been inspected during the period 1st July, 1908, to 16th January, 1909, and that 147, or 2*9 per cent., were found to have clinical symptoms of disease of the udder. The proportion of tuberculous cows in 1909 shows improvement when compared with the proportion in the antecedent period. The Council's veterinary inspector has found that farmers are disposing of their older cows and this may have affected the proportion of cows which were found to have tuberculous udders. The Royal Commission on Tuberculosis issued in January, 1909, a Third Interim Report. The opinion had already been expressed (Second Interim Report) that " a very considerable amount of disease and loss of life, especially among infants and children, must be attributed to the consumption • of cow's milk containing tubercle bacilli." If the udder be affected with tuberculosis, the milk contains tubercle bacilli; but may the milk contain such bacilli when the udder presents no evidence of disease ? The Commissioners answer this question affirmatively. They experimented with the milk of tuberculous cows showing no sign of disease of the udder during life, and found that the milk contained tubercle bacilli. They say " The presence of tubercle bacilli in the milk of cows clinically recognisable as tuberculous confirms the opinion we expressed in our Second Interim Report that the milk of such cows must be considered dangerous for human beings." They further investigated the risk of contamination of milk with tubercle bacilli contained in " dirt of various kinds from cows and the cowsheds," which as they say " is almost constantly present in milk as it reaches the consumer." They report that " Cows suffering from extensive tuberculosis of the lungs must discharge considerable numbers of bacilli from the air passages in the act of coughing, and some of the bacilli thus expelled may find their way into the milk. But our experiments indicate that the excrement of cows obviously suffering from tuberculosis of the lungs or alimentary canal must be regarded as much more dangerous than the matter discharged from the mouth or nostrils. We have found that even in the case of cows with slight tuberculous lesions tubercle bacilli in small numbers are discharged in the faeces, while us regards cows clinically tuberculous our experiments show that the faeces contain large numbers of living and virulent tubercle bacilli." Offensive Businesses. In the year 1909 the County Council received 265 applications for licences for slaughter-houses and granted 264. The following table shows the number of applications received and the number o slaughter-houses licensed in recent years. It will be seen that the number of these premises is con tinually decreasing t— Slaughter-houses. Year. No. of applications received. No. of premises for which licences were granted. Tear. No. of applications received. No. of premises for which licenoee were granted. 1892 543 537 1901 384 381 1893 538 529 1902 371 362 1894 518 506 1903 350 346 1895 497 485 1904 338 333 1896 478 470 1905 322 318 1897 460 460 1906 310 308 1893 442 429 1907 301 294 1899 419 411 1908 281 273 1900 405 393 1909 265 264 The number of slaughter-houses in each of the London sanitary areas (other than those at the City Corporation Markets in Islington and Deptford), and the frequency with which these slaughterhouses, in most of the districts, were inspected, is shown in the following table :— Sanitary area. Number of slaughter-houses. No. of inspections, 1909. No. of notices, 1909. Licensed at end of 1908. Licence lapsed or refused in 1909. Remaining at end of 1909. City of London 1 7 — 7 Battersea 5 — 5 78 — Bermondsey 2 1 1 51 — Bethnal Green 5 — 5 23 — Camberwell 14 1 13 129 2 Chelsea 6 — 6 99 — Deptford 3 — 3 42 — Finsbury 3 — 3 88 — Fulham 4 — 4 40 1 1The slaughter-houses within the jurisdiction of the City of London are not licensed by the London County Council. {Continued on next page.) 74 Sanitary area. Number of daughter-houses. No. of inspections, 1909. No. of notices, 1909. Licensed at end of 1908. Licence lapsed or refused in 1909. Remaining at end of 1909. Greenwich. 4 — 4 70 3 Hackney 24 3 21 393 3 Hammersmith. 9 — 9 234 11 Hampstead 5 — 5 97 5 Holborn 1 — 1 5 — Islington 34 — 34 1,863 — Kensington 11 1 10 246 — Lambeth 24 — 24 48 6 Lewisham 15 — 15 106 — Paddington 7 — 7 492 — Poplar 16 — 16 94 2 St. Marylebone 8 1 7 — St. Pancras 18 — 18 562 — Shoreditch 7 — 7 32 — Southwark 6 — 6 79 3 Stepney 7 1 6 18 — Stoke Newington 5 — 5 11 — Wandsworth 19 1 18 476 4 Westminster, City of — — — — — Woolwich 11 — 11 44 3 During the year the following authorised offensive businesses, other than that of a slaughterer of cattle, were discontinued : the business of a bone boiler, fat melter and tallow melter in Wandsworth ; the business of a fat melter in Kensington ; and the business of a tallow melter in Woolwich. Hence the number of premises on which scheduled offensive businesses were carried on declined from 76 in 1908 to 73 in 1909. The number of such authorised offensive businesses, except those in the markets under the jurisdiction of the City Corporation, was at the end of the year as follows:— Fat melters 19 Manure manufacturers 2 Tripe boilers 22 Soap boilers 12 Glue and size manufacturers 5 Tallow melters 7 Knackers 5 Gut manufacturers 3 Fellmongers 6 — Bone boilers 3 84 In several instances more than one offensive business is carried on at the same premises, hence the number of premises used for the purpose of these businesses is smaller than the number of such businesses. The districts in which these premises are situated, the number of premises, and, for most 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 1909. No. of inspections, 1909. Sanitary area. No. on Register at end of 1909. No. of inspections, 1909. Battersea 2 6 Islington 7 87 Bermondsey 12 105 Lambeth 4 12 Bethnal Green 1 4 Poplar 8 46 Camberwell 4 5 St. Marylebone 2 Deptford 3 38 St. Pancras 2 38 Finsbury 1 15 Shoreditch 1 3 Greenwich 2 Southwark 6 78 Hackney 2 16 Stepney 8 10 Hammersmith 4 73 Wandsworth 4 189 During the year the Council instituted proceeding against a firm manufacturing oleo, an edible article, for establishing anew the business of a tallow-melter. The magistrate decided that although the matter was not free from doubt, the business was not that of a tallow-melter and the Council subsequently sanctioned the establishment anew of the business as that of a fat-melter. Nuisances. Smoke nuisance. In June the Council had under consideration a report by the Public Control Committee containing recommendations for alteration of the law relating to smoke nuisance, and resolved to apply 75 to Parliament to give effect to the following proposals, which had been formulated after conference with representatives of the borough councils. The conference had expressed its concurrence with the first three of the proposals— 1. That section 24 (b) of the Public Health (London) Act, 1891, which provides that " any chimney (not being the chimney of a private dwelling house) sending forth black smoke in such quantities as to be a nuisance " shall be a nuisance liable to be dealt with summarily under the Act, should be amended by the deletion of the word " black." 2. That the word "chimney" in section 24 (6) of the Public Health (London) Act, 1891, should be deemed to include— (а) Openings through which smoke is emitted from buildings or places in which processes of manufacture are carried on, and the chimneys of any building or place where furnaces are used in operations carried on under statutory powers. (б) The chimneys of any Government workshop or factory. 3. That in special cases of nuisance arising under sections 23 and 24 of the Public Health (London), Act, 1891, the proceedings in respect of any nuisance may, at the request of and by agreement with the sanitary authority, be taken by the Council in such special cases. 4. That the power of the Council to take proceedings in respect of nuisance created by sanitary authorities under section 22 of the Public Health (London) Act, 1891, should be extended to apply to smoke nuisance from electricity or other industrial works,or from premises used for the treatment or disposal of refuse,or for disinfecting purposes, or from baths or wash-houses or other buildings or wharves owned, leased or occupied by sanitary authorities in which furnaces are used. 5. That the power of sanitary authorities under section 14 of the Public Health (London) Act, 1891, to take proceedings in respect of nuisance arising outside their respective areas should be extended to the Council as regards smoke nuisance arising outside the County of London. 6. That the Council should be empowered to expend such money as it may think expedient, not exceeding £500 a year, for the advancement of measures for the abatement of smoke nuisance. The following table, which is compiled mainly from information contained in the annua! reports, shows the action taken by sanitary authorities in respect of smoke nuisance during the year, so far as this ia stated in those reports. Sanitary Area. Observations and inspections. Nuisances and complaints. Intimations. Notices. Summonses. City of London 287 14 — Battersea 33 33 17 2 — Bermondsey 192 (chimneys) 20 — Bethnal Green 657 23 25 4 — Camberwell 69 20 2 Chelsea — — — — — Deptford 14 8 8 — Finsbury 134 24 4 10 1 Fulham 7 5 — Greenwich 255 7 3 Hackney 1,356 37 — Hammersmith 19 (premises) 21 3 — Hampstead 10 8 — — — Holborn 113 3 1 — Islington 480 19 1 Kensington 292 3 3 2 — Lambeth 25* 2 32 — Lewisham 115 1 — — Paddington 24 (premises) 6 1 — Poplar 61 41 25 — St. Marylebone 1,207 29 18 2 St. Pancras 853 16 16 5 — Shoreditch 31 23 5 — — Southwark 1,186 257 42 21 9 Stepney 64 64 — Stoke Newington 8 4 3 — Wandsworth 78 58 42 — Westminster, City of 2,605 44 93 6 — Woolwich 31 13 13 — *Exclusive of complaints by officers of the Borough Council. Nuisance from stable manure. Nuisance from stable manure is the subject of less comment than usual in the annual reports of medical officers of health. The enforcement of the by-law of the London County Council, prohibiting manure receptacles sunk below the surface of the ground, and of the regulations of the sanitary authorities, requiring the periodical removal of manure, has no doubt greatly contributed to the reduction of nuisance from this cause; but beyond this there has in recent years been constant decrease in the amount of stable manure in London owing to the replacement of horse by motor traction. The absence of a hot summer in 1909 has also had an undoubted effect in reducing the nuisance usually experienced from this cause. Hence there is little to record on this subject beyond the fact that in one or two districts horse owners were prosecuted for non-compliance with the requirements as to removal. 76 Bemoval of house refuse. The by-laws of the London County Council require house refuse to be removed from all premises not less frequently than once a week, and give opportunity for the institution of a system of daily removal. The Westminster City Council have for some time been developing a system of daily removal, and Dr. Allan now reports that since 1908 it has been put in operation throughout the borough. "The only part of the City where the daily collection has not yet been effected is part of St. Margaret and St. John district, where there are still six carts working on the weekly system." He adds that "Now, complaints are few, and the daily collection is finished by 10 o'clock in the morning." The practicability of instituting and maintaining a daily collection in one of the largest districts of London, in which inhabitants of all classes dwell, and in which houses and businesses of all kinds exist, is now demonstrated and the Westminster City Council have provided an object lesson which should go far to encourage other sanitary authorities to adopt a like course. The neighbouring borough of St. Marylebone has also added to the number of streets in the northern area in which the refuse is daily collected, and Dr. Porter reports that it was also decided to extend this system to other streets in the southern area. Moreover, dust shoots have been abolished and moveable receptacles have been provided in their place, and old disused brick receptacles have been removed or abolished. In Holborn, also, there has been, although in less degree, some extension of the system of daily collection. As in previous reports Dr. Warry calls attention to the large number of inhabitants in Hackney who decline to allow the scavengers to remove their house refuse when their houses are visited for this purpose. These " refusals " number some 4,000—5,000 a week, and in this connection it may be stated that at the date of the last census there were 30,600 houses in Hackney. Such refusal constitutes " obstruction " involving penalty, and a remedy therefore exists. The effect of systematic collection in relieving house occupiers of the difficulties experienced in earlier years is shown by a statement in the report of Dr. Harris that in Islington the number of applications for the removal of refuse in 1909 numbered only 67, whereas in 1891 there were 10,138 applications. Removal of offensive trade refuse. In previous reports reference is made to the fact that a system of collection of offensive trade refuse (fish offal) by sanitary authorities is in operation in the City, Woolwich, Finsbury, Wandsworth and Greenwich, a contractor being employed for this purpose in the City, Wandsworth and Greenwich. The charges made are stated in the reports relating to Finsbury and Woolwich. In Finsbury special bins are provided by the borough council, a deposit of 8s. being required for each bin, and " a sum varying from Is. to 2s., according to the quantity removed, is charged for each occasion when the bins are used." A specially constructed van is used for collecting this refuse. The charge made in Woolwich is 3d. a receptacle, charged per quarter in advance on the amount collected in the previous quarter. The medical officers of health of the City, Wandsworth and Greenwich state that the arrangements which have been made are working satisfactorily. The question whether the refuse from a restaurant was house refuse which the sanitary authorities were required to remove, or trade refuse, was the subject of a decision in the King's Bench Division in June, 1909, in the case of Lyons and Co., Ltd. v. the City of London Corporation. The case is thus stated in the " Justice of the Peace." :— " The appellants were the occupiers of premises which they used as a tea shop, providing customers with refreshments and food for consumption on the premises, some of the food being cooked or prepared on the premises. No one slept on the premises at night. The refuse from the premises consisted of ashes and clinkers, coffee grounds, newspaper, cabbage leaves, egg shells, dust and general dirt, broken crockery, tea leaves, potato parings, sweepings from the floors and sweepings from the rooms. It did not include scraps left by customers, which were given away in charity. The Court held that in the circumstances the refuse was house refuse." In a similar case heard at the instance of the Islington Borough Council by a Stipendiary Magistrate a like decision was given. Nuisance from flies. During the summer months observations were made as to the extent of nuisance from flies in the neighbourhood of a depot used for the manipulation of house refuse, a glue and size manufacturer's premises, and a railway siding at which trucks were loaded with stable manure and other refuse materials. Dr. Hamer's report on this subject is appended. (See Appendix IV.) Housing of the Working Classes Act. Proceedings of the County Council under Part III. of the Act. In February the Council accepted a tender for the erection of 32 additional cottages on the second part of Section B of the Norbury Estate for the sum of £6,579 14s. In July a tender was accepted for the erection of 110 cottages on the third part of Section B of the Norbury Estate, viz., 30 cottages with three rooms, 54 with three rooms and a box room, 25 with four rooms and one with five rooms, each cottage to contain a scullery and the usual offices. In respect of both tenders the Council undertook to supply the bricks. In July the Council accepted a tender of £19,343 for erection of 105 cottages on the third part of the Tower Gardens section of the White Hart-lane Estate, viz., 53 with three rooms and a scullery, and 52 with four rooms and a scullery. 77 In November the Council approved an estimate of £56,788 for the erection of cottages on thfinal part of the Tower Gardens section of the White Hart-lane Estate and on an adjoining plot of land in Benington-road. In December the Council decided to proceed with the development of, and the building of cottages on, the Old Oak Estate. Schemes under Part II. of the Act—Prospect-terrace Area, St. Pancras. The borough council completed the erection of artizans' dwellings on this area, thus completing the Prospect-terrace and Brantome-place scheme. Death-rates among persons resident in the Council's dwellings, 1909. The following death-rates obtaining among tenants of the Council's buildings relate to dwellings within the county which were occupied during the whole of the year 1909. The population thus dealt with comprised 28,195 persons, and the death-rate at " all ages," after correction for age and sex distribution, was 10.7 per 1,000 living, compared with 14'0 for London :— Cause of death. Death-rate per 1,000 living, 1909. Council's dwellings. n. All Causes—All Ages 10.7 14.0 „ „ age 0—5 24.3 37.8 „ „ „ 5—20 1.6 2.3 „ ,, ,, 20 and upwards 11.8 15.4 Diarrhœa 0.3 0.3 Principal epidemic diseases (excluding Diarrhœa) 0.8 1.0 Phthisis 1.3 1.3 Tubercular diseases other than Phthisis 0.3 0.4 Bronchitis 1.0 1.3 Pneumonia 1.1 1.5 Proceedinqs in respect of houses represented under Part II. of the Act as unit 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, 1909:— Sanitary area. Total number of houses concerning which the Council has received in. formaoion that representations have been made from the 1/1/09 to the 31/12/09 Number of houses dealt with by owners, without Magisterial intervention. Number of houses for which closing orders were granted. Number of houses for which olosing 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 14 - - 14 14 - - - - - - Bermondsey - - - - - - - - - - - Bethnal Green - - - - - - - - - - - Camberwell - - - - - - - - - - - Chelsea - - - - - - - - - - - Deptford - - - - - - - - - - - Finsbury - - - - - - - - - - - Fulham - - - - - - - - — - - Greenwich - - - - - - - - - - - Hackney - - - - - - - - - - - Hammersmith - - - - — - — - - — — Hampstead - - - - - - - - - - - Holborn - - - - - — — - - — - Islington - - - - - - - - - - - Kensington - - - - - - - - - - - Lambeth - - - - - — - - - - - Lewisham - - - - - - - - - - - Paddington - - - - - - - - - - - Poplar 6 - - 6 6 - - - - - - St. Marylebone 2 - - - - - - - - 2 - St; Pancras 9 — - - - - - - - 9 - Shoreditch - - - - - - - - - - - Southwark - - - - - - - - - - - Stepney - - - - - - - - - - - Stoke Newington - - - - - - - - - - - Wandsworth - - - - - - - - - - - Westminster, City of - - - - - - - - - - - Woolwich 4 - - 4 4 — - - — - - Total 35 - - 24 24 - - - - - 11 - 2057 L 78 The medical officer of health of Lambeth reports that an area in Marsh Ward, belonging to the Duchy of Cornwall, which includes Cornwall-place and Salutation-place and adjoining courts, was being reconstructed in 1909, a number of the leases having expired. This area was the subject of consideration by the County Council some years ago. Housing and Town Planning Act, 1909. The Housing and Town Planning Act, which was passed in December, 1909, makes important alterations in the law for securing the habitable condition of houses. The following provisions may be briefly mentioned:—The condition of letting implying that the house at the commencement of the holding is in all respects fit for human habitation, is by section 14 made to attach to the letting of a house or part of a house in London at a rent not exceeding £40, but this condition does not attach to the letting of a house or a part of a house for a period of not less than three years upon the terms that it be put by the lessee into a condition reasonably fit for occupation, and the lease is not determinable at the option of either party before the expiration of that term. Further, in respect of houses subject to this provision, by section 15 the condition is implied that the house shall during the holding be kept by the landlord in all respects reasonably fit for human habitation. The landlord is given rights of entry for the purpose of viewing the state and condition of the house and the local authority is empowered to require the landlord to execute such works as may be necessary to make the house fit for habitation, and if this requirement is not complied with, or the house is not closed, may themselves do the necessary work and recover the expenses from the landlord. By section 16 the power of a local authority to make and enforce by-laws for houses let in lodgings under section 94 of the Public Health (London) Act is, in the case of houses occupied by the working classes, made to extend to the making and enforcing of by-laws imposing any duty (being a duty which may be imposed by the by-laws and which involves the execution of work) upon the owner in addition to or in substitution for any other person having an interest in the premises and prescribing the circumstances and conditions in and subject to which any such duty is to be discharged. The owner or other person is given rights of entry for such purpose, and if the owner or other person fail to execute any work which he has been required to execute under the by-laws the local authority may themselves execute the works and recover the costs and expenses. Under section 17 the local authority in connection with the duty of inspecting houses is required to comply with such regulations and to keep such records as may be prescribed by the Local Government Board, and the local authority is empowered to make an order for the closing of houses unfit for human habitation, the owner being given the right of appeal to the Local Government Board. A room habitually used as a sleeping placs the floor of which is more than three feet below the surface of the part of the street adjoining or nearest to the room is to be deemed to be unfit for human habitation if it is not on an average at least 7 feet in height from floor to ceiling or if it does not comply with the regulations of the local authority for securing the proper ventilation and lighting of such rooms and their protection against dampness, effluvia or exhalation. A closing order in such case will only prohibit the use of the room for sleeping purposes. Section 43 prohibits the building of back-to-back houses, but such prohibition is not to prevent the erection or use of a house containing several tenements in which the tenements are placed backto-back if the medical officer of health certifies that the several tenements are so constructed and arranged as to secure effective ventilation of all habitable rooms in every tenement. Part II. provides for local authorities (in London the London County Council) to make, and, with the sanction of the Local Government Board, to give effect to a town planning scheme as respects any land which is in course of development or appears likely to be used for building purposes, with the general object of securing proper sanitary conditions, amenity and convenience in connection with the laying out and use of the land and of any neighbouring lands. 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 for the regulation of common lodginghouses came into force on the 1st October, 1903. 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 1894:— Year. No. of houses on register. Authorised number of lodgers. No. of day visits by inspectors. No. of night visits. No. of prosecutions. No. of convictions. Penalties and costs. No. of cases of infectious disease. £ s. d. 1895 626 29,574 — — 16 12 37 6 0 99 1896 596 29,140 28,331 — 31 30 112 16 0 71 1897 581 28,718 26,121 — 31 30 92 11 0 48 1898 560 28,332 27,658 — 29 29 167 3 0 44 1899 544 28,448 28,229 1,162 25 22 183 9 0 54 (Continued on next page.) 79 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 oosts. No. of cases of infectious disease. £ s. d. 1900 528 28,311 28,428 668 16 13 102 15 0 40 1901 514 28,037 35,225 2,133 16 15 96 3 0 166 1902 491 28,970 40,512 1,449 22 21 98 4 0 684 1903 470 28,893 33,402 4,790 6 6 26 11 0 53 1904 451 28,896 27,501 2,970 15 14 62 6 0 66 1905 413 27,571 28,158 1,565 21 16 77 3 0 14 1906 402 28,063 30,028 2,349 4 4 11 1 0 22 1907 395 28,651 33,630 2,307 3 3 12 9 0 27 1908 387 28,379 32,297 2,429 1 1 2 2 0 13 1909 383 28,302 29,324 1,286 3 3 22 0 0 19 It will be observed that since 1894 the number of common lodging-houses has steadily diminished. This reduction, however, is more apparent than real, inasmuch as in the earlier year every house was separately counted, whereas now adjoining houses in the same occupation are counted as one house and included under one licence. It will be seen, moreover, that although the number of houses has been reduced the authorised number of beds varies but little, thus showing, as I have before pointed out, that there is a tendency for the smaller houses to be replaced by a smaller number of larger houses. The number of cases of notifiable infectious disease reported in common lodging-houses was as follows :—Erysipelas, 7 ; scarlet fever, 5 : diphtheria. 3 : enteric fever, 4—Total, 19. 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, 1909 .— Sanitary district. No. of houses. Authorised accommodation. Men. Women. Couples. Total. Battersea 8 157 78 23 281 Bermondsey 5 1,073 — — 1,073 Bethnal Green 14 712 — — 712 Camberwell 6 536 — — 536 Chelsea 6 248 — — 248 Deptford 8 1,155 80 — 1,235 Finsbury 8 539 — — 539 Fulham 2 43 51 — 94 Greenwich 4 150 — — 150 Hackney 7 495 — — 495 Hammersmith 9 466 — 4 474 Hampstead — — — — Holborn 27 1,629 162 — 1,791 Islington 43 1,228 276 18 1,540 Kensington 24 431 272 — 703 Lambeth 7 693 — — 693 Lewisham 1 30 — — 30 Paddington 7 195 40 — 235 Poplar 9 1,143 — — 1,143 St. Marylebone 17 1,306 109 — 1,415 St. Pancras 9 727 36 — 763 Shoreditch 12 765 — — 765 Southwark 44 3,379 449 — 3,828 StepDey 54 5,310 667 180 6,337 Stoke Newington 1 37 — — 37 Wandsworth 10 185 5 20 230 Westminster, City of 17 2,300 75 — 2,375 Woolwich 24 536 44 — 580 London—excluding the City of London 383 25,468 2,344 245 28,302 Deaths among inmates of common lodging-houses. The following table shows the proportion of deaths from several causes per 1,000 deaths among males in common lodging-houses, the corresponding figures for London being shown for comparative purposes. The deaths of persons removed from common lodging-houses to public 2057 L 2 80 institutions have been included. The total number of deaths among lodgers (males and females) in common-lodging houses during the year was 806 ; the large majority of these deaths occurred in public institutions. Table showing the number of deaths of males at five age periods from certain causes per 1,000 deaths from all causes in London (1908) and licensed common lodging-houses (1908 and 1909). Cause of death. Age 25 to 85. Age 35 to 45. Age 45 to 55. Age 55 to 65. Age 65 and upwards. London 190S. C.L.H. 1908. C.L.H. 1909. London 1908. C.L.H. 1908. C.L.H. 1909. London> 1908. C.L.H. 1908. C.L.H. 1909. London 1908. C.L.H. 1908. C.L.H. 1909. London, 1909. C.L.H. 1908. C.L.H. 1009. Phthisis 386 500 512 325 463 589 209 307 289 110 314 260 28 148 119 Olher tubercular diseases 34 69 23 15 — 11 10 28 13 7 6 — 3 4 9 Alcoholism (including cirrhosis of the liver) 20 22 23 31 20 11 39 32 26 32 38 39 9 24 — urinary diseases 42 22 23 49 47 21 75 63 77 86 49 79 85 36 43 Violance, suicide 98 22 — 77 37 21 75 38 19 53 17 6 29 20 4 Cancer 28 22 — 59 47 21 124 38 77 161 43 120 103 76 64 Circulatory diseases 85 46 93 135 131 63 168 189 141 221 155 62 241 152 136 Nervous diseases 32 46 70 36 47 32 41 20 7 40 39 62 40 52 64 Bronchitis 14 22 47 28 37 42 44 78 115 77 155 175 164 192 191 Pneumonia 91 207 116 98 114 105 90 130 134 78 110 96 71 52 89 Other causes 170 22 93 147 57 84 125 85 102 135 74 101 237 244 281 Total (all causes) 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 Homeless 'persons. Appended to this report is a detailed account of the results of an inquiry into the number of persons in London who were homeless on the night of the 18th February, 1910. Previous inquiries into the same subject were made in the years 1904, 1905, 1907 and 1909. If reference is made to appendix V. to this report it will be seen that 969 persons presumably homeless were found in the streets on the night of the 18th February, 1910. In addition to this number, however, nearly 1,800 men were provided with food and shelter by various philanthropic bodies. These men had no bed on the night in question, but were provided with food, and the opportunity of resting for a few hours under shelter on the seats or floors of rooms or halls used for other purposes in the daytime. The appended report also shows that if to the number of persons found in the street are added the number of persons in casual wards, and the number of persons provided by charitable bodies with a bed in a common lodging-house or afforded opportunity by such bodies of sitting up for a few hours in a shelter, the total number reaches 6,644, all of whom might be regarded as homeless. It is worthy of note that the vacant beds in common lodging-houses on the night of the inquiry would have accommodated some 7,580 persons. Seamen's Lodging-Houses. Under the provisions of section 214 of the Merchant Shipping Act, 1894, the Council made by-laws for the regulation of houses accommodating seamen. These by-laws came into force on the 1st October, 1901. As the result of correspondence with the Board of Trade on the subject of the licensing of seamen's lodging-houses, it was thought desirable that the by-laws should be amended in certain particulars. This was accordingly done, the new by-laws were sealed by the Council on 16th December, 1909, and came into force on 1st January, 1910. An Order of His Majesty in Council making it an offence to keep a seamen's lodging-house within the County of London unless such house is licensed by the County Council, came into force on 19th February, 1910. Experience had shown that these powers were required for the proper supervision of such houses. It had often been found that houses used for this purpose were held on weekly tenancies, and that the business was frequently transferred from one house to another, the keeper being under no obligation to give notice to the Council of the change. Moreover, control over the persons keeping such houses was found to be necessary, and especially was this the case in the houses occupied by Chinese seamen, where overcrowding frequently occurred, and where opium smoking was constant. Hitherto there has been only one licensed seamen's lodging-house, the German Sailors' Home, Rich Street, Limehouse, which has accommodation for 79 seamen ; but now it is incumbent upon every keeper of a seamen's lodging-house to obtain a licence from the County Council, the penalty for keeping such a house without a licence being fixed at a sum not exceeding £100. Steps are now being taken to give effect to the Order in Council, but as, properly speaking, the action lies in the year 1910 the subject will be more fully dealt with in the annual report of that year. 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:— 81 Year. No. of houses on register. Authorised number of lodgers. No. of day visits by inspectors. No. of night visits. No. of prosecutions. No. of convictions. Penalties and costs. No. of cases of infectious disease. £ s. d. 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 1908 85 1,571 2,081 78 3 3 24 0 0 6 1909 80 1,524 1,983 84 7 6 15 0 0 - In the year 1909 proceedings before the magistrate were instituted in seven instances, resulting in six convictions, the penalties amounting to £7 18s. and £7 2s. costs. On the 31st December, 1909, the total number of seamens lodging-houses under supervision was 80, situated in the following metropolitan boroughs Metropolitan borough. Houses. Lodgers. Poplar 18 401 Stepney 61 1,097 Woolwich 1 26 Total 80 1,524 Houses Let in Lodgings. In London there were approximately some 24,000 houses let in lodgings regulated by by-laws made under section 94 of the Public Health (London) Act. These houses are (apart from those which are common lodging-houses) occupied by the poorest class of the London population and the special powers which are given by that section for their maintenance in clean and wholesome condition are the most valuable of any which can be exercised by sanitary authorities for this purpose. In the past considerable difficulties have arisen in connection with the administration of these powers owing to legal decisions, by which particular by-laws have been declared ultra vires. In 1909, in an appeal case " Arlidge v. Islington Borough Council," a by-law relating to cleansing was declared to be unreasonable, inasmuch as it required the landlord of lodging-houses to cause the house to be cleansed, although he might not be able to do this without committing a trespass. Hence, this by-law was rendered invalid. To meet this difficulty a provision (section 16) was included in the Housing and Town Planning Act (see page 78), which appears to provide a sufficient remedv. In the following table are shown the nnmber of houses let in lodgings on the registers ot the sanitary authorities, and the number of inspections and of proceedings under the by-laws relating to such houses :— Registered houses let in lodgings. Sanitary area. Number of places. No. of Inspections, 1909. No. of Notices, 1909. No. of Prosecutions, 1909. On register at end of 1908. Added in 1909. Removed in 1909. On register at end of 1909. City of London 291 5 10 286 † 333 — Battersea 123 — — 123 387 114 9 Bermondsey 224 4 9 219 881 * 5 — † 84 — Bethnal Green 517 23 23 517 2,323 659 — Camberwell 217 37 — 254 804 * 100 — † 356 — Chelsea 589 — 6 583 147 * 8 — v 124 — Deptford 269 4 — 273 — — Finsbury 1,224 — 1 1,223 * 46 — † 1,422 — Fulham 114 — — 114 — — — Greenwich 24 44 — 68 * 1 — † 42 *For overcrowding. †For other conditions. (Continued on next page.) 82 Sanitary area. Number of places. No. of Inspections, 1909. No. of Notices, 1909. No. of Prosecutions, 1909. On register at end of 1908. Added in 1909. Removed in 1900. On register at end of 1909. Hackney 463 — — 463 382 257 — Hammersmith 3,352 465 285 3,532 1,440 166 — Hampstead 315 49 — 364 427 8 — Holborn 681 — 44 637 1,051 * 15 * † 248 † 1 Islington (a) (a) 10,555 * 79 ♦ † 1.214 † 3 Kensington 2,056 20 — 2,076 9,484 * 112 * † 1,180 † 9 Lambeth 372 372 372 __ Lewisham 15 15 50 * 3 — † 3 — Paddington 1,343 26 49 1,320 7,958 * 136 ♦ † 3,578 † 26 Poplar 1,010 34 — 1,044 2,953 * 95 3 Night 139 † 481 St. Marylebone 758 — — 758 692 437 4 St. Pancras 2,271 12 3 2,280 2,398 * 86 2 † 1,214 — Shorediteh 286 — 28 258 293 63 — Southwark 1,247 29 11 1,265 3,685 * 164 4 † 3,073 — Stepney 2,805 75 82 2,798 2,790 * 485 1 † 1,476 † — Stoke Newington 138 156 21 273 * — † 89 — Wandsworth 267 8 275 722 * 31 * + 429 † 1 Westminster, City of 1,543 — 67 1,481 2,963 * 32 * † 770 † 9 Woolwich 359 41 5 395 730 140 3 (a) No register is now kept, under the Islington Borough Council's new by-laws, but the number of houses let in lodgings inspected during the year was 1,507. * For overcrowding. † For other conditions. The extent to which these powers are exercised by the several authorities obviously differs much more widely than can be explained by differences in the numbers and in the social circumstances of the populations in their respective districts. In some of the annual reports this branch of administration is discussed in more detail than in others. It is thus shown that in Paddington the work of annual cleansing occupies nearly the whole time of two inspectors from March to September or later. In St. Marylebone the re-registration of houses under the by-laws of 1907 has been steadily proceeded with. In Hampstead the number of houses registered is steadily increasing, but does not include all those which might with advantage be thus dealt with, the staff of inspectors being inadequate for this purpose. In St. Pancras and Greenwich the amendment of the by-laws was still under consideration. Furnished rooms. The subject of the regulation of houses let in furnished lodgings was under the consideration of the Public Health Committee of the Council during 1909. The rooms in such houses are frequently let for the night, a charge of l0d. or a shilling being made for their use. These houses have increased in number since, under the inspection of the Council, the accommodation for " married couples " in common lodging-houses has diminished. Houses let in furnished rooms are largely situated in the immediate neighbourhood of common lodging-houses, are occupied by persons of the same class as that which frequents common lodging-houses, and are often owned by the keepers of such houses. The need for their better control is being increasingly emphasised by experience gained of the nature of their use and of the effect which they have upon the localities in which they are situated. In June, 1909, the Council addressed the following letter to London Sanitary Authorities:— The Council has under consideration the question of the necessity for the exercise of increased control over a certain type of furnished room, the practice of letting such rooms for short periods, at a rate not exceeding 10s. a week, having recently become more general in various parts of the County of London. This class of room appears to be occupied by persons who are, if anything, of a more degraded character than those frequenting common lodginghouses; the rent is paid daily and the appointments of the rooms are mostly of a very scanty and dilapidated nature, the beds being, in many instances, verminous. The ease with which such rooms can be hired is, moreover, a great 83 incentive to immorality. It appears to the Council that the by-laws which have been made by the councils of the several metropolitan boroughs under the provisions of section 94 of the Public Health (London) Act, 1891, do not confer upon sanitary authorities adequate power for dealing with rooms of the above description. It is stated also that considerable difficulty is experienced in putting into operation the provisions of Part IV. of the London County Council (General Powers) Act, 1904, as to the destruction of filthy or unwholesome articles, owing to the frequency with which disputes as to the amount of compensation for articles destroyed arise. The existence of these circumstances has led the Council to consider whether in the interests of public health further legislation should be sought in respect of furnished rooms so let, to ensure that they should be maintained with due regard to sanitation. It appears to the Council to be most desirable that greater supervision and control than exists at present should be exercised over this class of house, which is nearly related in character to the common lodging-house, both in respect of the class of house and the social condition of the inmates, and, in fact, the demand for lodgings of this character exists, in the main, in localities where common lodging-houses are situated, the lodging-house and the furnished rooms not infrequently being owned by the same persons. The Council thinks that more effective control would be ensured if persons letting such rooms Were required to obtain an annual licence, to be granted after consideration of the fitness of the applicant and the structure and cleanliness of the premises. Such licences would be granted by the Council in the same manner as is done with regard to common lodging-houses. An alternative means of securing adequate supervision would be by investing the local sanitary authority with full power to inspect and enforce a certain standard of requirements, authority being given to the Council, with the consent of the Local Government Board, in each case to act in default of action by the local sanitary authority. The Council would be glad if the metropolitan borough councils would assist it in its deliberations by furnishing their views as to the means, by licensing or otherwise, by which the sanitary and moral condition of the inmates of these houses could be improved. The Council has no doubt but that this question has already been before the local sanitary authorities, and that those authorities have in their possession valuable information bearing on the subject, and I have to state that the Council will be very glad to receive any information of this nature which is available. The subject is still under the consideration of the Council. Water supply to tenement houses. Sanitary authorities have increasingly used the powers provided by section 78 of the Council's General Powers Act of 1907, for requiring the provision of a water supply to the upper floors of tenement houses. The following table shows the extent to which the powers referred to have been applied during 1909:— Water supply to tenement houses, 1909. Sanitary area. No. of premises caused to be supplied. No. of legal proceedings. Battersea 55 8 Bethnal Green 10 — Finsbury 70 2 Fulham 4 — Hammersmith 29 — Hampstead 85 — Holborn 70(a) — Islington 362 4 Lambeth 42 — Paddington 78 — Poplar (b) — St. Marylebone 164 3 Southwark 165 18 Stepney 3 1 Stoke Newington 34 — Wandsworth 13 — Westminster, City of 399 2 W oolwich 30 3 (a) Number of notices served. It is stated that in the majority of instances the work was completed during the year. (b) Notices were served in respect of a supply to some tenement houses in Bromley. Dr. Allan reports that in Westminster " owners are recommended in all cases to fit a proper sink in connection with the new supply on upper floors and so prevent risk of walls and ceilings being spoiled. Two large owners of property, having received notice in respect of some of their houses, decided to lay on additional supply of water to all their tenement houses. As a rule, the Council has not asked for more than one tap and sink between the first and second floors, but in some instances owners have laid on water to each floor." Dr. McCleary states that the number of houses dealt with in Hampstead in 1909 was 85. " In each house a water tap and a glazed earthenware sink were provided on each floor. The provision of a sink is important, for without it the water tap might become a source of dampness and cause considerable damage to the house. The section of the General Powers Act quoted above makes no provision for a sink, and in some cases the owners having provided water taps refused to fix sinks beneath them. In these cases the house appeared to be without the "sufficient drain" required by section 73 of the Metropolis Management Act, 1855, and after the service of notices under that section the sinks were duly provided. Fears have been expressed that these sinks might be misused and fouled and so 84 become a source of nuisance. This, however, has not been our experience in Hampstead. The provision of water taps and sinks has led to an improvement in the sanitation of the premises, and has been much appreciated by the tenants." Dr. Alexander reports : " In the month of March notices were served under this Act to provide a proper and sufficient water supply at some tenement houses in Bromley. After a short delay the work was carried out and there is now a supply tap and sink on each storey, which, needless to say, are greatly appreciated by the tenants." Dr. Sykes raises question in his annual report relating to St. Pancras, as to whether the absence of a water supply on the upper floors is a greater evil than the provision of water supply and sink, which he suggests would, when used by careless persons, be likely to cause nuisance, and he states that the St. Pancras Borough Council had not made use of the powers conferred upon them by this section and resolved that no action be taken in the matter. In each of the boroughs surrounding St. Pancras, however, viz., Islington, St. Marylebone, Hampstead and Holborn, these powers are being exercised and it may be hoped that the experience thus gained will provide sufficient reason for the St. Pancras Borough Council to reconsider their opinion. In the annual report relating to Woolwich, Dr. Davies gives the particulars of proceedings before the magistrate in respect of three houses concerning which the borough council had made an order for the provision of a water supply to an upper floor. He reports as follows:— Two cases were heard by Mr. Gill on the 11th October, 1909, and one case by Mr. Hutton on the 20th. The two cases heard by Mr. Gill were very similar. The houses consisted of six rooms on three floors, the washhouse, where the water supply originally was situated, being two steps below the basement. In both houses the families living in the house had joint use of the washhouse. One—No. 8—was occupied as follows:—One family occupied the ground floor front room and first floor front room; another family the basement back, ground floor back, and first floor back. The basement front was closed as unfit for occupation. In the other—No. 9—one family occupied the first floor, and another family the basement and ground floor. The upper flight of stairs consisted of 15 steps and the lower of 14. As a result of the notice, a water tap and sink were fixed in each house in the passage on the ground (or middle) floor, but no waste pipe was provided; and a control stop-cock was fixed in the basement washhouse on the branch water pipe supplying the new tap. It was proved in evidence that, as the result of some seven inspections made by two inspectors and the medical officer of health, at intervals in the three months succeeding the tap being provided, the water was found turned off at the control cock on all occasions but one, this being done presumably to prevent the new tap dripping, filling the small sink and overflowing, so causing a nuisance. Mr. Gill, after taking a week to consider the case, decided in favour of the defendant in the case of No. 8, and in favour of the Woolwich Borough Council re No. 9. He held that, as regards No. 8, the General Powers Act did not apply, as each of the occupiers of the house had separate occupation of a room on each floor, the tenant who sub-let to the other occupiers having sole legal occupation of the washhouse, although he permitted the other occupiers to use it. With regard to No. 9, the occupier of the two upper rooms had no water supply on the floor on which his rooms were situated, and he held it reasonable that there should be a supply, and fined the defendants 20s. and 23s. costs. The third case was also a six-roomed house on threo floors. The basement consisted of a washhouse with tap and sink (the only water supply in the house) and a room recently vacated on account of its low height and dark condition. A family of a man and wifo and one child lived on the ground floor, and a man, wife, and two children on the top floor. The staircase, consisting of 22 steps, in two flights, is in the middle of the house, hence unlighted, and the lower flight very dark. A notice having been served to provide a proper and sufficient supply for the tenants on the top floor, the owner fixed an additional tap outside of the house on the same level as the existing tap in the basement, but approached without the necessity of going to the basement. This was, as stated to the medical officer of health on inspection, no improvement, the tenant of the top room still using the tap in the basement. She had the alternative of coming down one flight of stairs, going outside the house by a side door on the ground floor, descending three more steps and a sloping passage, and so reaching the tap in the yard at the back; but she preferred, she said to the medical officer of health, going down the dark lower staircase inside the house. The owner, refusing to provide a water supply on the top floor, was summoned and the case heard by Mr. Hutton. Having heard the evidence, he adjourned the consideration, on his own suggestion, to view 'the premises. On the further hearing he asked the tenant of the top floor whether she was satisfied with the water supply and which tap she used. She stated she was satisfied and used the new outside tap. Mr. Hutton said, personally, he would not be satisfied, and if the tenant had said she used the tap in the basement he would have convicted the owner, but as it was he did not think it reasonably necessary to require a water supply on the top floor. In a few other reports it is stated that prosecutions were successfully instituted for non-compliance with the orders of the borough councils, and in a case occurring in Southwark in which there was an appeal to Quarter Sessions against the decision of the magistrate who had decided in favour of the borough council, the appeal was dismissed. In this case the house in question is thus described by Dr. Millson : " The premises are technically a tenemented house occupied by two separate families, the family without a supply of water being on the top floor. There are three storeys, the lowest one being a half basement. The existing supply of water is from two taps, one in the yard and the other in a washhouse in the yard." Provision in tenement houses for cooking and storage of food. In 1909 the Council obtained Parliamentary sanction to a provision empowering London sanitary authorities to require sufficient and suitable accommodation for the storage of food for the use of each family on the storey or one of the storeys of a tenement house in which are situated the rooms or lodgings in the separate occupation of such family. In 1908 the Council obtained powers for sanitary authorities to require in each tenement sufficient and suitable accommodation for the cooking of food. The requirements relating to accommodation for cooking and storage of food do not apply to any tenement house used or occupied as such before the passing of the Act. There is no doubt that these powers, with those relating to water supply, if duly exercised, will eventually improve the conditions under which a large proportion of the London population is living, As stated above, many sanitary authorities are utilising the powers to require additional water supply, and improved cleanliness of tenement houses thus provided is resulting. The later powers have 85 a much more limited application, but they will set a standard of accommodation by which tenement houses will be compared by the tenants, whose needs in these respects landlords will desire, and indeed eventually find it necessary, to meet. Houses infested with vermin. Section 20 of the Council's General Powers Act of 1904 empowers sanitary authorities to require the cleansing of rooms and their contents from vermin, and in default to do such cleansing themselves. Under these powers a large number of rooms and articles have been cleansed during 1909, and in a few instances prosecutions were instituted and penalties obtained for non-compliance with the order of the sanitarv authorities. The following table has been compiled mainly from information on this subject contained in the annual reports of medical officers of health:— Houses infested with vermin. Number of premises or rooms cleansed. Sanitary area. Number of rooms or premises cleansed. Sanitary area. Number of rooms or premises cleansed. City of London — Kensington 260 rooms. Battersea — Lambeth 148 persons & Bermondsey 146 rooms. houses. Bethnal Green 273 rooms. Lewisham 6 premises. Camberwell 30 premises. Paddington 172 premises. Chelsea 118 rooms. Poplar 232 rooms. Deptford 11 premises. St. Marylebone 24 premises. Finsbury 13 premises. St. Pancras 172 premises. Fulham 52 rooms. Shoreditch 99 premises. Greenwich 9 premises. Southwark 1,881 rooms. Hackney 220 premises. Stepney 1,395 rooms. Hammersmith 62 rooms. Stoke Newington 41 rooms. Hampstead 62 rooms. Wandsworth 70 premises. Holborn 26 premises. Westminster, City of 191 premises & Islington 124 premises. 16 rooms in Woolwich other premises. 159 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— (а) 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. The medical officer of health of Poplar reports that the borough council, in 1908, directed the attention of the Board of Inland Revenue to the insanitary condition of some certificated tenement dwellings in Bow, and the Board thereupon cancelled the certificate. Extensive repairs of the premises are being carried out with a view to renewed certification. The number of applications received and certificates granted during 1909 is shown in the following table:— 2057 m 86 Revenue Act, 1903—Certificates of exemption from inhabited house duty. Sanitary area. No. of houses for which applications for certificates were received during 1909. No. of tenements comprised therein. No. of tenements for which applications for certificates were Granted. Refused. Deferred or withdrawn. City of London Battersea 9 21 5 — 16 Bermondsey 18 38 38 — — Bethnal Green 9 177 160 17 — Camberwell 40 67 13 — 54 Chelsea 4 24 6 — 18 Deptford — — — — — Finsbury — — — — — Fulham 289 614 248† 72 294 Greenwich 57 162 8 154 — Hackney 3 10 10 — — Hammersmith 39 154 64 4 86 Hampstead 13 96 — — 96 Holbora 5 101 94 7 — Islington 8 78 31 47 — Kensington 10 51* 31 — — Lambeth 38 87 42 45 — Lewisham 27 59 59 — Paddington 6 31 18 4 9 Poplar — — — — St. Marylebone 8 61 55 2 4 St. Pancras 4 26 14 2 10 Shoreditch 3 26 22 4 — Southwark 21 78 78 — — Stepney 7 44 44 — Stoke Newington 6 30 30 — — Wandsworth 146 304 238 32 34 Westminster, City of 11 99 95 — 4 Woolwich 16 32 32 — — * Includes 20 tenements to which the applications for certificates did not apply. † Including 205 renewals. Underground Rooms. The provision in the Housing and Town Planning Act relating to the occupation of underground rooms for sleeping purposes does not come into force until the 1st July, 1910, and hence the proceedings of the London sanitary authorities were limited to underground rooms which were occupied separately. The occupation of underground rooms which did not comply with the requirements of the Public Health (London) Act of 1891, was found to occur in Hampstead in buildings erected as " flats," in which in seven instances caretakers were found to be in such occupation. Dr. McCleary calls attention to the fact that a sanitary authority has no power to prevent the construction of underground rooms which do not complv with the Public Health Act. The number of underground rooms dealt with in 1909 in the several sanitary areas is shown in the following table:— Sanitary area. No. of rooms illegally occupied. No. of rooms closed* or illegal occupation discontinued. Sanitary area. No. of rooms illegally occupied. No. of rooms closed* or illegal occupation discontinued. City of London Kensington 17 - Battersea 26 26* Lambeth 8 8 Bermondsey — — Lewisham — — Bethnal Green 6 6 Paddington — — Camberwell Poplar — — Chelsea 4 4* St. Marylebone 163 163 Deptford — — St. Pancras 6 6 Finsbury 18 18 Shoreditch 3 Fulham Southwark 4 4 Greenwich 4 4* Stepney 52 25* Hackney — — Stoke Newington 1 Hammersmith — Wandsworth — — Hampstead 82 82 Westminster, City of 42 42* Holborn 33 33* Woolwich 1 1 Islington 28 16* 87 Overcrowding. The difficulty of dealing with overcrowding of dwelling rooms owing to the poverty of the inmates is discussed in a few of the reports and Dr. Brown gives particulars of the circumstances of twenty-two cases of overcrowding found in Bermondsey during 1909. In all but two instances the family occupied but one room; in eight instances the husband was out of work; and in some other cases the scanty earnings appeared inadequate for the payment of rent of an additional room. Dr. Thomas, in his report relating to Finsbury, mentions the practice of some landlords who insist on a written statement as to the number of children in the family of a prospective tenant before letting their rooms, and he adds that the sanitary authority allows the most ample time for overcrowded tenants to get rooms elsewhere. The following table, showing the number of dwelling rooms found overcrowded in the several districts, is compiled from information supplied by the medical officers of health, mainly in their annual reports. Sanitary area. No. of dwellingrooms overcrowded. No. remedied. No. of prosecutions. City of London 9 9 — Battersea 86 86 2 Bermondsey 124 124 — Bethnal Green 140 131 — Camberwell 177 177 1 Chelsea 20 20 — Deptford 42 42 — Finsbury 88 88 — Fulham 32 32 — Greenwich 25 25 — Hackney 155 155 — Hammersmith 19 19 — Hampstead 7 7 — Holborn 56 56 — Islington 148 148 — Kensington 56 56 — Lambeth 21 21 — Lewisham 18 18 — Paddington 440 215* — Poplar 200 200 — \ St. Marylebone 240 240 — St. Pancras 148 148 1 Shoreditch 95 95 — Southwark 424 424 3 Stepney 645 632 4 Stoke Newington 2 2 — Wandsworth 131 131 — Westminster, City of 72 72 — Woolwich 32 32 — * No action taken in 225 cases, the deficiency of air space being very slight. Factory and Workshop Act, 1901. The Factory and Workshop Act, 1901, requires every medical officer of health to report specifically on the administration in his district of those provisions of the Act the administration of which is imposed upon sanitary authorities, 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 other information contained in the annual reports of medical officers of health, the following summary table has been prepared:— 2067 M 2 88 89 TABLE SHOWING PROCEEDINGS OF LONDON SANITARY AUTHORITIES UNDER THE FACTORY AND WORKSHOP ACT, 1901. Premises, Particulars, Class, 4c. City of London Battersea. Bermondsey. Bethnal Green, i Camberwell. Chelsea. Deptford. Finsbury. Fulham. Greenwich. Hackney. Hammersmith. Hampstead. Holborn. Islington. Kensington. Lambeth. Lewisham. Paddinglon. Poplar. St; Marylebone St. Pancras. Shoreditch. Southwark. Stepney. Stoke Newington. Wandsworth. City of Westminster. Woolwich. 1. Inspections. Fa00000ctories (including factory laundries) 3,938 677 37 169 252 7 109 973 77 89 51 626 73 123 447 94 26 154 210 94 13 129 192 104 76 33 817 30 55 Workshops (including workshop laundries) 5,166 1,951 63 5,415 2,717 1,063 404 1,729 723 332 2,544 1,399 663 1,100 1,820 3,313 839 1,803 2,020 1,416 2,005 1,122 3,802 1,717 4,242 176 3,366 2,975 238 Workplaces (other than outworkers' premises) 744 1,236 97* 1,072 837 -* 169 609* 234 178* * 542 365 2,129 1,133 49* 104 392 50* 1,524 259 219 710 2,188 73* 16* 1,902 1,460 85 Total (Inspections) 9.848 3,864 197* 6.656 3,806 1,070* 682 3,311* l,034 599* 2,595* 2.567 1,101 3,352 3,400 3,456* 969 2,349 2,280* 3,034 2,277 1,470 4,704 4,009 4,391* 225* 6,085 4,465 378 2. Defects Found. Nuisances under the Public Health Acts. Want of cleanliness 899 103 12 512 47 30 173 166 52 105 194 97 19 104 425 166 158 150 22 493 141 92 287 739 808 24 225 958 55 Want of ventilation 119 7 1 9 1 - 4 14 - 3 40 2 9 11 29 21 2 1 — 12 11 2 - 20 103 - 2 277 27 Overcrowding 18 2 — 8 4 1 1 4 3 1 17 1 14 5 9 15 6 11 2 5 2 1 — 20 79 1 3 44 1 Want of drainage of floors 1 6 1 11 1 1 6 7 16 — — 99 26 — 2 — — — 1 — 14 — — — 61 1 Other nuisances .. 1,423 179 55 493 45 12 63 454 8 31 137 127 28 216 511 72 158 59 1 230 71 10 53 843 347 36 311 719 37 Sanitary accommodation (Insufficient 42 13 10 10 7 — 33 6 6 6 3 3 6 34 20 — 1 — 2 13 8 9 19 50 1 31 44 12 | Unsuitable 2,343 130 17 95 47 2 57 251 13 15 121 23 9 107 603 96 288 61 12 6 17 11 43 47 99 30 155 667 ( Not separate for sexes 46 — 2 2 5 2 — 17 - 3 8 1 — 5 4U 8 6 3 1 4 11 2 11 2 13 — 12 85 3 u[fences under the factory & Workshop Act. Illegal occupation of underground bakehouse (s. 101) — — — — — — — — — — — — — — — — — — — — — — — — — — — — — Breach of special sanitary requirements for bakehouses (ss. 97-100) — 14 3 — — 6 — — 2 7 — 84 — 9 — 8 — 10 — — — 31 — — 19 — 6 — — Other offences (excluding offences relating to outwork) — — — 1 — — — 27 — — — — — — — — — — — — — 5 — — — — — — — Total (defects found) 4,891 454 101 1.130 167 54 298 967 84 177 530 354 82 463 1,750 432 618 298 38 752 266 163 403 l,704† 1,518 92 745 2,855 136 3. Homework. Outworkers'Lists (s. 107). Keceived twice in the year from employers Number of Lists 1,416 94 78 180 150 81 84 264 28 22 384 48 126 128 616 144 34 74 146 134 134 38 103 170 246 26 152 654 22 Outworkers C. 2,953 72 22 - 72 150 16 599 22 62 113 93 524 155 8 — — 105 14 51 57 — 56 — corresponding thereto W. 13,115 368 729 2,926 1,493 648 515 4,570 74 174 4,395 85 289 682 3,688 851 351 208 669 2,436 1,910 174 1,650 1,356 3,732 255 612 8,364 393 Received once in the year from employers Number of Lists 99 6 16 14 22 2 2 36 4 4 52 15 10 4 23 16 25 16 31 9 5 12 9 8 15 5 6 22 19 utworkers. C. 99 - 9 - - 25 - - - 12 4 — — — — — — — — 4 3 — — — rrespond- ing thereto 1 466 19 137 159 190 3 7 278 9 21 210 11 10 13 74 21 181 34 47 54 16 62 113 25 54 22 13 146 114 Number of addresses of outworkers received from other Councils 234 373 594 3,599 1,576 111 355 899 316 182 3,230 283 32 285 2,974 314 924 241 309 1,726 1,302 900 2,958 1,096 7,364 663 370 511 62 Number of addresses of outworkers forwarded to other Councils 16,193 215 291 1,463 451 550 287 4,799 36 81 2,168 110 363 486 1,204 869 274 95 426 1,292 1,420 156 1,380 739 1,529 155 334 3,402 80 Prosecutions -! t Failing to keep lists or permit inspection thereof _ — — — — — — — — — — — — — 1 — — Failing to send lists — — — — — — — — — — 3 — — — — — — — — — — — — — — — — — — Outworkers' Premises. Number of inspections of outworkers' premises 277 809 1,191 13,351 1,098 119 286 58 382 288 875 147 73 188 1,207 283 580 370 367 2,028 278 28 2,325 860 1,361 — 446 1,039 275 Outwork in unwholesome premises (s. 108) Instances — 78 108 — 37 2 25 25 — 7 — — 137 8 — 5 — — —1 — 177 — 498 — 39 392 14 Notices served — 76 108 — 14 2 — — 25 25 — 7 — — 66 8 — 5 1 — — — 177 — 497 — 39 437 14 Prosecutions — — — — — — — — — — — — — — — — — — — — — 2 — Outwork in infected premises (ss. 109, 110) Instances — 5 — — — 3 3 — — — — — 30 10 4 — 6 8 — — 3 27 99 — 6 243 — Orders made (s. 110) — — — — — — — — — — — — — — — — — — — — — — — — — — — Prosecutions (ss.109, 110) — — — — — — — — — — — — — — — — — — — — — — — — — — — 4. Workshops. Workshops on the Register at the end of 1309. Bakehouses § 28 78 97 89 159 34 73 60 69 66 110 61 35 31 241 98 214 93 65 97 78 133 73 107 172 27 140 84 58 Laundries 2,008 39 40 1,993 81 16 10 2,023 62 19 103 198 10 11 128 188 126 69 58 18 3,098 74 27 58 27 165 150 49 18 Other workshops 413 652 1,4536 448 183 166 365 153a 948 540 517 1,060 1,401 1,382 897a 466 1,004 388 a 1,642 1,199 2,294 2,604 1,367 2,691 163a Total (number of workshops on the Register) 2,036 530 789 2,082 1,6936 498 266 2,0996 496 238a 1,161 799 562 1,102 1,770 1,668 1,237a 628 1,127 503 3,176a 1,849 1,299 2,459 2,803 192 1,657 2,824 239a 5. Other Matters. Matters notified to H.M. Inspector of Factories. 1 Failure to affix abstract of the Factory and Workshop Act (s. 133) 90 67 — 36 38 11 15 18 — 10 73 — 14 12 205 82 36 65 11 32 8 2 98 35 13 118 160 2 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. 5). Notified by H.M. Inspector Reports (of action taken) sent to H.M. Inspector 23 1 5 60 10 9 3 47 4 1 42 10 1 9 3 20 10 2 — 23 41 10 55 93 334 2 6 125 2 23 — 5 60 6 5 — 47 4 1 37 10 1 9 1 12 10 2 15 23 22 10 55 14 268 2 6 125 — Other — — — 1 — 5 13 16 — — — 2 10 6 — 3 — — — 4 — — — 10 66 25 — — — Underground Bakehouses (s.101). Certificates granted during 1909 — — — — — — — — — — — — — — — — — — 8 — l — — In use at the end of 1909 23 31 32 27 63 28 24 36 50 18 50 33 22 23 99 75 72 20 58 28 78 133 43 40 58 19 47 71 17 a Includes workplaces. „ Includes workplaces other than places where fool is prepLd. | • Excluding inspections of restaurant kitchens, etc. † Includes defect, in homeworkers' premises § Including bakehouses not in use during the year. 90 In considering the foregoing tabular statement it is necessary to bear in mind that the facts have not always been uniformly treated in the reports from which the information is derived. As far as possible differences of treatment have been indicated by footnotes in the table. Subject to this, the number of workshops on the registers appears to be fairly constant during the last three years. In the last annual report attention was directed to the fact that the number of inspections in certain districts fell short of the number of premises on the registers, leading to the inference that an annual inspection of all premises was not carried out. The figures of 1909 relating to three of these districts viz., Bermondsey, Lambeth, and St. Marylebone, point to the same conclusion. The Bermondsey Borough Council has, on the representation of the County Council, been required by the Local Government Board to increase their staff of sanitary inspectors, and the report of the medical officer of health of St. Marylebone refers to reorganisation of the staff of sanitary inspectors in that district. The number of defects found in London showed in 1909 a slight decrease upon the number found in 1908, having been in 1908, 22,012, and in 1909, 21,522. Want of cleanliness was met with in 1908 in 7,130 instances, and in 1909 in 7,256 instances; want of ventilation in 1908 in 639, and in 1909 in 727 instances; and overcrowding in 1908 in 237, and in 1909 in 278 instances; want of drainage of floors was found in 1908 in 252, and in 1909 in 254 instances. 1904. 1905. 1906. 1907. 1908. 1909. Number of workshops on register 34,488 35,187 36,632 37,891 37,673 37,782 Number of inspections, excluding in- 84,600 86,071 79,526 81,171 84,058 84,174 spections of outworkers premises Total number of defects found 18,922 19,023 19,407 22,071 22,012 21,522 Want of cleanliness 5,752 6,522 7,206 8,319 7,130 7,256 Want of ventilation 799 828 736 652 639 727 Overcrowding 413 347 461 295 237 278 Sanitary Insufficient 403 284 296 256 78 377 c o n v e- Unsuitable or defective 3,645 3,411 3,717 4,229 5,255 5,377 niences Not separate for sexes 308 239 251 388 376 292 In connection with the subject of ventilation, Dr. McCleary states that six workshops in Hampstead were found to be warmed by gas stoves which were unprovided with flues to cary off the products of combustion, and he points out that " this is a contravention of section 6 of the Factory Act, in which it is laid down that the measures which in every factory and workshop must be taken for securing and maintaining a reasonable temperature in each room in which any person is employed . . . must not interfere with the purity of the air of any room in which any person is employed." Absence of flues was also found in eighteen instances in Kensington. The use of basement rooms as workrooms is again discussed by Dr. Parkes in his report relating to Chelsea, and he points out that their sanitary condition is unsatisfactory in respect of lighting, warming, ventilation, and in some cases in respect of aerial disconnection from water closets, and he reiterates his opinion that the use of such rooms should be prohibited unless they complied with certain conditions. In the designing of new buildings architects would thus be led to comply with these conditions if the basements are intended to be used as workrooms. Dr. Sandilands also calls attention to the use as workrooms of the basements of flats, of which he says there has been large increase in Kensington. He states that they are not designed for use as workrooms, and are in many instances without flues, badly ventilated, and so dark as to render the use of artificial light necessary throughout the working day. Places Where Food is Prepared for Sale. The annual reports give information as to the administration of the powers conferred on sanitary authorities by the Council's General Powers Act of 1902 (sec. 43) for controlling the conditions under which ice cream is prepared for sale. 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, 1909. No. of notices, 1909. No. of prosecutions, 1909. On register at end of 1908. Added in 1909. Removed in 1909. jOn register at end of 1909. City of London 246 248 1 Battersea 108 56 8 156 260 7 1 Bermondsey 99 34 — 133 253 18 — Bethnal Green 78 19 9 88 331 69 — Camberwell 216 27 24 219 423 11 1 Chelsea 38 — 5 33 21 1 — Deptford 128 18 14 132 197 17 1 Finsbury 84 13 15 82 66 15 — Fulham 151 7 22 136 215 8 — Greenwich 115 13 10 118 157 17 — Hackney 151 — 13 138 114 11 — Hammersmith 227 — 3 224 234 15 — Continued on next page. 91 Sanitary area. Number of places. On register at end of 1909. No. of inspections, 1909. No. of notices, 1909. No. of prosecutions, 1909. On registor at end of 1908. Added in 1909. Removed in 1909. Hampstead 76 4 2 78 167 7 — Holborn 41 2 4 39 92 1 1 Islington 230 — — 230 167 22 — Kensington 165 12 — 177 165 35 — Lambeth 24 — 24 24 — — Lewisham No register is kept. — Paddington 136 — 16 120 57 — — Poplar 140 27 25 142 390 23 — St. Marylebone 80 — — 80 3 St. Pancras 191 491 305 — 2 Shoreditch 90 4 5 89 161 18 — Southwark 115 12 5 122 206 37 2 Stepney 123 25 20 128 227 30 1 Stoke Newington 38 4 4 38 42 — — Wandsworth 251 46 23 274 433 46 Westminster, City of 64 146 182 8 — Woolwich 108 12 22 98 207 6 — One of the provisions of this section requires the vendor to exhibit on his barrow the name and address of the maker of the ice cream. Dr. Annis mentions in his annual report the practice of some itinerant vendors, who frequent open spaces, of wheeling their barrows to these open spaces and then removing the wheels from the barrow. In a case heard at the Greenwich Police Court, the magistrate refused to convict a vendor who had not complied with the above requirement for the reason that the wheels having been removed from the barrow it had ceased to be a barrow. Amendment of the provisions of this section has also been found to be needed for the reason that, while the section is designed to protect ice cream from contamination, it does not afford like protection of the materials used in its manufacture before the act of freezing. The Council has therefore decided to apply to Parliament for amendment of the section in these two respects. The medical officers of health of the City and of Deptford both mention that they have observed a reduction in the number of itinerant ice cream Vendors upon that found in previous years. Places where food is prepared for sale have been to a considerable extent inspected in recent years as workplaces under the Factory and Workshop Act. The inspections in 1909 related also to the exercise of the powers conferred upon sanitary authorities by section 8 of the Council's General Powers Act, 1908, for regulating the conditions under which food is prepared for sale, so as to protect it from contamination, and, as will be seen from the following table, a large amount of inspection of these premises has been carried out during the year. The medical officer of health of Hampstead, who refers to these provisions as "much needed powers," states that, in a considerable number of cases conditions were found that were in contravention of the Act. During the year 19 premises were altered, and many other premises were being altered to bring them into compliance with the Act. In the same way, steps" were taken in other districts for the removal of dirty and unwholesome conditions in the many restaurants, eating houses, cookshops and other premises in London in which food is prepared for sale. During the year the Council addressed a letter to London sanitary authorities inviting their opinion as to the desirableness of extending some of the powers of this section to costermongers' stalls from which food is sold, and in a few of the reports it is stated that the sanitary authorities favoured this proposal. The annual reports of medical officers of health supply information as to the number of premises inspected and the number of inspections which is shown in the following table:— Premises used for the 'preparation and sale of food* 1909. Sanitary area. Premises used for the preparation and sale of food. Number of inspections. Sanitary area. Premises useci for the preparation and sale of food. Number of inspections. City of London 861 1,126 Kensington 216 803 Battersea 95 242 Lambeth 245 103 Bermondsey 974 6,454 Lewisham 50 83 Betlinal Green 223 1,072 Paddington 403 794 Camberwell 185 380 Poplar 294 1,041 Chelsea 60 75 St. Marylebone 163 163 Deptford 111 157 St. Pancras 623 1,221 Finsbury 260 260 Shoreditch 253 302 Fulham 90 164 Southwark 305 1,080 Greenwich 117 156 Stepney 369 626 Hackney 52 51 Stoke Newington 25 25 Hammersmith 136 542 W andsworth 489 720 Hampstead 423 770 Westminster, City of 833 4,245 Holborn 382 1,936 Woolwich 83 83 Islington 738 822 * Other than bakehouses, milkshops, slaughterhouses, and iee-cream premises. 92 Inspection of Food. Regulations under the Public Health (Regulations as to Food)' Act, 1907. In 1909 the Local Government Board inserted in the London Gazette notices containing schedules of labels and marks declared in various countries to be admissible as Official Certificates in respect of foreign meat which consists of pork, or other edible parts of the pig. In September the Local Government Board issued amended regulations relating to foreign meat— "The Public Health (Foreign Meat) Amending Regulations, 1909." A circular letter of the Local Government Board shows the principal alterations made thereby in the Regulations of 1908, as follows:— Scrap Meat. The Foreign Meat Regulations, 1908, included boneless scrap meat in the definition of "Foreign Meat of Class I." Scrap meat or trimmings of carcasses, which contain bone, are, however, occasionally imported. They are usually contained in barrels or bags and described as "neck meat," "rib meat," or by other names. Their importation must be considered open to objections similar to those which attach to the importation of boneless scrap meat. The amending Regulations include meat which consists of scraps, trimmings, or other pieces, of such shape or in such condition as to afford insufficient means of identification with definite parts of a carcass, in the definition of " Foreign Meat of Class I.," whether or not bone is present in such scraps or pieces. In any case where the medical officer of health ascertains that meat of the kind referred to is being imported, the necessary notice applicable to " Foreign Meat of Class I." should be given. Bacon, Ham, Salted Mess Pork, Salted Pigs' Tongues, Salted Pigs' Heads, etc. The Foreign Meat Regulations, 1908, do not require that bacon and ham, or certain salted parts of the carcass of the pig which are prepared in a manner comparable to that in which bacon and ham are prepared, should necessarily be attested by an " Official Certificate " in evidence of approved inspection in the country of origin as a condition of their importation for use for human food. In the case of uncertified packages containing pigs' heads and other salted products, however, the meat has on several occasions been found to show evidence of tuberculosis or other disease conditions. In other cases the lymphatic glands which would naturally be present in the portions of the salted carcass have been removed before importation in such a way as to suggest that the object of the removal of the glands has been to conceal the fact that they were affected by disease, or to prevent any attempt to discover the existence of disease on arrival in this country. In regard to these salted articles, the amending Regulations include any severed part of the carcass of the pig which is not contained in a package bearing an " Official Certificate " in the definition of " Foreign Meat of Class I." if the lymphatic glands about such part are not present in their natural position. The stomachs or "maws" of pigs are sometimes imported, in brine or packed in salt, for human consumption. The amending Regulations include any salted part of the pig which is not a severed part of the carcass in the definition of " Foreign Meat of Class I." if it is not imported in a package which bears an " Official Certificate." Foreign bacon, ham, and salted pig products will be detained by Customs officers on receipt of an intimation from the medical officer of health that he desires to examine salted pig products which arrive from some specified country or port of shipment, or particular consignments of such meat. Requests for detention should contain particulars sufficient for the identification of the meat in question by the Customs officers. It will usually be practicable for the medical officer of health to examine salted pig products for the purpose of the Regulations without first requesting formal detention by Customs officers. "Stripped " Meat. The Board's attention has been called to the fact that meat, particularly beef, is sometimes imported in the form of carcasses, or portions of carcasses, from which the pleura or lining membranes of the thorax have been stripped. Removal of the pleura is frequently practised in order to conceal evidence of disease conditions. The amending Regulations include any meat which comprises the ribs, but which on importation is ascertained to be without the pleura in the category of "Foreign Meat of Class I." The addition thus made to the Regulations should receive special attention in connection with inspection made of imported beef. The annual reports of medical officers of health supply the following information as to the seizure of food unfit for human consumption. Dr. Collin gridge reports that in the Central Markets of the City there were seized 112 tons of diseased meat, 1,123 tons of unsound meat, 75 tons of unwholesome meat, 43 tons of poultry, 143 tons of offal, and 4 tons of fish. Of the diseased meat seized, tuberculous meat represented 56 tons. Arising out of these seizures there were five prosecutions and convictionsi In the Billingsgate Market 946 tons of fish were condemned, or 1 ton in 262 tons of fish delivered at the market. Fish in the Billingsgate Market is inspected by the Fish Meters of the Fishmongers' Company. The SaDitary Committee of the City Corporation have, after consultation with the Fishmongers' Company, recommended the appointment of an inspector by the Corporation for the purpose of inspection of fish in the market, but this recommendation has not been adopted. Of food stuffs delivered at the riverside wharves within the City, 133 tons were removed and disposed of as the result of the daily inspection. In the wholesale markets in Charterhouse Street, St. John-street, and Cow Cross Street, adjacent to the Smithfield Market, and situated in the Metropolitan Borough of Finsbury, 107 tons of diseased and decomposed foodstuff was seized. Among the articles seized was the body of a cat. "This cat," Dr. Thomas reports, "came as one of a consignment of rabbits and packed in a case with them in the ordinary way from Ostend. The circumstances were these—the cat, a fat, sleek, well-matured animal, weighing about 4 lbs., had been decapitated, its tail removed, and its carcase had been dexterously attached to the emaciated head of a rabbit, sewn on by ordinary grey thread. The rabbit's head was much emaciated, and probably belonged to a diseased animal, so that its carcase was useless. The cat was offered as an efficient substitute." Dr. Thomas also gives account of the condition of lemon squash and mineral water seized in a shop in Finsbury after the finding of the back-bone of a fish in a bottle of lemon squash; these beverages were found to be unfit for human consumption, and were destroyed. There were three prosecutions and convictions in Finsbury for the sale of meat unfit for human consumption. The amount of unsound food surrendered and seized in Islington amounted to 2 tons 4 cwt., and in nine instances there were 93 prosecutions and convictions in connection therewith. In Westminster nearly 50 tons of food stuff, submitted for examination, were destroyed, and in connection with articles seized there were three convictions. Tn Bermondsey over 71 tons of food stuff was removed and destroyed as trade refuse, and in connection with articles seized there were three convictions. Two of these convictions related to the seizure of the meat of a diseased horse, the meat being discovered in a passage at the rear of a butcher's shop. Both the butcher and the man from whom he had purchased the horseflesh were sentenced to three months' imprisonment. It was proved that the horse was slaughtered because of disease, and the flesh was purchased by the first defendant at 8d. a stone, and by the second defendant from the first at Is. a stone. In Southwark nearly 78 tons of food stuff, mostly landed at the wharves in that borough, were either destroyed or utilized for other than purposes of food. In this district there were five prosecutions and three convictions for selling unsound articles of food. In Stepney 358 tons of unsound food stuff, much of it landed at the wharves, were destroyed, and nearly 5,500 lbs. of diseased meat and offal were taken in the private slaughterhouses and were condemned. In this district there were eight convictions for selling unsound food. In Poplar various food stuffs, mostly tinned, landed at the wharves, were surrendered, and other unsound articles of food sold in other parts of the borough were dealt with. In St. Marylebone various articles of food were seized and in eleven instances convictions followed. In Shoreditch several convictions were obtained for selling unsound food, and in St. Pancras there was one conviction for depositing for the purposes of sale milk which was unfit for food. In Bethnal Green there were seven convictions. In the reports relating to Camberwell, Chelsea, Deptford, Fulham, Greenwich, Hammersmith, Holborn, Kensington, Lambeth, Lewisham, Wandsworth and Woolwich mention is made of seizures of articles of food, and in a few instances prosecutions followed. The medical officers of health of Bermondsey and Stepney both give account of articles of food dealt with under the Public Health (Regulations as to Food) Act, 1907. Among other matters mentioned in the annual report relating to Islington, is the institution in the Islington Cattle Market of a system of insurance, by which, on payment of Is. per head on bullocks and heifers sold for £12 or more, purchasers can obtain an indemnity if the carcase is subsequently seized. Dr. Harris writes:—" The result of this arrangement will undoubtedly be that butchers will be most anxious to give information respecting diseased cattle that come into their hands, and that in consequence the sale of diseased meat will become less." Disinfection. In the last annual report it was stated that the Paddington Borough Council had approached the Kensington Borough Council with a view to the joint use by the two authorities of the disinfecting station in Kensington, but that no agreement had been made. In the meantime a site in Paddington which the borough council had contemplated using had been otherwise disposed of, and hence the Paddington Borough Council are continuing to entrust their disinfection to a contractor. Dr. Allan reports that a suitable site for a disinfecting station for the Westminster City Council had been found, and that plans had been prepared for the erection of a suitable station, which was expected to be completed in 1910. Dr. Kenwood reports that the provision of the new disinfecting station in Stoke Newington referred to in the last annual report has justified all the predictions as to its value. An additional machine has been provided at the City station to meet the increasing demand for the disinfection of infected articles. Dr. Harris states that there has been considerable increase in the use of the disinfecting station in Islington, owing to the requirements of a firm who export the cast-off clothing of soldiers and sailors to foreign countries which was disinfected before exportation. In the annual reports relating to Kensington, Bethnal Green, and Deptford mention is made of the provision of a chamber for disinfection with formalin of articles which cannot be exposed to a high temperature. Dr. Alexander reports that the demand has greatly increased, for the " Electric Disinfecting Fluid " manufactured by the Poplar Borough Council. Shelters. Shelters for the temporary accommodation of persons during the disinfection of their rooms have been occupied to a very different extent in the several districts. Change in the methods of disinfection is in some degree responsible for some of these shelters being less used than formerly, but, as will be seen by the following table, in some districts the shelter is still much used. In recent vears shelters have been found to serve an exceedingly useful purpose in providing accommodation for persons who have been exposed to smallpox, who can be kept under observation in a shelter during the period of incubation of the disease. In cases where any of these persons develop small-pox, this occurs under conditions which do not expose other persons to risk of infection, and hence the extension of the disease is prevented. In other directions the shelters have proved of service. Thus Dr. Harris writes that the Islington shelter has been used for the cleansing of verminous persons under the Cleansing of Persons Act, of whom 31 were cleansed in 1909; the cleansing of school children from a like condition, 1,205 such children having been cleansed in that year; and the bathing and cleansing of midwives after attendance on cases of puerperal fever. The onlv change in the establishment of shelters mentioned in the annual reports is that one of the shelters in Lambeth has been discontinued owing to the site being required in connection with the erection of the County Hall. It is also proposed to discontinue the shelter of the Popular Borough Council, which is situated at Bromley, and erect a shelter and disinfecting house on vacant land in Glaucus-street, at a cost of £1,260. 2057 N 94 The following figures, which are mainly taken from the annual reports, show the extent to which the existing shelters were used during the year 1909:— Sanitary area. No. of persons accommodated. Sanitary area. No. of persons accommodated. City of London 24 Kensington (a) Battersea 20 Lambeth Bermondsey 39 Lewisham — Bethnal Green 17 Paddington (a) Camberwell — Poplar — Chelsea 58 St. Marylebone 39 Deptford — St. Pancras 23 Finsbury 22 Shoreditch 9 Fulham — Southwark 711 Greenwich 3 families Stepney 77 Hackney 83 Stoke Newington (used on 2 occasions) Hammersmith (a) Hampstead Wandsworth 1 Holborn 11(a) Westminster, City of 6 Islington 40 Woolwich ~ (a) No shelter is maintained by the Borough Council. In the case of Holborn, 11 persons were accommodated in the Finsbury Borough Council's shelter. Mortuaries. The number of bodies received into the mortuaries of the several sanitary authorities during the year is shown in the following table:— Sani tary area. Total number of bodies received into mortuary. Number of infectious bodies received into mortuary. Sanitary area. Total number of bodies received into mortuary. Number of infectious bodies received into mortuary. City of London 205 Kensington 323 2 Battersea 269 11 Lambeth 369 2 Bermondsey 207 14 Lewisham 141 3 Bethnal Green 342 6 Paddington 288 2 Camberwell 321 8 Poplar 287 1 Chelsea 159 3 St. Marylebone 374 4 Deptford 95 2 St. Pancras 412 11 Finsbury 308 7 Shoreditch 392 5 Fulham 164 2 Southwark 680 6 Greenwich 131 — Stepney 645 6 Hackney 467 6 Stoke Newington 44 — Hammersmith 234 4 Wandsworth 206 — Hampstead 85 — Westminster, City of 291 6 Holborn 97 — Woolwich 146 1 Islington 592 1 The Cleansing of Persons. The provision for the cleansing of verminous persons still remains very inadequate in London as a whole, but in some districts more suitable accommodation has been provided than in others. The number of persons cleansed in 1909 is shown in some of the annual reports, and the following table has been compiled mainly from the information thus supplied:— Number of persons cleansed in 1909. Sanitary area. Adults. Children. Sanitary area. Adults. Children. Battersea 1,373 321 Poplar 647 96 Bermondsey 91 927 St. Marylebone 11,114 4,684 Bethnal Green 14 1 St. Pancras 2,217 3,367 Camberwell 100 2,225 Southwark 111 2,324 Finsbury 2 — Stepney 570 313 Hackney 177 490 Stoke Newington 5 140 Holborn 219 — Wandsworth 23 12 Islington 31 1,205 Westminster, City of 6 — Kensington 18(a) — Woolwich 115 293 Lambeth (b) — (a) Dealt with by the Board of Guardians at the expense of the Kensington Borough Council, (b) Lambeth— See houses infested with vermin, page 85. 95 The number of persons who are cleansed in the several districts depends in large degree upon the nature of the accommodation which is provided, its accessibility, and the steps which are taken to make its existence known. The large number of adults who are cleansed in St. Marylebone affords abundant evidence of the willingness of persons infested with vermin to take advantage of any reasonable facilities which are given them for this purpose. In Woolwich, where a station was opened in November, 1906, 19 persons made use of it in that year. In 1907 it was used by 62 adults and 195 children, in 1908 by 101 adults and 161 children, and in 1909 by 115 adults and 293 children. A relatively small number of female adults resort to it owing, Dr. Davies thinks, to the fact that there is no female attendant. In his annual report Dr. Sykes gives an interesting account of the steps which have been taken by the Borough Council of St. Pancras to adapt the cleansing station in that district to meet the increasing demands for its use. During the year the Council, through its Public Health and Education Committees, was in communication with the London sanitary authorities for the purpose of making arrangements for the cleansing of adults from common lodging-houses and school children respectively.* The London Equalisation of Rates Act, 1894. The Equalisation of Rates Act provides that the London County Council shall in each year form a fund equal to a rate of sixpence in the pound on the rateable value of London. The contribution from each parish to the fund is to be in proportion to its rateable value. The fund thus formed is to be distributed among the sanitary districts in proportion to their population. Where a sanitary district comprises two or more parishes, and the aggregate of the contributions from such parishes is less than the grant apportioned to the district, the difference shall be paid out of the fund to the sanitary authority of the district, and no payment towards any equalisation charge shall be required from any parish in the district. Subject to the above, when the contribution from a parish is less than the grant due, the difference shall be paid out of the fund to the sanitary authority of the district forming or comprising the parish; and if it exceeds the grant to the parish, the Council shall, for the special purpose of meeting the excess, levy on the parish a county contribution as a separate item of the county rate. Every sum paid to a sanitary authority must be applied in defraying the expenses of the sanitary authority incurred under the Public Health (London) Act, 1891, and so far as not required for that purpose those incurred in respect of lighting, and so far as not required for that purpose those incurred in respect of streets, and where the sanitary district comprises two or more parishes the sum paid must be apportioned among such parishes in proportion to their population, and the amount apportioned to each parish credited to each parish in the reduction of the rate required from such parish towards the above-mentioned expenses. The sanitary authority is required to render annually to the Local Government Board a return showing the amount of the sum to be paid and the total expenses incurred in respect of the three subjects mentioned. If the Local Government Board, under section 101 of the Public Health (London) Act, are satisfied that the sanitary authority have been guilty of such default as in such section mentioned and have made an order limiting the time for the performance of the duty of the authority, the London County Council shall, if directed by the Local Government Board, withhold the whole or any part of the payment of the sum due to such authority. The Act provides that for the purposes of the distribution of the fund an estimate of population on the 6th April in each year shall be made by the Registrar-General upon returns which the Local Government Board receive from the authority making the poor rate in each parish showing the total number of houses entered in the rate book of the parish. The following table shows the estimated population on the 6th April, 1909, and the amount o excess of contribution over grant, or of grant over contribution, in respect of each district for the vear ended 31st March, 1910— Sanitary area. Estimated population, 6th April, 1909. Equalisation charge, being excess of contribution over grant for year ended 31st March, 1910. Net grant, being excess of grant over contribution for year ended 31st March, 1910. £ s. d. £ s. d. City of London 21,498 129,454 7 11 — Inner Temple 127 601 2 6 — Middle Temple 104 345 5 6 — Battersea 173,122 — 14,173 5 7 Bermondsey 128,735 — 6,816 18 4 Bethnal Green 128,720 — 16,603 16 1 Camberwell 270,059 — 29,202 10 - Chelsea 71,292 6,591 16 5 — Deptford 112,683 — 10,431 16 8 Finsbury 102,218 1,857 17 11 Continued on next page. * In Appendix IV. will be found a report by Dr. Hamer in which the seasonal prevalence of certain human parasites is discussed (pp. 7 et aeq.). 2057 N2 96 Sanitary area. Estimated 'population, 6th April, 1909. Equalisation charge, being excess of contribution over grant for year ended 31st March, 1910. Net grant, being excess of grant over contribution for year ended 31st March, 1910. Fulham 158,208 - 14,640 7 10 Greenwich 104,676 — 7,898 17 - Hackney 220,486 — 21,135 - 11 Hammersmith 121,701 — 7,857 19 3 Hampstead 88,728 6,733 9 9 — Holborn 53,705 14,209 10 8 — Islington 336,983 — 30,694 12 7 Kensington 185,360 17,031 9 3 — Lambeth 310,239 — 24,134 19 1 Lewisham 170,581 — 13,035 16 9 Paddington 145,251 4,352 14 9 — Poplar 167,146 — 18,470 4 11 St. MaryleboDe 125,336 19,633 2 - — St. Pancras 228,394 — 8,828 18 10 Shoreditch 116,680 — 7,229 3 5 Southwark 198,431 — 14,060 11 11 Stepney 285,884 — 29,949 17 2 Stoke Newington 52,537 — 3,515 1 11 Wandsworth 327,322 — 24,668 10 3 Westminster, City of 175,100 115,481 3 6 — Woolwich 138,493 — 12,946 11 8 Total 4,719,799 316,295 - 2 316,295 - 2 water supply. Dr. Houston, Director of Water Examinations, in his fourth annual report, for the year ended March, 1910, alludes to "the striking new fact . . . now shown in this report that London is not really drinking merely filtered raw river water, but raw river water which by storage processes has been purified bacteriologically antecedent to filtration to a remarkable extent." Storage, Dr. Houston says, acts in three ways. It permits of sedimentation; it favours devitalisation of "the microbes of waterborne disease"; and it has a "levelling" effect, spreading the dose of poison over weeks or months, and it may be, indeed, quite apart from any question of devitalisation, rendering innocuous " a microbial contamination which in a concentrated form would be apt to be highly dangerous." " These three factors of sedimentation, devitalisation, and equalisation are," says Dr. Houston, " of supreme importance in connection with the storage of impure river water antecedent to its filtration." During the year there appeared Dr. Houston's third and fourth research reports; the former dealing with the subject of storage generally, and the latter with the vitality of the cholera vibrio in raw river water with special reference to the question of storage. Health Visitors. London County Council (General Powers) Act, 1908. Section 6 of the above Act empowers the Local Government Board to make regulations prescribing the qualification, mode of appointment, duties, salary, and tenure of office of health visitors, and in September, 1909, the Board made an Order for these purposes. The Order—Article I. (1) and (2)— with respect to qualification, prescribes that:— I.—(1) A woman shall be qualified to be appointed a health visitor if she— (а) Is a duly qualified medical practitioner within the meaning of the Medical Acts; (b) Is qualified for the appointment of nurse by having undergone for three years at least a course of instruction in the medical and surgical wards of any hospital or infirmary, being a training school for nurses, and having a resident physician or house surgeon; (c) Is certified under the Midwives Act, 1902; (d) Has, for a period of not less than six months, undergone, in a hospital or infirmary receiving children as well as adults, and having a resident physician or house surgeon, a course of instruction including subjects relating to personal hygiene, and holds the certificate of the Royal Sanitary Institute for Health Visitors and School Nurses, or the certificate or diploma of the National Health Society, or of any other body which may from time to time be approved by the Local Government Board; (e) Has, in the service of a sanitary authority, or of the council of a borough or of another urban district or of any other public body or authority in England or Wales, discharged duties which are similar to those described in the Act or prescribed by these Regulations in relation to the office of health visitor, and produces such evidence as suffices to prove her competency; (2) Where, in the opinion of the Local Government Board, the circumstances so require, the sanitary authority may appoint to the office of health visitor a woman who, though not possessing any such qualification as is prescribed by sub-division (1), has a competent knowledge and experience of the theory and practice of nurture, of the care and management of young children, of attendance on women in and immediately after childbirth, and of nursing attendance in cases of sickness or other mental and bodily infirmity. Sanitary Inspectors. Appended to this report is a return showing the number of sanitary inspectors in London in June, 1910 (Appendix VI.). The return also shows the numbers of men and women inspectors in the several years since 1893, and the number of health visitors employed in the several sanitary districts. It should be noted that, as compared with the return published as an appendix to the annual report for the year 1907, there has been an increase in the number of men inspectors from 279 to 286, and one additional woman inspector has been appointed. 97 Midwives Act, 1902. The number of midwives giving addresses in London, whose names had been placed upon the Roll up to the end of 1909, was 3,629, made up as follows:— (a) 1,824 in virtue of a certificate obtained by examination prior to the Midwives Act, 1902. (b) 1,620 in virtue of a certificate from the Central Midwives Board. (c) 185 in virtue of having been in bona fide practice for a year prior to the passing of the Act. After correcting for removals and deaths, where such had been reported, the number of certified midwives said to be resident in London in 1909 is reduced to 3,285. Of these, 537 gave notice of intention to practise during the year or for shorter periods. The London midwives are classed as follows:— Number not giving notice of intention to practise. Number giving notice of intention to practise. Total. Class (a) 1,357 213 1,570 „ (b) 1,324 221 1,545 „ (c) 67 103 170 2,748 537 3,285 Many of the midwives who notified their intention to practise were connected with institutions and did not continue to work in London during the whole year, their places being subsequently filled by other midwives, who in turn also gave notice of intention to practise. It may be estimated that at any given time during 1909 some 420 midwives were practising in London. This represents some 13 per cent. of the midwives said to be resident in London. The remainder for the most part act as monthly or general nurses under the direction of medical practitioners. One practising midwife died during the year, 19 gave up practice, and 34 removed from the county. Of the practising midwives, 32 work entirely within poor law institutions or lying-in hospitals, and are under medical supervision. Others, living in their own homes, attend patients on behalf of charitable or poor law institutions, and are paid a fee for each case allotted to them. The rest practise independently or work for lying-in institutions not under the direction of qualified medical practitioners. Inspection.—All practising midwives (except those who claim exemption by reason of working in connection with hospitals and poor-law infirmaries under the direction of a medical practitioner) are subject to supervision by the Council's officers, 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 registers and case books, and the sending of the various notices to the local supervising authority. The work of inspection was carried out by Miss I. R. Shields, M.B., B.S., and Miss E. Macrory, M.B., Ch.B., L.M., D.P.H. In addition to the ordinary routine inspection, special inquiries are made into all cases of a septic nature, in cases of death of mother or child, and cases in which medical help has been advised on account of inflammation of the eyes. The inspectors also advise midwives on points of difficulty arising in the course of their duties. In some instances midwives have been accompanied to confinements or to the subsequent visits to patients in order to ascertain whether their methods of work are satisfactory. In cases where a midwife applies to the Central Midwives Board for approval to supervise the practical work of pupils training for examination, the inspectors make special inquiry to ensure that the applicants possess a requisite standard of efficiency, and the result of such inquiry is reported to the Board. During the year 1,562 visits were paid by the inspectors, including visits in special cases. In 904 instances the reports were satisfactory, in 108 instances unsatisfactory; in 494 the midwife was not seen owing to being away from home when the inspector called; and in the remaining 56 instances it was found that the midwife had removed or was not practising. The 108 reports where unsatisfactory conditions were found related to 83 midwives; 62 were reported to be unsatisfactory on one occasion, 18 on two occasions, 2 on three occasions, and 1 on four occasions. Most of the unsatisfactory reports above mentioned were cases in which some slight infringement of the rules had occurred, and the midwife's attention was drawn to the matter, and at a subsequent visit the inspector was able to report favourably. In cases of a serious nature or where there was persistent neglect to observe the rules, the case was reported to the Midwives Act Committee of the Council, and a letter of caution was sent to the midwife. This course was adopted in 15 cases for the following reasons:— Not advising medical assistance at once in cases of inflammation of eyes 4 Not advising medical assistance at once to mothers as required by rules 5 Not advising medical assistance at once to infants as required by rules 2 Failure to take and record patient's temperature 2 Neglect of mother or child 2 15 98 In one case a midwife was brought before the Committee and cautioned for not advising medical assistance at once when the placenta and membranes were not complete. Prima facie cases of negligence were found against 3 midwives and reported to the Central Midwives Board, and in addition a midwife who had previously been reported to the Board, and whom the Board had cautioned, was again reported for neglect and for employing an uncertified substitute. Nature of offence. Action taken by Central Midwives Board. Dirty and negligent Name removed from Eoll. Neglect of patient Cautioned. Neglect of patients and failure to visit Cautioned. Failure to take temperatures and employing uncertified substitute Cautioned. Legal proceedings were instituted against one midwife for failing to notify her intention to practise. This woman had removed from her former address in 1907 and was keeping a lying-in home, where a number of illegitimate children were born. There was reason to believe that she was trying to avoid inspection. She was fined £1 and £1 3s. costs. Seven midwives were reported to be more or less illiterate, but their registers and case books are entered up by other members of the family and the notices were properly sent in. The Council's inspectors have given much attention to the more ignorant midwives and instructed them in the use of the clinical thermometer, and the ordinary antiseptics, and in some cases these women have been induced to attend the Council's classes for midwives. There are 14 Jewish midwives who practise among the Jewish population in East London. Their difficulty in understanding the rules was met by the translation of the rules into Yiddish by the Jewish Board of Guardians. Two Italian midwives attend women of their own nationality in Saffron Hill district, and occasionally go to patients in other parts of London. Fees charged by midwives.—The fee a midwife receives for attending a confinement and the subsequent nursing varies in different localities from 5s. per case upwards, but usually a fee of 7s. 6d. (or, in cases of primipara, 10s.) is expected. Fees of 15s. and even £1 1s. have been paid on rare occasions. The charities employing midwives pay 5s. or 6s. per case, and provide the necessary drugs, registers, etc. It is apparent from the number of cases attended by midwives and the fees paid that only a small number can rely solely upon their practice as a means of livelihood. Many of them are married women, and do not trouble to obtain a large practice. 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 who have larger practices are approved by the Central Midwives Board, as qualified to give practical instruction to pupils preparing for the Board's examination, and receive fees from the pupils for this training. The lying-in hospitals in London receive into their wards some 5,000 women annually and provide for attendance on about 19,000 in their own homes. The latter cases are conducted almost exclusively by midwives. Some of the hospitals pay a fixed salary, others pay the midwife a fee for each case. The patients themselves are not as a rule required to pay for services rendered by district midwives attached to hospitals, and in the case of institutions there is either free attendance or only a nominal fee. Lists of births.—From information obtained under the Notification of Births Act, and from other sources in boroughs where the Act was not in operation during the whole year, it has been possible to get figures showing the number of births attended by particular midwives thus:— 4 midwives had over 500 cases in the year. 4 midwives had between 400 and 500 cases in the year. 9 „ „ „ 300 and 400 „ „ 8 „ „ „ 250 and 300 „ „ 1 ,, „ „ 200 and 250 „ „ 18 „ „ „ 150 and 200 „ „ 36 „ „ „ 100 and 150 „ „ 53 „ „ „ 50 and 100 „ „ 45 „ „ „ 20 and 50 „ „ Most of the midwives who had more than 300 cases in the year have qualified midwives to assist them, and are approved by the Central Midwives Board to supervise the practical work of pupils preparing for the Board's examination. It is estimated that, including the cases conducted for poor law infirmaries and for charitable institutions by midwives some 30,000 to 35,000 births—that is, between one-quarter and one-third of the births in London—are attended by midwives annually. Uncertified women.—In my report for 1908 I mentioned that a list had been compiled of 140 women not certified as midwives who were said to be practising midwifery. Twenty more names were added during the year, but, on investigation being made, it was found that, as in the previous year, the majority of cases were those in which a nurse or neighbour acted in emergency before the arrival of a medical practitioner. Some 900 or less may be taken as a fair estimate of the births attended by uncertified women who act entirely without a doctor. One woman was prosecuted for using a title implying that she was a midwife certified under the Act. She was fined 10s. and £1 3s. costs. 99 Medical help.—The rules of the Central Midwives Board provide that in certain circumstances which are set out in detail a midwife must decline to attend alone and must advise in writing that the case is one requiring medical help. The form on which this advice is given is sent to the medical man, and a copy of it is forwarded to the local supervising authority. The number of instances in which the Council received these notices was 2,894. The figures in previous years were:—1905,1,113; 1906, 2,320; 1907, 2,533; 1908, 2,755. The increase in the figures is probably due to the fact that midwives are realising the importance of securing medical assistance in compliance with the rules of the Central Midwives Board. Notices were thus sent in by 327 midwives. Midwives in infirmaries and hospitals under the direction of a medical practitioner are not required to comply with this rule. 1 midwife reported advising medical help, 159 times. 1 90 99 99 99 m9 „ •» 1 84 A 99 99 99 99 99 99 3 midwives „ „ „ „ between 60 and 80 times. 7 ,, ,, ,, ,, 40 and 60 ,, 18 „ „ „ „ „ „ 20 and 40 53 ,, ,, ,, ,, ,, ,, 10 and 20 ,, 243 .. .. .. .. .. less than 10 times. The reasons assigned by the midwife for advising medical help were as follows:— Pregnancy— Lying-in— Abortion or miscarriage 52 Abdominal swelling or tenderness 13 Deformed pelvis 7 Excessive sickness 5 Varicose veins 17 Offensive lochia 8 General health of patient 10 Rigor 5 Ante partum haemorrhage 110 Rise of temperature 173 196 Swelling of breasts 12 Post partum haemorrhage 84 Pains in leg 13 Convulsions or eclampsia 15 Labour— Collapse and exhaustion 34 Presentations— Mania 5 Unable to make out 18 Other illness 124 Abnormal vertex 32 491 Difficult breech 43 Child— Knee 2 Injury at birth 6 Face 35 Asphyxia 69 Funis 41 Malformation or deformity 85 Transverse 73 Inflammation of eyes 162 Placenta prævia 28 Jaundice 15 Twin birth 1 Cyanosis 11 Triple birth 1 Dangerous feebleness 380 Quadruple birth 2 Convulsions 33 Prolapse of vagina or uterus 14 Eruptions on skin 26 Prolonged labour (uterine inertia contracted pelvis, etc.) 523 Bleeding from cord 9 Death of child 36 Laceration of perineum or injury Still-birth 34 to soft parts 214 Other conditions in child 72 Retained or adherent placenta 207 938 Haemorrhage during labour 19 Infectious disease in patient's house.. 9 1253 No reason stated 7 2,894 Assuming that some 30,000 births are attended annually by midwives, the above figures show that midwives have advised medical assistance in 9.6 per cent. of the cases they attended; in 6.5 per cent. on account of the mother, and 31 per cent. on account of the child. Still-births.—During the year 221 midwives reported still-births in their practice, the number of still-born children being 676. The numbers in previous years were:—1906,574; 1907,740; 1908, 666. 1 midwife reported 19 still-births 19 1 „ „ 16 „ 16 3 midwives reported 11 still-births each 33 6 „ „ 9 „ „ 54 5 „ „ 8 „ „ 40 8 „ „ 7 56 6 „ „ 6 „ „ 36 14 „ „ 5 „ „ 70 25 ,, ,, 4 ,, ,, 100 27 „ „ 3 „ „ 81 46 „ „ 2 „ „ 92 79 „ „ 1 „ „ 79 221 676 The above figures, when compared with the estimate of 30,000 births, show that in 2.2 per cent. of the births the infant was still-born. 100 The form prescribed by the Central Midwives Board for notifying still-births provides for information as to (a) sex of child, (b) period of gestation, (c) whether macerated or not, (d) presentation. The information under (a) showed that 354 still-born children were males and 316 females, and in 6 cases the sex was not stated. The following table shows the number of still-born infants of 6, 7, 8 and 9 months' gestation, and whether they were macerated or not:— Condition of child. Total cases. Period of gestation. Full term 8 months. 7 months. 6 months. Under 6 months. Not stated. Macerated 383 147 80 94 47 13 2 Not macerated 276 186 31 33 18 6 2 No statement 17 2 1 — 2 3 9 Total 676 335 112 127 67 22 13 The presentations were as follows:— Vertex 398 Face or brow 6 Complicated vertex 44 Funis 10 Breech 108 Placenta prsevia 3 Complicated breech 10 *Born before arrival and presentation not given 32 Footling 34 Transverse 12 No statement 19 Total 676 Some additional information as to still-born infants was given by the midwife, and the following particulars relating to unmacerated infants of 8 or more months' gestation was obtained:— Infant one of twins 13 Cord decomposed 1 Hydrocephalic or malformed head 2 Syphilis 1 Child born before midwife arrived 8 Spina bifida 1 Abnormally large child 2 Injury to head 1 White asphyxia 4 Accident to mother— Deformed infant 3 Ante partum haemorrhage 1 Marginal placenta 1 Uterine inertia 1 Death of mother or child.—Under the rules of the Central Midwives Board midwives are required to give notice to the local supervising authority in all cases where the death of a mother or child occurs before the arrival of a medical practitioner. In 33 cases midwives reported the deaths of children, and in 5 cases notices of deaths of mothers were received. Inquests were held in all these cases, and also in cases where a medical practitioner, though present prior to death, had not been in attendance long enough to form any conclusion as to the nature of the illness. By the courtesy of the London coroners, notices of inquests in which midwives are concerned are sent to me, and one of the Council's inspectors is thus enabled to attend the court and hear the evidence. Much useful information is gleaned in this way, and the Council's inspectors are able to point out to the coroner any neglect on the part of the midwife to comply with the rules of the Central Midwives Board, which might have some bearing on the case under consideration. Reports of 127 inquests were reported during the year. These include, besides cases attended by midwives, some cases where an uncertified woman was in charge of the deceased. Twenty-six of the inquests were on the bodies of women dying during or after labour, and 101 were on the bodies of infants. In 110 cases no blame was attached to the midwife or uncertified person who delivered. The following table shows the cases in which the conduct of the midwife was adversely criticized by the coroner's jury. Confinement conducted by Deaths of mothers. Deaths of infants. Censured. No censure. Censured. No censure. Midwives 5 18 5 77 Uncertified women 1 2 6 13 6 20 11 90 * In some cases the midwife, although not present at the birth, was able to state the presentation, and these are classified accordingly. 101 In the foregoing table, where the conduct of the case by the midwife was criticised by the jury, the reason for the censure was as follows:— Not advising medical assistance early enough 6 Want of cleanliness and antiseptic precautions 4 Lack of ordinary skill (uncertified women) 4 Leaving a patient in a dangerous condition while going to obtain medical help 1 Not taking a patient's temperature 1 Making a declaration that a child suffocated in bed was still-born uncertined woman) 1 17 In every case where a midwife did not comply with the rules of the Central Midwives Board a letter of caution was addressed to her. The medical evidence given at the inquests was that death was due to the following causes .— Mothers. Infants. Septicaemia 11 Weakness from prematurity 15 Peritonitis 2 Atelectasis 22 Perimetritis 1 Congenital heart disease or malformation 10 Exhaustion from ante partum hæmorrhage 3 Suffocation in bed 11 Post partum haemorrhage 6 Suffocation during act of birth 7 Pneumonia and pleurisy 1 Convulsions 5 Fatty degeneration of heart 1 Cerebral haemorrhage 3 Suicide 1 Haemorrhage from cord 3 26 Malnutrition 2 Rupture of bowel 1 Acute inflammation of lungs 1 Bronchitis and broncho pneumonia 9 Jaundice 1 Syphilis 1 Suffocation from vomiting 1 Tubercle in mesenteric glands 1 Still-born 3 101 Puerperal Fever.—During the year 1909, 287 cases of puerperal fever were notified within the county, and the Registrar-General records 180 deaths from "puerperal septic diseases" during the year. In addition to these, 2 deaths occurred in 1910 of cases notified in 1909. The term puerperal septic disease used by the Registrar-General includes puerperal septicaemia, sapræmia and pyæmia, as well as peritonitis and metritis occurring in connection with parturition. A list of these deaths is obtained weekly from the General Register Office, and so it is possible to ascertain whether the notified cases terminate fatally. Women confined outside the county who die in institutions in London are included in the London deaths. Of the 287 notified cases, 132 proved fatal, a case mortality of 46 per cent. Of the 50 remaining deaths recorded by the Registrar-General, 10 were deaths in London institutions of women confined elsewhere, and probably notified as puerperal fever in the district where the confinement took place. The other 40 cases were either cases in which no diagnosis was made till after death or cases which for some other reason were not notified. All cases of puerperal fever occurring in the practice of midwives were investigated by the Council's inspectors, and full details of the illness obtained. Early information of notification of this disease is received from the Metropolitan Asylums Board and the Medical Officers of Health, and I am indebted to the latter for information as to by whom delivery was conducted. It has thusbeen possible to learn whether a medical practitioner was in charge of the case or whether the delivery took place in a hospital or poor law infirmarv or whether it was conducted bv a midwife or uncertified woman. Adding the 50 deaths of cases not notified in London as puerperal fever to the 287 notified cases, we have 337 cases as to which enquiries were made, and the result of the enquiries was as follows:— Delivery conducted by Cases. Deaths. (a) Medical practitioners (including cases attended by medical students and also cases in which, though a medical practitioner was in charge of the case, the birth took place before his arrival) 182 90 (b) Certified midwives (including cases in which the birth took place before their arrival) 83 39 (c) Medical practitioner and midwife (i.e., cases in which a midwife was unable to deliver and called in a medical practitioner) 6 5 (d) Confined in poor law institutions or hospitals 20 11 (e) Uncertified women acting as midwives 10 6 (f) Miscarriages and abortions where no attendant was engaged 26 21 (g) Cases where the patient died in London though confined elsewhere 10 10 Total 337 182 2057 o 102 Causes of death in the 172 fatal cases confined in London:— Cause of death. Notified cases. Unnotified, cases. Puerperal septicaemia and toxcemia 88 13 Puerperal peritonitis 12 12 Puerperal fever (not defined) 15 — Puerperal pycemia 5 3 Parametritis — 1 Sapraemia 1 1 Continued fever after miscarriage 1 — Pelvic cellulitis and cellulitis of leg 2 1 Pelvic abscess — 1 Septic pneumonia 1 — Puerperal metritis 3 — Phlebitis — 1 Phlegmasia alba dolens — 4 Perimetritis — 1 Meningitis and blood poisoning — 1 Puerperal eclampsia and mania 1 1 Collapse after child-birth and fever 1 — Puerperal endometritis 1 — Post partum haemorrhage and fever 1 — Total 132 40 The age incidence of the 337 cases of puerperal fever was as follows:— Total. Age 15-20. 20-25. 25-30. 30-35. 35-40. 40-45. Over 45. Age not known. Recovery cases 155 10 31 52 33 18 4 2 5 Fatal cases.. 182 1 32 54 53 29 10 2 1 In cases where a midwife was concerned, the Council's inspector visited the midwife and learnt particulars of the case and made enquiries with regard to other confinement cases recently attended by the midwife and took the necessary steps to ensure that the rules as to disinfection were carried out before the midwife resumed her practice. In addition to this, the medical practitioner who was called in was also seen by the inspector and his views of the case were ascertained. called in was also seen by the inspector and his views of the case were ascertained. The 83 cases attended by midwives were diagnosed as follows:— Diagnosis. Recovery cases. Fatal cases. Septicaemia 8 24 Sapraemia 24 2 Pycemia — 2 Peritonitis 2 6 Perimetritis — 1 Septic pneumonia — 1 Puerperal mania 2 1 Phlebitis — 1 Cellulitis of the leg — 1 No information obtained 8 — Total 44 39 The rule which requires that medical help shall be sought when a patient's temperature rises to 100.4° and remains above that figure for 24 hours, has proved useful in affording information concerning cases in which there is danger of the development of puerperal fever; 173 notices were received stating that medical assistance had been advised for this reason. The midwife was visited, and in 105 of these cases the inspectors learnt that the temperature had fallen and no further symptoms of puerperal fever presented themselves. In 64 cases the rise of temperature proved to be the first indication of septic trouble, and the inspector was thus able in some instances without awaiting notification to take steps to prevent the midwife from attending other women in childbirth until she had been thoroughly disinfected. The rise of temperature occurred most frequently on the third and fourth days of lying-in; 36 cases had a rise of temperature on one of 103 these days, and 15 subsequently proved fatal. The following table shows the day of the puerperium on which (a) a rise of temperature was noted, (b) medical help was obtained, (c) the case was notified as puerperal fever, and (d) the death took place in fatal cases 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. (a) Rise of temperature Recovery cases 1 1 9 12 4 6 1 1 1 — 36 Fatal cases 2 2 9 6 1 3 2 — 2 1 — 28 (b) Medical assistance obtained— Recovery cases 1 1 6 10 7 5 1 3 2 — 8 44 Fatal cases 4 2 6 6 2 4 3 — 3 2 7 39 (c) Notified as puerperal fever— Recovery cases — — 1 3 6 5 4 6 2 2 15 44 Fatal cases — 1 1 2 — 3 1 4 4 — 17 33f (d) When death took place in fatal cases 1 4 4 3 4 23 39 Of the 23 deaths occurring after the tenth day, 14 patients died within 20 days, 6 died within a month, 2 died two months, and 1 six months after confinement. In 3 cases in the above table medical assistance was advised by the midwife on account of abdominal pain, and in one case on account of post partum haemorrhage. All these four cases had no high temperature during the midwife's attendance. In 15 other cases medical assistance was called in by the patient's friends after the tenth day, and the date of rise of temperature, if such rise occurred, has not been learnt. These 15 cases are said to have first shown symptoms which led to the calling of a medical practitioner on the following days:—11 th day, 1 recovery; 12th day, 4 recovery, 2 fatal; 13th day, 1 recovery, 2 fatal; 16th day, 1 fatal; 17th day, 2 fatal; 19th day, 1 recovery; 32nd day, 1 fatal. The parity of women suffering from puerperal fever was ascertained from the midwives to be as follows:— Total. Primipara. 2 para. 3 para. 4 para. 5 para. 6 para. 7 para. 8 para. 9 • para. 10 para. Over 10. Multipara, no definite statement. No statement. Recovery 44 9 5 5 5 2 2 3 3 0 0 2 5 3 Fatal ,. 39 12 5 3 5 2 0 2 0 1 1 4 3 1 The following conditions were noted among the cases of puerperal fever attended by midwives:— Laceration of the perineum in 7 cases. Adherent placenta in 5 cases. Retained placenta in 3 cases. Ante partum haemorrhage in 1 case. Post partum haemorrhage in 3 cases. Uterine inertia and delay in birth in 3 cases. Decomposed faetus in 1 case. In 9 cases the birth took place before the midwife arrived and consequently she could not adopt proper measures to cleanse her patient before labour. One midwife had 5 cases of puerperal fever in her practice during the year. This midwife had a large practice. Her first case of puerperal fever occurred on August 1st. She ceased attending patients and was disinfected. She subsequently resumed her practice, and attended consecutively 65 patients, who did well. A second case of puerperal fever then occurred in her practice. This patient was confined on the 29th October, two months after the occurrence of the first case, and her illness was notified on the 3rd November. The midwife again ceased practice and was disinfected. Later she resumed her practice, and delivered some 18 women, all doing well, until November 20th, when one of those who had been confined on the 15th November had a rise of temperature on the 20th November, and on the 27th November was recognised to be suffering from septic pneumonia. On the occurrence of this symptom in this patient on the 20th November, the midwife, as a precautionary measure, again ceased practice and was disinfected, but subsequently resumed her practice, using entirely different appliances and attending numerous patients, two of whom, confined on the 27th and 28th November, apparently before the nature of the case notified on the 27th November was known to her, later developed puerperal fever. † Six cases were not notified. 2057 0 2 104 One midwife had three cases in her practice. The first case occurred in June, and the midwife was disinfected and resumed her work, delivering several women who had no symptoms of puerperal fever; the second patient was confined on 15th October, and was up on the 24th October, when the midwife ceased attending. This patient was subsequently taken ill, and died on 31st October; in the meantime, i.e., on 30th October, the midwife had delivered the third case before the second was notified. Eleven midwives had two cases each in their practice during the year. The interval between the cases in seven of these groups of two was 3 months, or more, and the midwife had been disinfected after the occurrence of the first case, and had attended several other cases in the meantime, all of which did well. In three of the groups the second case was delivered before any symptoms of puerperal fever had appeared in the first case, and hence there had been no opportunity of disinfection between the occurrence of puerperal fever in the first case and the confinement of the second. In the remaining group a brief interval separated the occurrence of the first and second cases of puerperal fever, but during this time the midwife had been disinfected. The first case proved fatal, but the second case was described as "mild sapraemia," and recovered. Two uncertified women each had two cases in their practice, the intervals between the cases being four and ten months respectively. Of cases attended by midwives in which death occurred, the patient was delivered in four cases by medical practitioners by the aid of forceps. In one case of transverse presentation, turning was effected by a medical practitioner; in three cases the foetus was dead, being described as still-born, macerated, or a miscarriage; in five there was laceration of the vagina or perineum; in three there was adherence of or retention of membrane or placenta; in one post partum haemorrhage; in one ante partum haemorrhage, drugs having been taken to produce abortion; in one " blood poisoning " four months before confinement; in one phlebitis after being delivered of triplets; one was a case of puerperal mania removed to an asylum; in one instance death occurred under chloroform. In two or three cases the exceptionally dirtv condition of the patient and the home are commented upon by the inspectors, and in one case the patient's clothes had to be taken out of pawn the day after the confinement. Ophthalmia.—It is the duty of midwives to advise that medical assistance should be sought in all cases of inflammation of the eyes, however slight, occurring in new-born infants. Notice of advising medical help is sent to the local supervising authority. In this way cases of inflammation of the eyes occurring in the practice of midwives are brought to notice. The attention of midwives has been specially directed to the importance of strictly observing this rule. During the year 162 notices were received from midwives stating that medical help had been advised on account of inflammation of the child's eyes. Three cases were reported by the borough health visitors, where it was found that the midwife had failed to realise the seriousness of the case, and no medical assistance had been obtained. In several cases there was delay in advising medical help, and the midwives were duly cautioned. In five instances where medical help was advised, it was not obtained. These were all slight cases, and all of them recovered. All the cases were investigated by the Council's inspectors, the midwife was interviewed to learn what antiseptic precautions had been taken, and the infant was visited to see that it was receiving medical treatment. The progress of the disease was followed and the final result ascertained where possible. In one case an infant died. 136 infants were eventually reported to be completely cured, but in 12 cases some impairment of vision resulted. In 16 cases the parents removed, and it was not possible to trace them and ascertain the result of the illness. The duration of the disease in the 136 cases in which there was a complete cure was as follows:— Disease lasting less than 10 days 47 cases. Disease lasting between 10 and 30 days 46 cases. Disease lasting over 30 days 43 cases. Many of these cases were, however, extremely slight. Assuming 30,000 confinements to be attended annually by midwives not working in hospitals or poor law institutions under medical supervision, the above figures show that inflammation of the eyes occurred in 5.3 per 1,000 births. The day inflammation of the eyes was first noticed was as follows:—Day of confinement, 9; 2nd day, 26; 3rd day, 17; 4th day, 23; 5th day, 23; 6th day, 20; 7th day, 15; 8th day, 13; 9th day, 14; 10th day, 3; after 10th day, 2; total, 165. A history of a discharge in the mother was obtained in 64 cases, i.e., in nearly 40 per cent. Midwives acting for some of the lying-in hospitals were taught in 1909 to use a solution of perchloride of mercury (1 in 4,000) for the eyes of infants whose births they attended, the eyes being washed with boracic acid lotion or sterile water immediately after the use of the perchloride; a few midwives used a much weaker solution of perchloride of mercury and those of a particular institution used a one per cent. solution of nitrate of silver followed by washing with boracic acid lotion. Other midwives used boracic acid lotion only, and a few, sterile water. In one case there was no opacity of the cornea and apparently no more serious result than a slight squint. The following details were obtained of 11 cases in which there was serious impairment of vision:— (1) No history of discharge in mother. Stickiness noticed on 4th day and pus on 10th day, when medical help was obtained. Result—Opacity covering lower half of each cornea. 105 (2) Profuse vaginal discharge in mother (child born before midwife's arrival). Symptoms on 3rd day, and medical help obtained at once. Result—Opacity covering greater part of right cornea. (3) No history of discharge in mother. Symptoms 3rd or 4th day; medical help obtained on 6th. Result—Opacity over lower part of right pupil, very small opacity over left pupil. (4) Slight leucorrhoea during pregnancy. Symptoms noticed on 4th day, medical help obtained on 10th day. Result—Opacity nearly covering right cornea. (5) Leucorrhoea during pregnancy. Symptoms noticed by midwife on 10th day and medical help obtained on 11th. Result—Leucoma over left cornea covering whole of pupil. (6) Leucorrhoea during pregnancy. Symptoms on 3rd day, medical help obtained same day. Result—Lens lost in right cornea. Opacity covering lower half of left cornea. (7) No discharge during pregnancy. (Edema at birth, pus on 6th day, when medical help was called. Result—Lens of right eye extruded. Opacity covering cornea of left eye, except a place the size of a pin point over left pupil. (8) Leucorrhoea during pregnancy (child born before arrival of midwife). Symptoms 2nd day, medical aid obtained 2nd day. Result—Leucoma covering right cornea entirely; opacity covering lower half of left cornea. (9) No history of discharge during pregnancy. Onset on 5th day, and medical help obtained same day. Result—Leucoma covering right cornea. Opacity covering left cornea. (10) Vaginal discharge during pregnancy. Symptoms first seen on 2nd day, and medical help obtained at once. Result—Thick opacity covering almost the whole of left pupil. (11) Vaginal discharge during pregnancy (child born before midwife arrived), symptoms noticed on 8th day, medical help advised on 9th, but not obtained until 11th, and then seen only once. Taken to hospital 15th day. Result—Dense leucoma covering the cornea of the right eye. The result of these eleven cases may be summarised as follows:— Blind in both eyes 2 cases. Blind in one eye, the other eye damaged 1 case. Blind in one eye, the other eye recovered 4 cases. Impaired vision in both eyes 2 cases. Impaired vision in one eye 2 cases. In 8 of these cases a weak solution of perchloride of mercury and in 3 boracic lotion was used for cleansing the eyes at birth. In 8 of these 11 cases it will be noticed that there was a history of vaginal discharge during pregnancy, and in nine of them the onset was on or before the fifth day of life. The 165 cases were in the practice of 68 midwives:— 1 midwife and her 2 assistants had 20 cases during the year 20 1 midwife and her assistant had 15 „ ,, 15 1 midwife had 10 „ „ 10 1 8 „ „8 1 „ ,, 7 „ 7 1 „ 6 „ „ 6 1 „ ' „ 5 „ „ 5 5 midwives had 4 cases each during the year 20 4 „ „ 3 „ ,r 12 10 „ „ 2 „ „ 20 42 „ „ 1 case each during the year 42 165 Investigation was made into the 20 cases which were attended by one midwife and her two assistants, and no reason was found for thinking that infection had been carried by the midwife or assistants. Nineteen of these cases occurred during the four months January to April, and in 10 of them there was a definite history of leucorrhoea in the mother during pregnancy, and in 2 other cases it was found that other members of the family had inflammation of the eyes at the time of the birth of the infant. The remaining 7 cases were of a slight character. A complete cure was eventually recorded in all the 20 cases. This midwife and her assistants attended some 170 cases of midwifery during these four months. Subsequent to the occurrence of these cases, the midwife at all births she attended for a period of one month used a 2 per cent. solution of silver nitrate, one drop of which was instilled into each eye as soon after birth as possible, and during that time no case of inflammation of the eyes occurred in her practice. In the remaining months of the year one other case was reported. With regard to the midwife and her assistant who reported the occurrence of 15 cases, enquiry proved that these were for the most part of a very slight character. The midwives with 10, 8 and 7 cases respectively had one case each in which there was serious impairment of vision. On the assumption that 30,000 of the London births were attended by midwives, the number of cases in which serious impairment of vision occurred was .37 per 1,000 births. In my report for 1908 reference is made to a circular which it was proposed to issue to 106 midwives as to the treatment at birth of the eyes of infants. The issue of this circular was not proceeded with, the Central Midwives Board having communicated to the Council for distribution among midwives the following memorandum:— INFLAMMATION OF THE EYES IN NEW-BORN CHILDREN. Ophthalmia Neonatorum. This is a very common cause of hopeless blindness, which is one of the greatest misfortunes that can happen to a child. A very largo number of children will be saved from blindness if the following directions of the Central Midwives Board are observed. The disease generally arises from purulent discharges from tho mother getting into the baby's eyes at birth. It is therefore of the greatest importance that this should be prevented:— 1. By curing such discharges if possible before labour. This requires medical treatment (Rule E. 19 (2) and (3) ). 2. By taking the greatest care that such discharges shall not be carried into the baby's eyes when it opens them for the first timo soon after its head is born. The discharges may be carried into the baby's eyes in the following ways:— (а) The discharges collect round its eyes, especially the eyelashes, and easily get into its eyes. This can be generally prevented if the midwifo observes Rule E. 14: "As soon as the child's head is born, and if possible before the eyes are opened, its eyelids must be carefully cleansed." They should be thoroughly wiped with clean material such as cotton-wool, lint, or rag, using separate pieces for each eye. The reason for this is that the piece used for wiping the first eye will be polluted by the discharges, and should not be used for the other eye. (b) New-born babies sometimes rub their eyes with their hands. This may rub the discharges into their eyes. When Rule E. 14 has been complied with the baby's hands must be carefully cleansed. (c) When the baby is bathed the discharges with which its body is covered during labour are washed off into the bath-Water. If its face is washed in this water, matter may get into the eyes. N.B.—The above directions are to be observed in all cases, whether purulent discharges are known to be present or not. The Central Midwives Board is determined, so far as lies in its power, to secure the strict observance of its rules and directions, and to punish any failure to comply with them, even in cases where no harm can be proved to have followed from their neglect. F. H. Champneys, M.D., F.R.C.P., December, 1909. Chairman of the Central Midwives Board. This leaflet was drawn up and issued at the request of the Board. Classes for midwives.—The Council has instituted classes for the instruction of midwives, eight of which are held in different parts of London during the year. Thus eight courses of lectures are given during the year. These classes have been utilised by midwives who have been in practice for many years, and also to some extent by pupils preparing for the Central Midwives Board to supplement the training received at the institution where they are undergoing training. It has been the practice of the Council's inspectors to recommend these classes to midwives who have shown want of knowledge in their work. Departmental Committee.—A Departmental Committee was appointed by the Privy Council in December, 1908, to consider the working of the Midwives Act, 1902, and in particular with reference to the supply of midwives and the cost of training, the remuneration of medical men summoned on the advice of midwives under the rules in pursuance of the Act, and the delegation of their powers by county councils under the Act, and I was instructed to represent to the Committee the views of the Council with respect to the need for a better system by which midwives could promptly obtain medical assistance in cases of difficulty, and with respect to other matters. I also gave evidence as to the need for the exercise of some control over lying-in homes carried on for gain. The findings of the Departmental Committee were embodied in a Bill, which was introduced into the House of Lords in 1910. Memorandum on Closure of and Exclusion from School. During 1909 a memorandum by Dr. Newsholme and Dr. Newman, medical officers respectively of the Local Government Board and Board of Education, was issued on administrative measures for the prevention of the spread of infectious diseases occurring among children attending public elementary schools, with special reference to the circumstances in which the closure of schools or the exclusion of individual scholars may be necessary. The object of the memorandum in the first instance is to co-ordinate the action of the medical officer of health and of the school medical officer so as to provide for the legalisation of the voluntary exclusion of particular scholars, or voluntary closure of schools or school departments, so as to avoid the loss of grant in the case of closure. The memorandum advises for this purpose that the medical officer of health should embody his recommendations in certificates which are transmitted to the school medical officer with a view to the formal authorisation required by article 53, in cases of exclusion, and to the approval required by article 45, in cases of closure. The memorandum also points out the need for the Education Authority to make regulations requiring school teachers, school nurses and attendance officers, to supply information to the medical officer of health, and to the school medical officer, regarding any children suspected to be suffering from infectious disease, and to exclude such children temporarily. The memorandum discusses various points of practice of which it may be said generally that they are based on principles commonly accepted and in the main adopted in London. Under the heading "Principles of Action" the memorandum discusses the need for knowledge by the teachers of the early and late symptoms of infectious diseases with a view to the exclusion from the school of children presenting those symptoms until a mcdical opinion can be obtained, and the need 107 for making prevalence of such diseases known to teachers and parents. The necessity of looking for missed cases is insisted upon. In this connection advice is given that the services of teachers and attendance officers should be utilised for giving information, both to the medical officer of health and to the school medical officer, not only of the existence of known cases of such disease, but also of any children who have recently been kept at home with illness of a suspicious character or concerning whom circumstances suggest the possibility of infection; and it is pointed out that" the absence of several children of one family from school at the same time, no matter what name is given to the complaint that keeps them at home, should be reported. In practice it has been found that such information of absentees has materially aided the medical officer of health in taking measures for the suppression of infectious disease." The ability of medical officers of health to utilise information concerning children who have recently been kept at home with illness of a suspicious character or concerning whom circumstances suggest the possibility of infection, should be distinctly greater in the future, inasmuch as the Council's General Powers Act of 1908 empowers sanitary authorities to appoint health visitors whose services might be utilised in making preliminary enquiries. No doubt so far as practicable early inquiry should be made into all cases of absence from school in which the cause of the absence is unknown, and any improvement which could be effected in this direction would tend to lessen the attendance at school of infectious children. On the subject of school closure the memorandum states that closure " should be advised by the medical officer only in circumstances involving risk of an epidemic, and not then as a matter of routine nor unless there be a clear prospect of preventing the spread of infection such as cannot be expected from less comprehensive action," the reason being that it will deprive the medical officer of health and school medical officer of information respecting attacks in their early stage or illness of doubtful nature which would otherwise be obtainable, and in any circumstances will interfere seriously with the education of the scholars. This sentence is no doubt intended to be read with a later sentence that " Closure of a school or of a particular class is justified when the general evidence points to this school or class as the source of infection and when cases of an infectious disease continue to occur in this class or school after every effort to discover the infective cases has been made." This question deserves comment for the reason that diphtheria has frequently persisted in a class or school during long periods, although it could not be alleged that the number of cases of the disease occurring at any one time could be deemed to constitute a circumstance " involving imminent risk of an epidemic." In some cases the closing of the class or school or the intervention of holidays has eventually terminated this incidence of the disease and has, indeed, appeared to be necessary for this purpose. Under these circumstances it may be that the interests of education would be served by an earlier closure than that which eventually has to be adopted. In determining whether closure of a class or school is necessary on account of prevalence of infectious disease the medical officer of health will no doubt make every effort to arrive at a correct conclusion as to whether the disease is spreading in the school, or is due to infection outside the school. In this matter he will doubtless be guided by his knowledge as to whether in the several invasions of families under his observation the first person to be attacked is the school-attending child. If he finds it possible to limit closure to a particular class or classes he will often be acting wisely if he excludes from other classes in the school the brothers and sisters of children who are members of the class which is closed. It is of course necessary that he should as far as practicable compensate for loss of information as to attacks in the early stages, which he would have derived from the school, by information, obtained by means of enquiring in the homes; but it may be pointed out that closure of a school must prevent attacks due to infection at school and that fresh invasions of families from this cause must cease. With respect to diphtheria the memorandum recommends the use of bacteriological methods for the discovery of infectious cases. These methods have been increasingly utilized in recent years, but it must be recollected that much more needs to be known concerning the extent to which they can be relied upon not only in indicating all infectious cases, but in distinguishing between such children and others who are not infectious. Beyond this it must not be forgotten that much may depend upon the completeness with which this method is applied, and that the mere sampling of children in a class by this means cannot be expected to give sufficiently satisfactory results. The memorandum suggests that in the light of further knowledge which will be gained, some modification of the rules for exclusion and closure may be indicated, and this observation especially needs to be borne in mind in connection with efforts made to deal with disease on bacteriological findings. It is further necessary to remember that infectious diseases vary very greatly at different times in respect of virulence, and probably also in respect of infectiousness. At the present time both scarlet fever and diphtheria have a very low fatality, and it will not do to assume that measures which may suffice for the moment will be found equally efficacious at other times. Among the risks to which school children are now exposed must be included that of infection by smallpox. Owing to the increased number of children who now remain unvaccinated, the amount of risk from smallpox to which children may be exposed in school if the disease again becomes prevalent, cannot be regarded as negligible. Under these circumstances it is well to remember that smallpox is a highly infectious disease, that the period between infection and appearance of the eruption may not infrequently be 16 or 17 days, and that the condition of the children as to vaccination needs to be taken into account in determining the question of closure of the class or of the exclusion of particular children. To the London County Council. November, 1910. Shirley F. Murphy, Medical Officer of Health. 108 Medical Officers of Health of London Sanitary Arras, in 1909. Sanitary area. Medical officer of health. City of London W. Collingridge, M.D. Battersea G. Q. Lennane, F.R.C.S.I. 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. Deptford H. W. Roberts, M.R.C.S. Finsbury A. E. Thomas, M.D. Fulham J. C. Jackson, M.R.C.S. 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 J. E. Sandilands, 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 C. Porter, M.D. St. Pancras J. F. J. Sykes, M.D. Shoreditch L. T. F. Bryett, M.D. South wark G. B. Millson, L.R.C.P. Stepney D. L. Thomas, M.R.C.S. Stoke Newington H. R. Kenwood, M.B Wandsworth P. C. Smith, M.D. Westminster, City of F. J. Allan, M.D. Woolwich S. Davies, M.D. APPENDIX I. London County Council SCARLET FEVER. Report by the Medical Officer of Health submitting a report by Dr. W. H. Hamer and Dr. T. Henry Jones on an outbreak of scarlet fever in London and Surrey, and a bacteriological report by Dr. Mervyn Gordon. In June last upwards of 400 persons living in districts in London and Surrey, and who consumed milk obtained from a particular milk company, were attacked by scarlet fever. From the outset there was strong reason for believing that a milk supply derived from a particular company was the source of infection, and in view of the fact that the occurrences of scarlet fever apparently due to this cause were widely distributed over the counties of London and Surrey, it was necessary that the health administration of both counties should be concerned in the inquiry. Hence inquiry into the circumstances of the outbreak was jointly undertaken by Dr. W. H. Hamer and Dr. T. Henry Jones, who was acting in place of Dr. Seaton, County Medical Officer of Surrey. These officers were assisted by the several medical officers of health of the affected districts as well as of the county and districts in which the company's depot and some of the farms supplying the depot were situated. They also had the advantage of assistance from Mr. Dunbar, veterinary inspector in the Public Health Department of the London County Council, and the services of Dr. Mervyn Gordon, assistant pathologist of St. Bartholomew's Hospital were retained by the London County Council. In their inquiries Drs. Hamer and Jones also had the active co-operation of the manager, the secretary and medical adviser of the company, who rendered all possible assistance in the work of investigation. From a perusal of the joint report, which I present, it will be seen that no reasonable doubt can be entertained^that the milk of a particular farm was responsible for the occurrences of scarlet fever in the districts of the two counties, and interest centres in the question how the milk of this farm acquired the ability to infect those who consumed it with this disease. In the past, two hypotheses of milk infection have been discussed, the one that the milk acquired its infective property from a human source, that it was in fact infected by the milker or by some other person suffering from scarlet fever ; the other, that the milk was infected by some condition of a cow or cows. It has on former occasions been observed that inquiry has failed to demonstrate that human agency had been responsible for the infective condition of the milk ; such inquiry has often shown that even when one or more of the persons engaged on the farm have suffered from scarlet fever the dates of their infection have been subsequent to the dates of infection of other persons living at a distance and who undoubtedly owed their attacks to consumption of the milk in question; in fact, that the persons engaged upon the farm had suffered as other persons from consumption of the milk. So in the outbreak investigated by Drs. Hamer and Jones it was found that scarlet fever did occur in the family of a milker, but that the evidence in connection with this occurrence could not be regarded as affording explanation of the infection of the milk by human agency, while it distinctly suggests that the milk was infective before leaving the farm. Careful inquiry, indeed, in the neighbourhood of the farm failed to yield any evidence of the existence of a human source of infection of the milk. The question of infection of the milk being of bovine origin needs to be considered. Under similar circumstances Sir William Power, in 1882, when investigating an outbreak of scarlet fever in certain London districts, made the suggestion that inasmuch as " there is one sort of relation between scarlatina and accidents of the puerperal state, another sort of relation becomes comparatively easy of belief," in fact, that " if scarlatina in man have other animal source than human source, it may be that one such source is the cow that has recently calved, a cow either not at all ill (except for her parturition) or not so obviously ill as to prevent her milk being used for human consumption." The suggestion thus tentatively made, in 1882, at once assumed large importance upon the demonstration by Sir William Power, in 1885, of the bovine origin of scarlet fever occurring in persons consuming milk from a Hendon farm the cows at which were affected with an eruption of the teats and udder. A similar development of scarlet fever in man, associated with the consumption of the milk of similarly affected newly-calved cows, or cows infected from such newly-calved cows, has been observed in a number of instances since that date. In London in 1892 and again in 1894 and in 1902, considerable prevalences of scarlet fever due to infected milk were strongly suspected to have been originally of bovine origin. In the present instance a like possibility was necessarily entertained, and it has been found possible by study of the farm operations, in minute detail, to show that just at the time when the milk first began to show infectious property, there was added to it the milk of three recently-calved cows, the calf of one of which had died after being suckled by the cow for four or five days. These circumstances, together with the fact that the three cows mentioned, and other cows at the farm, showed at the time of the inquiry appearances upon their teats and udders suggestive of Hendon disease, renders it probable that a morbid condition of the cow was responsible for the subsequent human illness. Dr. Mervyn Gordon has investigated the outbreak from the bacteriological side, and his report is appended. He isolated from all six specimens examined by him a particular streptococcus which he regards as being either the streptococcus anginosus (Andrewes and Horder) or the streptococcus mastitidis (Savage). Dr. Gordon draws attention in his report to a recent observation made by 21479 S.S./11144 2 Dr. Schleissner, of Vienna, with regard to the application of a " Fixation of Complement " test in scarlet fever, and Dr. Gordon suggests that in future this test may be found of value in the elucidation of outbreaks of scarlet fever of bovine origin by applying it to the serum of cows under suspicion. Dr. Schleissner's observation has, moreover, a further interest. It again brings to the fore the question of the precise nature of the relationship of the streptococcus to scarlet fever, although as yet there can be no definite pronouncement on this subject. Dr. Schleissner himself fully appreciates this, as he concludes his paper by remarking, " However much we may be tempted ... to regard the streptococcus as the causal organism of scarlet fever, we must, on looking critically into the question, admit that this new extension of our knowledge affords no certain proof of such hypothesis. The question remains an open one : all we can with certainty claim is that the streptococcus stands in the closest biological association with the disease." From the administrative side it deserves to be noted how, with the cordial assistance of the manager and secretary of the company, whose action deserves recognition, it was possible for early localisation of the source of the mischief to be effected, a possibility which was due to the system of record of distribution of milk which was maintained by this company and to the manager's intimate acquaintance with all the details of the business. Such system of record has been proved in this outbreak to be of value alike to the public and the company. Shirley F. Murphy, Medical Officer of Health. lstf October, 1909. 3 Joint Report by Dr. W. H. Hamer and Dr. T. Henry Jones upon an Epidemic of Scarlet Fever in London and Surrey due to an Infected Milk Supply, in June, 1909. Preliminary history of the outbreak in the affected districts. On the evening of June 15th Dr. Williamson, Medical Officer of Health of the Epsom Rural District, wrote to the Acting County Medical Officer of Health of Surrey informing him that 16 cases of scarlet fever had been notified or discovered in Worcester Park on June 14th and 15th, distributed in 13 houses, all of which oblained their milk supply from one purveyor. Suspecting that the infection was introduced by milk obtained from a wholesale company in another county, Dr. Williamson called at the office of the Local Government Board on June 16th in order to give early information of an outbreak which he thought likely to affect many districts. On June 16th Dr. Beale Collins, Medical Officer of Health of Kingston-upon-Thames, became suspicious that a few cases of scarlet fever notified in his district on June 14th, 15th, and 16th were due to the same wholesale milk supply and wrote to the Medical Officer of Health of the county from which this supply was drawn. On the same day Dr. Davison, Medical Officer of Health of The Maidens and Coombe, whose district was also affected, communicated by telephone his suspicions to the manager of the dairy company concerned, and received from him the assurance that all milk sent into the district should be pasteurised. On June 17th, at 8 p.m., Dr. Allan, Medical Officer of Health of the City of Westminster, informed Sir Shirley Murphy, Medical Officer of Health of the County of London, that he had heard of several cases of scarlet fever in Westminster occurring among persons obtaining their milk supply from a particular retail vendor, and that he was investigating the matter. On the morning of June 18th Sir Shirley Murphy made inquiries as to whether any local prevalences were manifesting themselves in London, and as to their possible relation to milk supply ; moreover, the Acting County Medical Officer of Health of Surrey (Dr. Jones) met Dr. Williamson (Epsom R.D.) and Dr. Davison (Maidens and Coombe) by appointment, in order to discuss with them the precautions to be taken in the affected dictricts. Upon visiting other districts on the same day Dr. Jones found that local outbreaks had occurred elsewhere in Surrey which appeared to be due to the same cause. On the same day (June 18th) the vendor in Westminster mentioned above discontinued receiving milk from the suspected source ; Dr. Allan (Westminster) had visited the local London depot from which the supply was distributed, and had communicated by letter with the secretary of the dairy company in the country; Dr. Beale Collins had also telegraphed to the manager of the company requesting him to stop his supply of milk to Kingston ; and Dr. Priestley, Medical Officer of Health of Lambeth, was advised of the occurrence of the outbreak, the local depot from which the Westminster supply came being in Lambeth. On the morning of Saturday, June 19th, Dr. Allan reported an increase in the number of cases in Westminster; Dr. Parkes, Medical Officer of Health of Chelsea, wrote saying that a few cases had occurred among customers of a Chelsea retailer who obtained milk from the same wholesale company ; and Dr. Caldwell Smith, Medical Officer of Health of Wandsworth, telephoned that in his district several cases of scarlet fever had been reported on the round of a retailer who was supplied by the same company. Thereupon Sir Shirley Murphy, after conference with Dr. Allan, decided to advise the manager of the company concerned that the sending of milk to London from the country depot which had furnished the supplies to Chelsea, Westminster and Wandsworth should be suspended. An appointment was made by telephone with a local manager of the company at a London railway station, and Dr. Hamer, Medical Officer (General Purposes), and Mr. Dunbar, Veterinary Inspector, London County Council, proceeded to this station. The local manager placed them in telephonic communication with the head manager in the country, who, upon the circumstances being explained to him, at once agreed to stop the entire supply from the implicated depot, and, save for a few churns of the afternoon's supply which had already left the branch depot, this was done. It was further arranged that Dr. Hamer and the manager should meet on the same afternoon at the company's main offices in the country. On the morning of the same day (Saturday, June 19th) Dr. Jones (Surrey County) visited and conferred with Dr. Pocklington, Medical Officer of Health of Wimbledon, Dr. Belilios, Medical Officer of Health of Merton, and Dr. Beale Collins, Medical Officer of Health of Kingston, in whose districts sudden outbreaks of scarlet fever appeared to be due to the same wholesale milk supply. Dr. Jones also telephoned to Sir Shirley Murphy (County of London) and Dr. Allan (Westminster). [It may be mentioned here, though the information was not forthcoming until later, that an outbreak of scarlet fever due to the same infected supply of milk was in course of development in the county borough of Croydon. Dr. Meredith Richards, the Medical Officer of Health of Croydon, has supplied particulars and made a number of suggestions for which the writers of this report are much indebted to him. He also visited the farm in the country at a later date.] All the information obtainable, both in London and in Surrey, now pieced together, confirmed the suspicion that the same milk supply was the infecting agent in the two counties. It had already been arranged that Dr. Jones (Surrey County) and Dr. Beale Collins (Kingston) should meet the manager of the suspected dairy company at Kingston in the afternoon (Saturday). Sir Shirley Murphy now arranged by telephone that Dr. Hamer should attend this conference with a view to meeting the manager at Kingston and to seeing Drs. Jones and Beale Collins there. Dr. Allan also proceeded to Kingston, but was obliged to leave before Dr. Hamer's arrival. The secretary of the dairy company came to Kingston, instead of the manager, and, the information obtained from him all went to show that the milk sent into the affected districts in London and in Surrey from one particular depot of the company was at fault, that depot receiving milk from some 31 farms and being one of 10 or 12 similar depots owned 21479 » 4 by the company in two counties. It was therefore definitely arranged that no milk from this suspected depot should be sent either into London or into Surrey, and accordingly none was supplied from the depot [after that day. The secretary of the dairy company stated that the Medical Officer of Health of a district in which some of the farms supplying the suspected depot were situated had already been commissioned by the company to examine and report on all the 31 farms, the company's attention having been directed as early as June 16th to the fact that milk from this depot was credited with having caused scarlet fever in Surrey. It was suggested that as farm after farm was given a " clean bill," by this medical officer of health, the supply might be brought into use again. To this, however, the obvious objection was raised that until the implicated farm should be discovered the entire supply of the depot must be regarded as suspect. Finally, it was arranged that Dr. Hamer and Dr. Jones should proceed to the head office of the dairy company in the country on the following day (Sunday) to examine the records of distribution, and afterwards, if necessary, to proceed to the inspection of the 31 suspected farms. Summary of investigations as to source of infection. On Sunday, June 20th, we accordingly went to the headquarters of the company in the country and were met by the manager and secretary, who had arranged for all records to be in readiness at the implicated depot eighteen miles away. We travelled therefore to this depot, where we were met by the medical officer of health of the district and by the medical officer of health of an adjoining district—previously referred to as having been commissioned by the dairy company to inspect the farms supplying the depot. The latter gentleman had already visited twelve of the farms and had heard of no cases of scarlet fever at any of them, but reported that at the cottage of a man employed on one of the farms—X—there were said to be some cases of German measles, and at two other farms —Y and Z—some cases of measles ; he had had no opportunity of examining the cases at X and Y. Upon investigating the records at the depot we found it possible to trace with a fair degree of accuracy the distribution of milk from individual farms to individual retailers in the affected districts in London and in Surrey. We therefore proceeded in the first instance to make a careful analysis of these daily supplies. At that time we had knowledge of nine or ten London and Surrey retailers whose customers had been attacked by scarlet fever. We arranged the names of these retailers at the heads of a series of columns (see Chart I.), and entered for the morning and afternoon of each day from June 6th to June 19th (when all milk from the depot was stopped) the names of the farmers supplying these vendors, so far as they could be ascertained. A preliminary analysis of these entries then caused some suspicion to fall in the first instance upon the milk supplied from farms X, Y and Z, and not upon any other supply. It was clear, however, that, if the records could be trusted, farm Z could even at this stage be for practical purposes excluded, for this farm had not supplied at least three of the implicated vendors at the time when the milk sold by them began to carry infection. From farm Y, milk had been sent to most of thejimplicated vendors, at one time or another, but never to one particular vendor whose customers had suffered conspicuously. From farm X it was recorded that milk had gone to all the implicated vendors at the time when their supplies became infective. It so happened that farms X, Y and Z were near each other. In view of these facts we decided to go at once to farm X, and the medical officer of health of the district in which the depot was situated kindly drove us thither in his motor car. Upon enquiring at the farm we were directed to the cottage of the farm carter, in whose family cases of German measles were said to have occurred. At this cottage, about half a mile from the farm, we found the carter, G. L., his wife, and three children—R. L. (aged 8), I. L. (aged 5) and A. L. (aged 2). The man, in the course of his daily work, habitually took the milk from the farm (X) to the depot; he also lent a hand in milking the cows whenever his help was wanted. He and his family had an allowance of one pint of milk daily from the farm, and this milk was, we were told, the only milk derived from the farm which was consumed locally. The milk was generally taken with tea, but occasionally drunk raw by the children. The history of illness in the family was as follows :— June 11th.—I. L. (5) sickened and was found to have a sore throat; later she developed a rash. June 13th.—A. L. (2) developed a sore throat. June 14th.—G. L. (the father) had a headache and was out of sorts. June 15th.—G. L., his wife, and R. L. (8) developed sore throats. G. L. stopped work on this date; he had milked two cows on the preceding evening. We were told that the family never left the village and had had no visitors since Christmas. R.L. and I.L., who generally slept together, attended school in a neighbouring village. On examination, I.L. was found still to have a sore throat, also some roughness of skin on the soles of both feet. A.L. was very poorly and had a sore throat but no peeling. R.L. was acutely ill; her throat was much congested, with exudation on both tonsils, the glands of her neck were swollen, and she had a typical scarlatinal rash (dusk}', punctate, erythematous) on her chest, back and limbs, but not on her face. None of the children had had coryza or lachrvmation. G.L. was still feeble ; he had had a sore throat and his tonsils were enlarged. His wife had had a sore throat, but it was almost normal again ; she looked and said she felt poorly. The farm (X) at which G.L. was employed consisted of two farmsteads—X1 and X2—with two separate herds of cows and cowhouses ; G.L. was carter for both and acted as auxiliary milker at both when necessary. He generally went first to get the milk from X2, milked two cows there morning and evening, helped to lift the churns into the cart, and then proceeded to X1, where he also occasionally milked a cow before helping to lift the churns into the cart, after which he took all the churns to the depot. He had nothing to do at either X1 or X2 with measuring the milk or filling the churns. 5 "We then visited farmstead X1, where lived the farmer, his wife and her sister, and the foreman milker, all adults. So far as we could learn, none of these persons had been ill save the foreman, who hiid suffered from influenza and sore throat two or three weeks before Easter, i.e., nearly three months previously ; he averred that he never drank milk. This man's illness was said to have begun with headache, followed by sore throat and swollen neck ; he had had neither rash nor peeling. He had been off work for a fortnight, of which he spent a week in bed, owing to feebleness. His doctor, whom we saw later, declared that the attack had unquestionably been one of influenza, which had been very prevalent in the district at the time. We inspected the 27 cows in the fields, where it was difficult to examine them carefully ; we noticed that one had a cough and seemed in rather poor condition. On farmstead X2 lived a milker, his wife and her mother and six children, among whom, it was stated, no recent illness of any kind had occurred. Subsequent enquiry, however, elicited the fact that one of the boys, aged 10, had suffered from digestive disturbance about three weeks previously, after eating green gooseberries, and had been away from school on that account for one afternoon ; he had had no sore throat or rash. At this farmstead there were 32 cows, all of which we inspected in the fields. Several of these cows had recently calved, and the condition of three of them excited our suspicion and suggested the necessity for veterinary examination. We arranged, therefore, to return to the farm on the following day (Monday), after obtaining the assistance of Mr. Dunbar, Veterinary Inspector of the London County Council. It now seemed desirable, before making further inquiry as to farm X, to make sure that there was no human source of scarlet fever infection at farms Y and Z already referred to. If there had remained any chance that the recently reported cases of measles at these two farms were really cases of scarlet fever, it was obvious that some suspicion would still attach to the milk derived from them. The diagnosis of measles at farm Z, however, had been vouched for by the Medical Officer of Health who had begun systematic inspection of the 31 farms; we therefore proceeded to farm Y There we found V.G. (9), the farmer's daughter, suffering from genuine measles ; the rash, now almost faded, had first appeared on June 16th and the child had had running eyes and a bad cold on the 11th ; she had been isolated since the 13th. We found her throat normal; she had no enlarged cervical glands and no sign of peeling. Three other younger children showed no signs of illness. V. G. had travelled in a pony cart and by train daily up to the 11th June to and from a school in a small town a few miles away with the children from the adjoining farm Z. Two of these children from farm Z had suffered from measles, one sickening on June 3rd and the other on June 10th. There had been other cases of measles in the school from May onwards, on account of which the boys' department had been closed ; but the girls' department, with six cases in all, had been kept open throughout. The illnesses at farms Y and Z were thus clearly ascertained to be genuine measles, and this fact tended to discredit an hypothesis that the milk at farms Y and Z was at fault. On the other hand, the suspicion entertained in the first instance that the milk from farm X was infective had been materially strengthened by the discovery of genuine scarlet fever in the carter's family, and our investigations were now especially directed to this particular farm. In order to complete the narrative of our investigations in the neighbourhood of the depot and farms, we may here state that on the morning of June 21st (Monday), while awaiting the arrival of the London County Council veterinary inspector, Mr. Dunbar, we further investigated the method of distribution of the milk at the depot (a matter to be referred to later); we also visited the village school and made enquiry as to various children reported to have been absent therefrom. All the information we obtained tended to show that there had been no scarlet fever in the district for several months and no outbreak in the school since the winter of 1906-7. On the afternoon of the same day (June 21st) we were joined by the Medical Officer of Health of the County, Dr. Tubb-Thomas (who kindly took us to the farms in his motor-car), and by Mr. Dunbar, and we all proceeded to make examination of the cows at the farmsteads X1 and X2. In view of the evidence against those farmsteads which now became available, the Medical Officer of the County thereafter undertook administrative control of the infected supply. On the 23rd June Dr. Mervyn Gordon visited the farmsteads X1 and X2, on behalf of the London County Council, having been commissioned to make bacteriological examination of material from cows presenting suspicious appearances. (See his report, appended.) Distribution of milk from the Depot. We now proceed to consider the chief questions of {etiological interest arising in connection with this outbreak, and first it is desirable to examine in detail the evidence incriminating the milk of farm X, derived from study of the distribution of the milk of the 31 farms. We had thought it unlikely, in view of the information available in the first instance, that the milk from particular farms could be definitely traced to particular vendors in London and in Surrey. Observation of the methods followed at the depot showed, however, that for practical purposes this could generally be done. The milk was always cooled before being sent away from the depot. During the summer months some of the milk, but not all, was pasteurised before being cooled. These two processes may be described here. Cooling.—On arrival at the depot the milk from each farm was tipped into a receiver capable of holding from 30 to 40 gallons ; from this it was pumped into a reservoir, thence delivered over a cooler, and run into churns, in which it was dispatched to its destination. During this process, some 8 quarts of each consignment of milk ran bacjv into the receiver when the jlumping was discontinued ; to make up for this loss it was the practice just wheu farmer A's milk was nearly exhausted to pour in 8 quarts of farmer B's milk, so that, theoretically, all A's milk should go to one consignee, while the 8 quarts last pumped, which ran back into the receiver, were assumed to consist of B's milk only, to which the rest of B's consignment was added for the next pumping, and so on. As a matter of fact, after the cooling process, the milk described as A's milk would contain a trace of B's; 21479 B2 6 B's would contain a trace of A's and of C's; C's a trace of B's and of D's, and so on. In the main, however, but little admixture of milk seemed to occur during the cooling process. No cleansing of the vessels used or of the refrigerator took place between each consignment of milk. When the milk from one farm was insufficient to fill the receiver, there was often some addition of milk from another farm, in order to ensure full vessels. Pasteurising.-As a rule, only the morning milk (or rather part of it) underwent this process, there being more time available for it in the morning than in the evening. It may be mentioned that some milk vendors refuse to accept pasteurised milk on account of its peculiar taste. During the "pasteurising" process the contents of the churns as they came into the depot were poured into a large receiver, being mixed whenever necessary to secure a full vessel. From the receiver the milk was pumped into a reservoir, delivering into a pasteurising cylinder, which was kept at a temperature of 150° to 160° F. The milk entered at the bottom of the cylinder and the process lasted while the milk flowed from the bottom to the top and out; this being a continuous flow the duration of exposure to the high temperature of any given specimen of milk could not be exactly stated, but it was variously estimated at from 5 to 15 minutes. In any case, the process of sterilisation could not be assumed to be a complete one. From the steriliser the milk passed over the refrigerator and was delivered into the churns. This process of pasteurisation, being continuous, involved mixing of milks as a matter of course. The consignments to vendors after pasteurisation could not be checked as from particular farms, and the only record of distribution kept was that pasteurised milk had been sent to the consignees. It will be obvious from this description that we had to reckon with the possibility that some even of the so-called pasteurised milk might be infective. The records supplied to us as to distribution of milk from the farms were therefore only to be trusted subject to considerable limitations. It was obvious that they did not completely account for all the milk from each farm. Milk not accounted for might be included in the pasteurised milk ; it might, again, have been separated, the cream being sold, and, again, it might have been made into cheese, while some skim milk was used for feeding pigs ; finally, the milk might have been dispatched in the raw state, at any rate in small quantities, to vendors not recorded as having received it, being mixed with other milk as above indicated, or used to make up a churn of milk in the main supplied by some other farmer which fell somewhat short of the required measure. Attention must now be directed to Chart I., showing the sources of supply to vendors in London and Surrey whose customers were attacked by scarlet fever. In this table letters A, B, C, etc., which indicate the several vendors, are placed at the heads of a series of vertical columns. In our original table prepared on June 20th, we took the names of vendors more or less at random, but in the present table the vendors are arranged (in the light of knowledge since obtained) in the order of development of scarlet fever in the several districts supplied by them. Our original table did not include vendors J, K, and L, of whose implication in the outbreak we had no certain knowledge on June 20th. Moreover, we included a vendor M, who was then suspected to be implicated, but whose customers it has since transpired did not experience any unusual incidence of disease. In this table zigzag lines indicate the dates of occurrence of first symptoms in the earliest cases, so far as they could be ascertained by careful enquiry in the several districts, and the table shows, broadly speaking, that milk from farm X was distributed shortly before the outbreak of scarlet fever in each of the implicated districts. We desire to call special attention to the case of vendor A. The information we received in the first instance was to the effect that the earliest cases among this vendor's customers were not notified until June 18th. Further enquiry, however, was made into the matter, and the Medical Officer of Health of the district concerned wrote as follows: " The doctor who notified nearly all the cases, on the 18th, says that he had several cases of sore throat during the week previous, not followed by rash and not notified. I have also notes of three similar cases where other persons in the house subsequently developed scarlet fever with rash." The records of milk distributed show that vendor A received two churns of milk sent from farm X on June 7th ; possibly the anomalous character of the early cases among his customers may justify the assumption that the milk possessed on that day a modified infective property as compared with that derived from the same source at a later date. At the time when we constructed our original table we were led to the conclusion that only three farms came under suspicion, but upon further consideration we added a fourth farm to this group. It was clear that the milk from the farm or farms at fault must have been distributed either raw or after "pasteurisation " in every one of the affected districts to account for the outbreak. Apart from any question as to human illness at any of the 31 farms supplying the depot, it may be stated that, excepting X, Y, Z and another farm, which may be designated as W, no one farm's milk had been sent to more than four of the affected vendors in June. The cases of Z, Y, W and X may be discussed in some detail. Taking the records as giving approximately a correct account of the distribution of the milk, it will be seen at once (vide Chart) that the milk of farm Z cannot have caused the scarlet fever. This milk was not sent to vendors B and C prior to June 13th, and did not go to E until the 15th, a date certainly subsequent to the outbreak of the epidemic in E's district. It did not go to F at, all, and it was not supplied to H between the 10th and 17th (H's cases were, as far as could be judged, probably infected about the 14th). Again, it was not supplied to G or A, while D had it only once on the 13th. Furthermore, most of Z's milk went to I, and yet I had only some 20 cases, while A, who had a great many more cases, did not, as already noted, receive Z's milk at all. Taking next the milk of farm Y. The date of consignment to C, June 15th, was here too late to account for the scarlet fever on his round; so also was the date (16th) of consignment to H. I had none of Y's milk, nor had G. On farms Y and Z it will be remembered there were cases of illness among children (see p. 5), which enquiry had shown to be cases of measles. The milk from farm W was sent to all the vendors known on June 20th to be implicated save G and A, but its dispatch on the 6th and on the 18th to I would not explain the phenomena observed Chart 1. %. Signifies 'pasteurised ' milk. 7 in his district, for his milk must have been infected about the 14th. Farm W had been visited by the Medical Officer of Ilealth employed by the company, but no case of human illness was found there. Turning now to the milk from X. This milk and this alone was supplied to all the vendors known on June 20th to be implicated. Moreover, in the districts of A, B, C, D and E, where the cases of scarlet fever occurred early in the outbreak (June 9th or 10th onwards), milk from farm X was consigned between June 7th and 10th, while in those districts where the cases were later in appearance (June 15th and onwards) the consignments were later, on the 14th or 15th. Again on June 14th the whole of the milk from farm X went from the depot unpasteurised. On no other day did this occur, and, judging by the number of attacks of illness immediately subsequent to it, this was the day on which the milk did most mischief. It should be noted that as regards vendor F we supposed on June 20th that milk despatched from farm X on June 6th and distributed on June 7th had caused the attack in his district. In the light of later knowledge we are disposed to think it possible, having regard to the date of commencement of illness of cases in his district, and to other circumstances to be referred to later, that the mischief, so far as he was concerned, may have been caused by some of the mixed (so-called " pasteurised ") milk received by him at a later date, say on June 9th. (See also circumstances of A's supply, page 8.) Disregarding for the moment the particular case of the vendor F, the above-named facts constituted in brief the evidence available on June 20th as a result of analysing the farm supplies. Soon afterwards the circumstances of two other districts, J and K (see Chart I.), in which infected milk had caused mischief, came to our knowledge, and in those two cases it transpired that milk from farm X had been distributed just prior to the two outbreaks. The case of district J was especially conclusive, inasmuch as this vendor received milk from farm X and from no other of the 31 farms supplying the implicated depot. In the case of L, a number of whose customers were attacked comparatively late in the outbreak, there is no record of milk from farm X having been supplied. It will be seen, however, from the chart that L received "pasteurised" milk, and therefore possibly milk from farm X that was incompletely sterilised, on each day from June 15th onwards. Distribution of milk from farm X. It was now deemed desirable, with a view to learning more precisely how matters stood as regards milk of farm X, and particularly to ascertaining when it became and how long it remained infective, to study in further detail the distribution of the milk from this fiirm (so far as this could be ascertained) and to compare this distribution with the dates of onset of symptoms in the several affected districts. In the books kept by the manager of the company it was recorded that this milk was distributed to various vendors as follows. The vendors whose customers were attacked are lettered as before, and with them are included J, K and L, vendors whose customers were also attacked but concerning whom we had no knowledge at the time when our analysis of the vendors' supplies was in the first instance made. Record of the distribution of the milk from farm X, on successive days, May 21st—June 19th. Unless otherwise stated, the milk was unpasteurised:— May 21st p.m.—Two vendors, none of whose customers were attacked. ,, 22nd a.m.—Separated. p.m.—One vendor, none of whose customers were attacked. ,, 23rd a.m.—No record. p.m.—" B," none of whose customers were attacked al>out this date, though they were later. ,, 24th a.m.—One vendor, none of whose customers were attacked. p.m.—Pasteurised. „ 25th a.m.—No record. p.m.—Two vendors, none of whose customers were attacked. ,, 26th a.m.—No record. p.m.—One vendor, " M "—No outbreak occurred among his customers. ,, 27th a.m.—Separated. p.m.—"A," none of whose customers were attacked about this date, though they were later. ,, 23th a.m.—Separated. p.m.—Pasteurised. ,, 29th a.m.—Pasteurised. p.m.—One vendor, none of whose customers were attack ed. „ 30th a.m.—No record. p.m.—One vendor, none of whose customers were attacked. „ 31st a.m.—No record. p.m.—Two vendors, none of whose customers were attacked. June 1st a.m.—Separated. p.m.—Two vendors, none of whose customers were attacked. ,, 2nd a.m.—Two vendors (i.), none of whose customers were attacked about this date, though they were later. (ii.), none of whose customers were attacked. p.m.—Two vendors (i.), none of whose customers were attacked about this date, though they were later. (ii.), none of whose customers were attacked. ,, 3rd a.m.—Separated. p.m.—Two vendors, none of whose customers wore attacked. ,, 4th a.m.—Separated. p.m.—"C," none of whose customers were attacked about this date, though they were later. ,, 5th a.m.—No record. p.m.—One vendor, none of whose customers were attacked. ,, 6th a.m.—No record. p.m.—" F —Cases occurred after the lapse of some days among "F's" customers, but apparently X milk was not infective on the 6th. (See page 8.) " G," none of whose customers were attacked about this date, though they were later. 8 June 7th a.m.—Separated. p.m.—" A "—Cases occurred a few days later among " A's " customers. ,, 8th a.m.—Separated. p.m.—One vendor, none of whose customers were attacked, and " B " and " C "—Cases occurred a few days later among their customers. „ 9th a.m.—No record. p.m.—" D "—Cases occurred a few days later among his customers. ,, 10th a.m.—No record. p.m.—" D " and " E "—Cases occurred a few days later among their customers. ,, 11th a.m.—No record. p.m.—Two vendors, none of whose customers were attacked. ,, 12th a.m.—No record. p.m.—One vendor, none of whose customers were attacked. ,, 13th a.m.—No record. p.m.—One vendor, none of whose customers wore attacked. and " O "—Cases occurred a few days later among his customers. ,, 14th a.m.—" H," " I," " J "—Cases occurred a few days later among their customers, p.m.—" K," " D "—Cases occurred a few days later among their customers. ,, 15th a.m.—Separated. p.m.—" K"—Cases occurred a few days later among his customers. ,, 16th a.m.— No record. p.m.—" B," who had already had this milk on the 8th. and "M"—No outbreak occurred among his customers. „ 17th a.m.—Separated. p.m.—" £)," who had already had this milk on the 9th, 10th and 14th. ,, 18th a.m.—No record. p.m.—No record. ,, 19th —None went out. If it be assumed, and the reasons for making tbis assumption will be given later (see below), that the date on which infected milk was distributed to F's customers was subsequent to June 6th, it will be seen from the above record that— (a) The distribution on June 7th, 8th, 9th and 10th of the milk from farm X was associated with the development of scarlet fever. (b) No cases of scarlet fever are known to have occurred among persons supplied on June J 1th and 12th with milk from farm X. (It should be mentioned, however, that on June 12th milk from farm X was sent to a London station, 15 gallons being consigned to a particular vendor. This vendor's customers were not attacked, but cases of scarlet fever developed on June 14th among consumers of milk obtained from the company and dispatched on June 13th from the London station in question, and it is, of course, possible that the persons attacked had drunk milk derived from farm X.) (c) On June 13th and onwards distribution of the milk was again associated with development of scarlet fever. In other words, it would appear that the milk distributed from farm X was infective on June 7th, 8th, 9th and 10th, non-infective on June 11th, and probably on the 12th, and became infective again on June 13th and onwards. If this assumption be made two points require explanation :— (1; The apparent escape of persons consuming milk obtained from vendors who received chance consignments of milk from farm X on one or other of the days 11th, 12th and 13th. In explanation of this the most likely hypothesis is that the milk sent from farm X to the depot included the milk of one or more infective cows on June 7th-10th, and again on June 13th and onwards, but that it did not include such milk on June llth-12th. Alternatively it might be suggested that on particular occasions only certain churns from farm X contained infective milk. It ■will be remembered that farm X comprised two separate farmsteads, X1 and X2. The milk from these might or might not be mixed, according to the amount of supply from each farmstead in relation to the size of the churns. No record as to whether such admixture had occurred was available. There were usually two or three churns of milk dispatched from farm X to the depot each morning and evening, and rather less in the evening than in the morning. Moreover, a considerable amount of milk was pasteurised at the depot each morning. If it be assumed that on the particular days, viz., June 11th and 12th, and partially on the 13th also (on the 13th—see Table—some milk was infective) some of the evening milk was also pasteurised, though of this we have no evidence, and that on those days only certain churns contained infective (as distinguished from non-infective) milk from farm X, and the milk in those churns happened to be completely sterilised by the pasteurising process, explanation of the observed phenomena would be forthcoming. The odds against such a combination of chance occurrences are, of course, considerable. (2) In the case of supplies F and A already referred to, and of M (see above, page 6) and N and P supplies not yet mentioned, the recorded facts do not fully explain the observed phenomena. F is said to have received milk from farm X only on the 6th, but it seems, judging by the dates of cases occurring on his round, that the mischief among his customers was of later date. As has already been noted, F received mixed "pasteurised" milk (possibly, therefore, unsterilised X milk) on the 9th, 10th and 11th, and it may be that some of this mixed milk caused the mischief. Again A is said to have received milk from farm X only on the 7th, when he had two churns of it. A also received mixed " pasteurised " milk, however, on a number of occasions, and having in view the extent to which his customers were involved, question arises as to whether some of this mixed milk was derived from farm X. Again, A's customers were in large part well-to-do people, who might be presumed to consume separately purchased cream, and some of this cream may have been derived from farm X. The escape of M's customers constitutes another difficulty. He may, however, have had only a very small amount of milk. Among the customers of N and P, vendors not included in Chart I., who were supplied by the dairy company from the implicated depot, a few cases of scarlet fever are known to have occurred, 9 but it is not recorded that the sufferers had milk from farm X at any time. They had milk from the implicated depot, and may have had " pasteurised" milk. In these instances, moreover, the customers were well-to-do, and infection by cream is also a possibility, in view of the fact that at the time of the outbreak the strawberry season was at its height. As regards the main discrepancies referred to under this heading (2), they are obviously of a sort likely to be met with in view of the facts that the destination of only some portions of the milk from farm X was entered in the manager's records, and that no precise statement can be given as to the destination of such portions of the cream, separated milk and pasteurised milk as were derived from farm X and supplied from the depot. Some of the milk from farm X was undoubtedly sent out to persons whose names do not appear in the records, and apparently F, A, N and P were among those who received it without definite entries of the fact. It is not possible to say exactly when the milk derived from farm X ceased to be infective. The supply was discontinued after June 18th ; certain precautions—wholesale pasteurising, etc.—had already been taken a day or two before this. An abrupt cessation of the prevalences in the several districts involved followed upon the discontinuance of the infected supply. The milk presumably remained infective for some time after this, for it is interesting to note that illness was developed three or four weeks later, in the family of the milker at farmstead Xs, the reported symptoms of which suggested scarlet fever. The nature of the illness was still in doubt when Mr. Dunbar visited the farm on July 26th. If this illness was caused by drinking milk, the milk must have remained infective for five or six weeks, dating from June 7th. The fact may be here recalled that in the Hendon outbreak, which commenced at the end of November, 1885, cases were traced to milk supplied as late as the beginning of the following January. Original cause of the outbreak. The question whether the outbreak was human or bovine in origin must now be discussed. Inquiry at the farms, at the milkers' cottages, and at the school revealed only two possible sources of human contagion. These demand careful examination; they are as follows 1. The milker who suffered from "influenza" two or three weeks before Easter. As regards this man, it must be observed that it is most probable that his illness was influenza. It was so diagnosed by the medical man who saw him at the time when he was indisposed, and influenza was then prevalent in the village. Moreover, between the time of occurrence of this illness and the outbreak of milk scarlet fever there was an interval of over two months. 2. The milker whose family sickened June 11th to 15th. The history of dates of onset was carefully investigated in these cases by us at the time, and we questioned and requestioned all those concerned. It seems clear that the milk possessed infective property at least four days before the appearance of symptoms of illness in any member of the milker's family. The dates are as follows :— June 7th, 8th, 9th and 10th.—Milk causing infection in Surrey districts. June 11th.—First case developed in milker's family (his daughter). June 13th, and for four or five days after.—Milk causing infection in Loudon and Surrey. The milker himself was attacked and stopped work on June 14th. It would appear, therefore, that the cases iu this milker's family were caused by drinking infected milk from farm X, in fact that the milk infected the milker and not the milker the milk. Inspection of the cows at farm X was made by us while they were in the fields on June 20th, and by Mr. Dunbar when they were in the sheds on the 21st and 23rd June. Mr. Dunbar reports as follows:— " Inspected 21.6.09. 23.6.09. " Report on the cows at the two farms described as farm ' X.'" " The nearer farm, X1—Is/ shed.—10 cows. No. 1, scars on several teats. No. 2, ' Ileddy,' calved end of February or first week in March, has a cough and is feverish, has one scar on right hind teat, and a serpiginous scar on right fore teat; on one teat there are 3 pustules. This cow was brought into the farm early in March when newly calved. She presents the most marked scabbing and scarring of teats and under parts of udder of any of the cows at the nearer or further farms. No. 5, a bleb on one teat containing sero-pus. " 2nd shed.— 6 cows. No. 2, scabs on right hand teat; this cow is now almost dry. No. 3, calved 18 months ago but is still milking. A scab on left hind teat and several small scabs on right hind teat. On left fore tear, a vesicle. No. 4, ' Daisy,' one teat shows a place where a scab has been removed. No. 5, 'Profit,' 3 scabs on one teat and evidence of scabs lately removed. " 3rd shed.—-11 cows and a bull. The third and fourth cows from the bull, ' May' and ' Gallant,' each have scabs on their right fore teats. " The further farm—X2, 1st shed.—7 cows. No. 1 on right, a red cow, has several small scabs. No. 2 calved a fortnight ago. No. 3, a white heifer, calved some weeks ago; several excoriations on left hind teat and a small scab on inner side of one teat. No. 4, a red heifer, calved some weeks ago, similar conditions ; a pustule on right hind teat. The sixth from the end, a red cow, similar conditions ; there are two large scabs. Fifth from right end, one pustule the size of a pea and four smaller ones on one teat. Seventh animal at end of shed, a roan heifer, calved recently, has a few blebs on the teats. " Single stall.—The cow in this stall calved on the 19th. " 3rd shed.—6 cows. First cow, similar blebs to those already noted. Third cow, similar blebs. Practically every one of the milch cows at the further farm has some evidence of vesicular or scabby conditions. Fourth cow apparently has arthritis of left hip joint. Fifth cow, several 10 small superficial excoriations, a scab about the size of half a threepenny piece on the udder and a similar one on left hind teat. Every teat more or less affected. " Five dry cows which had been out as the others had been, and living under the same conditions, presented no evidence of there having been any morbid condition on the udder or teats ; thus militating against an assumption that the lesions were of traumatic origin. Moreover, two recently calved cows which had not been milked showed no lesions. The last cow but one in the third shed was one of the two cows which calved a fortnight ago. " It should be borne in mind that on the dates of examination the affection from which many of the cows suffered had already passed the acute stage, but I could definitely state that the appearances observed were absolutely distinct from those seen in a number of outbreaks of cowpox which have come under my observation." It has been shown that most of the milch cows at farmstead X2 and several of the milch cows at farmstead X1 presented scabs and excoriations on the teats and udders: the conditions being similar to those first described in 1885 at a Hendon farm by Sir William (then Mr.) Power and since generally known as those of the " Hendon disease," inasmuch as similar phenomena to those observed at Hendon have from time to time been found to be associated elsewhere with outbreaks of milk borne scarlet fever. The existence of these conditions and the absence of any source of human infection at the farmsteads X1 and X2 make it a matter of interest to examine in detail the facts elicited with regard to the cows at these farms. 1. As to importation of fresh cows.—No cows had been newly brought to the farms since the beginning of March, i.e., nearly three months prior to the outbreak of scarlet fever. 2. As to calving of cows.—A cow at farm X2 calved on June 19th. This cow, at the time of our visit to the farm on June 21st, showed no signs of disease. Prior to this two cows at farm X2 were said to have calved " a fortnight ago," i.e., about June 5th. Neither of these cows had been milked, up to the time of our inspection, and their teats and udders appeared normal. Prior again to this, and roughly speaking some few days before or after the 24th May, three heifers calved, a red, a roan and a white heifer. The white heifer, we were told, calved first of the three, and several days before the others. These three animals were on June 21st standing in the first shed at farm X2. All presented distinct evidence of a diseased condition of the teats. As they had calved within a few days of one another they were for some time kept together in one and the same shed and they had since been close companions, and even on the evening of the 20th, before Mr. Dunbar's inspection, the fact was observed that the three animals kept together when they were out in the field. The calves of two of these heifers went to market on the same day. We were in the first instance led to believe that the heifers here in question were the red and the roan heifers. As will be seen later, this proved to be a mistake. The calves were in point of fact the calves of the white and roan heifers. We made careful inquiry as to the date, and were informed at first that it was a particular market day which could be fixed as being either May 24th or June 7th, and therefore from one of those days onwards the milk of the two heifers would have been sent to the depot. The difference of opinion among the milkers as to the day upon which the milk from the two heifers first came into use was a source of considerable trouble to us. There was agreement as to the day being a Monday, and as to that Monday being the day on which the particular market was held, hence it was clear the date must have been either May 24th or June 7th ; but while one milker was confident that the date was Jane 7th the other assured us, and this after some consideration, that the day in question was the 24th May. It seemed impossible at first to arrive at any certain conclusion with regard to the matter. It chanced, however, that the difficulty was afterwards discussed with a gentleman who is intimately acquainted with the locality in which the farm is situated, and who happened to be visiting the neighbourhood at this particular juncture. He took a very keen interest in the subject and made several suggestions with regard to it. Inter alia he pointed out that the dates of coming into use of milk from freshly calved cows could readily be fixed by noting variations in the daily amount of milk delivered to the company by the farmer. It was to be expected that an increase in the quantity supplied from the farm would be from time to time shown as the milk from recently calved cows freshly came into use, but against this has to be set the fact that some of the cows would as time went on become dry. The records were obtained from the company's manager, and Mr. Dunbar, the London County Council's veterinary inspector, again visited the farm, on July 26th, and obtained the corresponding records from the farmer and made further enquiry into the dates of calving of cows in the light of these records (see Chart II.). The chart shows that there was an addition of some seven gallons to the amount of milk supplied from the farm on June 7th. This day, however, was Monday, and there is throughout noticeable a tendency for the number of gallons supplied to fall to a minimum on Sunday and to rise again on Monday. But on further questioning the milkers, the facts as regards the particular Monday, June 7th, became sufficiently clear. The milker who had hitherto expressed the belief that the milk of the two heifers first came into use on May 24th abandoned his position and admitted the correctness of the belief of the other milker. It now transpired, however, that the calves of the white and roan heifers (not those of the red and roan heifers) were the two calves taken to market on June 7th. Mr. Dunbar asked what became of the calf of the red heifer, and to this the reply was that the calf died four or five days after it was born. Mr. Dunbar found that the heifer had on July 26th materially improved in health and the teats and udder were normal. It appears likely, therefore, that the whole of the milk of the white, roan and red heifers came into use for the first time on June 7th; though doubtless some portion of the milk of the white heifer, and perhaps some of that of the roan heifer, had been sent still earlier than this date to the depot. The red heifer's milk was not used at all until after the death of her calf, and thus probably on June 7th. The dates of calving of these three heifers must, on a review of all the statements made by the milkers, be approximately assigned as indicated on the chart. Cfrarf 2. 11 The circumstances are highly suggestive of a special pathogenic quality of the red heifer's milk which may possibly have caused first the death of her calf, and then, on the distribution of the milk in London and Surrey, produced scarlet fever among consumers in those counties. It would appear that June 7th, the day on which the red heifer's milk first came into use, was the day on which the milk from the farm first showed evidence of being infective. It is probable that for two or three days the property of infectiousness was confined to the milk of the red heifer ; but the roan and white heifers, with which the red heifer had then for some days past been closely associated, must soon have become also involved. The assumption that the infected milk of one or more of these heifers, after being distributed on June 7th, 8th, 9th and 10th, was for one reason or another not distributed on the llth and 12th, but that it and the milk of other cows which had now become infected was sent to the depot after that date until the time of stopping of the supply from the depot, would afford a satisfactory explanation of the phenomena of the outbreak. 3. As to spread of infection from cow to cow.-—An hypothesis that a cow disease originated among newly calved heifers at farm X- appears to require, in further explanation of the sequence of events, the assumption that there was transference of the diseased condition from cow to cow involving almost all the milch cows at this farm, the disease then further spreading to some of the milch cows at farm X1. Such transference, it may be noted, is possible, having regard to the fact that a particular milker each day milked one or two cows at each farm. (Carter G. L., see page 4.) 4. As to the possible origin of the cow malady.— No information could be obtained from the milkers as to when this cow malady first appeared in the herd. No admission was made that it had been observed before the time of our visit. As was mentioned on page 10, we were informed that no newly-bought cow was brought on to the farm since the first week March. Faute de mieux the possibility may be considered that the affected animals were infected by food ; a question to which attention wan called a number of years ago. It was ascertained that the cows were turned out to grass at the beginning of May; they had had no roots since the middle of April. There was a supply of hay at each farm, and a supply of cake which was replenished fortnightly was kept at farm X1, whence cake was from time to time sent to farm X2. The cake (and the statement holds good for this food alone) was supplied only to milch cows; dry cows had no cake, and, as has already been noted, the dry cows presented no lesions indicative of the cow malady. Obviously, however, the escape of the dry cows might be explained by the fact that as they were not milked no infection could be transmitted to them by the milkers' hands; and in this connection (see page 10) we may recall the fact that two newly calved cows were also unaffected. The clinical characters of the disease. In conclusion, we may briefly refer to some observations that we have been able to collect with regard to the peculiarities, clinical or other, of the disease in man and in the cow. In connection with several outbreaks of milk scarlet fever investigated by medical inspectors of the Local Government Board and medical officers of health, attention has been called to certain anomalies, clinical and other, which presented themselves ; and the question has even been raised as to whether milk scarlet fever is or is not identical with scarlet fever ordinarily so-called. The large number of coses, between 400 and 500, occurring in the present outbreak affords a particularly good opportunity for investigation of this question, and we have obtained an expression of opinion on the matter from each of the medical officers of health already named of the districts affected in Surrey, from Dr. Meredith Richards, of Croydon, and from Dr. Bruce and Dr. Beggs, superintendents of the Western and Grove Hospitals, to which most of the London patients were sent. All are agreed that the cases were indistinguishable from ordinary average cases of scarlet fever. If anything, the type of disease was somewhat mild, but, as Dr. Beggs has pointed out, the age distribution of the cases was slightly unusual, adults being not infrequently attacked, and this circumstance in itself would explain a lowered case fatality. Vomiting was a not uncommon initial symptom ; intestinal disturbances were, in this outbreak, at any rate, quite rare. As regards infectivity, to which question attention was specially directed, it was remarked in most of the reports that infection from person to person in the course of this outbreak was uncommon ; only in the report from one district was a different impression conveyed. It should be added that Dr. Parkes has furnished us with particulars of one invaded household in Chelsea in which three cases were notified on June 30th ; the dates of onset (June 15th and 16th) of two of these proved them to have been primary cases, but the date of onset of the third (June 26th) suggested that this was a secondary case. In connection with this third case, however, the possibility of a prolonged incubation period, of which cases have been recorded in recent years, should be borne in mind. There may be further mentioned the possibilities, first, that the case notified on June 30th was an instance of a relapse, or, secondly, that it was of altogether independent origin from the cases earlier notified. Dr. Meredith Richards has kindly furnished us with a detailed statement. He finds that of the 28 cases in Croydon eight occurred in four houses. Of these eight it would seem probable, he says, that the infection was due to a common origin, having regard to the dates of onset (house A, onset June 17th and 18th ; house B, onset June 17th and 17tli; house C, onset June 16th and 17th; house D, onset June 17th and 18th). "Apart from these duplicate cases," Dr. Richards says, " there were no multiple attacks, and this is all the more striking because there was a considerable number of young persons living in the invaded houses who had not previously suffered from the disease. The exact figures were as follows :— Number of invaded bouses 24 Number of scarlet fever patients 28 Total inhabitants of infected houses (exclusive of the 28 patients) 100 Of the total inhabitants (exclusive of the 28 patients), 17 are stated to have previously had scarlet fever, 73 are stated not to have had scarlet fever, and concerning the remaining 10 information 21479 O 12 could not be obtained. The ages of the persons living in infected houses who did not develop scarlet fever were as follows : — 0—5 5—10 10—15 15—20 20 and upwards. 11 10 8 6 65 (one of whom is said to have been previously attacked). (16 of whom are stated to have been previously attacked). With regard to the cow malady, the scabs and excoriations were in the main limited to the teats ; in one or two instances they extended on to the udder. In no instance did we discover evidence of loss of hair in patches. On June 21st when examination of the cows was made, there were but few recent lesions (papules, vesicles), but numerous crusts and scars. The lesions on the teats seem to have run their course in from a week to a fortnight. We had no opportunity of learning whether visceral lesions were present in the affected animals. Only in one cow examined were febrile symptoms (cough, a rapid pulse, staring coat) noted (see page 9, No. 2 in first shed). It is possible there may have been slight constitutional disturbances among some of the other affected animals prior to our visit. We were told that in no instance had sores developed on the hands of milkers. The milkers, moreover, denied having at any time noticed that the milk was ''ropy." We are greatly indebted to the medical officers of health of the various affected districts already named in the course of this report for the full information which they kindly placed at our disposal, without which a complete record of the outbreak as it affected the two counties would not have been possible. We are further indebted to the medical officers of health of the county and of the districts in which the depot and farms were situated for valuable help freely rendered at the time of our visit of investigation. We were so fortunate as to obtain during our enquiry in the district help from all those to whom we had occasion to apply. It is especially due to the manager secretary, and medical adviser of the dairy company concerned, to state that they gave us every assistance in their power and placed their books and records entirely at our disposal. W. H. Hamer, Medical Officer (General Purposes), County of London. T. Henry Jones, Acting County Medical Officer of Health of Surrey. 13 September, 1909. " Pathological Department, St. Bartholomew's Hospital, E.C. BACTERIOLOGICAL REPORT By Dr. M. H. Gordon. Sir,—During the month of June, 1909, an extensive outbreak of scarlet fever in the metropoltian district having followed the consumption of certain milk derived from two farms, and the circumstances of the outbreak having been found on investigation to point to the cows at these farms as a likely source of the infection, I was invited to investigate the matter from the bacteriological standpoint. Accordingly, on June 23rd, I proceeded, in the company of Dr. Hamer and Mr. Dunbar, to the two farms in question, X1 and X2. On arrival at these farms Mr. Dunbar examined each cow in turn and drew my attention to such abnormalities as were present. At both farms, a proportion of the cows showed on their teats, and occasionally on their udder, a discrete papular eruption which in some cases had passed to a pustular stage. At the date of my visit this eruption was on the wane, but I was able to collect material from the eruption on two cows at each of the two farms. I have made a bacteriological examination of the material thus obtained, and also of material removed by Dr. Hamer from cows at farm Xa on a visit a few days previously, with the following results :— 1. Microscopical examination. Coverglass preparations of the material showed the presence of one kind of micro-organism only, namely, Gram positive diplococci. 2. Cultures. Cultures were made of the material on agar and serum, incubated at 37° C. In all cases these cultures yielded a mixture of staphylococci and streptococci. The latter were in the majority. The staphylococci were all found to be examples of staphylococcus aureus and were not tested further. The streptococci were isolated in pure culture and their character investigated in detail, with the results seen in the accompanying table. It will be observed that six of the seven streptococci tested had identical reactions. The single streptococcus (2a) that differed from the rest is seen upon its reactions to be an example of streptococcus faecalis, and was probably a contamination. The type of streptococcus to which the rest of the streptococci conform is closely allied to two types of streptococci that have been described. The first of these was obtained by Drs. Andrewes and Horder from the fauces of persons suffering from scarlatina, and it was termed by them streptococcus anginosus. The streptococcus from the cows at farms X1 and X2 was like this streptococcus in general features, except that its chains were somewhat shorter, and neutral red was not reduced. Furthermore, the streptococcus from cows at farms X1 and X2 failed to exhibit pathogenicity for the mouse. The second type of streptococcus which the streptococcus from cows at farms X1 and X2 also closely approaches is a type found by Dr. W. G. Savage to be the most frequently found in mastitis in cows. Dr. Savage's streptococcus mastitidis is chiefly differentiated by him from streptococcus anginosus by the fact that it is less virulent for mice than streptococcus anginosus, but chiefly because streptococcus mastitidis produces mastitis in goats, whereas streptococcus anginosus does not. I have been unable to inject this streptococcus from the cows on farms X1 and X2 into goats so that I am unable to state which of these two streptococci that micro-organism most closely resembles. Before concluding this report, I venture to draw attention to a recent observation that may have valuable application in future outbreaks of scarlatina in which infection of the milk by human agency is apparently excluded, and the cow itself is under suspicion as the source of the infection. The discovery of Bordet and Gengou, of the Pasteur Institute, of the " Fixation of Complement " method has provided us with a specific test whereby we can recognise the presence of specific antibodies in the blood of an animal affected by a given infection. Schleissner, of Prague, in a recent paper entitled " Bacteriological and Serological Studies in Scarlet Fever" (Wien. Klin. Woch., xxii., 16, 1909. p. 553), has applied this test of fixation of complement to the serum of persons suffering from scarlet fever, with the result that he finds that by this, test the serum of scarlatina patients can be shown to contain a specific antibody for the scarlatinal streptococcus, from the second up to the sixth week of this disease. Control experiments made in the same way with serum from normal persons, and from persons suffering from diseases other than scarlet fever, were negative in this sense. In future outbreaks of milk scarlatina, therefore, by applying this test to the serum of cows under suspicion of having originated the outbreak, it should be possible to decide whether their blood contains the same specific antibody than is found present in the blood of persons suffering from scarlet fever between the second and sixth week of the attack. The information thus obtained may be found to furnish a valuable piece of evidence in elucidating the causation of such outbreaks. I have the honour to remain, Sir, Yours faithfully, M. H. Gordon. Sir Shirley Murphy. 14 Table showing the Characters of Streptococci isolated from Cows at Farms X1 and X2, June, 1909. No. Material. Broth 370 C. Acid and clot in milk. Saccharose. Lactose. Raffinose. Inulin. Salicin. Mannite. Neutral red. Growth on gelatine 22° C. Pathogenicity for mouse. 1 Farm X2. First shed. No. 3. Scab removed by Dr. Hamer Turbid, short chains + + + — — + — — — Nil 2 Farm X2. First shed. No. 5. Exudation removed by Dr. Hamer Ditto + + + — — + - - - do. 2a Farm X2. First shed. No. 5. Another colony Ditto — + + — — + + + + do. 3 Farm X2. First shed. No. 3. Exudation removed by me Ditto + + + — — + - — - do. 4 Farm X1. First shed. No. 2. Scab removed by me Ditto + + + — — + - — - do. 5 Farm X'. First shed. No. 4. Scab removed by me from another cow Ditto + + + — — + - - - do. 6 Farm X1. First shed. No. 5. Exudation from another cow Ditto + + + - - + - - - do. APPENDIX II. Xonbon County Council PULMONARY TUBERCULOSIS. Report by the Medical Officer presenting a report by Dr. Wanklyn as to the Action taken by London Sanitary Authorities with regard to cases of Pulmonary Tuberculosis. Public Health Department, February, 1910. The Committee instructed me in July last to inquire and report on the action which is being taken in each of the sanitary areas of London with regard to cases of pulmonary tuberculosis coming to the knowledge of the sanitary authorities. This inquiry was entrusted to Dr. Wanklyn, and I now present his report in which will be found an account of proceedings in respect of cases of this disease in each district. It is convenient to consider in the first instance the sufficiency of the arrangements which exist in London for cases of pulmonary tuberculosis to be made known to the Medical Officer of Health. The Council has, during the last few years, urged sanitary authorities to adopt a system of voluntary notification, and at the present time this system is in operation in every district in London except Paddington, Shoreditch, Bethnal Green, Stepney, Poplar, Battersea, Camberwell and Deptford. Under the Tuberculosis Order of the Local Government Board all cases of this disease occurring in poor law practices are required to be notified to the medical officers of health, and such notifications are received by the medical officers of health of the districts mentioned as well as of those in which a system of voluntary notification has been adopted. Moreover, the Secretary of the Brompton Hosiptal for Consumption has, since November, 1908, forwarded to me for distribution among the medical officers of health the addresses of patients attending the hospital and who have given their consent for this purpose. The certificates concerning these patients are communicated to the medical officers of health concerned whether their authorities have adopted a system of voluntary notification or not. A similar arrangement has since been made with the authorities of the Mount Vernon, King's College, St. Mary's, Middlesex, Westminster and Royal Free Hospitals. In some other instances the hospital authorities notify cases to the medical officer of health of the district in which the hospital is situated. Dr. Wanklyn has discussed the extent to which voluntary notification brings to the knowledge of the medical officer of health cases of pulmonary tuberculosis and he shows that the number of cases notified each year in the districts in which voluntary notification has been adopted falls short of the number of deaths occurring. I may supplement the information contained in his report by the following figures relating to sixteen districts for which the information is available and which include cases occurring in poor law practices notified in 1909 under the regulations of the Local Government Board :— Bolton. Voluntary notification. Compulsory notification. Total number of deaths from pulmonary tuberculosis 1902 1903 1904 1905 1906 1907 1908 1909 253 218 221 210 202 186 216 216 Number of notifications— (a) New cases 80 92 93 150 262 195 202 240 (b) Cases previously recorded (part) 2 2 2 7 8 13 21 19 1814 a Notifications Voluntary, 1908. 2,642 Deaths, 1908. 3,714 Notifications obligatory in poor law practices and voluntary in other practices. " 6,368 Deaths, 1909. 3,592 The result of the Tuberculosis Order has been that the number of cases notified has been more than loubled, but this number must still fall far short of the actual number of cases occurring. It may, therefore, be considered whether obligatory notification of patients in all classes of the population would produce very different results. In a few provincial towns voluntary notification has been followed by compulsory notification. I am indebted to the medical officers of health of three of these towns for information concerning the number of cases notified under each system. The following table enables the figures obtained from voluntary and compulsory notification in Bolton to be compared :— 2 The following table gives similar information for Sheffield :— Sheffield. Total number of deaths from pulmonary tuberculosis Voluntary notification. Compulsory notification. 1901 1902 1903 1904 1905 1906 1907 1908 580 491 573 536 490 452 524 564 Number of notifications— (a) New cases 282 326 519 826 741 698 779 793 (6) Cases previously recorded 41 62 200 375 306 412 454 487 A similar table relating to Edinburgh may be presented, but it needs to be stated that the results are not strictly comparable with those obtained in the other towns. During the last twenty years there has existed in Edinburgh a " Dispensary for the Prevention of Consumption " which has been instrumental in securing the notification of cases of this disease, and this fact may in part explain the smallness in the increase of number of notifications as the result of obligatory requirement to notify. The table does not enable distinction to be made between new cases and those previously notified. Edinburgh. Voluntary notification. Compulsory notification. 1903 1904 1905 1906 1907 1908 Total number of deaths from pulmonary tuberculosis 467 408 438 373 395 395 Notifications received 294 451 426 604 651 713 It appears therefore (a) that voluntary notification may fail to bring to the knowledge of the medical officer of health as many cases of pulmonary tuberculosis as there are deaths from this disease ; (6) that when voluntary notification is supplemented by obligatory notification of cases occurring in poor law practices the number of notifications is materially increased, but that it does not bring to knowledge more than a proportion of the clinically recognisable cases ; (c) that compulsory notification of cases of this disease, whether occurring in poor law or other practices, brings to the knowledge of the medical officer of health a number of cases in excess of the number of deaths, but, so far as may be judged from the experience of the provincial towns mentioned, this number is still obviously less than the number of the clinically recognisable cases. The most important of the reasons why a system of notification whether voluntary or obligatory fails to bring to knowledge more cases of pulmonary tuberculosis is that for such system to be effectual the patient must feel that he will derive some benefit from it. In the absence of prospect of relief being afforded him as the result of his illness being made known to the medical officer of health, he is unwilling that his state of health should be disclosed. This, indeed, was the experience of Sheffield, of which Dr. Scurfield, the medical officer of health, told me some two years ago, and quite recently he has written to me in the same sense. Sheffield, therefore, opened a hospital for twenty male patients in 1908 and twenty female patients in 1909. It was to provide opportunity for the early detection of cases of pulmonary tuberculosis that the physicians of Brompton Hospital have been willing during the last few years to examine, on the request of the medical officer of health, any member of the family of a patient attending at the hospital and whose state of health suggested the need for such examination. The proposal undoubtedly promised to be useful, and I have invited other hospitals to adopt the same course. It is, however, necessary to say that but little use has been made of the opportunity thus afforded by the Brompton Hospital, as the scheme has not brought under treatment any considerable number of persons in the early stages of this disease. Appended to Dr. Wanklyn's report is a statement, relating to each sanitary district, showing the steps which are taken in the interest of the patient and of those with whom he is associated on receipt by the medical officer of health of notice that an inhabitant of his district is suffering from pulmonary tuberculosis. These steps include visits to the house in one or two districts by the Medical Officer of Health, but usually by a male or female sanitary inspector or health visitor, and the giving of advice on a number of important points. In some districts, moreover, the services of a local health society are available for rendering assistance to the patient and his family, and for ensuring as far as possible the adoption of those prophylactic measures which are deemed to be necessary. Provision is therefore made in some degree in some districts for the supervision of the patient while he is in his own house. In some others the steps 20 Dr. Sykes, the medical officer of health, has analysed the notifiers in the year 1908 as follows :— Medical officers of Infirmaries (North and South) and of Workhouse 204 District medical officers 8 Staff of Mount Vernon Hospital 3 Staff of other Hospitals 5 Private practitioners 25 Other persons 4 249 On the receipt of a notification a visit is paid to the home (subject to what ia said below) by a woman sanitary inspector, who is able not only to make a sanitary inspection of the premises, but also to give personal attention to the individual needs of the patient. The medical officer of health is prevented by administrative and other business from visiting such cases himself. Elaborate measures are taken to obtain voluntary notifications from private practitioners, whose convenience and that of their patients is carefully studied. An outfit is supplied for forwarding sputa to obtain the results of a bacteriological examination. Books of medical certificate forms are sent out for notifying the disease. Copies of the leaflets which are handed to patients have been distributed to medical practitioners for their information ; and notice is sent that the notification is treated as confidential, that no sanitary inspection or other action will be taken unless it is requested, except that certain leaflets as noted will be posted to the patient. The leaflets mentioned include an offer of disinfection, an untearable card of general precautions and instructions, and a very useful list of societies, hospitals and other institutions concerned with the amelioration and prevention of the disease. This list supplies information which is not readily accessible to the general public. The woman sanitary inspector makes careful inquiry into the sanitary and other circumstances and reports fully thereon. She is instructed to make the inquiry with a view to helping the patient, the family, and the medical attendant. She is further warned that no action as to segregation, disinfection, or sanitary inspection (except on complaint) must be taken without the desire of the patient or family and the advice of the medical attendant; and that it is preferable to fail to get statistical evidence than to lose friendly relations with the patient. It is found that to get arranged a cleanly room, open windows, a supply of food for the children, a change of occupation or of residence for the patient, perhaps removal to an infirmary or hospital or a rest at a sanatorium or other home occupies, in even one case, a great deal of time and thought. But in the result valuable work is done by the sanitary staff, and is of the kind that is likely to be of the greatest use in the prevention of the disease. The patient is befriended, and encouraged to help himself, at the same time that help is being sought for him. There is no Health Society in St. Pancras ; recourse is often had to the Children's Care Committees, to the Invalid Children's Aid Association, to various religious bodies and to the Charity Organisation Society. But the want is greatly felt of additional help for visiting homes, of money help, and of some means of co-ordinating the efforts made by the various agencies scattered in the field of preventive work. Endeavour is made to keep the patients and houses under observation and to ascertain any secondary cases that may be ailing. No systematic medical examination of contacts is possible. The Borough Council does not itself retain any sanatorium beds, or provide sputum flasks for patients. Borough of Shoreditch. In an estimated population of 115,227 there were during the year 1909, 234 deaths from phthisis. No form of notification had been in use in the Borough prior to the year 1909, and the above cases, i.e., the deaths, were all that had come to the notice of the sanitary authority. Dr. Bryett, the medical officer of health, is not able personally to visit the cases now disclosed by the Public Health (Tuberculosis) Regulations, 1908, but to every private dwelling where a case is found to exist, a sanitary inspector is sent to inspect; he makes a report, and a copy of a pamphlet is left which sets out the special risks of the disease and the means of avoiding and preventing it; disinfection is performed when thought desirable, and after every removal or death it is offered, and the offer is usually accepted. There is no medical examination of contacts. It is not possible to keep cases under continuous observation. There is no local charitable institution to which cases are referred. The sanitary authority retains no sanatorium beds. The bacteriological examination of sputum is arranged for medical practitioners by the Borough Council free of charge. Sputum flasks are not distributed by the Council to patients. Year. Cases notified. Deaths from phthisis. 1902 — 217 1903 — 272 1904 — 254 1905 — 228 1906 — 233 1907 — 242 1908 — 234 21 Borough of Southwark. There were 403 deaths from phthisis during the year 1908, the estimated population of the Borough being 210,442. The medical officer of health, Dr. Millson, estimates that there are in the Borough at least 2,000 cases of the disease; he is strongly in favour of compulsory notification. Voluntary notification has been in force since the year 1902 and the following table shows the notifications since then and the yearly deaths. Year. Cases notified. Deaths from phthisis. 1902 46 550 1903 307 496 1904 323 489 1905 297 443 1906 399 429 1907 335 425 1908 427 403 On receipt of a notification of a patient who lives at home, a visit is paid by a sanitary inspector, who makes an inspection of the premises, and hands a printed card of precautions to the patient. He also reports the personal circumstances of the patient. Disinfection is carried out once weekly with formalin, and once every three months a more radical disinfection of the premises and articles therein is undertaken. A certain number of cases, principally children, the medical officer of health is able personally to see : but pressure of other work prevents him from seeing all the notified cases and from examining contacts for secondary cases. There is no systematic medical examination for this purpose. There was no doubt in Dr. Millson's opinion but that special staff were required for dealing with tuberculosis. It is possible, generally speaking, to keep the cases under observation, owing to visits of disinfecting staff to the homes, or to friends coming to the health office for disinfectants. But little else can be done by the sanitary authority to alleviate the patient's condition. No sanatorium beds are retained by the Council, but the medical officer of health has reported in favour of beds being so retained, and the matter is under consideration. A weekly list of cases is forwarded from the health office to the Southwark Health Society, to enable them to be followed up. Arrangements are made by the Borough Council to have specimens of sputum bacteriologically examined for medical practitioners free of charge, and sputum flasks are given away to patients. Borough of Stepney. In the year 1908, the estimated population being 310,706, there were 494 deaths from phthisis. There has been no system of voluntary notification in the Borough ; but the medical officer of health, Dr. D. L. Thomas, is of opinion that there would be advantage in a compulsory system of notification. Dr. Thomas was of opinion that there were not less than 3,000 cases of tuberculosis in the Borough, and that many were foreigners who returned to their homes before death. On receipt of a notification under the Public Health (Tuberculosis) Regulations, 1908, a sanitary inspector inspects the premises and leaves a leaflet of instructions for the prevention of the spread of consumption. It is not possible to pay more than one visit to the same patient or deal with him personally. The medical officer of health is unable, from pressure of administrative and other work, to visit cases personally or to examine the contacts. Disinfection is performed at the death or on removal of a patient. Sputum flasks are given to patients. In 59 cases during the year 1908 sputum was examined by the Lister Institute at the instance of the Borough Council for the Jewish Board of Guardians. The Council does not retain any sanatorium beds, though the question of doing so is under consideration; it is in touch with the Stepney Association of Public Welfare, which, among other subjects, deals with cases of tuberculosis. Year. Cases notified. Deaths from phthisis. 1902 — 579 1903 — 633 1904 — 642 1905 — 524 1906 — 526 1907 — 482 1908 — 494 Borough of Stoke Newington. During the year 1908 there were recorded 59 deaths from phthisis, the estimated population being 54,015. Voluntary notification has been in force in the Borough since the year 1902, and the cases notified year by year since then are as follow, compared with the deaths for the corresponding years. Year. Cases notified. Deaths from phthisis. 1902 26 66 1903 44 64 1904 28 90 1905 40 70 1906 25 55 1907 38 50 1908 17 59 22 There is a highly organised system for dealing with cases of tuberculosis. Each case, as notified, is personally visited by the medical officer of health, Dr. Kenwood ; he has so visited every case notified since notification came into force. Acting in co-operation with the medical attendant, and with his consent, he visits the home and leaves a copy of a leaflet of general instructions,and files in his office a record of the patient's circumstances. The medical visit is followed up by a series of visits either by the female sanitary inspector, who reports on the condition of the premises, or by one of the voluntary health workers, or by visits of both. The voluntary health workers number eight, each having a separate district; they meet regularly and report to the medical officer of health then and at other times. In this way constant observation is kept on the homes and families of comsumptive patients. Certain cases also obtain individual assisttance and material relief, owing to their being reported to the Invalid Children's Care Association or to the Charity Organisation Society. The medical officer of health visits certain cases repeatedly and has noted some secondary cases among contacts, but he is unable to make a systematic medical examination of contacts. Such cases as receive sanatorium treatment do so through charitable agencies ; the Borough Council retains no sanatorium beds. Dr. Kenwood, who has given much attention to the subject, considers that tuberculosis, if individual cases are to be effectively dealt with, must be approached by voluntary effort, acting in co-operation with the sanitary authority. Disinfection is carried out after death or removal of the patient and at other times as occasion requires ; there is also supplied to each house as much disinfectant for room or personal use as the patient requires. The Council undertakes to have specimens oi sputum bacteriologically examined for medical practitioners free of charge ; it does not provide sputum flasks for patients. Borough op Wandsworth. The deaths in the year 1908 from phthisis were 282. The population was estimated as 289,500. Voluntary notification has been in force since the year 1903, with the following results :— Year. Cases notified. Deaths from phthisis. 1902 — 221 1903 88 237 1904 118 288 1905 104 271 1906 74 274 1907 49 268 1908 85 282 Upon receipt of a notification a visit is paid to the house by one of the female sanitary inspectors ; the premises are inspected and reported on and any defects remedied : disinfection is carried out when necessary; a spit bottle is given to the patient; a card of instructions is left with the patient or friends; a number of details regarding the personal condition of the patient are noted and advice is given about regimen ; inquiries are made about the health of persons in contact with the patient and in certain cases the female sanitary inspector advises the calling in of a doctor to see some member of the family who may be ailing. As long as the premises contain a case of the disease they are kept under observation by the female sanitary inspector, who visits once a quarter or oftener ; at death or removal disinfection is offered, and if the patient moves to a known address his name is notified to the medical officer of health of the district. Dr. Caldwell Smith, the medical officer of health, finds it impossible personally to visit the cases, but considers that a medical examination of contacts would be very useful for disclosing early cases. The Borough Council has no control over or disposal of any sanatorium beds, and, generally speaking, so far as individual patients are concerned, little assistance can at present be given to them by that authority. It is not in special touch with voluntary aid societies. There is no local health society. Facilities are provided by the Council for the bacteriological examination of sputum for medical practitioners, free of charge. City of Westminster. In an estimated population of 170,545 there were 213 deaths during the year 1908 from phthisis. Voluntary notification has been in force since the year 1903, and the cases so disclosed and the deaths have been as follows:— Year. Cases notified. Deaths from phthisis. 1902 — 328 1903 124 (9 months) 301 1904 148 268 1905 112 265 1906 78 241 1907 110 235 1908 155 213 On receipt of a notification a visit is paid to the patient's home by the assistant medical officer of health, and inquiries made as to the patient's circumstances and the sanitary condition of 23 the house. These are noted and filed for reference. Printed suggestions are left as to general hygiene, and inquiry is made as to the health of other members of the family and friends, but no systematic examination of contacts is undertaken by this officer. The case is then sent on to the Westminster Health Society for regular visiting and for such arrangements to be made for the patient's welfare as may be found desirable or possible. Dr. Francis Allan, the medical officer of health, considers that the examination of contacts or suspected secondary cases requires special arrangements, owing to the fact that if a contact who may be ailing is referred to a medical practitioner or to a hospital, without special attention being drawn to the case, early signs of disease may easily be overlooked. The question of sanatorium beds being retained by the Westminster City Council is under consideration. At present the Health Society is the means by which patients are enabled to reach sanatoria; and the Society works in co-operation with the Jewish Health Board, the St. Anne's Fund Trustees, the Invalid Children's Aid Association and the Charity Organisation Society. Arrangements are made by the City Council to have specimens of sputum examined for medical practitioners free of charge. Sputum flasks are distributed by the Health Society. Borough of Woolwich. In an estimated population of 131,346 during the year 1908, there were 160 deaths from phthisis. Voluntary notification has been in force since the year 1902, the cases notified and the number of deaths in each year being as follow :— Year. Cases notified. Deaths from, phthisis. 1902 189 181 1903 167 176 1904 186 205 1905 145 190 1906 176 169 1907 150 161 1908 154 160 Dr. Sidney Davies, the medical officer of health, endeavours to see every notified case himself when the patient lives at home, and with very few exceptions has succeeded in doing so up to the present; he is not able, however, to pay a succession of personal visits to keep the patient under observation, and he does not consider that such detailed attention is compatible with the general supervision of his department which is required from a Borough medical officer of health. The cases in the Borough, however, are kept under observation by the sanitary staff, although the female sanitary inspectors are precluded by pressure of other work from attending to this, and the want of additional staff is much felt. At the notification of a case, a card of instructions for the avoidance and prevention of consumption is handed to the patient, and general inquiries are made about the health of the other members of the family. A sanitary inspection is also made, and any defects are remedied. Disinfection is carried out when necessary and was performed at 157 premises during the year 1908. Individual attention is paid to the patient; he is provided with a spit cup at cost price, and his sputum is examined at the Lister Institute on behalf of the Borough Council. Application on his behalf for admission to a sanatorium is entertained from the medical practitioner in attendance. Seven beds in the Maitland Cottage Sanatorium, Peppard, Oxfordshire, are maintained by the Council, and patients are sent there on the recommendation of the medical officer of health, who decides as to the suitability of the applicant. Applicants are required to show that they are not in a position to pay the fees required at a self-supporting sanatorium. All the seven beds were occupied throughout the year 1908, and there was generally an excess of demand for them over supply. Three of the beds are intended for one month's rest and treatment, and to have an effect which admittedly may be no more than educational, so that on returning home a similar style of life may be kept up. The Borough Council works in association with a charitable fund which assists in prolonging the stay of certain patients considered suitable for such aid. A record has been kept of the results of the cases dealt with, and although in many cases arrest of the disease has not followed sanatorium treatment, the general results have been encouraging. Dr. Davies states that even those patients who are too far advanced in consumption to benefit very materially have their lives lengthened and learn how to continue the treatment at home and to avoid being dangerous to their neighbours. Of the 70 applicants entered on the register for admission to the sanatorium in the year 1908, 40 were admitted ; 11 were too far advanced for admission ; 3 were found to be not tuberculous, and 1 could not afford to give up work. Others were admitted to convalescent homes, consumption hospitals, other sanatoria, or the infirmary; but all received instructions as to the means to be taken to promote their own health and to avoid infecting other people. Dr. Davies is of opinion that much additional good work could be done by definite medical examination of contacts, so that early cases might be picked out, and by keeping patients at home under observation by a special inspecting officer of the public health department. APPENDIX III. 1 APPENDIX III. CEREBRO-SPINAL FEVER IN LONDON DURING 1909. With regard to the occurrence of cerebro-spinal fever in London during the year 1909, there is again little of importance to record. There has been nothing approaching epidemicity. III cases were certified. In addition there were 12 cases diagnosed during life and not certified, and 16 other cases only diagnosed at death and not certified. Thus 139 cases in all occurred in London. It is noteworthy that there was a rise in the figures in March. This requires comment, lest hereafter the figures should be thought to support some causative influence which was, in fact, non-existent. The following table shows the character of the rise:— Certified cerebrospinal fever cases in London during the year 1909. No. of week. No. of cases. No. of week. No. of cases. No. of week. No. of cases. No. of week. No. of cases. 1 1 14 8 27 2 40 1 2 — 15 9 28 1 41 — 3 — 16 5 29 3 42 — 4 2 17 6 30 1 43 1 5 1 18 — 31 1 44 2 6 — 19 1 32 — 45 — 7 1 20 2 33 — 46 1 8 2 21 1 34 1 47 — 9 1 22 2 35 3 48 1 10 2 23 3 36 1 49 3 11 8 24 3 37 1 50 1 12 7 25 3 38 1 51 — 13 6 26 2 39 3 52 7 For most of the year, as will be seen, from 0—3 cases occurred every week. But in the eleventh week, viz., that beginning on 14th March, the figures suddenly rose to 8, remained thereabouts for seven weeks, and then fell to normal again. It might well be thought that there had been a slight outbreak and that possibly some climatic influence had been operating. But this was not the case. The cases were scattered about London, and no sort of grouping or connection could be traced. At the same time it is clear that 50 notifications, nearly one half of those received during the whole year, were received during these seven weeks. The explanation may be found in the following circumstance. During the week preceding this rise, a circular was sent by the Clerk of the Council to every medical practitioner in London, informing them that cerebro-spinal fever was made notifiable for a further period of twelve months. It is in accord with experience that when the attention of the medical profession is strongly directed, in this or in other ways, to the possibility of any particular disease being prevalent, notifications of that disease are apt to increase. This appears to have been the case in the present instance. Such a reminder appears to act in the way of suggesting to medical practitioners the question " Can such-and-such a case be cerebro-spinal fever ? " a question which usually is not so vividly in mind. The certified cases were inquired into by the respective medical officers of health of the district, and the inquiries were followed up by myself. I endeavoured to ascertain the origin of every case and what factors bore on its causation. In this connection I interviewed the friends or relatives of nearly every patient and where necessary the medical attendant. Commonly the patients were in hospital. Inquiry was made into the previous history of patients and into the history of the parents and the family, particularly whether similar cases had occurred previously in the family. Attention was also directed to the condition of the mucous membranes of the patients ; and to the association of their disease with other diseases ; and to a number of other points which might possibly throw light on the causation of this disease. No single circumstance was found which would suggest that any one verified case had had any connection with any other, nor was there evidence of any common cause acting. In a word, it may be said that there was no evidence of the disease being infectious. In this regard the same mystery surrounds the disease, and the same perplexity exists in the minds of the profession, as has previously been noted. The question "What is exactly cerebro-spinal fever ? " is heard as often as before. It cannot be denied that it is a very elusive entity, and the diagnosis nearly always turns on bacteriological research. Bacteriology apart, there would be very little cerebro-spinal fever in London at the present time. It is interesting to analyse shortly the diagnoses of the cases. Of the 123 diagnosed during life, 59 were not confirmed by subsequent examination. Of the remaining 64 cases in which the final diagnosis agreed with that made originally, no bacteriological or post-mortem diagnosis was made in 15 cases ; and in another 29 the disease was specified as posterior basal meningitis, a sub-acute disease allied to cerebro-spinal fever, but commonly regarded as non-infectious. Thus only 20 remain, out of a total of 123 originally diagnosed, in which the acute form was diagnosed, and confirmed bacteriologically. But these 20 cases were not diagnosed by the same bacteriologist and therefore may have presented 2 important differences. It has been noted in former years that what one bacteriologist may accept as cerebro-spinal fever another may reject, the difference between them being not merely a difference of opinion, but a difference as to what features are required to be present before a case can be properly classed as the true disease. Considerable interest therefore attaches to the fact that these 20 cases were diagnosed by 11 different bacteriologists. The nomenclature in use by the profession continues to be confused. "Spotted fever" the popular term, is occasionally met with; cerebro-spinal fever, epidemic cerebro-spinal meningitis, a sporadic case of epidemic cerebro-spinal meningitis, meningococcal meningitis are the accepted medical terms in common use; with, of course, posterior basal meningitis. But it is not uncommon for a case to be described, although the meningococcus has been recovered, merely as "cerebro-spinal meningitis," a term which is applicable to every case of inflammation of the meninges that exists. Year by year it becomes clearer that, until there is a uniform standard of classification and nomenclature, little useful knowledge is likely to be acquired of a disease of which, so far as recent London cases are concerned, the very existence may be called in question. October, 1910. W. McC. Wanklyn. / APPENDIX IV. Londen County Council. FLIES AND VERMIN. Report by the Medical Officer of Health presenting reports by Dr. Hamer, Medical Officer (General Purposes), on Nuisance from Flies and on the Seasonal prevalence of Vermin in Common Lodging Houses. (Ordered by the Council to be printed, March 1st, 1910.) During the summer of 1909 investigations with regard to "Nuisance from Flies," on lines similar to those followed in 1907 and 1908, have again been made. In addition, however, to counting the flies caught at the various places of observation, the species have been, as far as practicable, determined, and charts showing the seasonal distribution of these species have been prepared. Two methods of capturing the flies have been employed, first by means of sticky papers and, second, by "balloons"; the results obtained will be found to present certain marked points of contrast. This fact suggests that caution is necessary in comparing the work of observers employing differing methods in different localities. In the light of the three years' records now available, a further examination of the "fly hypothesis" of causation of diarrhoea and typhoid fever can be made. The view expressed in previous reports, that a critical attitude, as regards acceptance of this hypothesis, should be maintained, must be still adhered to. During the year 1909 observations were made with regard to the prevalence of fleas, bugs and lice in beds and bedding in common lodging-houses. By plotting out the figures, curves showing the seasonal distribution of these three kinds of vermin have been obtained and are exhibited in Diagram IV. Supervision of common lodging-houses probably gives better facilities than can be found in any other branch of work for this purpose, for, notwithstanding the fact that the Council's inspectors are continually employed in the examination of houses and beds for evidence of the existence of vermin with a view to their destruction and prevention, there is abundant opportunity for the daily reinfection of beds by those who are habitually infested with these pests. The fact, however, that there is a constant conflict between the two opposing forces—the action of the inspectors and of the keepers of the houses on the one hand, and the continued reintroduction of vermin into the houses on the other—renders the result, so far as it indicates a natural phenomenon, somewhat uncertain. Dr. Hamer's report shows the difficulties which were met with in the inquiry and the steps which were taken to surmount these difficulties, but it should be remembered that the observations of a single year must not be accepted too unhesitatingly as showing with any exactitude the seasonal prevalence of vermin, even if the method of inquiry adopted, the only one which seemed possible, provides a sufficiently reliable basis for inference. These results are, however, deserving of being put on record if for no other purpose than that of encouraging others who have opportunities to make similar inquiry. In reading Dr. Hamer's report it needs to be borne in mind that the percentages of infested beds have been obtained by precise and detailed examination of each bed selected as a statistical unit. This examination has been made by highly skilled observers, and the slightest evidence of the presence of vermin, nits, stains, etc., has been regarded as sufficient reason for inclusion of the bed in the infested class. Dr. Hamer's report (page 8) also shows the efforts which have been made to secure the same severe standard by each observer so as to obtain as far as possible uniformity of method. Observations concerning the rat-flea and plague and the bug and relapsing fever, suggest possibilities with respect to the common infectious diseases, and point to the need for extension of knowledge concerning the natural history of human parasites in this country. An early step in this direction is to learn their seasonal prevalence, and Dr. Hamer endeavours to supply on this point such information as it has been practicable to obtain by inquiry during one year in London common lodging-houses. 546 Shirley F. Murphy, Medical Officer of Health. A 2 Dr. Hamer's Report. Part I.—Nuisance from Flies. In continuation of the observations of previous years, study has been made of the question of fly nuisance in certain selected localities. Instead, however, of dealing with twelve centres around which 163 places of observation were chosen as in 1907, or with nine centres surrounded by 141 places of observation as in 1908, only three centres were, in 1909, selected from among those studied in 1907 and 1908, and around them 35 places of observation in all were chosen. The three centres were— (1) A depot used for the manipulation of house refuse. (2) A glue and size manufacturers' premises. (See report of 1908, p. 2.) (3) A railway siding at which trucks were loaded with stable manure and other refuse materials. While the inquiry was thus limited in its geographical scope, it was considerably extended in respect of points of detail. Thus the work of previous years was undertaken only during the period of special fly prevalence, but in 1909 it was started in the middle of May and continued until the end of October. Again, experience had shown that species not commonly found on sticky papers could be trapped in balloons. The attempt was, therefore, made in 1909, to institute comparison of the results obtained, first by use of gummed papers exposed in 35 places of observation as in previous years, and second by use of fly balloons (25 in number) exposed in the open air, but in close proximity to the doors or windows of living rooms. The flies caught were classified into genera, and where practicable into species, and curves have been constructed giving the seasonal distribution of the various sorts of flies caught by one or the other method. This work was undertaken by Mr. E. P. Bates and Mr. A. C. Palmer (both of the Public Health Department), and their familiarity with the process of classifying flies, proved of great service. In several instances, in which some doubt arose, appeal was made to Mr. E. E. Austen of the British Museum, who has kindly named the specimens for us. All the flies caught in balloons, numbering from 4,000 to 20,000 a week, according to the time of the year, were sent to 8, St. Martin's-place for examination. Some difficulty was experienced early in the season, when the method adopted (at the place of capture) for killing the flies was to pour boiling water over the balloon containing them. This plan proved unsatisfactory, the flies were rendered moist and prone to decompose. Mr. Bates, therefore, suggested that a wooden box should be constructed, large enough to hold a balloon, and that it should be made as air-tight as possible by means of a close-fitting lid, with hinges and a clamping screw. The balloon containing the flies was placed in the box, sprayed with benzene, and the box was then closed for three or four minutes. Sorting was in this way rendered much less difficult, as the flies were kept dry and their natural colours were maintained. A further advantage was that the benzene killed not only the flies but their parasites, which the hot water sometimes failed to do. Larvae, however, were unaffected save when exposure to benzene was prolonged. The method of killing by hot water employed early in the year afforded striking instances of the vitality of flies; the use of benzene proved far more effective. Last year many flies were found mutilated, the contents of the abdomen or eye being eaten out, so that only a shell remained; and there was much speculation as to the cause. Early this year there were found, in a particular catch containing many flies thus mutilated, two specimens of Rove Beetle (Pterostichus madidus and Calathus cisteloides).* Later, more specimens of these two beetles were frequently found, and always in conjunction with mutilated flies. Earwigs also have a marked partiality for flies. The results of the year's work may be considered under the following heads:— 1. The total yield of flies on fly papers. The observations made with sticky papers have now been continued for three years, and it is possible to make a comparison of the results obtained on a uniform system. The curves in Diagram I. are drawn to a common scale, so as to admit of such comparison. For 1907 two sets of figures are charted on the curve, and the area between the upper and lower boundary lines thus obtained has been shaded. The upper boundary line represents the actual total numbers obtained at the 163 centres of observation dealt with. The lower boundary line gives the comparative figures obtained by reducing these totals in the proportion so as to make the 1907 figures comparable with those of 1908. The line which gives the figures for 1908 is based on the results obtained at the 141 centres in that year. The yield of flies in the two years may, therefore, be compared by examining the 1908 line and the lower boundary of the shaded area between the two 1907 lines. In 1909 there were only 35 centres, the figures therefore have been multiplied by four so as to obtain results for that year determined on the same scale as those of 1907 and 1908. All three lines thus represent the yield of flies obtained by use of fly papers at approximately the same number of centres of observation. Again, for purposes of comparison, the figures giving the diarrhœal mortality, week by week, have also been plotted out in Diagram I. It will be seen that the diarrhœal curves of the three years exhibit features which reflect, as it were, peculiarities of the corresponding fly curves—thus, as regards diarrhœal mortality, there was in 1907 a wholly exceptional delay in the rise to a maximum, and the same phenomenon is conspicuous also in the fly curve of that year. Close study of the three pairs of curves (fly curves and diarrhœal mortality curves) reveals many similar correspondences. (See P. 4.) * Kindly identified by Mr. E. E. Austen, 3 2. The evidence as to nuisance at particular premises. Observation was maintained, as in 1907 and 1908, at centres surrounding a dust depot. During 1907 this depot was used throughout the summer, and great nuisance from flies resulted. In 1908 operations, resumed during cold weather, were discontinued at the end of June, and a marked falling off in the number of flies followed; indeed, it was estimated that there were some 6,000,000 fewer flies in houses within a radius of two hundred yards of the depot during the summer of 1908 than in that of the previous year. In 1909 work at the depot was continued until the first week in July, but the meteorological conditions seem to have afforded opportunity for many flies to hatch out during July, inasmuch as early in August there was a smart rise in the numbers. While there was no such extreme development of nuisance as in 1907, it became clear that the use of the depot, up to the time named, caused serious fly nuisance, despite the fact that operations were entirely discontinued after that date. It should be noted that there was again, as in previous years, complaint of nuisance from smoke from the destructor chimney of the depot; this formed the subject of correspondence between the London County Council and the Borough Council owning the depot, and also of several reports by H.M. Inspector in connection with Pritchard's-road School. The Board of Education, indeed, intimated that, unless some steps were taken to abate the nuisance, it would have to consider the suitability of the school buildings for use as an elementary school. The chief special point of interest at the two other centres around which places of observation were chosen, in 1909, arises in connection with the prevalence of the particular species of fly, Protocalliphora groenlandica, to which reference was made in last year's report. The centres in question are near one another, one of them is a glue and size maker's premises, on which bones are received, the other is a railway-siding, to which, in addition to much stable manure and refuse material, the bones just referred to are brought on their way to the glue and size works. The sacks of bones contain vast numbers of larvae of the "special green fly," indeed the ground beneath some vans containing these sacks was found one day last summer to be covered by larvae, so that from a little distance this portion of the yard surface had the appearance of snow. On this occasion the unloading of the vans had been delayed, and the weather was warm. Late in the summer a system of destroying the larvae was adopted at the glue works, and it was found that this had some influence in lessening fly nuisance in surrounding houses. It was at first thought that observations on the occurrence of the special green fly at varying distances from the glue-works would enable a judgment to be formed as to the distance to which flies wander in their peregrinations. It was soon found, however, that this fly was caught not only around the glue works but also at houses surrounding the railway siding more than half-a-mile away. The suggestion was then made that the occasional presence of a railway truck containing bones, which would ultimately be carted away to the glue works, determined this distribution of the special fly near the railway siding. The observations of 1909, however, show that the special green fly was occasionally met with, not only near the glue works, but also in other parts of the town, so that the distribution of this fly in London is clearly not so limited as to enable it to be used as an index of the wandering capacities of flies. 3. Differences observed in the yield of flies obtained by using different forms of fly traps. The criticism has been made upon the methods employed in 1907 and 1903 that the exposure of sticky papers in living rooms does not give a complete record of the distribution of the various species of flies which enter dwellings. In order to obtain further light on this question in 1909, in addition to the use of sticky papers, balloons appropriately baited were exposed in the open air, but in close proximity to houses. Diagrams II. and III. exhibit the results obtained. The flies were sorted, by Mr. Bates, as far as practicable, into species (or at least the genus was determined), and in the diagrams the numbers of the six principal genera of flies are separately charted. The lowest eurves in Diagram II. relate, in each instance, to the common house fly, Musca domestica. The next curve in order gives the total for Musca and Homalomyia (the lesser house fly, Homalomyia canicularis being, no doubt, the species captured in the large majority of instances). Calliphora erythrocephala and Calliphora vomitoria (the "Blue-bottle Flies") were then added in to the totals, and the curve thus obtained follows next in order. Next the number of Protocalliphora groenlandica (the "special green fly" of former reports) was added. Then follows the curve obtained by adding in the numbers of Muscina stabulans, and last of all comes the genus Lucilia (Lucilia ccesar being the common species). Comparison of the flies caught in balloons with those caught on papers shows that while, among the latter, Musca greatly predominates, and other species (save Homalomyia) are very rarely met with, in the balloons all six genera are well represented, and, indeed, Calliphora bulks even more largely than Musca itself. The curves possess interest, but the results do not appear to affect the main conclusions drawn, in former reports, from use of sticky papers only. It seems clear, in view of the great predominance of Musca domestica inside houses, that any prejudicial influence exerted in relation to contamination of food supplies is more likely to be due to this species than any other. In Diagram III. the results are given in a different form—each genus of flies being shown in a separate chart—all the curves are drawn to a common scale. This diagram shows that, in the case of Homalomyia, the two methods of trapping the flies do not give greatly divergent results; in that of all the other flies (save Musca) balloons yield far more flies than papers. Stomoxys calcitrans,a, biting fly met with in a cowshed in 1908, has only rarely been captured in 1909. In the latter year no cowshed was kept under observation, but occasional visits, by one of the Council's inspectors, to the cowshed centre of last year showed that the fly was still present there in large numbers. 546 a 2 4 It will be observed that numerous specimens of Protocalliphora were caught from the middle of June until mid-September. Both species, P. groenlandica and P. azurea were apparently represented, though Mr. Bates thinks the latter was more frequently met with after the beginning of August, nearly all the earlier specimens being Protocalliiphora groenlandica. Whilst Musca, Homalomyia, and Muscina showed a steady increase, as the season progressed, Protocalliphora varied in an erratic manner, the numbers rising and falling from week to week without apparent reason. Thus in the week ending 21st August, when Calliphora and Lucilia showed marked increase, following a spell of thirteen days warm dry weather, Protocalliphora began to decrease, but rose again at the end of the month. The Rev. W. J. Wingate, in his book on " Durham Diptera," has remarked on the presence of Protocalliphora in considerable numbers during the time that a small manure factory was in existence in a particular neighbourhood, followed by their complete disappearance when the business was discontinued. Of the genera Muscina and Lucilia there is not much to say except that in London they appear to be most numerous in the neighbourhood of street markets where meat and fish are sold. A remarkable point noticed with regard to Muscina was the frequency with which it was infested with parasites. This was especially the case in early June, and of 300 flies of this genus then examined 40 were thus affected. The parasites were very small, and in some instances were aggregated so closely together that no part of the fly's abdomen was visible. In fact, the vermin formed a sort of chain mail, and must have been numbered by hundreds. Mr. E. E. Austen, to whom some specimens were sent, pronounced them to be Gamasid mites, allied to those found on dung beetles. Another parasite generally occurring singly, and as a rule on Musca domestica, was occasionally observed ; in size it is comparable with one of the compound eyes of this species. . In addition to flies belonging to genera named in Diagrams II. and III., others were occasionally met with—Hydrotcea deutipes (some 900), Sarcophaga hcemorrlwidalis (some 340), Scatophaga stercoraria (some 170), Spilogaster uliginosa (some 100), and nearly 100 further specimens belonging to other species. 4. The distribution of flies in sexes. In the inset chart of Diagram I. the percentages of male and female flies caught in balloons are shown. This determination of the sexes is based upon the examination of many thousands of specimens. In the Diagram, opposite each generic name is shown a series of columns, corresponding to successive weeks, each series having an irregular line upon it. The portion of each column above this line represents the percentage of male flies, the portion beneath that of female flies. The curve for all flies shows that the two sexes are fairly equally distributed throughout the summer, and that for Calliphora also shows nearly equal distribution of males and females. The curves for Protocalliphora and Lucilia are more irregular. In the case of Musca there is some slight tendency for males to predominate early in the season, and females later. Homalomyia proves quite exceptional, for the males distinctly predominate throughout, constituting between 75 and 85 per cent of all the flies of this species caught. A similar distribution so far as Homalomyia is concerned was found to hold good last August in a house in the country. Specimens of Homalomyia caught indoors were generally males, but out of doors small swarms of Homalomyia were occasionally encountered, and examination showed that these were females. The latter persistently settled upon human beings,, and were a source of considerable annoyance, while the flies of this genus met with in living rooms gave little or no trouble of this sort. It may be noted as a point of interest, that in the house in the country just referred to Musca domestica was not met with; Stomoxys calcitrans was fairly plentiful, but the large majority of the flies indoors belonged to the species Homalomyia canicnlaris, and were male flies. Further Observations on the Relation of the Fly to Food Contamination and to Spread of Disease. (a) Correspondences in the fly and diarrheal curves.—This question has already been discussed in the reports of 1907 and 1908, and it possesses interest, inasmuch as the observed correspondences have been cited as a proof that flies cause diarrhoea. The phenomena might be explained, however, as has been pointed out, on the assumption that the same causes (temperature, rainfall, etc.) which operate upon the curve of a particular year in the one case (diarrhoea), also produce the corresponding variations observed in the other case (number of flies). If, moreover, the curves of one year be compared with those of another, discrepancies are found to present themselves. Thus in the Report (October, 1908) on Nuisance from Plies, certain features of the 1907 and 1908 fly curves were commented upon, as telling in favour of an explanation by a common cause, rather than by the hypothesis that flies cause diarrhoea. In a similar way, appeal may be made to Diagram 1. of the present report. The ascending portion of the fly curves of 1907 and 1909 almost exactly correspond, and thus it may be said that, so far as prevalence of flies is concerned, the two years stood throughout the months of July and August almost exactly on a par; yet the figures showing the rise of diarrhoea mortality in those years reveal a marked contrast, for in 1909 a sharp rise reaching a maximum in August was observed; while in 1907 the rise was very slow, and the maximum was not attained until the end of September or early October. Considerations of this sort make it clear that, if flies play any considerable part in causing diarrhoea, the effect produced by them is, at any rate, much obscured by other influences, and too great importance must not be attached to correspondences in the fly and diarrhoea curves of any one year. On the other hand, as has before been stated, even granting 5 that the general contour of the two curves is broadly traceable to common causes, there remains a possibility that some effect may be exerted upon diarrhoea prevalence by flies. In this connection the following considerations need to be borne in mind. It is generally assumed—to quote words used by Dr. Longstaff 30 years ago—that there is a specific cause of diarrhoea, such as "some animal or vegetable matter in a state of change, or even a living germ." This cause may itself be subject to meteorological influences, and may, therefore, operate more intensely at one time of year than another. On the assumption that the fly acts as carrier, the prevalence of diarrhoea must be determined not merely by the distribution of flies, but also, and, indeed, more particularly, by the seasonal intensity of operation of the specific cause. This fact is apt to be lost sight of by those who hold that, because there is a fairly precise correspondence in time of flies and diarrhoea, there is therefore a causal relationship between them. If, on the other hand, as some maintain, almost any organism associated with putrefaction may communicate to food materials the ability to cause diarrhoea, it should be noted that the quantity and quality of germs floating in the air are largely influenced by season, and it may be found that the seasonal curve for "totalgerms" presents correspondences with the curves both of flie3 and diarrhoea. If this should be demonstrated to be the case, the role of the fly in spreading diarrhoea may prove to be, at most, only a subsidiary one. (6) Comparison of the seasonal curves of " intestinal diseases " and of flies.—It has been claimed that the fly has been largely concerned in some instances in spreading typhoid fever; indeed, in America the insect has been designated the " typhoid fly." A difficulty which presents itself in this connection has been felt both here and in America. Thus, in Dr. Daniel D. Jackson's report on the "Dissemination of Intestinal Diseases through the agency of the Common House Fly," a chart is given showing weekly deaths from diarrhoea and from typhoid fever in relation to temperature. The typhoid fever deaths have, however, been set back two months, and the curve thus brought into correspondence with that of diarrhœal deaths. It is explained that this has been done to cause the curve " to correspond to time of contracting the disease." It is difficult to justify so long a period as two months being fixed upon. Inasmuch as both the typhoid fever and diarrhoea curves relate to deaths, an antedating of some five weeks only would appear to be indicated. The same discrepancy is manifest in this country, as Dr. Peters has shown (Trans. Epidem. Sect. R.S.M., 1908-9, pp. 5 and 43). Dr. Peters, who it must be noted is dealing with diarrhoea deaths and typhoid fever notifications, says, " the beginning of the typhoid is seen to average about four weeks later than the diarrhoea, or about three weeks if a reference be made in each case to the date of infection." Thus, in America and in England, the time of maximum distribution of infective material is some three weeks later in typhoid fever than in diarrhoea. This fact is not reconcilable with a thesis that the seasonal curves of diarrhoea and typhoid fever are determined solely by extent of prevalence of a common carrier, viz., the fly. On behalf of the fly hypothesis it might, however, here again be urged that the specific causes of both diseases themselves respond to seasonal influences—the diarrhœal harvest maturing first, then three or four weeks later that of typhoid fever. Although there is not simultaneity, spread of infection may, in both cases, be facilitated by the fly, just as flowers of different species, maturing] some earlier some later in summer, are fertilised by insects. (c) The decline in jxrevalence of diarrhoea in relation to diminution in number of flies.—In a previous report it was pointed out that the London diarrhœal curve of 1907 showed marked decline at a time when the number of flies was still excessive, and reference was made to the observation of Dr. Niven, Medical Officer of Health of Manchester, to the effect that " the descent in the number of deaths precedes the diminution in the number of flies." Further experience confirms these observations. Thus the London deaths, in the early weeks of September, 1909, showed a distinct tendency to decline, and the disease must presumably, allowing for incubation, etc., have shown a similar tendency at least a week or two earlier, i.e., at the end of August. Yet throughout the first half of September flies were much more numerous than in the first week in August when diarrhoea was rapidly increasing. Dr. Niven has suggested that the phenomenon may be due to exhaustion of susceptible material. But it is observed not only in years of high mortality, when such exhaustion might have influence, but also in years of very low mortality, when it could not operate to any appreciable extent. The fall of diarrhoea, in the first fortnight of September, commonly observed in an ordinary season, in London to-day, occurred also, allowance being made for change of style, in Sydenham's time. That author writes : " This disease, however much it may be epidemic, very rarely occurs beyond the limits of the month of August, the month in which it begins. This makes me admire the beautiful and subtle mechanism of Nature in the determination of the origin and decline of epidemics, since even, although the same causes, viz., the abundance of fruit" (and he might have added, the prevalence of flies), " are common to the months of September and August, the effect is different." It has, however, been suggested that the actual gross number of flies is of minor importance, and that activity and habits, in relation to visits to infected material and to food, must more especially be considered. Thus, Dr. Nash says (Journal of Hygiene, September, 1909, p. 158): " The numerical abundance of flies visiting food and more particularly milk, directly after or within a few hours of settling on objectionable matter, whether out of doors or within a dwelling place," determines the amount of diarrhoea. He adds : " Although flies may appear to be quite as numerous in houses after the diarrhœal curve begins to descend, when the temperature of the air falls perceptibly they are less active in their habits, and do not peregrinate to the same extent in consequence of the cold, but make for the warmer corners of the room and pay less attention to feeding." This description would, doubtless, hold good in late October, when autumn is well established, but in 1909 our own observations, made directly on this point, show that during late September and early October flies were particularly 6 active, flying in and out of and about living rooms, and alighting upon food materials, and yet at this time the diarrhœal prevalence of the year was practically at an end.* (d) Some further considerations.—A study of typhoid fever and diarrhoea prevalences in the light of a hypothesis which attributes their spread to one and the same carrier, the fly, raises further questions. In the first place—Does heavy incidence of the one disease, upon a locality, imply a like incidence, in one or more years, of the other disease ? Sir George Buchanan investigated this point in certain English towns more than forty years ago, and concluded that, while some correspondences were noted, " there remain sufficiently obvious differences between the fluctuations of mortality from typhoid and from diarrhoea to make it probable that other influences than those affecting fever have operated on the prevalence of epidemic diarrhoea." Dr. Niven (Annual report, 1894) wrote in a similar sense, saying : " The causes of typhoid fever are, in fact, much more complex than those of summer diarrhoea." Later (Annual report, 1898), he suggested that possibly midden privies operated prejudicially in Manchester in promoting both typhoid and diarrhoea prevalences, but he added " other influences besides that of local filth conditions " enter very largely into the causation of high mortality from diarrhoea. Dr. Newsholme (Public Health, December, 1899) pointed out that the table of the Registrar-General, giving average death-rates for diarrhoea and typhoid fever 1888-1897, shows that there is no necessary association in the positions of towns in respect of high or low mortality from these diseases. He says: " Sunderland is worst (thirty-third) in the list for fever, only twenty-third for diarrhoea ; Swansea is thirteenth for fever, third for diarrhoea; Brighton is second best for fever, only eighth among thirty-three towns for diarrhoea," and so on. Reference to the corresponding table relating to the last ten years reveals similar discrepancies. If the fly play an important part in determining prevalence of the two diseases, exceptions such as are here in question need explanation. Then, in the second place, question arises as to the association of diarrhoea and typhoid fever with faulty systems of excrement disposal. Dr. Longstaff, in 1880, said: " We may dismiss as untenable " the theory that the disease (diarrhoea) is due to filthy privies, for they " are as common or commoner in the country than in the large towns, and are, therefore, not likely to be the cause of a town disease." Again, Sir George Buchanan, in 1888, commented upon the maintenance of the death rate from diarrhoea " after years of sanitary work in England." On the other hand, several observers have inclined to an opposite view, and Dr. Boobbyer, of Nottingham, has in recent reports repeatedly urged that privies favour the spread of both diseases. The suggestion has been made that inquiry as to diarrhoea in relation to flies is likely to be more profitably pursued in towns in which the dry method of disposal of excreta is still in operation than it is ir London or any other well drained and sewered town. It is, however, noteworthy that in the poorer parts of towns provided with water-carriage removal, high rates of diarrhoea mortality still prevail; moreover, while the contrast between town and country is now far more marked than it was thirty years ago the disease remains pre-eminently one of large urban communities. As regards diarrhoea, a further question arises. There is good reason for thinking that maternal neglect plays an exceedingly important part here. It is true that many " diarrhœal towns " have faulty systems, of excrement disposal, or contain exceptionally poverty-stricken populations. But among possible influences that of employment of married women away from home unmistakably emerges on careful study of the figures!. What bearing has this fact upon the fly hypothesis ? On the one hand it may be argued that domestic neglect is particularly likely to afford scope for the fly. On the other, as Dr. Ballard insisted, the question of such neglect, with other influences of urban conditions, while most marked in diarrhoea, is "noticed also in respect of infant mortality from other causes." Mr. Foulerton, in a recent report (1908-9), indeed, argues that" the insanitary circumstances which, in the case of artificially fed children, increase the liability to death during the summer months, from a diarrhoea resulting from bacterial infection of food, will, in the months of the year when climate influences favour the development of pneumonia, provide the opportunity for effective bacterial invasion of the lungs." As Dr. Longstaff has said, "the lungs are susceptible in cold weather and the intestine in hot." But if bacterial invasion can be accomplished in winter without the assistance of the fly, why not in summer also? However this may be, it becomes clear that a high death-rate from diarrhoea may be favoured by many influences which have no necessary dependence upon the existence of large opportunities for the spread of infection. The death-rate is thus a very rough and unreliable test of the incidence of the disease. The ordinary difficulties encountered in comparing death-rates, are further aggravated in the case of diarrhoea by the fact that, while the very young and the very old contribute most largely to the deaths, the disease itself is not limited to the extremes of life. This last named consideration especially emphasises the value of notification. * Dr. Nash refers in the same paper (p. 159) to two outbreaks, one of dysentery and one of typhoid fever, which had been attributed to flies bred in deposits of house refuse, and, he argues, in support of this view, that there might have been dysenteric polluted matter at one side of the dust heap and typhoid material at the opposite side. The difficulty which presents itself with regard to this thesis is that of explaining why all the flics carrying typhoid material travelled north-east, and all those carrying dysenteric material north-west; the respective fly swarms making for separate destinations nearly half a mile apart, and dysentery-laden flies invariably choosing the one, and typhoidladen flies the other destination. † Miss Collet (Journal of the Royal Statistical Society, 1898) has pointed out that poverty, as gauged by a domestic servant test, follows, as a rule, high percentage of employment of married women in factories ; and hence the difficulty of separating the one influence from tho other is great. There is, however, doubt as to how far the domestic servant test can be relied upon, in a comparison made between a number of towns, including Lancashire and Yorkshire towns, and also towns in the Midlands ard South of England. 7 Notification of Diarrhoea.—In Woolwich a system of notifying diarrhoea during the summer quarter has now been in force since 1905. If similar effort to ascertain the facts were made elsewhere material of great value would soon be available. Dr. Sidney Davies, medical officer of health of Woolwich, has prepared a report on 844 cases notified in the years 1905-8, and he indicates some of the directions in which advances in knowledge may be looked for. Two interesting points, raised by Dr. Davies, may be here referred to. With regard to evidence of protection afforded by a first attack, the Woolwich figures show that there were notified a second time three children in 1906, one in 1907, and again only one in 1908. If the attack-rates of each year be applied to the populations attacked and escaping in the previous year, it will be found that the numbers three and one and one are those which might have been predicted on the supposition that the question was one of mere chance. Thus, at most, it could only have been expected that two children, attacked in 1906 or in 1907, would have again been notified in 1907 or 1908. The fact that there was only one such case in each of those years does not justify the conclusion that a first attack affords protection. A further point made is the lack of evidence of special incidence of diarrhoea in the neighbourhood of dung-pits. This tallies with similar observations on a larger scale made by Dr. T. Orme Dudfield in Kensington, and by Dr. Harris in Islington, and again with inquiries made in 1908 with the co-operation of Dr. Porter in Finsbury (See Report on Flies, 1908, p. 5). The fact has special interest in connection with the question as to whether flies act as carriers, having in view the close association of Masca domestica with collections of stable manure. Direct infectivity.—In conclusion, it may be remarked that a subject which especially demands study is, how far infectivity from case to case plays a part in determining prevalence of diarrhoea. Dr. Ballard said the disease "is usually regarded as non-communicable"; but he added, "communicability is a quality not unknown among cases of epidemic diarrhoea." He cited some remarkable observations made on this subject by Dr. Bruce Low, and these are often quoted. It is deserving of note, therefore, that the outbreaks occurred in country districts, and three of the four in May February, and December respectively. The fourth, it is true, prevailed from September 8th to the beginning of December, 1886, but this is late for summer diarrhoea, which attained its maximum in that year in the third week of July. Dr. Niven (Annual Report, 1904) has, however, made a study of instances of possible case to case infection in Manchester, and quite recently a critical review of the whole question has been made by Dr. Sandilands (Proc. Roy. Soc. of Med., 1910). The difficulty which has to be faced is that of determining, in the event of several members of a family being attacked by diarrhoea, whether one has infected the other, or whether all are alike attributable to some common cause. There is evidence, bearing on the question, from institutions, but this evidence is very conflicting. (See, for example, a paper by Dr. Ralph Vincent, " The Etiology of Zymotic Enteritis," 1910.) Further observations are much needed : the belief that case to case infection has large importance is commonly entertained, but the arguments against this view cannot be ignored. The question in dispute is intimately bound up with that as to the part played by the fly. Until a final decision is arrived at it is well not to forget that prevention involves, as the President of the Royal College of Physicians has said, "something more than the circumvention of a bacillus." It may well be argued that if this holds good of diseases of so called "established bacteriology," it may not unprofitably be kept in mind also in connection with diarrhœa. There are three considerations which especially emphasize the importance of strengthening resistance and influencing general conditions of environment. Firstly, fatal diarrhoea mainly occurs in young infants, in whom the incidence is especially marked, in the heavily invaded towns at any rate, at a particular age, say from three to six months. Secondly, fatal diarrhoea preponderatingly occurs in particular hot weeks, and, thirdly, heavy death-rates from diarrhoea are closely associated with special domestic and social conditions. Dr. Newman (Infant Mortality, 1906) says it has not been necessary, in the intervening years since 1858, greatly to modify the view then expressed, by Sir John Simon, that " infants perish under the neglect and mismanagement which their mothers' occupation implies." This opinion is, on the whole, confirmed by recent experience, which goes to show that much more can be accomplished by combating the special domestic and social evils in question, than by attacking either a hypothetical organism or its supposed carrier the house-fly. Part 2.—A Statistical Record op the Results op Routine Inspection of Beds in Common Lodging Houses for Vermin. During 1908 an attempt was made to record week by week, on a uniform basis, the extent to which beds in common lodging houses yielded evidence of the presence of fleas, bugs, and [lice. In each of eleven inspectors' districts ten beds were examined daily, on five days out of seven making a total of 550 beds weekly, In the case of each bed the sheets were carefully scrutinised for lice and the beds were divided into four classes— Those on which one louse was discovered. Those on which two lice were discovered. Those on which three lice were discovered. Those on which more than three lice were discovered. The percentage of beds belonging to the last class varied from nearly 8 per cent. in February, to about 2 per cent. in June. The actual numbers relating to these (the very verminous beds) are small, and for the purpose of determining the seasonal prevalence of lice it is preferable to deal with the much larger figures obtained by grouping together all four classes above named. The figures giving 8 the percentage of the whole number, constituted by beds on which any evidence of the presence of lice was found, varied from a maximum of 31 per cent in the first week of February to a minimum of 12 per cent. in the first week of June. The results are of course based on the examination of beds in many houses. In particular premises the percentage was found to be quite low. On the other hand, the lodgers frequenting some of the shelters, for example, are more often verminous than not, and it is thus found that each time a bed is used it becomes verminous. The seasonal curve formed by the weekly figures is shown in Diagram IV. It maintains a high level for the first three months of the year, is low in April, May, and June, rises a little in July, more decidedly in the late summer and autumn months, and shows a tendency to maintain a high level for the remainder of the year. The seasonal variations stand in marked contrast to those to be now referred to as having been observed in the case of bugs and fleas. Evidence of the presence of bugs was, for the purposes of this statistical inquiry, searched for in some 550 beds weekly. The seasonal curve thus obtained (see Diagram IV.) was at a low level in the early part of the year, rose in April, May and June, and after some irregularities attained a maximum in the thirty-fifth week (first week of September). It then fell, with some interruption in midOctober, reaching a low level again at the end of the year. It will be seen that the percentages for bugs are far lower than for lice. In the former case the conditions can be and are more effectually controlled by keepers of common lodging houses. In dealing with fleas, it was originally intended to count, as flea-infested, all beds in which any evidence of the presence of a flea was found (either a flea itself or a flea-mark being discovered). As will be seen later, this rule was not in all instances strictly adhered to. The curve in Diagram IV. follows much the same course in relation to season as does that for bugs. At first the level is low, it then rises in April, May, June, July and August to a maximum in the first week of September : from thence onwards, however, the decline is less abrupt than in thecase of bugs, though after the 45th week the flea curve descends quite suddenly to approach the level at which it started early in the year. The following possible sources of error need to be borne in mind in studying the curves showing the seasonal distribution of vermin. (1) The disturbing influences attendant upon the introduction of a special system of inquiry of the kind here in question. It was only to be anticipated that the fact that on given occasions a minute and detailed examination of particular beds was made, and a record of the results entered up, would be likely to cause special carc to be devoted to cleanliness by the keepers and deputies having control of those beds. With a view, therefore, to preventing disturbance of statistical results the scheme of investigation was so ordered that the beds, examined week by week, were selected from a considerable number and constituted, as far as possible, a random sample from each inspector's district. The principle has, speaking generally, been adhered to, but detailed study of the dates of examination of beds in individual houses shows some departure from it, and in correspondence there is observable a maintenance in two districts of the high level originally attained in September for some weeks after that date: the phenomenon is less marked in the figures relating to the other nine districts. (2) The difficulty of preserving an uniform standard with regard to the severity of the test applied. In the case of lice and bugs, no serious trouble has been experienced. In that of fleas, two main difficulties have been encountered. It was arranged at the outset that beds, in which either fleas or flea-marks were found, should be placed upon the black list. This rule has not been absolutely adhered to. Thus, by some misunderstanding, no regard at all was paid to flea-marks in the earlier months of the year in two districts. Attention was not directed to this defect until the middle of May but from that time onwards the two inspectors in question included flea-marked as well as flea-infested beds. The presence of fleas in bed-clothing is difficult of ascertainment owing to the rapid movements of the flea, and the possession of particularly good sight may have had influence in determining that comparatively large numbers have been returned in some instances. A more serious question arises in respect of flea-marks, for, while no difficulty can be felt as regards the majority, occasionally marks are encountered as to the nature of which there is doubt, and, in practice, it is found that some observers record a larger number of flea-marks than others, even when they have subjected to examination beds in the same lodging houses. Indeed, as time went on, there was manifested a tendency on the part of the investigators to take a broader view of the interpretation of the definition of a " flea-mark." Furthermore, during the summer holidays, when there was an interchange of districts between the inspectors, attention was necessarily directed to differences of standard, and this circumstance may have had some disturbing influence for the remainder of the year. In point of fact, the figures in three districts, over and above the two already mentioned, show that the number of flea-marks returned during the later months of the year was disproportionately large. (3) The migratory habits of the common lodging house population. A third difficulty has clearly to be faced in connection with these observations. The common lodging house population is not a stationary one. As regards quantity, the variation in numbers is not so great as to make it likely that this in itself would be a serious disturbing influence. As regards quality, however, the increase in numbers, noted as the autumn advanced, was, in part, due to the return to London of persons who had been engaged in work in the hop fields, and of tramps and others driven into town by the approach of winter. These persons were found in a considerable proportion of instances to be verminous. The " hoppers " returned to the lodging houses in late September and 9 early October; the tramps and immigrants from the country generally came rather later. There can be no doubt, therefore, that in October there were special causes favouring verminous conditions in common lodging houses, over and above the ordinary seasonal influences, affecting such conditions in the population at large. In other words, it may be inferred that if the curve for fleas had been obtained from observations made on the general population, it would have exhibited a somewhat more abrupt fall, after attainment of its maximum in the early part of September, than was actually the case. It will be seen, then, if due weight be given to these various considerations, that the true flea curve must be held, after attainment of a maximum in early September (35th week), to have fallen more decidedly and suddenly than that actually shown in the diagram. In fact, the real curve approximates more closely to the bug curve. Question has from time to time been raised as to the possibility that fleas, bugs and lice may transmit disease.* The autumnal high level in the flea and bug curves suggests comparison with the curves of diseases which have an autumnal prevalence. Study of Diagram IV., in conjunction with the notification curves given in the Report of the Medical Officer of the County of London for 1903 (Opp. p. 13), shows a rough correspondence between the flea and bug curves and some of these notification curves. Having regard to the comparisons which have been made between the curves of seasonal prevalence of flies and of diarrhoea, it becomes a matter of interest to examine these rough correspondences a little more closely with a view to learning whether they throw any light upon the general question of possible insect carriers of infection. In the cases of scarlet fever and diphtheria, there are certain facts which suggest the desirability of keeping an open mind as to whether the last word has been said concerning the mode of spread of infection. For example—the special incidence upon children, and particularly upon children in schools. The evidence as to fomites and the alleged clinging of infection to houses or rooms, or in schools to particular departments or even classrooms.† Furthermore, mention may be made of the fact that scarlet fever rarely spreads from an infected to an uninfected child in the ward of a well-managed hospital, but such spread does occur ("return cases") after children are sent back to their homes.‡ The possibility cannot, of course, be absolutely excluded that a biting insect has played a part in transmitting infection from case to case in some instances, and that in the absence of such intermediary, infection has not been transmitted. In the year 1909 the London scarlet fever and diphtheria curves, it may be said at once, were quite atypical. A considerable milk outbreak of scarlet fever occurred in June and July, and disturbed the ordinary development of the rise usually observed in those months. Apparently, however, the true autumnal maximum for scarlet fever occurred in the thirty-eighth and that for diphtheria in the thirty-ninth week; while the maxima for both the biting insect curves occurred in the thirtyfifth week. There was thus an interval of three or four weeks between the attainment of the maxima in the latter instances and in the former. In the case of flies and diarrhoea, no such interval is, as a rule, observed, the curves are practically superimposed one upon another. The bearing of this fact upon the hypothesis of fly causation of diarrhoea has been already considered, and it has been pointed out that there is, in the absence of any such interval, little, if any, time available for dissemination of infection, incubation, etc. It must be remembered, however, in this connection, that there is no need for time for development of an organism in the body of the fly. The suggestion has never been made that the hypothetical organism of diarrhoea passes a phase of its existence within the fly in the manner demonstrated for the malaria organism within the mosquito. If the fly merely acts as a carrier there is, at any rate, no question of allowing time for such development It will be interesting to learn whether or no the figures for future years confirm those of last year, in respect of showing an interval between the time of occurrence of the maxima for fleas (or bugs) and the maxima for scarlet fever and diphtheria. Obviously, at the present time, no more can be said than that the subject is one deserving of further study. The difficulties encountered in constructing a seasonal curve for fleas are considerable, but they should be surmounted, if it be only with a view to throwing further light on the study of seasonal curves of disease in relation to corresponding curves for possible carriers of infection. * For example, Dr. Copeman, F.R.S., in a recent report on Enteric fever at Workington, raised question as to whether, in certain instances, direct inoculation by means of flea-bites had occurred. † Dr. Niven has referred (Annual Reports, 1897-1901) to evidence of "the tenacity of the disease as regard particular departments." He says, "It may go on for a year or more in a department, attacking a case in May, another in June, another in July, and so on." Again, he observes, " The history of scarelet fever in schools seems to imply a low power of aerial transmission." ‡ Mr. T. W. Thompson (Vol. XV. Epidem. Soc. Trans.), in discussing the " return ease " problem, enumerated possible causes of the differing incidence on one as compared with another class of household. He referred to the influence of school attendance, social circumstances, etc., but concluded. " some more obscure factors are at work, factors perhaps closely bound up with the natural history of scarlet fever." W. H. Hamer, Medical Officer (General Purposes). 546 DIAGRAM 1 Diagram shewing the relation in point of time betweep preva/ence of files and diarrœal mortality in Londen in the years 1907,1908 and 1909. DIAGRAM II. Diagram shewing the number of files belonging to 6 principal genera caught in balloons and on papert during the summer of 1909. DIAGRAM IV. Diagram shewing the seasonal prevalance prevence of three kind of vermin. APPENDIX V. London County Council. HOMELESS PERSONS. Report by the Medical Officer submitting the result of a census of homeless persons taken on the night of 18th February, 1910. (Ordered, by the Council to be printed 14th June, 1910). On several occasions during the six years just past the Public Health Committee has instructed me to take a census of homeless persons in London, and the fifth of these enumerations was made on the night of the 18th February, 1910. The following figures enable comparison to be made of the several results:— Number of persons found homeless at night. Date. Men. Women. Young Persons. Total. 29th January, 1904 1,563 184 50 1,797 17th February, 1905 1,869 312 .. 2,181 8th February, 1907 1,998 402 4 2,404 15th January, 1909* 566 †1,629 170 23 2,388 18th February, 1910 732 † l,778 220 17 2,747 * Since my report for 1909 was printed it has been ascertained that 300 men wore provided with food and shelter for a few hours at the Salvation Army lodging house in Middlesex-street, City. Those'figures were not included in that report, but opportunity has been taken in the present return of including them wherever they affected the total numbers. † Men accommodated for a few hours in shelters but unprovided with beds. As mentioned in my last report on homeless persons, the figures for 1904 relate to an area somewhat smaller than that included in more recent years, and it is estimated that if the same area had been covered the number might have been 2,000 in that year. The system instituted last year by the Salvation Army, of allowing homeless persons to rest for several hours in a shelter where they were also fed, has been continued during the past winter, the majority of the men being received in a large building in Great Peter-street, Westminster, which the Army is adapting for use as a common lodging house. On the night of the 18th February, 1910, 850 men were provided for in this shelter, 300 men at a shelter in Middlesexstreet, City, and 278 men at another shelter in Blackfriars-road, Southwark. In the King's Tents belonging to the Church Army there were 78 men at work; whilst in a shelter opened in conjunction with the Tents there were 139 men waiting for their turn at wood-chopping, which entitled them to food and a ticket for a bed in a common lodging house on a subsequent night. In other institutions, affording shelter and food only, there were 133 men. Thus the total number of persons provided with food and shelter but no bed was 1,778. To this number must be added 969 persons found in the streets, giving a total of 2,510 men, 220 women, and 17 young persons under the age of 16 years, including one girl. This figure, however, does not represent the total number of persons who might be regarded as homeless on the night of the enumeration, inasmuch as several licensed common lodging houses provide free accommodation, and there are, moreover, some night refuges, not licensed by the Council, providing free beds for the destitute. The inmates of these institutions numbered some 2,350 persons, i.e., about 1,290 in free common lodging houses, and about 1,060 in the unlicensed institutions to which reference has just been made. The persons occupying these institutions have not been included among the homeless in previous years owing to the difficulty of obtaining accurate information, and they have been therefore again omitted in order that the figures for the several years may be strictly comparable. The Church Army, the " Christian Herald " (Willow Street) Mission, and other charitable bodies too, distribute tickets entitling tho holder to a night's lodging at a common lodging house, and from inquiry at the several common lodging houses I learn that on the night of the census at least 368 men and 80 women availed themselves of this means of obtaining shelter. For the sake of convenience the information contained in this paragraph has been summarised, and will be found in Table V. at the end of this report. The figures relating to the years 1909 and 1910, given in the above table, show that 149 more, men obtained free food and shelter in the later than the earlier year, and the number of men, women and young persons apparently under sixteen years of age found in the streets was in the later year greater by 210. There was thus an increase in the number of actually homeless persons of 359. 714 S.S./2084 2 In dealing with any comparison of figures relating to the homeless, however, regard must be had for the number of persons occupying common lodging houses and casual wards, as there is continual interchange among the three classes. The two following tables show the use made of the common lodging house and casual ward accommodation on the several occasions on which enumeration was made. For the figures relating to the casual wards I am indebted to Mr. J. S. Davy, C.B., of the Local Government Board. Licensed Common Lodging Houses Date. Authorised accommodation Number of persons occupying beds. Men. Women. Couples. Total. Men. Women. Couples. Total. 29th January, 1904 25,718 2,281 447 28,893 21,058 1,517 390 87 Children 23,442 17th February, 1905 25,671 2,450 422 28,965 21,055 1,578 357 34 Children 23,381 8th February, 1907 25,599 2,436½ 245 28,525 20,438 1,598 207 22,450 15th January, 1909 25,976 2,365 245 28,831 20,059 1,483 161 21,864 18th February, 1910 25,902 2,344 245 28,736 19,346 1,456 177 21,156 Casual Wards. Date. Accommodation. How used. Men. Women. Women and children. Total. Men. Women. Children. Total. 29th January, l904 1,243 410 114 1,767 1,034 175 9 1,218 17th February, 1905 1,213 420 120 1,803 926 210 3 1,139 8th February, 1907 — — — 1,882 — — — 1,137 15th January, 1909 1,241 444 122 1,807 1,001 184 3 1,188 18th February, 1910 1,219 454 119 1,792 928 173 6 1,107 The next table shows the total common lodging house and casual ward accommodation, the extent of its use, and the number of homeless persons in each year. Date. Accommodation (persons). Persons. C.L.H. Cas. wards. Total. C.L.H. (Inmates.) Cas. wards. (Inmates.) Homeless. Total.* 29th January, 1904 28,893 1,767 30,660 23,442 1,218 1,797 26,457 17th February, 1905 28,965 1,803 30,768 23,381 1,139 2,181 26,701 8th February, 1907 28,525 1,882 30,407 22,450 1,137 2,404 25,991 15th January, 1909 28,831 1,807 30,638 21,864 1,188 2,388 25,440 18th February, 1910 28,736 1,792 30,528 21,156 1,107 2,747 25,010 * These figures do not include the persons in the unlicensed homes and institutions referred to in table No. IV these persons might be regarded as belonging to the common lodging house class. From these tables it will be observed that there is a continuous and steady reduction in the number of inmates of common lodging houses, and in comparing 1910 with the previous year there is a difference to the extent of 713 men and 27 women, though the beds occupied by couples showed an increase of 16. There was thus a nett difference of 708 persons. In casual wards, too, the figures for the several years, on the whole, show a decline, and the persons, accommodated on the 18th February last were fewer by 81 than those received on the 15th January, 1909. There was thus a deficit of 789 persons in common lodging houses and casual wards together. To be set against this there is an increase of 359 in the number of homeless persons, leaving a total of 430 persons who have been removed from the class of people now being considered, whether by way of admission to public institutions, death, or improvement in circumstances cannot be stated. If the figures for men and women are treated separately there is some difference to be observed. In comparing the 1909 and 1910 figures, the later results show a decrease of 713 men in common lodging houses, and 73 men in casual wards, or 786 men in all. In the "homeless" figures, however, there is an increase of 325 men, leaving a nett deficiency of 461 men. It might be pointed out in passing that nearly 300 more tickets for beds in common lodging houses were distributed last year than this year, which might account for part of the large diminution in the lodging house population and the large increase in the number of homeless men observed in 1910. With regard to women, the figures for 1910 show a decrease of 27 in the lodging house population, and 11 in the casual ward population, or 38 in all. The increase in the number of homeless women was 50, and this in spite of the fact that 153 tickets were this year distributed entitling the holder to a free bed in a common lodging house. This is quite a new departure, inasmuch as the number of tickets for women given away in previous years was so small as to be negligible, and it might, therefore, be suggested that 3 the real number of homeless women this year was as much as 200 in excess of last year's figures, though, as will bo mentioned later in this report, the issue of the tickets appears to have had a disturbing influence upon the paying inmates of common lodging houses, and this influence has been felt even in the threepenny Salvation Army shelter for women, which at one time had never a vacant bed, but which now has from 50 to 80 beds empty every night. Whilst referring to the casual wards I might mention that I caused some inquiry to be made with the object of discovering if possible what became of the men who were refused admission to two of the most popular wards, viz.:—the City Casual Ward, Thavies Inn, and the Marylebone Casual Ward. At the former place, at 5 o'clock on the evening of 10th February, 7 women and 50 men were waiting for admission. All the women and about 20 of the men were admitted. The remainder scattered very quickly, some to get to the Marylebone Casual Ward by 6 p.m., and others to reach Lambeth Ward by 7 p.m. The Lambeth Ward, however, it was ascertained from these men, is not popular on account of the task imposed. Several of the men made their way to the Embankment to share in the distribution of food which takes place under the supervision of Mr. and Mrs. Eustace Miles. I am informed that 30 or 40 men are turned away from the City Casual Ward every evening, and that they go either to the Embankment or to other casual wards. At Marylebone there were 42 applicants, of whom 34 were admitted. Of the 8 remaining, 2 said they were going to Paddington, but on being informed by some of their companions that they would have half a ton of stone to break and would have to remain for two nights, they decided to go to Chelsea. Two were going to Islington, and 2 to Mill Hill on the way to Uxbridge. One went to the Embankment, and the last man disappeared. It appears that there is ample time to try for admission into several wards on the same evening; for instance, the City at 5 p.m., Marylebone at 6 p.m., Lambeth at 7 p.m , and Chelsea up to 8 p.m. The night of 18th February last was clear and not cold for the time of year. It is, therefore, not remarkable that only 10 men and 20 women were found seeking shelter on staircases and under arches. The figures and weather conditions for previous years are compared with the night to which this report relates in the following statement:— Weather conditions and number of persons found on staircases and under arches. Year. Weather conditions. Males. Females. Total. 1904 Cold at first followed by rain. 100 68 108 1907 Fine and not very cold — — 50 1909 Heavy rain followed by strong, cold wind. 49 39 88 1910 Fine and not very cold 10 20 30 The number of men on the Embankment waiting for the distribution of tickets by the Salvation Army entitling the recipient to food and shelter but no bed was 1,524, and 1,450 of these men were provided for in this way. The remaining 74 received no tickets. Some of them, however, may have been included among the 119 men provided each with 8 oz. bread and margarine between midnight and 4 a.m. at Medland Hall, Limehouse. Earlier in the evening, at 6 p.m., the same institution supplied a similar meal to each of 280 men. In my report of last year I commented upon the use made of free shelters by women, and I instanced Dr. Barnardo's Homes in St. John's-place (now Penzance-place), Kensington, and Commercial-street, Whitechapel. Although the number of apparently homeless women in the streets was 50 more this year than in 1909, the former home, licensed for 43 women, contained only 23 women, and the Whitechapel Home, authorised to receive 71 women, was occupied by only 14 women and 8 children. The average number received in the Whitechapel home on Friday nights in 15 consecutive weeks preceding the night of the census was only 14 women and 10 children. As I have before mentioned, however, the "Christian Herald" (Willow-street) Mission this year has distributed amongst women a number of tickets each night, the possession of which enables the bearer to obtain a free bed at a common lodging house, and this may have had some influence in causing these two shelters to have fewer inmates. I learn that on the night of the last enumeration 153 tickets were so distributed. It is also worthy of note that the Salvation Army threepenny shelter in Whitechapel, licensed for 276 women, which used to be filled each night, has for some time past had a shortage of from 50 to 80 lodgers. In the lodging houses for women generally, the result of extended observation shows that about 35 per cent, of the authorised number of beds are empty each night. On the other hand, a night refuge for destitute women in Providence-row, where no charge is made, is full every night. As was the case last year, there is a considerable amount of free food distributed in London during the day time, in addition to that given away at night in connection with shelter schemes. Thus the Eustace Miles distribution takes place twice a day, and from 500 to 600 men are supplied on each occasion. Daily Graphic coupons are received in return for 200 meals a day at Millbankstreet shelter, and for something approaching 1,400 meals a week at Hanbury-street shelter. At another shelter (Ham-yard) about 150 persons are given a free meal each day, whilst 1,000 penny dinners are supplied. At the free shelters, both licensed and unlicensed, food is supplied as well as lodging; at some places for nothing, at others in return for labour. The distribution of bread and margarine at Medland Hall to 400 men on the night of the 18th February has already been referred to. This number is, in fact, supplied with a similar meal every night in addition to the occupants of the shelter, numbering 343 persons. The "Christian Herald" (Willow-street) Mission and the 4 Salvation Army supply a large quantity of food at low prices to the general public, and the former body also provides some thousands of free meals every week. Of course, it is possible and probable that much of this food goes to people of a different and perhaps less necessitous class than that now under consideration. As in previous years, some inquiry was made at the Church Army Tents with a view to ascertaining the length of time the applicants for help had been in London, for it has been frequently remarked that the facilities offered for obtaining free food and shelter attract men from the country. Of course the figures obtained must be accepted with a considerable amount of reserve, because, apart from the small number questioned as compared with the very large number taking advantage of charity, the men may doubtless have reasons of their own for concealing the locality from wbich they have come. It has been suggested, for instance, that it may be thought that the questions are asked with a view to tracing men who have left wives and families chargeable to the rates in other parishes. It is stated by the Church Army, moreover, that they take great care in selecting men for assistance, and it is probable that if more extensive inquiries were instituted amongst men helped by charities, who make little or no investigation into antecedents, the results might be somewhat different. However, the results obtained are given for what they are worth:— Year. No. of men questioned. Length of stay in London. Less than 1 month. From 1 to 12 months. No. No. 1905 100 30 — 1909 158 16 39 1910 (February) 2617 36 1910 (March) 984 12 I append the following tables summarising the information obtained on the night of the 18th February, 1910 Table I. shows the number of homeless persons and their distribution in certain localities. Table II. shows the authorised accommodation in common lodging houses, the number of beds occupied, and the number of beds vacant in the City of London and in each metropolitan borough. Table III. shows the free accommodation in shelters provided by philanthropic bodies, and licensed by the Council, but does not include the beds in ordinary common 1 dging houses occupied by persons on the night of the census whose accommodation was paid for by charitable organisations. Table IV. shows the accommodation in shelters not licensed as common lodging houses. Table V. summarises the information contained in the third paragraph of the report, and shows the total number of persons who might be regarded as homeless on the ground of being unable to pay for a bed, but does not include persons permanently provided for in public institutions. (Signed) Shirley F, Murphy, Medical Officer or Health. 17th March, 1910. 5 TABLE I. Number of Homeless Persons distributed according to locality. Locality. Men. Women. Young persons. Embankment.—Waiting for the distribution of tickets by officers of the Salvation Army *1,524 — — Charing Cross, Shaftesbury-avenue, Holborn, City, Shoreditch 75 33 — I.ong-acre, Great Queen-street, Kingsway, Finsbury, Broadstreet, Bishopsgate 73 11 1 boy Millbank, Wardour-street, Soho, Long-acre, Chancery-lane, Ludgate-hill 121 33 9 boys 1 girl King William-street, London-bridge, Thames-street, Dockstreet, Aldgate 110 28 — Wheeler-street-arches, Booth-street-dwellings, Flower and Dean-street-arches and stairs, Commercial-street 89 60 — Westminster-bridge, Vauxhall, Borough, New Kent-road, Peckham-rye 20 1 5 boys Knightsbridge, Edgware-road, Westbourne-grove, Notting hill, Shepherd's Bush, Kensington, Fulham, Chelsea 95 19 1 child Lambeth, Southwark, Bermondsey, Wandsworth 149 35 — Totals 732 220 14 lads and 1 girl (14—16 yrs). 1 boy (7 yrs.). 1 child *1,450 of these men obtained tickets for food and shelter, and are included among the persons occupying shelters. The remaining 74 dispersed after the distribution of tickets, and would have been included among the homeless in the streets, or as inmates of other institutions, if they were able to find shelter. TABLE II. Common Lodging Houses. Sanitary District. No. of Houses. Accommodation. Census on 18th-19th February, 1910. No. of vacant beds on 18th-19th February, 1910. Men. Women. Couples. Men. Women. Couples. Men. Women. Couples. Battersea 8 157 78 23 105 23 3 52 55 20 Bermondsey 5 1,073 — — 993 — — 80 — — Bethnal Green 14 712 — — 493 — — 219 — — Camberwell 6 536 — — 413 — — 123 — — Chelsea 6 248 — — 134 — — 114 — — City of London* 1 434 — — 427 — — 7 — — Deptford 8 1,155 80 — 537 18 — 618 62 — Finsbury 8 539 — — 345 — — 194 — — Fulham 2 43 51 — 31 46 — 12 5 — Greenwich 4 150 — — 89 — — 61 — — Hackney 7 495 — — 302 — — 193 — — Hammersmith 9 466 — 4 308 — 4 58 — — Hampstead — — — — — — — — — — Holborn 27 1,629 162 — 1,353 106 — 276 56 — Islington 43 1,228 276 18 825 175 13 403 101 5 Kensington 24 431 272 — 292 148 — 139 124 — Lambeth 7 693 — — 585 — — 108 — — Lewisham 1 30 — — 17 — — 13 — — Paddington 7 195 40 — 154 23 — 41 17 — Poplar 9 1,143 — — 616 — — 527 — — St. Marylebone 17 1,306 109 — 1,077 101 — 229 8 — St. Pancras 9 727 36 — 567 20 — 160 16 — Shoreditch 12 765 — — 541 — — 224 — — Southwark 44 3,379 449 — 2,435 305 — 944 144 — Stepney 54 5,310 667 180 4,210 417 142 1,100 250 38 Stoke Newington 1 37 — — 35 — — 2 — — Wandsworth 10 185 5 20 150 3 15 35 2 5 Westminster 17 2,300 75 — 1,858 50 — 442 25 — Woolwich 24 536 44 — 454 21 — 82 23 — Totals 384 25,902 2,344 245 19,346 1,456 177 6,556 888 68 *For the figures relating to the City of London I am indebted to Dr. W. H. Collingridge, medical officer of health. Note.—In addition to the figures given above there were in Rowton Houses on the same night 4,413 men and 607 vacant beds, or 62 more vacant beds than in 1909. 6 TABLE III. Number of permanently Free Beds in premises licensed as Common Lodging Houses on the night of the 18th February, 1910. In other licensed Common Lodging Houses, some 400 or 500 beds occupied on that night were paid for by charitable institutions, chiefly by the Church Army. Premises. Free beds. For labour. Men. Women. Children. Men. Bermondsey. Salvation Army, Spa-road — — — 414 Bethnal Green. Holy Trinity Church, Old Nichol-strect (Closed) — — — Church Army Labour, Warner-place — — — 69 Finsbury. Church Army Home, Banner-street — — — 121 Kensington. Barnardo's Home, St. John's-place — 23 — — St. Pancras. Salvation Army Home, Argyle-square — — — 96 Stepney. Medland Hall 318 — — — 28, Betts-street — — — — Barnardo's Home, Commercial-street — 14 8 — Salvation Army, Quaker-street — — — 197 Westminster. Ham Yard Hospice, Great Windmill-street 20 — — — 338 37 8 897 Unoccupied on night of census 25 85 — 51 TABLE IV. Number of persons in Shelters, etc., not licensed as Common Lodging Houses. Sanitary district. Free beds. For labour. Men. Women. Children. Men. Bermondsey. (1) — 4 — — Holborn. (1) 33 24 — — (2) — 19 — — Southwark. (1) — — — 86 Stepney. (1) 21 — — — (2) 139 109 11 — 193 156 11 86 There were on the same night in Church Army Labour Homes and the Homes for Women 422 men and 194 women. 7 TABLE V. A Table summarising the information contained in the third paragraph of this report, and showing the total number of persons who might be regarded as homeless on the ground of being unable to pay for a bed. Description. Men. Women. Young Persons. Total. Number of men who received food and were allowed to rest in 3 Salvation Army shelters 1,428 — — 1,428 Number of men in the King's Tents 78 — 78 Number in shelter in connection with the King's Tents 139 — — 139 In other institutions where food and shelter only is given 133 — — 133 Persons found homeless in the streets 732 220 17 969 In licensed common lodging houses where no charge is made 1,235 37 8 1,280 In unlicensed houses where no charge is made 701 350 11 1,062 *Beds in licensed common lodging houses paid for by charitable institutions 308 80 — §448 Persons in casual wards 928 173 6 1,167 Total number of persons found homeless, or resting in shelters, or occupying free beds in common lodging houses, shelters and casual casual wards 5,742 860 42 6,644 *The figures here given are probably not complete, as they were obtained by inquiry at the several lodging houses. For instance, the Church Army alone gave away 357 tickets for men, and the Willow-street Mission 153 tickets for women. These two bodies, however, would distribute the bulk of the free tickets. London Country Council. SANITARY OFFICERS. Report by the Medical Officer on the Sanitary Staffs of the Corporation of the City of London and of the Metropolitan Boroughs. (Printed by order of the Public Health Committee, 9th Jane, 1910). I present herewith a return of the sanitary officers in London similar to those published between 1893 and 1908. The following table compares the numbers of sanitary officers in the several years for which returns have been issued:— Year. Inspectors. *Whole-time Health Visitors. Year. Inspectors. * Whole-time Health Visitors. Men. Women. Men. Women. 1893 188 — — 1903 281 20 — 1894 219 — — 1904 285 28 — 1895 227 1 — 1906 281 38 — 1898 250 6 — 1908 279 40 — 1901 264 11 — 1910 286 41 12 It will be observed that in 1906 the number of men inspectors was four less than in 1904, and that in 1908 there was a further reduction of two men. Since 1908, however, the number of men inspectors has been increased to 286, or one more than in 1904, this result being due to the appointment of additional inspectors in the following districts:—Bermondsey, 3; St. Marylebone, 4; the City of London, Deptford, St. Pancras, and Wandsworth, 1 each, whilst Finsbury, Paddington, Southwark and Stoke Newington have reduced their staffs of men inspectors by one each. In the case of Southwark it should be stated that the borough council has not yet definitely decided that the vacancy shall not be filled. It might also be mentioned that Camberwell, Deptford and Greenwich have each at the present time one inspector less than in 1904, but that Greenwich is contemplating an increase of staff. The number of women inspectors since 1908 has increased by one, there being two new appointments, one each in Hampstead and Stoke Newington, and a reduction in Finsbury, where a vacancy recently occurring has not yet been filled. In the case of Stoke Newington the woman inspector occupies also the position of health visitor, and has taken the place of one of the men inspectors who obtained an appointment elsewhere. Concerning the appointment of health visitors, I may mention that for some years past some of the borough councils have appointed health visitors, and others have utilised for the purpose of the work of health visitors the services of the women sanitary inspectors. The Local Government Boar d having expressed the opinion that this work formed no part of the duty of a sanitary inspector as prescribed by the Board in its General Order of 1891, the County Council, in repaying from the County Fund the moiety of salaries of sanitary officers, was compelled to deduct certain agreed suras for the proportion of time devoted to the duties of a health visitor. For this and other reasons, the Council in its General Powers Bill of 1908 included clauses empowering borough councils to appoint, subject to the regulations of the Local Government Board, suitable women (to be known as health visitors) for the purpose of giving advice as to the nurture, care and management of children, and the promotion of cleanliness. For its own part the Council sought to be empowered to repay out of the County Fund a sum not exceeding one-half of the salary of any such properly appointed health visitor. These clauses passed into law, and came into force on the 1st January, 1909. Regulations, made under the Act, prescribing the qualifications, mode of appointment, duties, salary and tenure of office, were issued by the Local Government Board in September, 1909. Under these regulations twelve wholetime health visitors have been appointed, and six women sanitary inspectors have been appointed also as part,-time health visitors. In several boroughs the work of health visitors is still done by the women sanitary inspectors who have not yet been appointed specially for this purpose. Details of the duties of these officers are shown in the return. *Appointed under the Council's General Powers Act, 1908, section 6. 1000—5.8.10—1573 S.S./3674 2 The following table shows the number of sanitary officers in the several sanitary districts in the years 1908 and 1910:— District. No. of Sanitary Officers. District. No. of Sanitary Officers. Inspectors. Wholetime Health Visitors. Inspectors. Wholetime Health Visitors. 1908. 1910. 1910. 1908. 1910. 1910. M. W. M. W. W. M. w. M. W. W. Battersea 11 2 11 *2 1 Paddington 10 2 9 2 _ Bermondsey 8 — 11 — 1 Poplar 8 1 8 1 1 Bethnal Green 9 1 9 1 — St. Marylebone 7 3 11 3 — Camberwell 12 1 12 1 — St. Pancras 14 2 15 2 — Chelsea 3 1 3 1 — Shoreditch 6 — 6 — 1 Deptford 6 — 7 — 1 South wark 13 3 12 3 — Finsbury 9 2 8 *1 2 Stepney 18 — 18 — 1 Fulham 7 1 7 1 — Stoke Newington 3 — 2 *1 — Greenwich 5 — 5 — — Wandsworth 10 2 11 2 — Hackney 15 2 15 2 — Westminster 10 2 10 2 — Hammersmith 9 — 9 — 1 Woolwich 8 2 8 — Hampstead 6 1 6 †2 — City of London 17 3 18 3 Holborn 3 1 3 1 — London 279 40 286 41 12 Islington 20 2 20 2 — Kensington 11 2 11 2 2 Lambeth 13 2 13 2 1 M = Men. 319 327 Lewisham 8 2 8 2 — W = Women. *One inspector appointed also as health visitor under the L.C.C. (General Powers) Act, 1908, section 6. †Both inspectors appointed also as health visitors. The return differs somewhat from the returns published since 1902, inasmuch as the salaries of the various officers are given in place of the gross figures relating to number of houses, population, etc., taken from the 1901 census. The average for each sanitary inspector, however, based on these figures has been retained, and it will be seen that there is in London as a whole, one sanitary inspector to every 1,748 inhabited houses, and to every 13,873 persons. Of this average population more than half, or 7,491 persons, at the date of the census occupied tenements of less than five rooms, and of these persons 2,220 were living more than two in a room. Public Health Department, 8, St. Martm's-place, W.C. July, 1910. Shikley F. Murphy, Medical Officer of Health. RETURN OF SANITARY OFFICERS. JULY, 1910. 4 5 SANITARY OFFICERS. Metropolitan borough. Number of sanitary officers. Annual salary on 1st July, 1910. Other details. Census 1901. Houses let in lodgings. Duties of sanitary inspector Assistants. Clerical staff. Inspectors. Health visitors. Average per sanitary inspector. No. of houses let in lodgings on the register. No. of times a year these houses are inspected. Inhabited houses. Tenements. Tenements under 5 rooms. *Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Men. Women. Battersea 1 1 † 300 Chief Inspector. 1,805 2,999 1,853 233 12,993 6,846 1,414 123 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. The food inspector takes samples under the Food and Drugs Acts, and inspects slaughterhouses, butchers' shops, sausage factories, ham and beefshops, etc. One inspects factories, workshops and workplaces. One (woman inspector) inspects places employing female labour, and investigates cases of puerperal fever. She also visits the houses of children who are about to be discharged from isolation hospitals after scarlet fever and diphtheria, and inspects houses reported verminous. One (woman inspector) is concerned with duties under Public Health Act, 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. (a) 9 disinfecting assistants. 6 ] 180 Food Inspector. (b) 5 drain-testing assistants. 1 170 7 160 (c) 1 mortuary keeper and 1 temporary assistant. 1 130 115 Also receives £30 per annum as health visitor 1† 85 l 110 District Inspectors receive in addition £10 per annum for new drainage work. 11 2+ l Ber- mondsey 1 l 125 Food Inspector (also receives £125 per annum as assistant under unsound food regulations). Food Inspector (also receives £211 per annum as assistant under unsound food regulations). 1,438 2,643 2,006 391 11,887 7,832 2,339 219 at end of 1909. 4 Eight inspectors have each an assigned district, in which they carry out all the duties arising under the Public Health Act and Factory and Workshop Acts. The inspectors also supervise drainage work reconstruction. One special inspector devotes his whole time to the inspection of food landed at wharves and riverside premises, acting under the Public Health Act, the Unsound Food, and Foreign Meat Regulations. The two food inspectors act under the Sale of Food and Drugs Acts, each having an assigned district extending over half the borough. One of these inspectors acts as deputy inspector to the special wharves inspector, and also devotes a small part of his time to the examination of food under the Unsound Food Regulations. The health visitor has duties under the Notification of Births Act, visits houses after notification of pulmonary tuberculosis, and inquires into deaths of infants. (a) 6 disinfecting assistants. 4 and 1 office youth. 1 163⅛ (ft) 1 mortuary keeper. (c) 1 shelter caretaker (female). 1 185 Food Inspector. 3 175 3 140 2 130 105 11 — l Bethnal- green 1 1 325 Chief Inspector (also receives £75 per annum for other duties). 1,400 2,821 2,373 638 12,968 9,885 3,841 517 Twice in each year. The chief inspector, 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 makes special visits and inquiries over the whole of the borough. The woman inspector investigates cases of diarrhoea, and other diseases of young children, reports on the sanitary condition of the premises, and visits houses where births have occurred. (a) 1 general assistant and disinfector. 6 6 200 (b) 3 disinfectors 2 190 Also receives £6 per annum as health visitor. (c) 1 mortuary keeper 114 9 1 — Camberwell 1 1 250 Food Inspector. 2,821 4,383 2,456 313 19,949 9,050 1,924 254 Once, and a irregular periods. The inspector who carries out work under the Food and Drugs Act is emergency inspector under all Acts of Parliament relating to public health, and is also concerned with smoke nuisances. 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. The woman inspector is chiefly concerned with laundries, factories and workshops employing female labour. (a) 1 superintendent and 7 disinfecting assistants. 5, in addition to chief clerk, who 7 200 2 175 1 147 (b) 1 mortuary keeper. was formerly a sanitary inspector. 1 117 150 12 1 — *For the purposes of this report the term "overcrow ded tenements" is applied to those tenements of less than 5 rooms which at the date of the 1901 census were occupied to the extent of more than two persons per room. †Dual appointment approved by Local Government Board. 6 7 SANITARY OFFICERS. Metropolitan borough. Number of sanitary officers. Annual salary on 1st July, 1910. Other details. Census 1901. Houses let in lodgings. Duties of sanitary inspector. Assistants. Clerical staff. Average per sanitary inspector. No. of houses let in lodgings on the register No. of times a year these houses are inspected. Inspectors. Health visitors. Inhabited houses. Tenements. Tenements under 5 rooms. Overcrow ded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Men. Women. Chelsea 1 l 265 Chief Inspector. 2,160 4,367 3,020 478 18,460 9,431 2,665 583 Not specially visited, but visited as part of ordinary house-to- house tion. The chief inspector carries out duties connected with infectious disease and complaints, and obtains samples under the Food and Drugs Acts. Two have an allotted district, in which each is concerned with houseto-house inspection, and inspection under the Factory and Workshop (a) mortuary keeper, who assists disinfectors when required. None. 1 170 1 120 120 Act. They also arrange for the disinfection of clothing and bedding by the disinfecting assistants. The woman inspector is concerned with inspection of workshops and outworkers' homes where female labour is employed. She also makes special investigations, visits mothers of newly-born infants, and inquires into notified cases of tuberculosis. (6) 2 disinfecting and draintesting assistants. 3 l — Deptford 4 l 200 2,260 3,516 1,994 238 15,771 7,409 1,428 273 Once. Five 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 Milkshops 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 are qualified to act under the Food and Drugs Acts. One health visitor. (a) 3 disinfecting assistants. 1 2 185 1 132½ 100 7 — l Finsbury 1 *1 * 2 250 Chief Inspector. 1,031 2,677 2,279 708 11,274 8,705 3,969 1,233 Average twice or three times. The chief inspector supervises generally. Five have each an allotted district in which they carry out duties (a) 2 disinfectors. 1 chief and 2 junior clerks. 1 300 Meat Inspector, posed 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. They take it in turns to inspect the market streets and hawkers' barrows on Saturday evening and Sunday morning throughout the year. One of these inspectors has charge of the canal boat inspection on the Regent's canal, which traverses his district. One is specially concerned with factory and workshop inspection. One is a special meat and market inspector and exercises close supervision over the wholesale dealers in Cow Cross-street, Charterhouse-street and St. John-street, just outside Smithfield. The woman sanitary inspector is specially deputed to visit and inspect homeworkers' premises, workshops where females are employed, kitchen restaurants, and also houses where cases of measles occur. She also arranges for the subsequent disinfection. The two health visitors visit houses where births have recently occurred, and advise mothers as to clothing and feeding their children. They make inquiries into the deaths of infants, and hold infant weighing days at three centres in the borough every week. (6) 2 keepers of the mortuaries and coroners' courts. One of these assists in disinfecting rooms. The other works the steam disinfector, and his wife attends to those who are temporarily housed in the Council's shelter. 4 180 1 170 1 160 140 Also receives £10 per annum for health visiting. 100 (c) 1 van driver, who upon occasions assists with disinfection. 8 *1 2 Fulham 1 l 200 Food Inspector. 2,317 4,017 2,710 293 17,161 10,170 1,861 114 Twice. Five have each an assigned district, in which they perform all duties arising under the Public Health Act and Factory and Workshop Act. One is employed on duties arising under the Food and Drugs Acts, and in the inspection of places where food is sold or stored. The inspector employed in the supervision of the drains of new houses, also inspects houses let in lodgings and does other special work. The woman inspector is chiefly engaged in the inspection of workshops, etc., where women are employed, but also visits after notification of births. (a) 4 disinfectors and 1 driver. 2 3 180 (6) 1 mortuary keeper. 1 145 1 140 Also receives £40 per annum for new drainage work. 1 105 115 7 l — Greenwich 1 225 2,848 3,940 2,175 240 19,154 8,252 1,589 81 Frequently. 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 2 200 1 195 1 150 5 — — *Dual appointment approved by Local Government Board. 8 9 SANITARY OFFICERS. Metropolitan borough. Number of sanitary officers. Annual salary on 1st July, 1910. Other details. Census 1901. Houses let in lodgings. Duties of sanitary inspector. Assistants. Clerical staff Average per sanitary inspector. No. of houses let in lodgings on the register. No. of times a year these houses are inspected. Inspectors. Health visitors. Inhabited houses Tenements. Tenements under 5 rooms Overcrowde tenements Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Men. Women. Hockney 9 1 200 Also receives £26 per annum for duties under Canal Boats Act. 1,802 2,870 1,711 217 12,89* 6,16< 1,314 463 Once. Twelve have each an assigned district, in which they carry out 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 woman inspector visits workshops, laundries, etc., where female labour is employed. One woman inspector visits the houses of outworkers. (a) 1 dust inspector and one assistant. 4 and 1 messenger 1 174 1 190 (b) 9 assistants for disinfecting. 1 180 1 170 (c) 1 mortuary keeper, 1 caretaker and wife for disinfecting station and temporary shelter. 2 160 200 1 140 (d) 1 drain-testing assistant, 1 smoke nuisance assistant. 15 2 — Hammersmith 8 1 180 1,689 2,868 1,723 243 12,471 6,140 1,466 3,589 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. Two are employed on houses let in lodgings. One is employed on duties arising under the Food and Drugs Acts and duties transferred from the London County Council. One is concerned with factories and workshops, and smoke nuisances. One health visitor. (a) 2 assistants for disinfection. 3 1 120 100 (b) 1 mortuary keeper. (c) 2 drainage inspectors. 9 — 1 Hampstead 1 *1 * 300 Senior Inspector. 1,412 2,112 897 108 10,243 3,026 652 364 No fixed number of times. Frequency of inspection is governed by character of houses. The senior inspector supervises generally, makes special inspections and investigations, 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, workshops and workplaces. He also takes all samples under the (a) 3 disinfecting assistants. 3 and 1 clerk draughtsman. 2 200 1 180 (6) 3 drain-testing assistants, one of whom acts as mortuary keeper. 1 160 1 155 150 Also receives £10 per annum for health visiting. *1 * 95 Also receives £30 per annum for health visiting. Food and Drugs Acts. Two women inspectors visit premises where females are employed and tenement houses. They also inquire into cases of infectious disease. Both work as health visitors, and one visits notified cases of phthisis. 6 *2 * Holborn 1 1 170 Including allowance of £25 per annum for residing in district. 1,176 3,447 2,693 696 14,851 8,931 3,719 637 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 Drugs Acts. The woman inspector is engaged on special inspections under the direction of the medical officer, such as factories, workshops, and restaurants where females are employed, outworkers' homes, and visits houses in connection with the prevention of consumption, the non-notifiable infectious diseases, and infant mortality. She also carries out duties under the sale of Food and Drugs Acts. (a) 2 disinfecting assistants. 3 2 185 (b) 1 mortuary keeper. 140 3 1 Islington 1 1 800 Chief Inspector. 1,757 3,597 2,536 458 15,227 8,928 2,589 Under new bylaws no register is kept. The number of times varies. The 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). They 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 women inspectors visit workshops and out-workers' homes where females are employed, and restaurant kitchens. (a) 2 permanent and 2 temporary disinfectors. 8 1 250 Meat Inspector. 15 184 1 178 1 172 1 148 130 1 100 20 2 *Dual appointment approved by Local Government Board. 1573 B 10 11 SANITARY OFFICERS. Metropolitan borough. Number of sanitary officers. Annual salary on 1st July, 1910. Other details. Census 1901. Houses let in lodgings. Duties of sanitary inspector. Assistants. Clerical staff. Average per sanitary inspector. No. of houses let in lodgings on the register No. of times a year these houses are inspected. Inspectors. Health visitors. Inhabited houses Tenements. Tenements under 5 rooms Overcrowde tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Men. Women. Kensington l 2 2 300 Chief Inspector. 1,702 2,950 1,624 354 13,587 5,648 2,016 2092 Variable, according to requirement of ind i v i d u a 1 cases. The chief inspector exercises supervision. Ten have each an allotted district, in which they are concerned with all duties arising under the Public Health (London) Act, the Factory and Workshops Acts, and the Housing of the Working Classes Acts. 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. The two women inspectors 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 and whooping cough The two health visitors act in connection with the Notification of Births Act for the prevention of infant mortality (a) an inquiry officer for cases of infectious diseases who is also overseer of disinfection of houses and infected articles, and 3 disinfectors, including one man who acts as engineer. 5 10 200 150 100 (b) mortuary keeper. (c) sanitary labourer for assisting in testing drains. 11 2 2 Lambeth 1 1 1 205420 Food Inspector. 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 concerned with all duties arising under the Public Health and Factory and Workshop Acts. One inspector deals with smoke nuisances, and carries out duties under the Food and Drugs Acts, assisted by a deputy. The district inspectors supervise the execution of drainage works in both new and old houses. The two women inspectors carry out duties under the Factory and Workshop Act, inspect underground conveniences and perform duties of a general character. The health visitor carries out duties under the Notification of Births Act for the prevention of infant mortality, and visits babies fed on milk from the Municipal Depot. (a) 1 superintendent and 10 disinfecting sistants. 4 and 1 boy clerk. 10 1841120 1 1631820 1 133¼ (b) 2 mortuary keepers and a deputy. 1531820 1 1121220 1021220 (c) 1 temporary caretaker of shelter(female). (d) 1 manageress of milk depot. 13 2 1 Lewisham 4 1 200 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 women inspectors visit laundries, work places, &c., where females are employed, and make special investigations into cases of infectious disease, infant mortality, etc. (a) 7 disinfecting assistants. 3 1 195 (b) 2 drain-testing assistants. 1 190 2 150 125 1 105 8 2 — Paddington 2 2 250 Meat and Food Inspector. 1,607 3,060 1,983 309 13,089 6,657 1,775 1330 Six or more times. Five 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, and he is inspector under the Sale of Food and Drugs Acts. The two women inspectors visit all workplaces where women are employed and make inquiries into infectious diseases not scheduled for notification. They also do health visiting. (a) mortuary keeper. 5 1 220 (6) 4 navvies (employed for opening defective drains, etc.). 6 200 150 (c) 1 disinfecting assistant. 9 2 — 1573 B 2 12 13 SANITARY OFFICERS. Metropolitan borough. Number of sanitary officers. Annual salary on 1st July, 1910. Other details. Census 1901. Houses let in lodgings. Duties of sanitary inspector. Assistants. Clerical staff. Average per sanitary inspector. No. of bouses let in lodgings on the register. No. of times a year these houses are inspected. ' Inspectors. Health visitors. Inhabited houses. Tenements. Tenements under 5 rooms. Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Men. Women. Poplar 3 1 l 195 Also receive £1 per annum each under unsound food regulations. 2,513 3,976 2,913 490 18,758 11,722 3,078 1044 A large number very frequently and many also at night. 2,953 inspections in 1909. Seven have each an assigned duty in which they carry out duties under the Public Health, Metropolis Management, Factory and Workshop, Food and Drugs, Canal Boats, and Housing and Town Planning Acts. Three of these inspectors act also as assistant officers under the Unsound Food Regulations. One visits houses let in lodgings. The woman inspector visits all places where female labour is employed and sanitary offices of schools for girls. She also makes enquiries under London County Council General Powers Act as to verminous clothing. The health visitor is also the Organising Secretary of the Poplar Health Visiting Association, comprising some 60 voluntary workers. (a) 1 chief and 4 disinfecting assistants. 5 (one a certified Sanitary Inspector, London). 3 194 2 180 (6) 5 labourers (who assist inspectors). Seven of these inspectors receive in addition £5 per annum for work under Canal Boats Acts. 185 (c) 1 female attendant at the Glaucus-street shelter. 140 8 1 l St. lebone 1 1 168½ Also receives £6½ per annum for new drainage work. 967 2,258 1,639 370 9,521 \ 5,297 2,010 292 At least twice a year. All premises are being reregistered as rapidly as possible. Five inspectors have each an allotted district in which they carry out all the duties arising under the Public Health and cognate Acts. Two inspectors supervise all drainage work, whether reconstructive or new work, but in addition do some work of a general character. One food inspector takes samples under the Sale of Food and Drugs Acts. One makes house to house inspections and visits houses let in lodgings. One supervises the sanitary conveniences, the public mortuary, the work of disinfection, etc. The temporary inspector acts as dust inspector. Three women inspectors carry out duties under the Factory and Workshop Act, the Cleansing of Persons Act, the Notification of Births Act, inspect schools and inquire into infant mortality and cases of phthisis. (a) 3 disinfecting assistants. 1 chief and 2 assistant 1 110 Also receives £60 per annum as superintendent of sanitary conveniences and mortuary. (b) mortuary keeper. clerks. 1 office boy 1 170 (e) caretaker of shelter(female). 1 110 Also £56 per annum new drainage work. (d) 1 bath attendant. 1 160 (e) 1 female attendant (part time). 1 100 Also £56 per annum new drainage work. 1 155 (f) 1 messenger 2 150 Also £6½ per annum new drainage work. 1 136½ 1 104 Temporary inspector. 160 1 107 Also £13 per annum for health visiting. 1 104 *11 3 — St. cras 3 1 225 Also receives £35 per annum for health visiting. 1,395 3,355 2,648 597 13,842 9,164 3,319 2288 at end of 1909. Twice a year. Thirteen inspectors have each an assigned district in which they deal with infectious diseases, complaints, drainage and nuisances generally. One of these inspectors also carries out duties under the Food and Drugs Acts, and the by-laws regulating slaughterhouses and dairies and the periodical inspection of food in his own district. Two inspectors carry out solely the duties under the Food and Drugs Acts, and the by-laws regulating slaughterhouses and dairies. They also periodically inspect food places. One of these inspectors carries out duties under the Canal Boats Act. Two women inspectors divide between them the inspection oi factories, workshops and workplaces where women are employed They visit houses where births have occurred, homes of verminous children, and notified cases of phthisis. (a) 1 foreman and 3 disinfecting assistants 1 chief clerk, 7 assistant clerks. 8 200 2 190 (b) caretaker oi mortuary and coroner's court and 1 contact shelter attendant and attendant at cleansing station and children's baths. 1 180 1 120 150 1 105 15 2 — ditch 4 l 185¼ Including £20 per annum for market duty, and £5¼ for Saturday and Sunday duty. 2,124 4,505 3,823 1,045 19,773 14,930 5,921 258 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. 293 visits in 1909 Each of the six 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 Acts and from time to time to be on duty in the street markets on Saturday evenings and on 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 Acts. One of the inspectors is on duty for the purposes of food inspection and for taking samples under the Food and Drugs Acts on each evening of the week between 6 and 10 p.m Two inspectors are on duty on Saturday evenings and on Sunday mornings. The health visitor acts under the Notification of Births Act. (a) 1 general assistant. 3 1 165¼ (b) 1 disinfector and 2 assistants 1 145 Including £25 per annum for market and Saturday and Sunday duty. (c) 1 mortuary keeper. 100 (d) caretaker(female) of shelter 6 — l *Including one temporary inspector. 14 15 SANITARY OFFICERS. Metropolitan borough. Number of sanitary officers. Annual salary on 1st July, 1910. Other details. Census 1901. Houses let in lodgings. Duties of sanitary inspector. Assistants. Clerical staff. Average per sanitary inspector. Inspectors. Health visitors. No. of houses let in lodgings on the register. No. of times a year these houses are inspected. Inhabited houses Tenements. Tenements under 5 rooms Overcrow dec tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Men. Women. wark 1 1 240 Assistant to M. O. H. 1,392 3,187 2,641 542 13,745 9,861 3,071 1265 At least four times a year. Many monthly, some weekly. The inspector who acts as assistant to the medical officer of health helps in supervising and co-ordinating the work of the inspectors. One acts as a Food and Drugs inspector. Nine 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. The woman chief inspector visits workshops and does special work. The two women inspectors visit houses let in lodgings, and premises where births have occurred. (a) 2 engineers. 6 1 220 Food and drugs inspector. 1 200 (b) 10 disinfecting assistants. 5 180 Also receives £10 p.a. as assistant under unsound food regulations. 1 170 (c) 2 mortuary keepers, and a superintendent and his wife at reception house. The superintendent is concerned with infectious disease. 2 150 1 190 180 Chief woman inspector. 2 160 (d) 1 assistant drain tester. (e) 1 woman attendant for cleansing verminous children. 12 3 — Stepney 6 1 250 Also receives £ll½ for work under unsound food regulations. 1,748 3,395 2,732 919 16,589 11,622 5,510 2798 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 food stuffs landed on wharves. One health visitor. (a) 14 disinfecting and general assistants. 8 1 218½ 1 230 3 220 4 200 1 170 2 150 100 18 — 1 Receives also £90 p.a. as health visitor. 2,572 3,941 1,938 166 17,082 6,204 945 Stoke Newington 1 1 * 220 1 195 273 All once, some twice annually. Each of the two inspectors has an assigned district in which he carries out general sanitary duties. The woman inspector also acts as health visitor. In the former capacity she inspects workshops and workrooms where women are employed, homes of outworkers, and houses let in lodgings. As health visitor she does work under the Notification of Births Act, assisted by six voluntary workers. (a) 1 disinfecting assistant. 1 30 2 *1 * Wandsworth 9 1 200 Three of these inspectors also receive £1 per annum each under the Canal Boats Acts. 2,905 3,827 1,619 117 17,849 5,871 / 795 268 Twice and more frequently if there be any special reason. Ten have each an assigned district in which they carry out duties under the Public Health Act, including all by-laws and repair of drains and sanitary fittings. They also take samples under the Food and Drugs Acts 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 women inspectors are chiefly occupied in visiting 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 four inspectors under the control of the surveyor. (a) 10 disinfecting assistants. 4 1 181420 (b) 3 mortuary keepers. 1 161420 Also receives £25 per annum as health visitor. 125 1 12056 Also receives £241/6 per annum as health visitor. 11† 2 — Westminster, City of 7 1 220 1,530 3,437 2,222 362 15,251 6,969 1,988 2 200 1481 2963 inspections were made in 1909. Eight district inspectors. Two perform duties under the Food and Drugs Acts, abatement of smoke nuisances, inspection of street markets, slaughterhouses, offensive trades, cowhouses, and inspection of food generally. The two women inspectors are engaged in the inspection of workshops, workplaces, etc., where female labour is employed, and also they inspect houses let in lodgings. Note.—The appointment of a health visitor is under cons ideation. (a) 8 disinfectors. 5 1 150 160 (6) 2 drain testing assistants. 1 150 10 2 — (c) 1 mortuary keeper and 2 assistants. (d) 1 woman in charge of shelter and 1 cleaner. *Dual appointment approved by Local Government Board †There are also four inspectors under the control of the Surveyor concerned with drains and sanitary fittings in old and new houses. 16 17 SANITARY OFFICERS. Metropolitan borough. Number of sanitary officers. Annual salary on 1st July, 1910. Other details. Census 1901. Houses let in lodgings. Duties of sanitary inspector. Assistants. Clerical staff. Inspectors. Health visitors. Average per sanitary inspector. No. of houses let in lodgings on the register. No. of times a year these houses are inspected. Inhabited houses Tenements. Tenements under 5 rooms Overcrowded tenements. Population. Population in tenements under 5 rooms. Population in overcrowded tenements. Men. Women. Woolwich 1 1 ‡ 280 Chief inspector. 1,809 2,458 1,402 124 11,718 5,098 773 395 Two or four times a year. The chief inspector 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 arc inspectors under the Food and Drugs Acts, and one inspects dairies, cowsheds, and milk shops. Three, who are qualified meat inspectors, in rotation inspect the market, slaughterhouses and principal butchers' shops. One inspects workshops where women are not employed. One woman inspector visits houses let in lodgings, workshops where women are employed and verminous houses. One woman inspector visits houses where births have occurred, and acts as health visitor. Both the women inspectors visit houses from which cases of phthisis, measles, zymotic enteritis, etc., have been notified. (a) 3 disinfectors. 4 6 165 1 130 (b) 3 drainage workmen. 140 1‡ 85 Also receives £50 per annum as health visitor. (c) 1 mortuary keeper. (d) 1 manager and 4 assistants at milk depot. 8 2 ‡ City of London 3 1 300 Senior inspectors. 184 254 157 24 1,282 506 139 286 Two are concerned with notified infectious diseases. One is specially engaged in carrying out the provisions of the Sale of Food and Drugs Acts. Three are concerned with duties arising under the Public Health Act Three are concerned with duties arising under the Factory and Workshops Acts. Nine inspectors are engaged in meat inspection. Three women inspectors visit workplaces where women are employed and one of these in addition to the ordinary duties of a sanitary inspector visits houses in connection with births and with infant mortality. (a) 2 assistant inspectors of meat (on probation). 5 3 250 2 180 Assistant to inspectors. 1 100 1 450 Veterinarv inspector. (b) 1 matron at shelter. 1 350 Senior meat inspector. 3 250 Meat inspectors. (c) 1 mortuary keeper. 1 225 Meat inspector. 1 200 Meat inspector; (d) 1 disinfecting assistant. 1 160 Meat inspector. 1 150 Meat inspector. 170 1 150 1 120 18† 3 — County of London' 286 41 12 1,748 3,117 2,055 381 13,873 7,491 2,22 ‡Dual appointment approved by Local Government Board, †Includes nine meat inspectors.