Act 14 Urban District of Acton. Annual Report OF THE Medical Officer of Health FOR 1906, Urban District of Acton. Annual Report OF THE Medical Officer of Health FOR 1906. Public Health and Isolation Hospital Committee. Mr. Councillor E. F. HUNT (Chairman). F. A. BALDWIN. J.P. E. MONSON, J.P. J. W. JARRATT, J.P. „ D. P. CRONIN. A. C. CRANE. S. F. HOLLOWAY. E. E. B. LANDON. 2 by the order of the Local Government Board, dated March 23rd, 1891, article 18. jjsction 14, it is prescribed that the Medical Officer of Health shall make an Annual Report to the Sanitary Authority, up to the end of December in each year, comprising a summary of the action taken, or which he has advised the Sanitary Authority to take, during the year, for preventing the spread of disease, and an account of the sanitary state of his district generally at the end of the vear. The report shall also contain an account of the inquiries which he has made as to conditions injurious to health existing in the district, and of the proceedings in which he has taken part or advised under any Statute, so far as such proceedings relate to those conditions; and also an account of the supervision exercised by him, or on his advice, for sanitary purposes, over places and houses that the Sanitary Authority have power to regulate, with the nature and results of any proceedings which may have been so required and taken in respect of the same during the year. The report shall also record the action taken by him. or on his advice during the year, in regard to offensive trades, to dairies, cowsheds and milk-shops. The report shall also contain tabular statements (on Forms to be supplied by us. or to the like effect) of the sickness and mortality within the district, classified according to diseases, ages and localities. In a memorandum issued by the Local Government Board in November, 1906. it is recommended that the report shall deal with the extent, distribution and causes of disease within the district; and should give an account of any noteworthy outbreak of epidemic diseases during the year under review, stating the result of investigations into their origin and propagation, and the steps taken to check their spread. As these reports are for the information of the Local Government and of the County Council, as well as of the Council of the District, a statement of the local circumstances and a history of local sanitary questions, which may seen superfluous for the latter, may often be needed by the former bodies. Under section 132 of the Factory and Workshop Act, i9or. the Medical Officer of Health is also required in his Annual Report to report specifically on the administration of the Act in workshops and workplaces, and to send a copy of his Annual Report, or so much of it as deals with this subject, to the Secretary of State. ANNUAL REPORT OF THE Medical Officer of Health FOR THE URBAN DISTRICT OF ACTON, For the Year 1906. 130 Churchfield Road, March, 1907. To the Chairman and Members of the Acton Urban District Council. Gentlemen, I have the honour to submit to the Council a report on the Sanitary conditions of the district, together with the vital and other statistics for the year 1906. The most noticeable feature in regard to infectious disease was an extensive epidemic of Measles, resulting in 27 deaths. There were limited outbreaks of Scarlet Fever, but in no instance did the disease assume a formidable aspect. The mortality from Diphtheria and Enteric Fever continues very low. There is an increased Infantile mortality to be noted, due in the main, to the large number of deaths from Diarrhoea during the very hot summer which we experienced. In regard to the sanitary work which has been effected, there is probably little of a startling nature to chronicle. The work has been of a routine kind, and, I believe, of a substantial character. A large amount of progress may be recorded in many directions. 4 The principal features of the vital statistics for the year have been as follows:— Estimated Population: 52,000. Birth Rate: 29.5 per 1,000 inhabitants. Death Rate: 13.2 per 1,000 inhabitants. Infantile Mortality: 130 per 1,000 births. Zymotic Death Rate: 2.4 per 1,000 inhabitants. Respiratory Death Rate (excluding Phthisis): 2 per 1,000 inhabitants. Phthisis Death Rate: .9 per 1,000 inhabitants. Death Rate from other forms of Tuberculosis: .5 per 1,000 inhabitants. TOPOGRAPHY. The district, with an area of 2,304 acres, is about 3 miles in length, and about 1½ miles wide. It is irregularly quadrangular in shape. It is bounded on the north by Willesden, on the east by Hammersmith, on the south by Chiswick, and on the west by Ealing. For Poor-law purposes, the parish forms part of the Brentford Union, and for Parliamentary purposes, it is within the Ealing division of Middlesex. For municipal purposes, the district is divided into four wards, North-East, North-West, South-East and South-West. The underlying stratum of the district is London clay, 200 to 300 feet thick, with a slightly southerly dip. This clay forms the exposed surface over the greater part of the district north of the Great Western Railway, but in the central and western portions the clay is covered with a bed of ochreous gravel, which, in some parts, reaches a thickness of 10 or 12 feet. In the eastern and southern portions, the clay is covered with "Loess," a rich loam or brick earth, with patches of gravel and sand. POPULATION. In last year's report, the various methods by which the population of a district is estimated, were mentioned, and reasons were given for discarding the method adopted by the Registrar-General. It was then stated that the nearest approach to a correct estimate would probably be attained by calculating the number of new houses erected 5 and occupied since the Census, and allowing 6.2 persons for each house. This figure represents the average number of persons occupying each house at the Census. At the present time, the average number of persons to each house is probably higher than 6.2. At the Census of 1901, there were 6,086 inhabited houses in the district, besides 454 uninhabited houses. Between March 31st, 1901, and June 30th, 1906, 2,165 dwellinghouses have been erected and occupied, and 65 public buildings, such as schools, offices, churches, etc. On June 30th, 1906, there would be in the district 8,610 dwelling houses and 160 public dwellings. Allowing 3 per cent, for vacancies, an average of 6.2 persons per house would give a population of 51,782. As there is reason to assume that the average number is now slightly over 6.2, for the purpose of this report, the population has been estimated at 52,000 inhabitants. With the assistance of the Surveyor and Accountant, an attempt has been made to estimate the population of each ward, and I believe the following table is fairly correct:— North-East Ward 13,000 North-West Ward 11,000 South-East Ward 11,000 South-West Ward 17,000 BIRTHS. The number of births registered during the year was 1,533—801 males and 732 females. This number corresponds to a birth-rate of 29.5 per 1,000 inhabitants, which is 1.1 per 1,000 lower than that of 1905 and 1.2 per 1.000 below the average rate for the 10 years 1896-1905. The birth-rate for the whole of England and Wales in 1906 was 27 in the 76 large towns it was 27.9. and in the 142 smaller towns 26.5. The infants registered as having been born out of wedlock numbered 39, which figure corresponds to a rate of 25 per 1,000 births, or .7 per 1,000 living. This is lower than the illegitimate birth-rate 6 in England and Wales, but in rural districts illegitimacy is always more prevalent. The figure 29.5 does not represent the actual birth-rate of the district, and the illegitimate birth-rate is higher than 25 per 1000 births. 1,533 is the number of births registered in the district; some births occurred in outside institutions, but a list of these has not been obtained. The birth-rate is not usually considered within the realms of public health, and we are deterred even from an adequate discussion of it by what has been stigmatised as a spurious delicacy, and by a wholly false conception of morality. Although the remedy is beyond the control of Sanitary Authorities, it is important that we should ascertain whether the population is being chiefly recruited from the fit or from the unfit Preventive medicine must enlarge its scope if it is to continue to reduce the general death-rate, and if, more particularly, it is to make substantial advance in promoting the physical fitness of the people and to create an impression upon such diseases as infantile diarrhoea and measles. We know that since 1877 the birth-rate in this country has been steadily declining, but "it is as important that the right people should be born as that the wrong people should not be born." Not only has the birth-rate in England and Wales during the last 25 years undergone a decrease of nearly 20 per cent., but there is reason to believe that the fewer beings now born are born of the less healthy and less thrifty classes. It is the birth-rate of the middle classes and the better type of working man that has been falling off at such an alarming rate. It is unnecessary to produce statistics in order to ascertain the relative position of the wards socially. A glance at the number of deaths from the various diseases in each ward will at once convince any observer as to who are best and least fitted for the struggle of life. Consumption or Phthisis is a disease which eminently reflects the influence of poverty, being determined by overcrowding, physical privation, anxiety, want of rest, and all the factors which are dependent on poverty. More than half the deaths from Consumption occurred in the South-West Ward. Similarly, Infantile Diarrhoea, though dependent upon various causes, is most fatal in those children whose general standard of vitality is lowered. 45 out of the 79 deaths from Infantile Diarrhoea occurred in the South-West Ward. 7 A great deal has been written to the effect that its population is the most valuable asset of a country. Whether it be so or not depends on the character of the population, and if the diminished birth-rate were operating in the proper quarter it would possibly be a sign to welcome and not to regret. The births have been allocated amongst the wards this year for the first time, and the following table gives the number, and rate per 1,000 livine. in each ward:— Number. Rate per 1,000. North-East Ward 325 25 North-West Ward 229 20.8 South-East Ward 255 23.2 South-West Ward 724 42.6 DEATHS. Number ... ... ... ... 687 Rate per 1,000 ... ... ... 13.2 Rate per 1,000 in England and Wales 15.4 Rate per 1,000 in 76 large towns 16. Rate per 1,000 in 142 smaller towns 14.4 The total number of deaths registered in the district was 597, but certain corrections have to be made in order to obtain the exact number of deaths belonging to the district. On Table I. instructions are given concerning the corrections which should be made before arriving at the net number of deaths belonging to the district. The first correction is the subtraction of the deaths of non-residents from the total registered in the district. By the term "non-resident" is meant persons brought into the district on account of sickness or infirmity or accident and dying in public institutions here. Seven non-residents died in the district. One of these died of Diphtheria at the Fever Hospital and belonged to Hendon. Six non-residents sustained fatal accidents in the district—four on the railway, and two were run over in the street. The second correction which has to be made is the addition to the total of the deaths of "residents," registered in public institutions beyond the district. 8 By the term "residents" is meant persons who have been taken out of the district on account of sickness or infirmity and died in public institutions elsewhere. The "public institutions" to be taken into account are those into which persons are habitually received on account of sickness or infirmity, such as hospitals, workhouses and lunatic asylums. Ninety-seven residents died outside the district, and these deaths occurred in the following institutions:— Isleworth Infirmary 44 West London Hospital 12 Wandsworth Asylum 8 St. Mary's Hospital 5 Guy's Hospital 2 Middlesex Hospital 2 Bethlehem Hospital 1 St. Peter's Hospital 1 Evelina Hospital 1 St. Mark's Hospital 1 Homeopathic Hospital 1 Hampstead General Hospital 1 Children's Hospital, Paddington 1 Mount Vernon Hospital 1 Grove Hospital, Tooting 1 Charing Cross Hospital 1 Queen Charlotte's Hospital 1 University College Hospital 1 Cancer Hospital, Chelsea 1 Cancer Hospital Fulham 1 St. Thomas's Hospital 1 London Hospital 1 Chest Hospital, Bethnal Green 1 Victoria Hospital, Chelsea 1 St. Joseph's, Chiswick 1 Camden Square 1 Beaumont Street, Marylebone 1 Weymouth Street 1 9 One death occurred on the District Railway at Brompton, and another in a cab in Mortimer Street, Marylebone. The total number of deaths belonging to the district is 687, which corresponds to a death-rate of 13.2 per 1,000 inhabitants. Another correction is necessary before a comparison can be instituted between this district and neighbouring ones. This correction is dependent upon the sex distribution and the age constitution of a district. Females live longer than males, and though there is a preponderance of females over males in Acton, the death of males exceeded those of females by 11. Three hundred and forty-nine males and 338 female deaths occurred last year. If the sex distribution has not altered since the Census the death-rate last year among males was 14.8 per 1,000, and among females 11.8. A more important factor is the age-constitution of a population. The tendency to death is greater among persons living at the extremes of life—among infants and old people. The ages at death last year were as follows:— Under 1 year. 1 to 5. 5 to 15. 15 to 25. 25 to 65. Over 65. 201 91 26 19 194 156 In order to neutralise the errors in death-rate arising from sex and age-constitution, the Registrar-General has devised a method by which they can be corrected. This method is based upon the deathrate of each sex at different ages throughout England and Wales, and by this means series of factors are obtained, by which the recorded death-rates of different towns can be multiplied, so as to make them comparable with that of England and Wales and with each other. The figures by which the recorded or crude death-rate should be multiplied, in order to correct for variations of sex and age distribution, is called the factor for correction for the particular district; and when the recorded death-rate is multiplied by the factor for correction, the result is the corrected death rate for that district. The factor for correction for Acton is 1.04240, so that if the recorded death-rate. 13.2, be multiplied by this figure, the corrected death-rate is 13.7. 10 Ward Distributions. The deaths were distributed as follows:— North-East North-West. South-East. South-West. 137 135 122 293 Based upon the estimated population given on a preceding page, the death-rate of each ward per 1,000 inhabitants would be North-East. North-West. South-East. South-West. 10.5 per 1,000. 12.3 per 1,000. 11 per 1,000. 17.2 per 1,000. On Table IV. will be found the number of deaths in each ward from the different diseases, and it will be observed that the excessive mortality in the South-West Ward is confined to 5 diseases—Measles, Diarrhoea, Phthisis, Pneumonia and Bronchitis. The three former diseases are dealt with separately, and the five reflect the influence of poverty upon the death-rate. When one reflects on the various causes productive of ill-health, and of that more intense form which ends in death, the influence of poverty, and more particularly of unsettled poverty, loom larger and larger. The death-rates of those inhabitants who end their lives in the Union Infirmary may be taken as one of the indices of poverty, and the following figures are significant. Forty-four deaths occurred in Isleworth Infirmary; of these, 8 belonged to the North-East Ward, 5 to North-West, 2 to South-East. and 29 to the South-West. The death-rate per 1.000 amongst persons dying in the Infirmary for the several Wards would be: North-East .6 North-West .5 South-East .2 South-West 1.7 ZYMOTIC DISEASES. Deaths 124. Death-rate 2.3. The so-called Zymotic death-rate includes deaths from the seven Zymotic diseases, namely Small-pox, Measles, Whooping Cough, Scarlet Fever. Diphtheria. "Fever," and Diarrhoea. With the exception of Small-pox, these diseases are dealt with in separate paragraphs. 11 SCARLET FEVER. One hundred and seventy cases of Scarlet Fever were notified, and 7 deaths were caused by the disease. Although occurring within the district, one of the deaths did not belong to Acton. On November 3rd, a child died at Kingswood Road. Her parents lived at Notting Hill. She was notified as suffering from Scarlet Fever in July, and removed to one of the Metropolitan Fever Hospitals. She was discharged in October, and came on a visit to some relatives who lived at the address given above. Though discharged from the hospital free from infection, she was suffering from nephritis, to which complication of Scarlet Fever she succumbed on November 3rd. There is an increase in the number of cases and in the number of deaths. The largest increase of notifications occurred in the NorthEast Ward. The Ward distribution was as follows:— North-East. North-West. South-East. South-West. 62 29 37 42 Possibly, the Ward distribution does not convey a correct impression of the factors which operate in the spread of the infection. Of the total number notified, 109 attended school, and the tion of scholars was:— Priory 26 Central 23 Beaumont Park 13 South Acton 9 St. Mary's 7 Rothschild Road 4 Willesden Junction 3 Southfield Road 2 East Acton 1 Catholic School 1 Private Schools 7 12 Outside Schools. Kenmont Gardens 1 Latimer Road 1 City of London 1 St. Marylebone, Higher Grade 1 Oaklands Road, Hanwell 1 Private Schools 8 A certain amount of doubt exists as to the role which school attendance plays in the spread of Scarlet Fever, and until we know more of the etiology of the disease, it is unwise to venture upon any very definite opinion. Hitherto, two modes have been accepted whereby the disease is spread. The first is direct infection to other persons in close contact with the actual sufferer. This mode is easily appreciated, but it has been taken for granted that the disease may also be spread in some indirect manner not yet properly understood. There is hardly a disease concerning which opinions have so materially changed as Scarlet Fever. It was formerly held that the disease was not infectious until the skin had commenced to peel, and that it continued infectious as long as the peeling of the skin lasted. Both theories have been discarded. Scarlet Fever is infectious from the commencement of the symptoms, and the condition of the skin is no criterion of the infectiousness of the patient. It is possible, of course, that the disease is spread in some indirect manner, but the more closely the inquiries are made, the less numerous do the indirectly infected cases become. It is true that the untraced cases constitute the great majority occurring in urban districts, but it is also probable that many, if not most of, the untraced cases have been infected by persons suffering from so mild a form of the disease that the illness has not been recognised. It is these slight, undetected, or "missed" cases, as they are called, which are the most effectual promoting causes of an epidemic, and for this reason mild outbreaks are the most difficult to meet and dangerous to the public. During the year we had several instances of these undetected cases, giving rise to limited outbreaks in different schools. Between June 2 and July 11, 17 cases of Scarlet Fever occurred amongst children attending the Central Schools. It was obvious from the distribution of the disease that the school had something to do 13 with the spread, but it was not until July 2nd that a "missed" case was found. He had attended school throughout his illness, and immediately after his removal the outbreak subsided. At other times a "missed" case was found in the house, and the same phenomenon was observed, but as the number of susceptible children was smaller, the spread was not so extensive. In February, a school card was received, intimating that some children were absent from Gloucester Road, and an examination of the inmates of the house revealed the fact that there were four persons on the premises suffering from Scarlet Fever. A similar state of affairs was noticed in a house in the Parade, where four children were found suffering from the disease. Altogether 34 secondary cases were notified, but with 5 exceptions the first and subsequent cases in the house were notified together; in 3 instances, the patients were nursed at home, and in 2. the first case had been removed to Hospital. In one of the latter it is doubtful though, whether the second case was infected from the previous cases in the house, as the first patient had been removed to Hospital three weeks before the second developed any symptoms. In 3 houses there were 4 cases notified from each, in 5 houses 3 cases occurred in each, and 2 cases occurred in each of 17 houses. There were 3, which in all probability were "return" cases. Two of these occurred at one house in Gunnersbury Lane. The "infecting" case had been in the Isolation Hospital for 12 weeks, and was discharged on August 28th. Two sisters had been staying at Hawley, and returned on September 9th; one of them developed symptoms on September 12th. and the other on October 1st. 1 was on my holidays when the first child was discharged from the Hospital, and could not make an examination of the child until September 18th. On my return, I examined the "Infecting" case, and though it was stated that the child had had a small sore on his nostril since his discharge from the Hospital. I could detect nothing which could give rise to infection, except the presence of adenoid growths at the back of the throat. There had been no running from the ears during the course of the illness, and the skin had finished peeling some time prior to his discharge from the Hospital. It is impossible to state positively what was the cause of the prolonged infection, but it is probable that the germs ■were retained in the throat, owing to the abnormal condition of its lining. 14 The third case occurred in Kingswood Road. The "infecting" case was discharged from the Hospital on November 7th. On November 14th, a sister was taken ill, and notified of Scarlet Fever on November 19th. The "infecting" case had been in the Hospital for over 6 weeks, and had not suffered from any complication. I examined him again on November 18th, and could detect no symptom or sign which would lead one to suspect his freedom from infection. The second case in the same house may have been merely a coincidence; and the infection may not have been conveyed by the child discharged from the Hospital. The following incident will illustrate this possibility. A child living at Weston Road was a patient in the Hospital. On November 11th, the parents were informed that probably the child would be discharged on November 12th, but after an examination of the child on the latter date, it was decided to detain her in the Hospital for at least another week. On November 13th her sister at home was taken ill, and removed to the Hospital on November 18th. If the first child had been discharged on November 12th (which originally, had been our intention), the second one would have been considered a return case. It is possible, in the last case, that some article which had been in contact with the child before removal to Hospital, had escaped disinfection, and was brought forth in the preparation made for the reception of the convalescent. Complaints are sometimes made that Isolation Hospitals have not been instrumental in stamping out Scarlet Fever in districts where most of the cases are removed to a Fever Hospital. The above instances are given to showhow difficult it is to fulfil the most essential conditions if the spread of the disease is to be prevented. The infection must not be handed on by the patient before seclusion, and all infected material left behind must be rendered sterile. Very rarely is isolation practised at the commencement of the illness, and we have no means of ascertaining if all the infected articles have been disinfected. Moreover, the patient should have recovered perfectly before he is cleansed and discharged from seclusion, but we have no means of ascertaining whether the patient is absolutely free from infection or not. In Diphtheria, the conditions are different; the germ has been isolated, and a bacteriological examination can always be made before the patient is discharged from the Hospital. 15 DIPHTHERIA. Forty-five cases of Diphtheria were notified, and 2 deaths resulted from the disease. In each instance death had resulted before the notification was received. With a case-fatality of less than 5 per cent. it is unnecessary to state that the disease was of a very mild character. To what extent the introduction of Antitoxin into general use has modified the type of disease it is difficult to venture an opinion, but as far as Acton is concerned, nothing has been more significant than the diminished mortality witnessed within the last 10 years. Since 1897, the decline has been almost continuous, as the following figures show: 1897 28 deaths. 1898 8 „ 1899 7 » 1900 4 ,, 1901 4 „ 1902 6 „ 1903 4 ” 1904 2 ,, 1905 4 ” 1906 2 „ Last year, only three towns in England and Wales showed a lower mortality incidence. Diphtheria is essentially a disease of childhood, and as the birth-rate in each of these three towns was under 20 per 1,000, the comparative freedom of Acton from Diphtheria is eminently satisfactory. ERYSIPELAS. Thirty-five cases of Erysipelas were notified, and 1 death resulted from the disease. The retention of Erysipelas amongst the notifiable diseases is a demonstration of the necessity of fresh public health legislation. The views held as to its causation have undergone a vast change since the 16 Infectious Diseases Notification Act was passed. It is now generally held that Erysipelas can be caused by various organisms, and cannot be regarded as a specific disease in regard to its etiology. It is true that a relationship exists between Erysipelas and Puerperal Fever, but so there does between the latter disease and any ordinary abscess or even a gum boil. Disinfection is carried out after Erysipelas, only when some special circumstances demand it. TUBERCULAR DISEASES. Forty-eight deaths were registered as due to Phthisis, or Consumption. which number is equal to a rate of .9 per 1,000 inhabitants. Twenty-six deaths were caused by other tubercular diseases—Tubercular Meningitis 14, General Tuberculous 4, Tubercular-Peritonitis 3, Tubercular Enteritis 2, Tabes Mesenterica 2, and Tubular Kidney 1. Of the total deaths from Tubercular Diseases, 38 were of males and 36 of females. Forty-nine deaths were in persons over 15 years of age, and 25 in children under that age. In England, Phthisis in adults has diminished since 1850 by 48 pet cent., but Tubercular diseases in children have increased by 27 per cent. It is impossible to give comparative figures for Acton, as deaths of residents occurring in institutions outside the district were not obtained prior to 1905, and last year 26 out of the 74 deaths, or 35 per cent., occurred in such institutions. The same phenomenon has probably occurred in this district. The increase is due to Tuberculosis of the abdomen, caused possibly by the ingestion of infected milk. Thirty per cent. of all the cows giving milk in this country are tuberculous, but probably such milk is not dangerous until the udder is affected. About 2 per cent. of the cows have tuberculous udders. Our inquiries were more particularly directed towards the deaths occurring from Phthisis, or Tubercle of the Lung. 17 Of the 48 deaths, 24 were of males and 24 of females. Prior to their attack of illness their employment was:— Males. Labourer 5 Laundryman 3 Clerk 2 Mechanical Engineer 2 Plasterer 2 Painter 2 Engine Driver 1 Lift Attendant 1 Dairyman 1 Sword Patentee 1 Railway Guard 1 Carman 1 Messenger 1 No Occupation 1 Females Household 11 Laundress 4 Teacher 2 Nurse 2 Domestic Service 1 No Occupation 4 Out of the 48 deaths from Phthisis, 19 occurred in Public Institutions. This is a high percentage, but it is doubtful if this is due to a full appreciation of the danger during the last four or five weeks of the illness. Twelve of the deaths occurred at Isleworth Infirmary and 3 at Wandsworth Asylum. Although there are numbers of special hospitals and Sanatoria for tubercular patients, with the exception of the Workhouse Infirmary, there are no institutions for advanced cases. Early cases, where any traces of the Bacilli occur in the sputum, are dangerous, but the danger from them is trifling compared to that from the advanced and fatal cases. The last 4 or 5 weeks are the most deadly in the spread of the infection. It is a difficult matter in Phthisis to ascertain the source of infection although inquiries were made into all the deaths that occurred in the district. All that can be said as to the source in any case is, that the exposure of a patient to a particular source of infection has been more frequent or prolonged, or that the infection is more actively disseminated in one case than in another, and that, therefore, that cause is the principal one. 18 In 12 instances there was a history of Consumption in the family, but we know that hereditary transmission is so rare as to be left out of the question. In the majority of cases, the sputum must be regarded as the main source of infection, and the germs must have reached the lungs by inhalation. It is difficult not to infect the rest of the family when a case occurs amongst the poor. The whole family have to live in two or three ill-ventilated rooms, and the patient is left without the nursing he requires. At night he sleeps in the same room as other members of the family do. The sufferer scatters the morbid matter secreted by his diseased lungs every time he coughs, and his relatives close beside him must inhale the poison. Thus whole families are infected. In one case inquired into 9 members out of a family of 11 had succumbed to the disease. In another family, the father, son, and 3 of the daughters died from the disease. Instances of 2, 3, or 4 deaths from Consumption in the same family were not infrequent. Such events awaken in the minds of those who do not know the infectiousness of tuberculosis the opinion that it is hereditary, whereas its transmission in the cases in question was due solely to the simplest processes of infection, which do not strike people so much, because the consequences do not appear at once, but generally after the lapse of years The fact that some of the family escape is no argument against its infectiousness. Apart from the question of immunity, the infectivity or communicability of a given disease bears an inverse ratio to the duration of. the malady. The object of the parasite is to provide for the continuance of its species. Tn Measles, Scarlet Fever, and the acute infectious diseases where their duration is short, the communicability is high, since the opportunities afforded to the parasite of reproducing its species are limited. In Consumption, on the other hand, where the duration of the disease is long, the communicability of the disease is low, as ample opportunities are afforded for its propagation. It is on this assumption that disinfection is carried out after the death of the patient, though in a large majority of the cases the damage has already been done. Disinfection was urged in all cases where death has occurred, but only in 17 instances was the offer accepted. It is pointed out on another page that the most dangerous period is the last month of the disease, and arrangements have now been made so as to obtain a list of those removed to the 19 Infirmary suffering from the disease, so that disinfection may be carried out immediately after removal. Of the 17 instances in which there was no family history of the disease, in 5 there had been a definite exposure to infection. Three had nursed consumptive patients, and in the fourth, the husband probably contracted the disease from his wife, as the latter had died from the disease 3 years previously. In two instances no information could be obtained, and in ten no definite history of exposure could be ascertained, but in six of the latter, their employment constantly exposed them to infection. Three were employed in laundries—two females and one male. Although laundresses do not appear to suffer excessively from Consumption, yet the sorting of the linen which may contain dried infective sputum must expose them to the risk of infection. (At the Census in Acton, 15 per cent. of the female population over the age of ten years were employed in laundry work; last year 16 per cent. of the deaths from Consumption in females over ten years of age, occurred amongst laundresses). There are two methods by which Tubercle may be prevented; the first aims at strengthening the natural immunity of the race, and the second endeavours to limit the spread of infection. Although all sanitary efforts tend towards the first object, the special arrangements made by the Council have been directed for the most part with the object of limiting the spread of infection. To attain this end the first essential is accurate information as to the distribution of the disease, and to gain this information the Council adopted the principle of voluntary notification in June, 1903, the sum of 2S. 6d. being paid for each case notified. The result has been far from satisfactory, and only six notifications were received during the year. The want of success is probably due to the impression that notification would have a prejudicial effect on the individual suffering from the disease. It is admitted that it is not absolutely necessary to notify all cases of Consumption, but where owing to domestic conditions the patients are sources of danger to the people in contact with them, it is essential the cases should be notified so that instructions may be given and precautions taken. 20 If the sputum is collected in a spittoon and burnt or otherwise destroyed it is probably dangerous to no one. Even if thrown into dry and well-lighted surroundings, exposed to the rays of the sun. it loses its dangerous properties. But if it remains in dark and damp surroundings it will maintain its activity for a long time, and thus it is that Tubercle claims more victims from gloomy, ill-ventilated and dark dwellings. There is an admitted danger in tuberculophobia, but the fact that Consumption is curable should make notification easier. Half the human race has tubercle and goes on living without knowing it. Stress has been repeatedly laid upon the curability of Consumption, but the greatest difficulty has been experienced to persuade the victims of the disease to take advantage of the arrangements made by the Co uncil. In July, 1905, an agreement was entered into whereby the Council maintained three beds at the Northwood Sanatorium. Only twelve persons applied for admission during 1906, and of these four were in too advanced a state to benefit from the treatment. Very rarely the three beds were occupied during the year, and from a return issued, it was shown that two beds would more than suffice for the applications received. Our first difficulty is to get at the sufferers in the first stage of the disease. In the earliest stage the patient coughs and has a cold Either he takes no notice of it or goes to a chemist and has a mixture for his cough. Weeks and months go by, and if the weather is inclement he gets worse; if it is mild, he has periods when he appears better, followed by more serious attacks. Then fever and wasting set in and he has to give up his work. This is the time he usually seeks medical advice, but he has entered a stage when skilled treatment is probably useless. The Council has done almost everything in its power to obviate this difficulty. It undertakes the bacteriological examination of all suspicious cases, and during the year thirty such examinations were made, but in almost every instance the patient was too far advanced to benefit from Sanatorium treatment. In France anti-tuberculous dispensaries have been established. Foremen are educated and they advise their fellow workmen to seek treatment in the first stage. Besides the difficulty of obtaining early information of the disease, there are other obstacles which prevent some of the sufferers 21 from taking advantage of Sanatorium treatment. Two of the persons admitted to Northwood prematurely discharged themselves from the institution though they were making satisfactory progress. The reason assigned was, that they were the bread winners of the family, and there was no one to maintain the family whilst they were undergoing treatment. To secure early treatment it would be necessary to render aid to the dependents of the sufferer in addition to treating the patient. Freed from anxiety, he would enjoy a better hope for recovery. To some of those who have applied, it has been pointed out what "cure" means in consumption, and in one instance the sufferer was able to obtain an outdoor employment after his discharge from the Sanatorium. Unfortunately, a large number of patients do not quite appreciate what a "cure" in consumption means. The disease is not "cured" in the same way as Diphtheria, Scarlet Fever and Small Pox are. There is no disease that is so frequently arrested as Consumption, but it is equally true that there are no subjects so liable to a relapse as the consumptive patients, and this constitutes a fundamental difference between Consumption and the other diseases mentioned above. Consumption is similar to Scarlet Fever and Diphtheria in this respect, that they are infectious diseases and caused by microorganisms, but there is this broad distinction to be drawn between them —in one class, an attack renders the individual more liable to a relapse, or more correctly, to a recurrence, whilst in the other one attack usually confers an immunity from further attacks of that particular disease. The object of the residence at the Savtorium is two-fold—to arrest the progress of the disease and to inculcate in the patient the principles which underly the treatment. The first can be accomplished in all cases of Consumption that have not advanced too far. To accomplish the second object you must select the class of people treated, otherwise a relapse occurs as soon as the patient returns to the conditions under which he contracted the disease primarily. The disappointment he feels is proportionate to the hope born. To this extent, we should frankly admit the limitations of Savtorium treatment. unless, of course, the authorities governing such institutions can combine them with working colonies, where poor patients could be put in the way of fitting themselves for a useful outdoor life after 2 2 leaving the Sarvtorium. The majority of the poorer classes who suffer are accustomed to an indoor life, and if sent to the country or to one of our colonies would be helpless. MEASLES. In 1906. 27 deaths were registered as due to Measles, but before we deal with the special features of the recent epidemic, it may be cf interest to trace briefly the history of the disease in the district during the last quarter of a century. This survey, I hope, will convince the Council of one important fact; that in spite of the improvement which is noticeable, there is still a deplorable sacrifice of life upon the altar of this one disease alone. For purposes of comparison, Acton is more fortunate than most other centres of population. If the relative incidence of Measles on certain age-groups be considered, it will be found that the mortality from the disease falls heaviest on children under 5 years of age. Throughout the kingdom the birth-rate has been steadily and continuously diminishing during the last 20 years, and, consequently, the proportion of children under 5 years of age, to the entire population, is now less than it formerly was. Where a falling birth-rate has been in progress, a comparison of the death-rate from Measles extending over a number of years would be fallacious. On the other hand, in Acton, since 1890, the birth-rate per 1.000 inhabitants has been fairly constant. It is, of course, understood, that we are now dealing with the proportion of children to the entire population and not with the birth-rate. Owing to various causes, the age-constitution of the population in Acton has changed, and the relative number of women between the ages of 15 and 45 has increased. This accounts for the apparent constancy of the birth-rate, but if the rate be expressed as the ratio of births to the number of married women between the ages of 15 and 45 years, the same phenomenon would be observed here as in the rest of the kingdom. In view of the fact that the relative proportion of children under 5 years has not altered, the usual method has been adopted, and the mortality from Measles has been expressed as the number of deaths per 100.000 of the population. In the circumstances, a comparison with the years 1890-1905, based upon the total number of deaths registered, is a fair and legitimate one. 23 On the following page a chart is given, which shows the number of deaths from Measles per 100,000 inhabitants during the last quarter of a century, but owing to the marked difference in the birth-rate, too much reliance must not be placed upon the figures for the years prior to 1890. It will be observed with what regularity Measles appears in an epidemic form. An epidemic made its appearance almost every second year, and the district was visited by a major epidemic at intervals of 4, 3, 4, and 6 years respectively. If these periods were analysed more minutely, the cyclical character of the epidemic would be made still more evident. For instance, the figures for 1897 and 1898 really belong to one epidemic; the outbreak commenced towards the latter part of 1897 and continued during the earlier months of 1898 The experience of Acton has been somewhat similar to that of the whole of England and Wales. The means adopted for the prevention of Measles have not. up to the present, had the effect of steadily and continuously reducing the death-rate. During the third quarter of the last century, there was a decided improvement, but this was followed by a serious rise towards the end of the century. This rise will be made more evident if we dissect the figures in the chart and take the mortality for certain definite periods. The following Table gives the annual number of deaths per 100,000 inhabitants in quinquennial periods for the 25 years, 1882-1906: 1882-86. 1887-91. 1892-96. 1897-1901. 1902-1906. 32.6 66.6 50.2 13.6 29 For purposes of comparison, the figures have been expressed as the number of deaths per 100.000 inhabitants, but they may appear clearer and distinct if the actual number of deaths be given. In the 25 years, 259 deaths have been caused by Measles. In the same period Scarlet Fever, Diphtheria and Typhoid Fever combined have been the cause of 286 deaths. In the quarter of a century Small-pox has caused 13 deaths, but in Measles we have a disease which claims as its tribute every year almost that number of lives. The victims of the latter form the silent, the innocent and the unprotected portion of the community. 24 Chart showing the number of deaths from measles per 100,000 of the population for the 25 years,1882-1906. 25 The public cannot be aware of the serious drain upon life which an outbreak, of measles entails; if they did, greater precautions would be taken to prevent its spread. It is the commonest of expressions, "Oh, it is only Measles," and the superstition is general that a child must get Measles, and the sooner he gets it the better. Probably, no superstition is attended with more disastrous results. The utter folly of such a belief cannot be too strongly emphasized. After a certain period, the older the child, the less susceptible he is to the disease, and even if they contract the disease, children over 5 years of age rarely succumb. The age at which relatively the greatest number of children die of Measles is the second year of life; while after the third year has passed there is a rapid decrease in the proportion of children dying of this disease. Dr. Theodore Thompson, in his report to the Local Government Board on the control of Measles, states " that the incidence of attack is different from that of death. For while the main incidence of death is on the second year, the incidence of attack is chiefly on the third, fourth and fifth years. From this different incidence of attack and of death it results that the fatality from Measles is very much higher in the second year of life than in any of those succeeding years. While, therefore, more children die of Measles in the second year of life than at any other age, more children are attacked by this disease in each i f the three years following; so that children in the second year of life, although less susceptible to attack, are much more likely to die if attacked than any other children." It is more than probable that the above remarks hold true of the present epidemic, though it is impossible to produce figures to verify them. Dependent, as we are, upon school notification, it follows that the majority of cases amongst children under school age would not be reported except where children from the same house attended school. The following figures, though, would suggest that the number of deaths which occurred at different age-groups did not represent the relative number of cases at the same ages. Three hundred and forty-five cases were reported and investigated, and the ages of these were:— Under 1 year. 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-10 Age uncertain. 11 21 8 12 55 92 74 36 3 5 28 26 The ages at death were as follows:— Under 6 months 1 6 and under 12 months 3 Total under 1 year 4 1 and under 2 years 14 2 and under 3 years % 6 4 and under 5 years 1 5 and under 6 years 2 Total 27 Of course, it is understood that these figures do not represent the relative number of cases at different ages which occurred during the late epidemic. It is explained above that the majority of the cases which come to the knowledge of the Sanitary Department would be children who attend school, and Measles occurring among younger children would remain unreported. The above figures, though, do bear out the assumption that the fatality from the disease is lower in children above the age of 2 years. This aspect of the question is worthy of consideration, as bearing upon the epidemicity of the disease. If the assumption be correct, and it probably is. the length of the inter-epidemic period is of importance. If the inter-epidemic period could be lengthened, not only some children would have reached an age when they would be less susceptible to an attack, but a larger number of children will, when the epidemic arrives, have reached ages at which the disease is little fatal. A number of lives would thus be saved, which are now sacrificed to Measles. Our first concern, therefore, would be with the measures adopted to meet epidemic prevalence of the disease, and the means by which it'may be controlled so as to arrest or delay a threatened epidemic. The other measures would be directed towards restraining the spread of Measles in invaded households. 27 These, in the main would constitute our most important means towards attaining our first object, for the isolation of every case of Measles from the first onset to the end of the third week would undoubtedly enable an outbreak to be brought abruptly to a close, as no second crop of cases would occur. This ideal will, probably, not foi the present be accomplished, but the attention paid to invaded households would tend to secure more precaution on the part -of parents. Two factors which play an important part in the spread of an epidemic are the early infectiousness of the disease and the occasional mildness of the symptoms. Measles is infectious during the period in which the patient has running from the eyes and nose, and before the rash appears. It is true that Koplik described some spots on the mucous membrane of the mouth; these make their appearance at the onset of the disease, but their early appearance is often useless for purposes of prevention, as a doctor is not usually called in attendance until a rash is observed. On account of this early infectiousness, the difficulty of preventing an epidemic will be appreciated. Whatever the ultimate cause may be. the disease is contracted through personal contact with an infected case, and though this personal contact was not clearly proved in every instance, yet the course of the outbreak plainly suggests that its spread was thus facilitated. The main outbreaks were in South Acton, Rothschild Road and Beaumont Park Schools. The disease first showed itself in the south-western part of the district, and on January 29th 13 cases were reported from the South Acton Infants' School. Between January 29th and February 15th, 65 cases were reported from this school. The Infants' School at Rothschild Road was probably attacked about the same date, though information did not reach the Sanitary Department of an outbreak at this school until February 2nd. On that date 34 cases were reported. Both these schools were closed from February 5th to March 2nd. 28 Roughly speaking, the outbreak spread from west to east, and the number that occurred to the north of the Uxbridge Road was small. The attendance at St. Mary's and.the Priory Schools was not appreciably affected, but cases occurred in Beaumont Park School towards the beginning of February. The earliest cases at the latter school were reported on February 8th, and between that date and April 3rd, 150 cases occurred amongst children attending this school. The school was closed from March 12th to March 23rd. Only 6 cases were reported amongst children attending the Priory School, and all these lived to the south of the High Street. Towards the end of March the outbreak gradually subsided, though 2 deaths occurred in April, 3 in May, and 3 in June, as compared with 11 deaths in February and 8 m March. The street distribution of the deaths was as follows:— Stirling Road 4 deaths. Colville Road 3 „ Park Road North 3 „ Holland Terrace 3 ,, Cunnington Street 2 „ Fletcher Road 2 „ Bollo Bridge Road 2 „ Antrobus Road 1 death. Bolton Road 1 „ Bridgman Road 1 „ Somerset Road 1 „ Speldhurst Road 1 „ Gloucester Road 1 „ Bollo Lane 1 „ Clovelly Road 1 „ The 27 deaths occurred in 25 households, one death each in 23 houses and 2 deaths in each of two houses. Of the 27 children amongst whom Measles proved fatal, 2 only attended school when they contracted the disease, but this proportion does not truly represent the influence of school attendance on the spread of the outbreak. In the case of sixteen of the children, there 29 was a connection between school attendance and infection, as Measles was introduced into the house by one of the children attending school. This connection of school attendance and infection brings us to a consideration of the preventive measures against Measles. Formerly, it was the practice to exclude all the children of infected houses from attending school, but in the boys' and girls' departments, the classes arc protected to such an extent on account of the pupils having previously suffered from the disease, that there was no fear of Measles spreading in the higher standards. An exhaustive enquiry has recently been made by Dr. C. J. Thomas, for the London County Council, into the spread of Measles among children attending the elementary Schools of Woolwich. He found that " the disease tends to spread whenever a class accumulates unprotected members to the extent of between 30 and 40 per cent., and when spread has begun it continues until the proportion is reduced to between 15 and 20 per cent. unprotected." Acting upon this experience, the Education Committee of the London County Council have adopted the following addition to their Code of Instructions to Teachers:— Children suffering from Measles must be excluded for at least one month. Children coming from houses where Measles exists, but who are nor themselves suffering from the disease, should be dealt with as follows:— A child attending other than an infants' school who has had Measles need not be excluded from attendance at school. A child attending other than an infants' school who has not had Measles must be excluded from attendance at school until the Monday following the expiration of fourteen days from the occurrence of the first case. A child attending an infants' school, whether or not it has had Measles, must be excluded from attendance at school until the Monday following the expiration of fourteen days from the commencement of the last case. In the main, the above rules were carried out here, but there was a lack of uniformity in the various schools, as to the conditions under which a child was excluded from attendance. 30 The desirability of issuing definite rules to teachers and attendance officers might be considered by the Education Committee. As might be expected, though the older children were not generally excluded, Measles did not spread in the boys' and girls' departments. It is now held that in the vast majority of instances, if not in all, Measles is spread as the result of personal contact. It is doubtful if an apparently healthy person can act as a carrier of infection. There is always the danger that lurks in the early infectiousness of Measles, but, for reasons previously stated, the age incidence of the disease at the present time minimises this risk in the case of boys' and girls' departments. It is possible that some of the older classes i-i the infants' departments might be saved the inconvenience of closure. Except in certain better-class districts 75 per cent. of children above 5 are protected; yet owing to the exigencies of attendance, the whole department is closed. Before the withdrawal of Article 10 r of the old Code, separate classes could be closed. Now, if separate classes are closed, the average attendance suffers; whilst closure of the whole department is welcomed when the attendance falls below a certain mark. It may be inferred from the foregoing remarks that closure of the three schools involved w'as resorted to primarily for the sake of average attendance, and not with any decided hope of checking the spread of the epidemic. At any rate, it must be admitted that the latter object was not attained. Under the conditions obtaining in Urban Districts, it is doubtful if school closure has much effect. But if school closure is to be of any avail, it must be done at the earliest opportunity, and at the start of the outbreak. The practice of waiting until the attendance falls below a certain mark does no good, and the responsibility of protecting the average attendance could well be placed on shoulders other than those of the Sanitary Department if some definite rule be adopted. At present a very great difference of opinion exists. Dr. May, the Medical Officer of Health for Aston Manor, submitted to 99 authorities the question of what percentage of children absent from a 31 school or department on account of Measles lead to a recommendation of school closure, and the replies were as follows:— No fixed percentage 47 2 to 5 per cent. 2 5 to 10 per cent. 6 10 to 15 per cent. 10 15 to 20 per cent. 8 20 to 25 per cent. 3 25 to 30 per cent. 1 30 to 35 per cent. 7 35 to 40 per cent.0 40 to 45 per cent. 1 45 to 50 per cent. 1 50 per cent. 2 No replies 11 Tf information could be obtained of the earliest cases school closure could then be resorted to with some prospect of success. To attain this object, the information from the schools must be systematical, and notification carefully made during inter-epidemic periods as well as when epidemics of Measles prevail. Unfortunately, there is no satisfactory system by which a teacher becomes aware of the cause of the absence of a pupil. If a note is not received, he is dependent on a hearsay report from any child who happens to live near. The question has been raised on another occasion as to the desirability of adding measles to the Schedule of Notifiable Diseases. The compulsory notification of Measles has, as yet. been tried in only a few towns, and, I believe, that only two towns have published fully the results of such notification. As early as 1881 the Corporation of Aberdeen obtained powers for the compulsory notification of Measles. Under the Aberdeen Local Act of 1881, notification by the medical attendant only was required. After the passing of the Infectious Disease Notification Act. 1889. the Town Council adopted it in 1891, in order to obtain the advantage of dual notification, that is, by the medical attendant and by the householder. 32 After a report from the Medical Officer of Health, the compulsory notification of Measles was stopped in February, 1903, as experience appeared to show that the benefits scarcely justified the large cost. No doubt a question may arise as to the completeness of the record of cases of Measles during these years. It must be admitted that the notification of any disease is rarely absolutely complete. Some cases are unrecognised, and others may be wilfully concealed. In Aberdeen, though, the compulsory powers were rigidly applied throughout the whole period, and when required, proceedings were instituted against defaulters. The following Table gives the average annual mortality in Aberdeen from Measles for 100.000 inhabitants:— 1856-1872. 1873-1887. 1888-1900. 61 44 51 The conclusion which Dr. Hay, the Medical Officer of Health for Aberdeen comes to is " that it is obvious from these considerations as to the prevalence of Measles, and as to the mortality from the disease, it is impossible to assert with confidence that notification has enabled us to exercise any distinct and effective control; and it can scarcely be urged that we have not made a sufficiently lengthy trial." The other town that tried the compulsory notification was Burtonon-Trent, where Measles was scheduled as a notifiable disease from 1894 to June 30th, 1900. During the period notification was in force, there was no diminution in the number of deaths, nor were the inter-epidemic periods lengthened, as the following table will show: Notification not in Force. Deaths from 1887 1888 1889 1890 1891 1892 1893. Measles 8 20 26 2 3 52 7, Births 1565 1.575 1634 1481 1636 1511 1625 Notification in Force. January 1st to 1894 1895 1896 1897 1898 1899 June 30th, 1900 Deaths 36 2 86 7 31 o 36 Birtns 1533 1572 1512 1430 1463 1429 33 If we compare the six years before, and the same period after notification was adopted, we find that the number of births during 1888-1893 slightly exceeded that of 1894-1899, and, therefore, the number of susceptible children would, if anything, be larger in the former period, but the mortality from the disease was lower during the former period. The result cannot be deemed satisfactory. Dr. Millard, who formerly was Medical Officer of Health for Burton, attributes this want of success to the fact that many cases were unreported, and also to the early stage at which Measles is infectious. A medical attendant is not always called in when Measles makes its appearance in a family; while the householder rarely reports the presence of Measles in his dwelling, whether a doctor has been called in to see the case or not. To this extent, therefore, compulsory notification commonly fails to afford to Sanitary Authorities complete knowledge of all the cases that occur in their district. In view of the experience gained by those towns that have placed Measles amongst the compulsory notifiable diseases, it appeals that success is more probable along other paths, more especially in a development of school notification. The appointment of a Health Visitor enables the Council to utilise the information thus obtained. As soon as a case is reported, the house is visited, and if there is no doctor in attendance, general instructions are given as to the management of the case and isolation of the patient. Circulars are also distributed. Except in exceptional circumstances, disinfection is not carried out. Under the conditions which prevail, we have no choice in the matter, but in the present state of our knowledge of the disease, it is doubtful if disinfection would be of much value. In the case of Diphtheria, Typhoid, and Consumption, we know that the germs which cause these diseases can survive for long periods on articles of apparel or bedding or on the walls of rooms which have not been disinfected. Outside the body, the measles-germ has probably a very short life, and to substantiate this. I may record the result of inquiries made by Dr. Newsholme in Brighton. In the spring of 1904. there 34 was an epidemic of Measles In Brighton, and in August and September of the same year every house was visited in which, during the previous seven months cases of Measles had occurred. No disinfection had been carried out in any of these houses. Six hundred and twenty-five houses had been invaded by Measles; in 534 of these houses the occupants were the same as on the first visit, and no further children had been attacked by Measles. The immunity of the 169 children in these houses, who had not previously acquired Measles, had continued. Of the remaining houses. 23 on investigation were found to be empty, and in 66 of these new families were living or new babies had been born. Eighty-six new children had come into these presumably infected houses, and 27 of them were unprotected and possibly exposed to infection. The duration of their exposure in the presumably infected houses varies from 17 days to 4b months. None of them acquired Measles, and Dr. Newsholme concludes that if there had been a few instances of Measles among the number he should have refrained from pressing a case based on scanty data, even though the majority of the children had escaped infection. But in view of the fact that the entire experience points in one direction, it is justifiable to infer provisionally that the infection of Measles is shortlived and that domestic cleansing suffices for disinfection. This conclusion is obviously subject to revision if a series of unfallacious positive facts are forthcoming at any future time in contradiction to the negative facts here adduced. Apart from the expense which disinfection would involve, there are other reasons against adopting it as a general practice. It has been positively stated that Measles is infectious before the disease is recognised, and the children are not kept to one room. Besides, even when recognised, little attempt is made at isolation, and the children are allowed to roam about the house, possibly, before they are free from infection. It would obviously be useless to disinfect the bedroom alone, when other rooms had been exposed to infection. An endeavour was made to impress upon the parents the necessity of keeping the child apart from the other children in a suitable rcom during the infectious period. In some instances the instructions were not regarded owing to inadequate accommodation in invaded houses. In some districts the difficulty has been met by the 35 removal of Measles to hospital. In Brighton, the Medical Officer of Health recommended that he be authorised, so far as their accommodation would permit, to admit cases of Measles which cannot be properly treated at home. Some saving of life would, doubtless, be secured by this means. I am afraid that here hospital accommodation would not be practicable except on very rare occasions. During the whole of the period that Measles was epidemic last year, our hospital was required for the isolation of other diseases. In the remote possibility that our hospital accommodation would permit it, the Council might consider the desirability of isolating Measles in exceptional circumstances. WHOOPING COUGH. Whooping cough was returned as the cause of 5 deaths. Measles and Whooping Cough occur frequently in association with each other. There is a difference of opinion as to the order of sequence in which the two diseases occur in respect to each other. The disease was most prevalent in the South-West Ward. INFANTILE MORTALITY. It has been explained in previous reports that the infantile mortality is usually expressed as the ratio of deaths in children under one year of age to the total number of births registered. It was stated on a former page that all the births belonging to Acton are not registered within the district, and though an arrangement is now made whereby all the deaths of residents occuring outside the parish are included in the returns of this district, a like system does not obtain in respect of the births. For instance, the death of a child occurred in Queen Charlotte's Hospital within a few hours of birth the death is included in the statistics for this district, but the birth is not. A similar circumstance occurred at th? Isleworth Infirmary. The outside deaths affect the Infantile Mortality to the extent of 5 per 1,000. One hundred and ninety-three deaths under one year of age were registered in the district, and 8 infants under one year of age died in public institutions beyond the district, making a total of 201. This latter figure corresponds to an infantile mortality of 130 per 1.000 births, or a death-rate of 4 per r,ooo inhabitants. In addition 91 deaths occurred between the ages of one and five years. Althgether 42 per cent. of the total deaths in the district occurred among children under five years of age, and 29 per cent. occurred among infants under 12 months old. In 1906, the infantile mortality in England and Wales was 133; in the 76 large towns it amounted to 146, and in the 142 smaller towns it was 138 per 1,000 births. Compared with 1905 there was an increase of infantile deaths from the following diseases : Diarrhoeal Tuberculous Measles Diseases Diseases Overlaying 1905 2 43 7 2 1906 4 80 11 4 Tne following diseases showed a diminished death-rate: Convulsions Bronchitis Pneumonia Wasting Disease 1905 13 13 21 47 1906 6 7 16 46 The only cause of death which shows a marked difference in its mortality is Epidemic Diarrhoea. The Ward distribution was as follows: N. West N. East S. East S. West 34 32 28 107 During the year the district was rearranged into four Wards instead of three, and as the former division has been utilized for statistical purposes, it is not possible to compare the infantile mortality in each Ward with previous years. Moreover, this year the births for the Wards have been separately arranged, so that the infantile mortality of each Ward can bp expressed as a ratio of deaths under one year to every 1.000 births. In 1905, there were in the North Ward 27 deaths under 12 months old, in the East Ward 60 and in the West Ward 75. The infantile mortality in 1906 in the Wards was: N. West N.East S. East S. West 148 97 110 147 37 Three of the Wards have an infantile mortality of over 100 per 1,000 births, and only one is below that number; but it should be explained that the high mortality of the North-West Ward is due to the large number of deaths which occurred in that portion situate to the south of the High Street and to the East of Gunnersbury Lane. Out of the 34 deaths of infants which occurred in the North-West Ward, this area was responsible for 16. The conditions which prevail in the above-mentioned portion of the North-West Ward approximate closely to those of the SouthWest Ward, and one of these is included in the term overcrowding. Overcrowding may embrace such a variety of circumstances that its use is open to misconstruction. The term is here used not in its legal sense, but to denote the aggregation of people under such conditions as to injuriously affect the weakest members of the community. We should clearly distinguish between overcrowding of site and overcrowding of the dwellings. It is sometimes assumed that overcrowding must ensue as a result of the movement of the rural classes to towns, but this emigration in itself, does not always tend to an exalted infantile mortality. If a comparison be made of the South-East and South-West Wards, the distinction between overcrowding of site and overcrowding of rooms will appear clear. The area of the former Ward is 199 acres, and of the latter 240 acres. The estimated population is 11,000 and 17,000 respectively. The South-East Ward contained 55 persons to the acre, and the SouthWest Ward 74. This difference in the density of the population to the acre is not sufficient to account for an infantile mortality of no per 1.000 in the one, and of 147 per 1,000 in the other. Of more importance is the overcrowding of rooms, which prevents them being efficiently ventilated. It is assumed that a house is overcrowded if the average number of persons per room exceeds two. It is estimated that in average sized rooms the cubic feet of aii space is sufficient for two people, as a change equal to three times per hour is generally all that can be borne under the conditions for warming in this country, or that is practically attainable with natural ventilation. In all tenements with less than four rooms, it usually follows that during the night, the actual number in each room probably reaches, if not exceeds, four. This overcrowding of rooms, 38 with its accompanying vitiation of the atmosphere bears a close relation to a high infantile mortality, but it is a common experience to find the overcrowding more marked in three-roomed tenements than in those of one and two rooms. At the Census, only a small percentage of the latter were occupied by families having children, and this fact accounts for the excessive mortality in three-roomed tenements as compared with those containing one and two rooms. Inquiries were directed as to the number of rooms occupied by the family where an infant death had occurred, and of 135 deaths inquired into it was found that 15 families occupied 1 room. 14 families occupied 2 rooms. 81 families occupied 3 rooms. 17 families occupied 4 rooms. 8 families occupied 5 or more rooms. These figures do not represent the true relation which overcrowding bears to infantile mortality. Fifty-eight infant deaths were not specially inquired into, and of these the majority occurred in families occupying more than 5 rooms. For our present purpose, it is taken for granted that in all cases not inquired into, the family occupied more than five rooms. With this correction, the percentages work out as follows:— 7.8 per cent, of infant deaths occurred in one-roomed tenements. 7.3 „ „ „ two-romed tenements. 42 „ „ „ three-roomed tenements. 8.8 „ „ „ four-roomed tenements. 34.1 „ „ „ five-roomed tenements and over. At the census of 1901, there were 8.326 separate tenements in the parish, and the number of rooms occupied by each family was as follows:— 612 families occupied 1 room each. 716 families occupied 2 rooms each. 1,512 families occupied 3 rooms each. 1,277 families occupied 4 rooms each. 4.209 families occupied 5 rooms and over. 4.209 families occupied 5 rooms each and over. 39 The following table shows the excessive mortality in the smallersized houses:— Percentage of total tenements at Census. Percentage of deaths under 12 months old in 1906. One-roomed dwelling 7.3 7.8 Two-roomed dwelling 8.3 7.3 Three-roomed dwelling 18 42 Four-roomed dwelling 15 8.8 Five-roomed dwelling and over 50 34.1 But overcrowding is not the only factor in the production of a high infantile mortality in these particular areas and in the smaller houses. Overcrowding, in the sense now used, is inseparably connected with other evils. Both overcrowding and one of its resultants —high infantile mortality—are merely symptoms; the malady lies deeper and involves educational, moral, social and industrial problems which only remotely touch medicine. These questions will not be entered into, except as far as the figures at our disposal may serve to illustrate their effect upon the infantile mortality. In a district, such as ours, instruction in domestic subjects is especially necessary. Young women enter upon the responsibilities of motherhood in utter ignorance of the requisites of feeding, clothing and tending of infants. It is not possible to put back the hand of time, and to say that prior to wedlock the woman must be engaged in domestic work. The girl who enters some industry, such as laundry work, has her energies well occupied with her daily task, and when she becomes a mother, enters on her new life with hardly any conception of what its duties consist. It is hardly possible, perhaps, to teach domestic subjects in an elementary school, but the machinery whereby these subjects may be taught should not be beyond the ability of the combined action of the education and health authorities. To imagine that nature can be trusted in these matters is folly. A mother has not an instinctive knowledge of what is necessary for a child's welfare, no more than the child has an instinctive knowledge of its own requirements. The mortality of first-born children should indicate that a modern woman carries no instinctive system of baby management with her 40 in her brain. Out of 135 deaths, 61 were first-born, and it cannot be argued that this period marks the direst poverty in the history of the family. This ignorance is seen at its worst in the case of illegitimate children, and its results are deplorable. Of the total births, 39 were born out of wedlock, and 22 illegitimate children died before reaching the age of 12 months. These numbers correspond to an illegitimate infantile mortality of 564 per 1,000 births. Eleven of these deaths were due to errors of feeding—10 from Diarrhoea and one from Marsamus. In spite of the fact that the mortality amongst illegitimate children was more than four times as high as that of children born in wedlock, there was no evidence of any wilful neglect. The standard of living, though, in all instances was low, and there was a lack of personal and domestic cleanliness. All were artificially fed, as the mothers were compelled to earn their own living, and their offspring were deprived of the natural food of the infant. The illegitimate child is exposed to all the disadvantages of married female labour, and derives none of its benefits; as is shown when dealing with Diarrhoea, the hand-fed child fares ill as compared with his bieast-fed brother, but the illegitimate child has to contend with other conditions which are inimical to his welfare. At the present time, it may almost be stated that the only educational work amongst the poorer classes in domestic economy and the elementary laws of hygiene is carried out through the Health Visitor. To render the work of the latter really efficient, it should be supplemental to the work of educational authorities. Direct teaching upon the rearing of infants may be out of place in elementary schools, or even in secondary schools, but the value of a Health Visitor would be greatly augmented if the elementary laws of hygiene had been inculcated into the mothers when they attended school as children. A large number of the mothers have not formed habits of cleanliness and care of the person, and, unfortunately, before the sanitary authority hears of the birth of a child irreparable damage has often been done. In England, a birth need not be registered for a period of six weeks. In Scotland this period has been shortened to three weeks. In France, civil registration has to be 41 made within three days. The Corporation of Huddersfield has succeeded in obtaining power to compel the registration of a birth within 48 hours. Section 73 of the Huddersfield Corporation Act, 1906, provides "that it will be the duty on and after November 1st, 1906, of the father of every child born within the borough, if he is actually residing in the house where the birth takes place at the time of its occurrence, or in his absence of any person in attendance on the mother at the time of birth or within six hours thereafter, to send or give Notice of the birth to the Medical Officer of Health of the borough within forty-eight hours after such birth. Every person required to give or send such notice who fails to give or send the same shall, unless he satisfies the court that he had reasonable grounds to believe that notice had been duly given, be liable, on summary conviction, to a fine of not exceeding twenty shillings, including costs, for each offence." It may be stated that a period of two months now elapses before the premises can be visited by the sanitary authority. Seventy-one deaths occurred before the children reached the age of two months. In other words, the circumstances connected with 71 of the infantile deaths were for all practical purposes beyond the control of sanitary) authorities. But this does not exhaust the inadequacy of the present registration machinery. It has been reported to the Health Committee that the number of wrong addresses given by parents is on the increase. In some districts as high a proportion as five or ten per cent, of the births are not recorded at all. There is no necessity to enumerate the causes which lead to this deception, probably the desire to escape vaccination is one of the most potent. It is sufficient that the practices exist, and with the present registration system they will continue and prosper. The registrar has no means of detecting these abuses. The infantile mortality had decreased between the ages of 3 and 12 months, but under the age of 3 months the rate had been stationary. But to obtain the best results in the prevention of infantile mortality, the work of preventive medicine should commence before even the birth of the child. Last year, there were 25 deaths from Prematurity, 5 from Congenital Defects, 4 from Injury at Birth, 16 42 from Congenital Debility. Besides these. 40 still-births were buried in the public Cemetery. Most of these were due to ante-natal causes, and although it is impossible to obtain definite statistics, there is no doubt but that chronic alcoholism in the parent exerts a most injurious influence upon the offspring. Experimental methods have provided us with proofs that alcohol given to a pregnant animal finds its way to the foetal tissues. Of 120 inebriate women in a Liverpool prison there were born 600 children, of whom 335 died under two years or were deadborn. Further, there was also found to be a progressive death-rate in the alcoholic family; the number of dead births a iin deaths under two years increased as time went on, these fatalities being more numerous among the later born than the first-born children of these inebriates. But alcoholism is not the only factor, and the necessity of issuing some simple instructions to the expectant mother on the Hygiene of Pregnancy has been informally discussed by the Health Committee. The matter will be again brought before the Committee, so tha> the means and agencies by which these instructions may be issued can be discussed. The vices of alcoholic excess, the use of certain drugs, and the incidence of certain diseases must eventually be overcome by the moralist, but possibly they bulk less largely than the great economic condition of poverty which brings to the mother insufficient food, insufficient rest, excessive work, and extra stimulation. In this district, poverty is the chief cause of married women's labour. The mothers go out to work, not from choice, but from necessity. It is doubtful if work is injurious to the expectant mother, provided it be not heavy or prolonged. The improved food and greater comfort which mis work means, more than counteracts its disadvantages. In view of the tendency to impose further legal restrictions upon married female labour, the subject demands investigation, and before the actual effect of the employment of women on the infant mortality can be determined, we should have exact information not only as to the sanitary surroundings of the selected areas, but also as to the kind of employment. In the laundry industry, the married women work, as a rule, only four days a week, and we have yet to be convinced that this 43 labour, if not carried on later than the seventh or eighth month of pregnancy, exerts a harmful influence upon the offspring. Miss Anderson, in her evidence before the Committee on Physical Deterioration, cited Acton as a district where inquiry might be profitably made as to the extent and effects of employment of mothers in laundries. Pressure of other work has prevented us from making inquiries as to the extent, but some of the effects were inquired into. Investigations were made into those deaths which were probably due to antenatal causes, and to what extent they were affected by employment of the mother whilst pregnant. The causes of death most profoundly affected by antenatal causes are Prematurity, Congenital Debility and Convulsions, and the incidence of the mortality from these causes in certain districts of the parish is not immaterial to the subject under consideration. The area referred to on a previous page, i.e., the South-West Ward and that portion of the North-West Ward south of the High Street, could be designated as the home of the married female portion of the laundry industry. Of the total deaths among infants 111 this area, prematurity was certified as the cause of death in 11per cent., Congenital Debility 3.7 per cent., and Convulsions in 1.5 per cent. In the rest of the district the figures were—Prematurity 15 per cent., Congenital Debility 16 per cent., and Convulsions 3 per cent. Possibly, It would be fairer if these figures were given as a ratio of the deaths from these causes to the births registered in the two areas. The mortality from these causes would be as follows:— Selected area. Rest of District. Prematurity 18 per 1,000 births. 14 per 1.00a births. Congenital Debility 6 per 1,000 births. 15 per 1,000 births. Convulsions 2.4 per 1,000 births. 3 per 1,000 births. It is admited, of course, that the number is too small to draw any definite conclusion, but they may be useful in any future investigation upon the infantile mortality. To supplement the above, inquiries were also made as to the occupation of the mother where a child had died from these causes. Thirty deaths were inquired into; of these, in 20 instances the mother was not engaged in any occupation except house work, and in 10 the mother had to leave her house during the day for the 44 pose either to support herself and family or to supplement the earnings of her husband. Seven were employed as laundresses, but in 6 instances the mothers had not been to work for some time prior to her confinement. This period of rest varied from a month to six weeks. Two mothers were employed as charwomen and one as a waitress and the three had continued to work up to within a few days of their confinement. These figures cannot be regarded as conclusive evidence of the effect upon the infantile mortality, of employment in a particular industry during pregnancy, as sufficient data are not to hand. Not only the extent of such labour should be ascertained, but the conditions which obtain in the different industries. It would not be feasible to place the same restrictions upon an industry where the work is light and married female labour is limited to 4 or 5 days a week, as upon some of the factories in the Midlands and North of England. DIARRHCEAL DISEASES. The number of deaths from Diarrhoea was 80, which is equal to a rate of 1.5 per 1,000 living. Sixteen deaths were registered as due to Enteritis or Gastritis. Since 1900, when the Royal College of Physicians recommended the adoption of the term "Epidemis Enteritis" as a synonym for Epidemic Diarrhoea, and the disuse in medical certificates of death of such terms as Gastro-enteritis, Muco-enteritis, and Gastric Catarrh, the number registered as due to Diarrhœa has increased, whilst the deaths from Gastro-enteritis has apparently diminished. It would be useless, if a comparison be made, extending over a period of years, to limit it to deaths from Diarrhoea, as a number of deaths formerly registered as due to Gastro-enteritis would now be certified as Diarrhoea. The deaths from Diarrhœal diseases in 1906 numbered 96, and of these 80 were under 1 year. As far back as 1887, Dr. Ballard included Diarrhœa among the principal zymotic diseases, but the specific organism has not with certainty been isolated. The vital manifestations of the organism are 45 in some way closely associated with season. Over 90 per cent, of the deaths occur during the months of July-October. There is a large increase in the number of deaths compared with 1905, and whatever views may be held as to the causation of Diarrhœal diseases, there can be no doubt as to the beneficial influence of an excessive rainfall. The total amount of yearly rainfall bears no direct relation to the mortality; most of the deaths occur during the months of July-October, and the factors entering into their causation would operate most potently during these four months. 1 ne prevalence of Diarrhoea is more closely related to the number of days upon which rain falls than to the actual amount of rainfall; it varies almost inversely with the number of rainy days. Though this ratio does not work out with mathematical accuracy, it is sufficiently close to warrant the assumption that the relation is one of cause and effect. The factor may be beyond the control of a sanitary authority, and probably few would be daring enough to wish for a wet holiday season, but the manner in which it operates should teach us something in the prevention of Diarrhœa. The diminished prevalence is probably not due to the purifying action of rain on the atmosphere, as in such circumstances the amount of rainfall would be the determining influence, though it is well known that a heavy shower in summer has a cleansing effect on the air. It is fortunate that such is not the mode of action, as nature could not be imitated in this respect. It is now generally held that the prevalence of Diarrhoea is dependent on the state of the soil. It is probable that the micro-organism has its habitat in the superficial layers of the soil, where, in the form of decaying animal matter, it has its pabulum and manufactures its poison. Though the theory that the maximum mortality from Diarrhoea coincides with the temperature of the earth at different depths is now doubted, very few doubt the intimate association of the disease and conditions of the soil. If we consider the state of the streets and backyards, the influence of rainy weather is explained. Organic matter is constantly being deposited on the streets; in dry weather this becomes pulverised and carried in the form of dust into the houses. Rain maintains in a condition of moisture collections of dust and refuse, which, in a dry state, would be carried by the wind or other agencies, and deposited in food, more especially in milk. To prevent dust, the surface of the street must be kept 46 clean, but in dry weather, unless the road watering be unstinted, more harm than good will accrue from scavenging, as the dust finds its way into the dwellings. The sweeping should take place while the surface is moist. A more potent factor, probably, is the state of the yards at the rear of the dwellings. Though there is no excuse for the accumulation of refuse around houses, it is surprising how often this nuisance occurs. The air space around the smaller houses is sufficiently limited, but the Inspectors constantly have to draw attention to all kinds of deposits which are allowed to accumulate. It must be admitted, though, that the fault does not always lay with the householder. The backyards of some of the older premises are insufficiently and improperly paved, and however careful one may be, it is almost impossible to prevent the impregnation of the soil with organic matter unless a portion of the backyard be imperviously paved. The work of enforcing the bye-laws as to paving of backyards and open spaces is gradually and continuously carried out. and it is hoped that very soon every house will conform with the enactment. These considerations do not fully explain the coincidence between earth temperature and the incidence of Diarrhœa. High earth temperature means a previous high air temperature, and high air temperature means an enhanced rate of multiplication of the microbes present in milk, together with the formation of dust, which may play a considerable part in the contamination and infection of the food. But a high air temperature commenced towards the latter part of June, 1906, and continued in an intense form throughout July, but the deaths from Diarrhœa did not start until August. During July there was no death from Diarrhœal diseases. Dr. Nash has pointed out that the diarrhoea curve closely follows the life-history of the common house-fly, and he suggests that they art largely responsible for the infection of food, which is the ultimate cause ot the disease. He suggests that if, instead of Ballard's microorganism. we merely say an organism whose manifestations are dependent upon conditions of season, we shall be nearer the truth; and he suggests that this organism is the common house-fly. which, beginning to make its appearance in June, becomes a veritable pest during July and the early part of August; after that its existence tends 47 to become a mere sexual one. and it decreases in number. " This creature is often termed the harmless fly. I ccrtainly give it the first place as a pathogenic agent during the summer months. It is a useful scavenger if kept in its place, but when allowed to fly straight from the dung or refuse heap to commit suicide in the milk bowl, or alight on the lips of a sleeping infant, or walk over meat and other articles of food on the table, I repeat that I consider it the most active pathogenic agent during the summer, and the principal causes of summer Diarrhœa." Dr. Fraser, of Portsmouth, in his Annual Report, also associated an epidemic of Diarrhoea with accumulations of refuse and the usual litter of rubbish associated with the making of bricks in the town. The heat of the refuse and the brickmaking had afforded a breeding ground for millions of flies, that had been passing backwards and forwards from the refuse to the houses, and he attributed the epidemic in a certain district of Portsmouth entirely to the infection of the food in the houses by these insects. This particular epidemic occurred during a period when there had been no deficiency of rain, nor had the heat been excessive. The families that suffered were by no means of the lowest classes, being composed of respectable working and middle classes; their houses were new, clean, and, as a rule, well kept. Curiously, in Acton, the district in the vicinity of the refuse tip and the brick works was the area least affected by Diarrhœa. On page 68 is given a list of the streets, together with the. number of deaths caused by Diarrhœa in these streets. The figures are admittedly limited, but it does seem curious that so few deaths occurred from Diarrhœal diseases to the north of the Great Western Railway, as undoubtedly this constitutes the fly-infected area of the district. It was stated that the article of food most frequently contaminated is milk. That this is so is suggested by the age incidence of the fatal cases. The following table gives the ages at death:— Under 1 month. 1-2 months. 2-3 months. 3-4 months. 4-5 months. 2 9 10 11 10 5-6 months. 6-7 months. 7-8 months. 8-9 months. 9-10 months. 9 6 4 7 5 10-11 months. 11-12 months. Total under 12 months. 5 1 78 1-2 years. 5-15 years. Over 65 years. 11 1 1 48 The comparative immunity of children under 1 month is explained by the fact that in this district the mothers usually suckle the children for about 4 or 6 weeks, and an overwhelming majority of the cases of infantile diarrhoea occur in artificially fed children. All authorities are agreed as to the enormous advantages which infants who have been fed on their mother's milk possess over those who depend on an artificial nourishment. No food, however scientifically prepared and carefully administered, can efficiently take the place of the child's natural sustenance. Nothing replaces human milk in its nutritious qualities for the infant. Most artificial foods are but poor substances for the natural food, unless prepared with the utmost care. The artificial foods, inj a large number of instances, set up digestive disturbances, which render the infant liable to attacks from the bacteria that happen to be present in the food. Not only is the artificially-fed infant more susceptible to attack, but the risk of infection is greater. Breast milk is comparatively sterile, and it passes direct from the mother to the child, without any intermediate state of transit during which infection may take place. But with artificial feeding infection may lurk in the milk, in the vessels in which it is carried, and in the bottle. Of 75 deaths from Diarrhœal diseases into which inquiries were made, 72 were artificially fed. and only one wholly breast fed, one family had left, and in one the information was refused. It is impossible to give statistics as to the percentage of breastfed to artificially-fed children in the district. It was stated above that a large number is suckled for 4 or 6 weeks, sometimes for a longer period. The numbers given when birth inquiries are made would, therefore, be entirely unreliable. An attempt was made during the year to ascertain the proportion of children amongst the artisan class brought up entirely on the breast for a period of six months after birth, but the obstacles were so great that the work was abandoned. In this district where a large number of married women are employed in the laundry industry the percentage of breast fed children is small. 49 Of the 72 deaths amongst hand-fed children, 29 of the mothers were employed in some industry which entailed leaving the house and placing the infant under the care of some other person. To what extent can artificial feeding be obviated? Can some means be devised whereby the mothers who are employed in some industries may partially suckle their children? In the past we have endeavoured to instruct the mothers by means of leaflets on the feeding of infants. A selection is made of the birth returns, and the most suitable ones are visited by the Health Visitor, and the following leaflet is left at the house:— URBAN DISTRICT OF ACTON. Feeding and Care of Infants. If possible, Suckle the Child for 7 to 10 months, and wait for cool weather before weaning. Do not wean the child because there is not enough milk, but give cow's milk and barley water as well. Feed at regular intervals; never between times. The child may be thirsty, especially in the summer, and water may stop its crying. Wean gradually; after weaning it may have bread and milk and once a day broth or beef tea, a lightly boiled egg, or light milk puddings, but milk should be its principal food up to the age of 18 months. Keep the baby warm; clothing should be of flannel or woollen material, and fairly loose in fit. Use stockings, not socks. Sponge the child all over every morning, and dry it well. Change wet napkins as soon as possible. Give the baby plenty of fresh air. and take him out whenever the weather is fine; keep the windows open. Infants must sleep alone in a cot and not with the parents. 50 ARTIFICIAL FEEDING. When the baby cannot be suckled, up to the age of 9 months give him nothing but milk and water, or milk and barley-water, sweetened with a little sugar. For the first month feed every two hours. Gradually lengthen the intervals of feeding so that at the end of 3 months the baby is fed every 3 hours. The following proportions are usually required at the different ages:— Age. Quantity at each meal. 1-6 weeks, 1-oz. of milk and 2-ozs. barley-water. 6-12 weeks. Equal parts of milk and barley-water, about 3-azs. of each. 3-6 months. 4-ozs. of milk and 2-ozs. barley-water. 6-9 months. Pure milk may be given, about 6-ozs. at each feed. Boil the milk before using, especially in the summer. Do not again use the milk that remains after the child has finished. Keep two bottles, and use alternately; after using, wash with hot water and a little soda. Rinse out several times, and keep in cold water until again required. NEVER USE Bottle with rubber tubing. The boat shaped bottle is the best. Dummy teats or comforters. Skimmed milk, always use fresh milk. Teething powders, soothing syrups, gin and other spirits, except by doctor's orders. D. J. THOMAS. Medical Officer of Health. Recipe for Barley-Water.—Put two teaspoonfuls of pearl barley in a saucepan with one pint of cold water. Boil gently for two hours, and strain through muslin. 51 The issue of the above leaflets is justified by the experience which we have gained in our inquiries into these Diarrhœal deaths. As stated in a preceding paragraph, the necessity to emphasize the importance of suckling the child is shown by the fact that only one wholly breast-fed infant died. In 44 instances the mother was not employed in any occupation but housework, and it may be taken for granted that only a small number was compelled to wean the child prematurely for physical reasons. If inability to suckle had been the cause of weaning, one would expect to find some instances where th? child had been partly on the breast and partly on the bottle. The advice to use cow's milk was not generally followed. Thirtyfour were fed on cow's milk, 31 on condensed milk, and 10 on various proprietary foods. The only possible point in favour of the use of condensed milk is that it is rendered sterile in its process of manufacture; but in the majority of the houses where it is used that advantage is destroyed within a few hours of the opening of the tin. In one respect one has to report a great advance. The bottle with the rubber tubing is steadily going out of fashion. Thirty-four boat-shaped bottles were in use and 16 bottles with rubber tubing. Nothing can be more objectionable than the latter. It is impossible to keep it clean. The milk and the warm water decompose the rubber, and the exposed rubber becomes a place of deposit for filth. In Infantile Diarrhœa, the most important factor undoubtedly is improper feeding, but it must not be inferred that the whole problem ends with the conditions that obtain within the house of the consumer. The whole question of the milk supply is intimately bound up with the prevention of Summer Diarrhœa. Prior to its delivery to the consumer, the milk may become contaminated at the farm, and during its distribution, and the practical question is, what could be done to secure a milk supply pure enough to be used with safety for infants who are artificially fed? In Acton, the conditions have materially changed within recent years. Twenty years ago most of the milk was, produced within the district or in the immediate neighbourhood. At the present time only 52 three retailers keep their own cows. There are altogether 71 purveyors of milk registered, and 68 of them obtain their milk from outside sources. We have to depend upon a supply which is not capable of supervision by our own officials. Apart from this aspect of the question, the difficulty of transport from the farms also arises. It is well known that warm transit means impure decomposing milk. The railway companies do not provide different vehicles for the summer from those used in the winter, and none provide refrigerating vans for milk in this country. These and similar considerations have acted as stimuli in the establishment of Municipal Milk Depots in different parts of the country. At the recent conference on Infantile Mortality., this question was dealt with by flr. McCleary, who gave particulars of the work done at Battersea. Most speakers praised the work done by these depots, but it was admitted that they dealt with a symptom and not with the cause. Some were inclined to believe that our efforts should be aimed at obtaining a pure milk supply, and thus obviate the necessity of pasteurizing and such treatment of the milk. A much stricter supervision of the milk supply is necessary, especially in rural districts, where the conditions under which it is produced leave much to be desired. One word of explanation is necessary as to the objects of these •depots. The argument has been used that their establishment tends to diminish the number of mothers who suckle their babies. The work of a milk depot should not be looked upon as limited to the handing of bottled, modified and more or less sterlized milk over a municipal counter. It is claimed that the milk depot may be made even to promote breast feeding among mothers. At Battersea, the milk was not supplied for ah infant under 9 months old, unless the mother could produce a written recommendation from a doctor that she was unable to suckle her child. The same objection has been raised to the establishment of Municipal Creches. It has been said that it would discourage breast feeding. It will be remembered that a clause was proposed in the Acton Improvement Act empowering the Council to establish and 53 maintain one or more creches. The Parliamentary Committee, though professing sympathy with the object, refused the application. Under the industrial conditions which prevail in the district, the refusal seems to have been prejudicial to the interests of the Public Health. We are not at present concerned with the economical aspect of Married Female Labour; the effects of such labour are dealt with in another paragraph. It was pointed out by Councillor Hunt, Chairman of the Public Health Committee, in a paper read at the Congress of the Royal Institute of Public Health, that "there are in Acton some 450 laundries, employing 4,500 females. No less than 23 per cent, of them arc married women and widows, of whom a large proportion have young families. These young families are often farmed out—or placed out—at rates varying from fourpence to eightpence per head per day. The persons who take charge of these children are generally aged people living in squalor, too often heavy spirit-drinkers, and quite unfit to take charge of infants. Sometimes one old woman will have the care of as many as seven or eight children in one dirty little unventilated room. The children are left very much to chance; they have no regular or proper feeding; the bottles are not kept clean, nor is the food wholesome. To try and persuade the baby-minders to be attentive and cleanly is labour in vain." In a report by the London County Council, the advantages connected with creches were shortly summarized as follows :— The creche is usually healthier and cleaner than the child's home, the treatment is more enlightened, and the method of feeding better adapted to the child's tender yars. Every creche can show children who have come there miserably anaemic and suffering from rickets, whose health has visibly improved after some weeks of the creches' treatment. Where no creche exists, the mother who is obliged to go out to work for her living, is compelled either to leave the child during the day where it cannot be properly cared for, or to place it out to nurse in either case at a cost in excess of her means. At the creche the child is taught cleanliness and good habits, becomes stronger and healthier, and is given a better chance in life. 54 Many creches state that when the children are old enough to go to school, it is possible tc distinguish them from the other children, not only because they are healthier looking, but because they are better behaved, have better manners, and are more obedient. Creches are under medical supervision, and the promptitude with which a case of sickness is treated often prevents more, serious consequences. The mother is required to bring the child clean; better methods of feeding are learnt; and the cleanliness and discipline of the creche insensibly react to the advantage of the home. A misapprehension seems to exist in the minds of some of the opponents as to the nature of a creche. It is assumed that all municipal creches must be of the same pattern and managed in an uniform manner. The establishment of a large creche, which would entail the segregation of a large number of infants, would be a mistake. It would expose the children to the risks of infectious disease, as well as depriving the majority of them of their mothers' milk. These results need not follow if the creches are small and if possible numerous. The creches would then be conveniently situated, and the mothers encouraged to attend twice a day or oftener to suckle their infants. A creche has been started in the neighbouring district of Hammersmith through the agency of philanthropic persons. Possibly, some liberal-minded philanthropists may be induced to try the experiment in South Acton. The French, who are the pioneers in this movement, consider that the ideal creche should be conducted by a private body and inspected and partly supported by the municipality. This plan ensures personal interest and proper public supervision and control. Such a creche might also be made an educational centre. The Inter-Departmental Committee on Physical Deterioration recommended that wherever it was thought desirable, owing to the employment of married women in factories, or for other reasons, to establish municipal creches, girls over fourteen might be made to attend occasionally, and the teaching of infant management to such girls should be eligible for aid from the grant for public education. 55 CANCER. Forty-four deaths occurred from Cancer or Malignant Disease. The Ward Distribution was as follows:— North-East Ward 13 North-West Ward 10 South-East Ward 8 South-West Ward 13 It is impossible to state accurately the relative prevalence of the disease in the different wards unless we know the age distribution of the population in each ward. Car;er is essentially a disease of advanced years, or, at any rate, of late middle age; 13 of the deaths occurred amongst people under 50 years of age and 30 in those over 50. It has been said that the disease is more prevalent in low-lying districts; the distribution of the disease in Acton lends no colour to that theory. It is undoubtedly true that Cancer is on the increase throughout the kingdom. A comparison with past years cannot be made for Acton, as the returns from outside institutions are not available before 1905, and in 1906, 12 out of the 44 deaths occurred outside the district. Seventeen of the deaths were in males and 27 in females. The preponderance of females is entirely due to the number of deaths from Cancer of the Reproductive Organs. In 6 instances the Uterus was affected, in 1 the Ovaries and in 4 the Breast, all in females. It is significant that the greatest increase in recent years has been due to the large number of deaths from Cancer of the Alimentary canal. There were in Acton last year 16 deaths from Cancer of the Stomach and Bowels. It is probable that some of these deaths in former years would not have been correctly diagnosed, and the apparent increase may have been partly due to improved methods of diagnosis. According to all experience, this does not entirely explain the relative frequency with which the digestive organs are attacked. Cancer of the Alimentary canal is now of more frequent occurrence than formerly. 56 The seat of the disease in the others was as follows:— Tongue 3. Lower Jaw 2 Bladder 2 Face, Foot, Femur, Omentum, Retro-peritoneum, Kidney, Gall Bladder, Mediastinum, 1 each. In two instances the seat of the disease was not mentioned. INQUESTS. Thirty-two deaths were certified by the Coroner, the cause of death being :—• Suicide 4 Fall from bicycle 1 Overlaying 4 Injury to throat 1 Gas Poisoning 2 Want of attention at birth 1 Fall from a train 2 Syncope 8 Run over by a cart 2 Diphtheria 1 Run over by a motor car 1 Convulsions 1 Run over by a train 1 Laryngitis 1 Fall in street 1 Strangulated Hernia 1 MORTUARY. Thirty-three bodies were removed to the Mortuary, and 15 postmortem examinations were made. With one exception, all the bodies deposited in the Mortuary were the subject of a Coroner's inquiry. The body upon which an inquest was not held was removed from a house in Hooper's Mews last August on account of decomposition. ISOLATION" HOSPITAL. An account of the Council's Isolation Hospital at Friars Place was given in last year's report, and the most important improvement to note is the installation of an apparatus to heat the pavilions by means of hot water. It was reported that the heating was not entirely satisfactory; tenders were invited, and the work was carried out by Messrs. Haden. During the year 197 patients were admitted. On January 1st, 1906, there were 10 patients remaining under treatment, and on January 1st, 1907, 19. During the year 180 patients were discharged and 8 died. 57 Diphtheria. Thirty-seven cases of Diphtheria were admitted; 34 of these were from Acton, and 3 from outside districts. The only death from Diphtheria was of a child admitted from Hendon. In 3 instances a mistake in diagnosis was probably made; at any rate, the results of a bacteriological examination proved negative. Thirty-four cases of true Diphtheria were therefore treated in the Hospital with 1 death, or a fatality of 3 per cent. Scarlet Fever. 152 cases of Scarlet Fever were admitted—150 from Acton, I from Slough and I from Hendon. Six deaths occurred. Three "return" cases were admitted. The conditions under which these occurred have been detailed in a preceding paragraph of the report. The percentage of " return " case^is not high compared with other districts, but when the conditions under which the patients sometimes have to be discharged are considered, the results are very gratifying. There is no discharge block at the Hospital. When possible the observation block is used as a discharge block, and the patients are quarantined there for a few days prior to discharge. The difficulty arises when for some reason the observation block is not available, and the " return " cases occurred when more than two diseases were being isolated at the Hospital. In such circumstances, the patients have to be discharged directly from the wards, and as the pavilions have no separation wards, there is no possibility of keeping the acute and convalescent patients apart. Enteric Fever. Five cases of Enteric Fever were admitted, and three deaths occurred. Erysipelas. One case of Erysipelas was admitted. Erysipelas is not usually isolated in the Hospital, but the circumstances of this case rendered it absolutely necessary that he should be nursed away from his house, and he was removed to the Hospital at the request of his medical attendant. 58 One other patient was admitted. She was admitted as a doubtful case of Enteric Fever, and succumbed. A post mortem examination was allowed, and the cause of death was Cirrhosis of the Liver. DAIRIES AND MILKSHOPS. There are 71 names of persons 011 the register, who carry on the trade of dairymen or purveyors of milk in the district, or an average of 1 milk store to every 732 persons. In London, this number varies from 1 store to every 205 persons in Stepney, to 1 to every 839 in Paddington. These figures seem to suggest that we compare favourably with neighbournig districts in respect to the conditions in which the milk is sold. Twenty-five of those registered are dairies or shops selling dairy produce only, and the other 46 are general shops selling milk in addition to a variety of articles, including, in some instances, soap, firewood, and other articles liable to create a dusty atmosphere. If 1 London the latter class constitutes about 80 per cent, of all the milk-selling premises compared with 65 per cent, in Acton. It is a very difficult matter to keep the milk clean in these general shops, but, unfortunately, there is no direct power conferred on local authorities of refusing to grant registration to unsuitable shops. Clause 6 of the Dairy Order of 1885 enacts that every local authority shall keep a correct register of all milk sellers and purveyors in their district, and they shall register every such person who applies. Under the regulations, the Council has power to insist upon certain conditions of cleanliness to be observed. In most instances the counterpan is covered with muslin, and this prevents the grosser forms of contamination. Our power of control over the milk supply is limited bv the fact that most of the milk consumed in the district comes from outside sources. Of the 71 persons registered, 3 only are cowkeepers, and this constitutes a need not for more legislation, but for a more direct and uniform enforcement of the legislation which now exists. COMMON LODGING HOUSES. There are two registered common lodging houses in the district, with accommodation for 150 lodgers. Under the Acton Improvement Act, 1904, the registration of a common lodging house or of the keeper of a common lodging house, shall operate for one year 59 only, and application for the renewal of such registration shall be made to the Council on or previous to the fifteenth day of May in each year. Application for the renewal of both was made last year and granted. OFFENSIVE TRADES. Three offensive trades were registered. One application was received during the year and granted. The premises are situated on the canal bank near WiUesden Junction, and are utilized for the manufacture of a chemical fertilizer. Owing to accidents to the machinery, complaints were received as to a nuisance, but recently no cause for complaint has arisen. The other two offensive trades are carried on in South Acton, and were established before 1875. The premises are used for the purpose of fat extraction, and their construction leaves much to be desired. Notices have been served upon the occupiers, and proceedings are pending. SEWAGE DISPOSAL. The disposal of the sewage of the district is in a transition stage, and the works authorised in the Acton Sewage Act of 1905 are in hand. The development of the district rendered it absolutely necessary that arrangements should be made to deal with the increasing volume of sewage, as the treatment which it undergoes at present cannot be deemed adequate or efficient. Prior to 1855, the sewage of the district emptied untreated into the Thames, the rain water falling upon a small margin of the district along the western boundary drained into the Sutton Lane watercourse, which conveyed it through Chiswick into the Thames. Most of the houses existing in Acton in 1855 drained into the Stamfcrd Brook, which coursed through Acton, Fulham and Hammersmith and emptied into the Thames at the latter place. Under the Metropolitan Management Act of 1855, the Stamford Brook sewer, together with other sewers, was vested in the Metropolitan Board of Works. The latter body diverted the Stamford Brook from the Thames and connected it with the sewers of the Metropolitan Main 60 Drainage System, thereby causing the sewage and drainage of Acton to flow into the Metropolitan system of sewers. No difficulty arose until the district developed towards the late seventies, but in 1882 an injunction was obtained to prevent the district of Acton from sending any further soil water into the Stamford Brook. The population of the district at that time was estimated at 18,000 inhabitants. In consequence of the injunction, a provisional order was obtained, which authorised the Local Board of Health to acquire landsand to construct and maintain thereon works for the purification and disposal of the sewage and drainage coming from part of the parish. These works, when they were opened, provided for the treatment of the sewage by the International Sewage Purification Company's process. The sewage was precipitated in tanks by ferrozone, and wasfiltered through a polarite filter. These tanks—3 in number—had a capacity of about 500,000 gallons. Subsequently the works were altered, and the tanks were utilised as septic tanks, in which the sewage was first treated. It was then distributed over coke breeze filters, and the effluent discharged into the Thames. For a time,, this system answered well, and produced good results, but as the district developed, the amount of sewage passing through the tank and filters increased, and the results became less satisfactory. The Council was unable to enlarge the tanks or the filters, but under the Act of 1905, power was obtained to send the whole of the soil sewage into London, and to discharge the storm overflow water into the Thames. The contractors at the present time are engaged in altering the works and constructing a large storm water sewer through Acton and Chiswick into the Thomas. The works are under the direction of Sir Alexander Binnie, and will probably be completed in about a year's time. REFUSE DISPOSAL. A small amount of refuse is taken daily to the Brentford Destructor, where it is burnt, but the larger portion is deposited on land to the north of the Great Western Railway, near the cemetery, This land has been used for this purpose for many years, and a more ungainly heap does not exist in the parish. Throughout last summer the houses within a radius of half-a-mile were pestered with flies generated partly on this refuse heap. Refuse accumulations in this 61 way not only create inconveniences, but sometimes, possibly, are capable of infecting neighbouring houses. It is impossible even to mitigate the evil by the use of disinfecting and deodorizing substances; it has been found in other places that they constitute but a very slight palliative, the cost of which would not be justified by the results obtained. Moreover, the methods employed to disinfect the refuse are most difficult of application. The Council is fully aware of the utter unsuitability of the site for tipping purposes, and the question of a refuse Destructor has been discussed for many years. It was originally intended to erect a Destructor on the Friar's estate, purchased by the Council. The consent of the vendors was refused, and a site selected in Southfield Road. The consent of the Local Government Board to erect a •destructor on the latter site was withheld. Finally, the Council purchased a site adjoining "The Friars," and a Committee of the Council is now making arrangements for the erection of the Destructor. The consent of the Local Government Board has been obtained, and it is hoped that an advance will now be made, and the practice now carried out will soon be abandoned. The amount of refuse to be disposed of yearly exceeds 12,000 tons. 62 Table 1. VITAL STATISTICS OF WHOLE DISTRICT DURING 1906, AND PREVIOUS YEARS. Year. Population estimated to Middle of each Year. Births. Total Deaths Registered in the District. Total Deatns in Public Institutions in the District. Deaths of Non-residents registered in Public Institutions in District. Deaths of Residents registered in Public Institutions beyond District Nett Deaths at all Ages belonging to the District. No. Kate * Under 1 Year of Age. At all Ages. No. Rate per 1,000 Births registered. No. Rate* No. Rate* 1 2 3 4 5 6 7 8 9 10 11 12 13 1896 30,564 894 29.2 151 170 435 14.2 ... ... 29 464 15.1 1897 31,952 973 30.4 193 198 470 14.7 ... ... ... ... ... 1898 33,404 995 29.8 181 182 507 15.2 ... ... ... ... ... 1899 34,901 1,068 30.6 200 187 509 14.6 ... ... ... ... ... 1900 36,508 1,080 29.5 182 168 528 14.4 15 ... ... ... ... 1901 38,373 1,211 31.5 206 170 519 13.5 6 ... ... ... ... 1902 41.000 1,242 30.3 186 150 593 14.4 12 ... ... ... ... 1903 43,802 1,422 32.4 150 105 430 9.8 8 ... ... ... ... 1904 46,780 1,450 30 207 143 576 12.3 9 ... ... ... ... 1905 50,000 1,527 305 162 106 537 10.7 27 1 92 628 12.5 Averages for yrs 1896-1905 387,284 11,862 30.6 1,818 153 5,104 132 ... ... ... ... ... 1906 52,000 1,533 29.4 193 125 597 11.5 29 7 97 687 13.2 * Rates in Columns 4, 8, and 13 calculated per 1,000 of estimated population. Total population at all ages at Census of 1901, 37,744. Number of unhabited houses at Census of 1901, 6,114. Average number of persons per house at Census of 1901, 6.1. Area of District in acres (exclusive of area covered by water) 2.304. Union Infirmary, not in District. Outside Institutions, see body of report. 63 Table 2. VITAL STATISTICS OF SEPARATE LOCALITIES IN 1906. ACTON. Population estimated to middle of year 52,000 Births registered 1,533 Deaths at all ages 687 Deaths under 1 year 201 North East Ward. Population estimated to middle of year 13,000 Births registered 325 Deaths at all ages 137 Deaths under 1 year 32 North West Ward. Population estimated to middle of year 11,000 Births registered 229 Deaths at all ages 135 Deaths under 1 year 34 South East Ward. Population estimated to middle of year 11,000 Births registered 255 Deaths at all Ages 122 Deaths under 1 year 28 South West Ward. Population estimated to middle of year 17,000 Births registered 724 Deaths at all ages 293 Deaths under 1 year 107 64 Table 3. CASES OF INFECTIOUS DISEASE NOTIFIED DURING THE YEAR 1906. NOTIFIABLE DISEASE. Cases notified in whole District. Total Cases notified in each locality. Number of Cases removed to Hospital from each locality. At all Ages. At Ages—Years. North-East. North-West. South-East. South-West. North-East. North-West. South-East. South-West. Under 1. 1 to 5. 5 to 15. 15 to 25. 25 to 65. 65 and upwards. Small-pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cholera ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diphtheria 46 ... 11 23 5 7 ... 15 5 15 11 1.3 3 9 9 Membranous Croup ... ... • • • • • • ... ... Erysipelas ... 35 2 8 2 19 7 3 12 13 1 Scarlet Fever 170 40 1C7 17 5 62 29 37 42 61 25 26 38 Typhus Fever ... ... ... ... ... Enteric Fever 12 ... ... 3 3 5 ... 1 3 5 3 ... 2 1 3 Relapsing Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Continued Fever 1 ... ... ... ... 1 ... ... ... ... 1 ... ... ... ... Puerperal Fever 3 ... ... ... ... 3 ... 1 ... 1 1 ... ... ... ... Plague ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Chicken Pox 3 ... 2 1 ... ...• ... 1 ... ... 2 ... ... ... ... Phthisis 6 1 ... ... 3 2 ... 3 1 2 ... ... ... ... ... Totals 276 2 55 142 30 42 5 90 41 72 73 74 30 37 50 65 Table 4. CAUSES OF, AND AGES AT, DEATH DURING YEAR 1906. Causes of Death. Deaths at the Subjoined Ages of " Residents," whether occurring in or beyond the District. Deaths at all Ages of "Residents" belonging to Localities, whether occurring in or beyond the Parish Total Deaths whether of " Residents" or "NonResi dents" in Publiclnstitutions in the District. All Ages Under 1 year. 1 and under 5 5 and under 15. 15 and under 25. 25 and under 65. 65 and upwards. North-East Ward. North-West Ward. South-East Ward. South-West Ward. Small-pox ... ... ... ... ... ... ... ... ... ... ... ... Measles 27 4 21 2 ... ... ... 1 2 3 21 ... Scarlet Fever 7 ... 3 3 ... 1 ... ... 1 4 2 6 Whooping-cough 5 3 2 ... ... ... ... 1 ... 1 3 ... Diphtheria and Membranous croup 2 ... ... 2 ... ... ... 1 ... 1 ... 1 Croup ... ... ... ... ... ... ... ... ... ... ... ... Fever— Typhus ... ... ... ... ... ... ... ... ... ... ... ... Enteric 3 ... 1 2 ... ... ... ... 2 ... 1 3 Other continued ... ... ... ... ... ... ... ... ... ... ... ... Epidemic Influenza 6 ... 2 ... ... 3 1 3 ... ... 3 ... Cholera ... ... ... ... ... ... ... ... ... ... ... ... Plague ... ... ... ... ... ... ... ... ... ... ... ... Diarrhœa 80 70 9 ... ... ... 1 10 15 16 45 ... Enteritis 16 10 2 2 ... 1 1 3 4 4 5 ... Puerperal Fever 3 ... ... ... ... 3 ... ... ... 1 2 ... Eyrsipelas 1 ... ... 1 ... ... ... ... ... ... 1 ... Other Septic Diseases 6 ... ... ... ... 5 1 1 2 ... 3 l Phthisis (Pulmonary Tuberculosis) Other Tubercular 48 ... 1 ... 6 36 5 9 8 6 25 ... Diseases 26 11 10 3 ... 2 ... 9 2 7 8 ... Cancer, Malignant Disease 44 ... ... ... ... 28 16 13 10 8 13 2 Bronchitis 42 7 6 ... 1 9 19 7 6 7 22 1 Pneumonia 55 17 17 2 2 8 9 5 13 7 30 2 Pleurisy 2 ... ... ... ... 2 ... 1 ... 1 ... ... Other Diseases of Respiratory Organs 6 2 2 ... ... 1 1 1 1 1 3 1 Alcoholism— Cirrhosis of Liver 10 ... ... ... ... 8 2 3 3 3 1 1 Venereal Diseases 3 2 ... ... 1 ... ... ... 1 1 1 ... Premature Birth 25 25 ... ... ... ... ... 4 6 2 13 ... Diseases and Accidents of Parturition 4 ... ... ... 2 2 ... 1 1 ... 2 ... Heart Diseases 44 2 ... 4 3 18 17 11 10 11 12 2 Accidents 15 4 1 1 1 6 2 3 6 ... 6 3 Suicides 4 ... ... ... ... 4 ... ... 2 1 1 1 All other Causes 203 44 14 4 3 57 81 50 40 43 70 5 All Causes 687 201 91 26 19 194 156 137 135 12 2 293 29 66 67 Table 5. INFANTILE MORTALITY DURING THE YEAR 1906. Deaths from stated Causes in Weeks and Months under One Year of Age. CAUSE OF DEATH. Under 1 week 1-2 weeks. 2-3 weeks. 3-4 weeks Total under 1 month. 1-2 months. 2-3 months. 3-4 months. 4-5 months. 5-6 months. 6-7 months. 7-8 months. 8-9 months. 9-10 months. 10-11 months. 11-12 months. Total Deaths under One Year. Common Infectious Diseases. Small-pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Chicken-pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Measles ... ... ... ... ... ... ... ... ... 1 ... ... ... 1 ... 2 4 Scarlet Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diphtheria : Croup ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Whooping Cough ... ... ... ... ... ... ... 1 ... ... ... ... ... ... 1 1 3 Diarrhœa, all forms ... ... ... 1 1 7 6 11 9 9 6 2 7 6 3 3 70 Diarrhœal Diseases. - Enteritis, Muco-enteritis. Gastro-enteritis ... ... 1 ... 1 1 3 ... ... ... ... 1 ... ... 1 ... 7 Gastritis, Gastro- intestinal Catarrh ... ... ... ... ... 1 1 ... 1 ... ... ... ... ... ... ... 3 Premature Birth. 12 3 1 7 23 1 ... ... ... ... ... 1 ... ... ... ... 25 Congenital Defects 4 ... ... ... 4 ... 1 ... ... ... ... ... ... ... ... ... 5 Wasting Diseases. Injury at Birth 4 ... ... ... 4 ... ... ... ... ... ... ... ... ... ... ... 4 Want of Breast-milk, Starvation ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Atrophy, Debilitv, Marasmus 4 1 1 1 7 3 2 2 ... ... 1 ... ... 1 ... ... 16 Tuberculous Meningitis ... ... ... ... ... ... ... ... 1 ... ... 2 ... ... ... ... 3 Tuberculous Peritonitis: Tuberculous Diseases. Tabes Mesenterica ... ... ... ... ... ... ... 2 ... 1 1 1 ... ... ... 1 6 Other Tuberculous Diseases ... ... ... ... ... ... 2 ... ... ... ... ... ... ... ... ... 2 Ervsipelas ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Syphilis ... ... ... 1 1 ... 1 ... ... ... ... ... ... ... ... ... 2 Rickets ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Meningitis (not Tuberculous) ... ... ... ... ... ... ... 1 ... ... 1 1 ... 1 ... 1 5 Convulsions 1 2 1 ... 4 ... 1 ... ... ... ... ... 1 ... ... ... 6 Bronchitis ... ... ... ... ... 2 1 ... 1 ... ... 1 ... ... 1 ... 7 Laryngitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 1 2 Pneumonia ... 1 ... ... 1 ... 1 1 1 ... 1 1 4 3 l 3 17 Suffocation, overlaying 3 ... ... ... 3 ... ... ... ... 1 ... ... ... ... ... ... 4 Other Causes ... ... 1 1 2 4 2 ... 1 ... ... ... ... ... ... 1 10 28 7 5 11 51 19 21 18 14 13 10 10 12 12 8 13 201 Population estimated to middle of 1906, 52,000. Deaths from all Causes at all Ages 687. Births in the year legitimate 1,494. legitimate infants 179. illegitimate 39. Deaths in the year of illegitimate infants 22. 68 TABLE VI. List of streets, together with the number of Diarrhœal deaths in those streets :— Osborne Road 6 Davis Road 1 The Steyne 6 Antrobus Road 1 Stirling Road 4 Southfield Road 1 Hanbury Road 4 Priory Road 1 Colville Road 4 Mansell Road 1 Bollo Lane 4 Beaconsfield Road 1 Bollo Bridge Road 3 Church Road 1 Somerset Road 3 Wolseley Road 1 Bridgman Road 2 Mill Hill Terrace1 Leythe Road 2 Junction Road 1 Berrymead Gardens 2 Cock and Crown Yard 1 Packington Road 2 Winchester Street 1 Petersfield Road 2 Valetta Road 1 Brouncker Road 2 Wilcott Road 1 Rothschild Road 2 Florence Road 1 Church Path 2 Grove Road 1 Bolton Road 2 Neal's Cottages 1 Seymour Road 2 Brookfield Road 1 Beaumont Road 2 Birkbeck Grove 1 Acton Lane 2 Bayham Road 1 Chaucer Road 2 Alexandera Road 1 Shaftesbury Road 1 Alfred Road 1 Mills Row 1 Stanway Road 1 Strafford Road 1 Maldon Road 1 Berrymede Road 1 Birkbeck Avenue 1 Park Road East 1 Hereford Road 1 Mill Hill Road 1 York Road 1 The Parade 1 Victoria Road 1 Agnes Road 1 69 FACTORIES AND WORKSHOPS ACT, 1901. Section 132 of this Act reads :— "The Medical Officer of Health of every District Council shall, in his annual report to them, report specifically on the administration of this Act in workshops and workplaces, and he shall send a copy of his annual report or so much of it as deals with this subject to the Secretary of State." In the case of factories, the duties of a District Council are few. The Council is charged with the duty of seeing that every factory ir its district is provided with means of escape in case of fire. This duty is carried out by the Surveyor's department. The other duty in regard to factories is the enforcement of Section 22 of the Public Health Amendment Act, 1890. The inspection of factories comes within the province of H.M. Inspector of Factories. Where any sanitary defect is discovered by him in a factory, which is remediable under the law relating to public health, and not under the Factory and Workshop Act, he informs the Council of the defect, and it is the duty of the Council to arrange for the remedy of the defect. The Factory Inspector also notifies to the local authority any matter coming under his notice which should be attended to by the local authority. Ten such references from H.M. Inspector of Factories were received during the year; 3 related to want of separate sanitary accommodation for the sexes, I to insufficient sanitary accommodation, and I to a defective water closet. There was one reference to each of the following conditions :— Defective drainage of washhouse floor, Dirty roof of washhouse, Defective floor of washhouse, Excessive steam in washhouse, Unventilated gas-heater in workroom. LAUNDRIES. Laundries do not come within the definition of factory and workshop; but under section 103 of the Act, they are, as far as sanitation and means of escape from fire are concerned, to be treated as factories if mechanical power is used; if mechanical power is not used, as 70 shops. Certain laundries are excluded from the Act, such as laundries worked by inmates of a prison, reformatory school, religious institutions, or by members of the same family dwelling on the premises, and in which not more than two persons from outside assist the members of the family. The latter class of laundry is termed a domestic laundry, and where they exist, are a standing menace to the public health. They not only escape the attention ©f the Factory Inspector, but are also outside the cognisance of the local sanitary authority, and so go without supervision. The clean and dirty linen comes into close contact in the narrow passage and in other parts of the house, and there is every opportunity for infection to be conveyed from one article to the other. The actual washing is done in some small outbuilding reeking with steam and in an atmosphere loaded with all forms of impurity. Where the domestic laundry survives, there is no means of knowing where it exists. It is unregistered, and a list compiled to-day would be practically worthless in six months time; they spring up, change their abodes, or die out from month to month. The importance of keeping laundries under observation is recognised, but instead of noting where the real danger obviously lies, there has been a tendency to harass the already much regulated and inspected big laundry. In some districts the Medical Officer of Health is given power to require laundrymen to furnish him with lists of their customers. This is simply a source of exasperation to the wellconducted laundries, which are the only ones really affected, whilst the precaution is almost useless in the interests of public health. On several occasions it has been shown that although infection may reach a big laundry, when some of those who sort the foul linen may contract the disease, yet it never gets beyond the washhouse. The temperature in modern rotary washing machines is sufficiently high, and thorough treatment is carried on for a sufficiently long time to sterilize the linen. In a laundry properly planned and built for the purpose, the sorting room, where the foul linen is received, and the packing room, where it is put into hampers for delivery, are quite distinct. They are frequently separated by the whole length of the laundry, so that the risk of direct infection conveyed from the foul to the clean linen is practically non-existent. Fortunately, in Acton, there are not many domestic laundries, and practically all places where laundry work is carried on. are under 71 supervision. There are 285 laundries registered as workshops, and 207 other houses registered as places where home work is being done. Possibly, the list of out-workers is not complete, but the danger of infection is not so great as in the case of domestic workshops. The risk only occurs when a case of infectious disease occurs in the house. There is no mixing of foul and clean linen, and infection cannot be spread in that way. All the linen has been sorted and washed before it arrives at the outworkers' premises, and the subsequent delivery is undertaken by the laundry proprietor. As a rule, only one cass of work is done by each outworker; for instance, blouses may be given out to one outworker, and dresses to another, but the articles are always washed at the laundry, and simply prepared and ironed by the outworker. WORKSHOPS AND WORKPLACES. The District Council has to keep a register of all workshops within its district. To assist the Council in keeping the register, the Factory Inspector forwards any notices of occupation of a workshop which may be sent to him. During the year 23 notices of occupation were received by the Council. At the end of the year there were 420 workshops on the register. A majority of these consisted of workshop laundries. As will be seen on the table at the end of the report, 37 defects were found on the premises, nearly half of which referred to want of cleanliness. There are 27 bakehouses on the register. 8 of which are underground. A special report was presented upon the condition of the underground bakehouses when the certificates were granted. Only one breach of the special sanitary requirements for bakehouses was found, and this consisted of a drain communicating directly with the bakehouse. HOMEWORK. Section 107 of the Act prescribes that the occupier of every factory or workshop engaged in certain kinds of work—to be specified in an Order of the Home Office shall keep in a prescribed form and manner lists of the names and addresses of all persons directly employed by him outside the factory or workshop, and the places where 72 they are employed; and also that he shall send, on or before the 1st day of February and the 1st day of August in each year copies of those lists to the Council. The last Home Office Order placed the following classes of work in this category:— 1. Making, cleaning, washing, altering, ornamenting, finishing and repairing of wearing apparel and any work incidental thereto. 2. Making, ornamenting, mending, and finishing of lace and of lace curtains and nets. 3. Cabinet and furniture making and upholstery work. 4. Making of electro-plate. 5. Making of files. 6. Fur-pulling. 7. Making of iron and steel cables and chains; making of steel anchors and grapnels. 8. Making of cart-gear, including swivels, rings, loops, gear buckles, mullin bits, hoops and attachments or all kinds. 9. Making of covers for, and the covering, finishing, altering or repairing of, umbrellas, sunshades, parasols, and articles of a similar character, and any work incidental thereto. 10. Making of paper bags and paper boxes. 11. Brush making. 12. Making of stuffed toys. Throughout the country there is a general complaint that lists are very irregularly sent in, and though Acton compares favourably with most similar districts, it is probable that our list of outworkers is an incomplete one. In October, a circular was received from the Home Office, in which the Secretary of State directed the attention of the Council to the enforcement of the provisions of the Factory Act, that dealt with the subject of homework. This circular was considered by the Health Committee in November, and the requirements of the latest Order on the subject were advertised in the local papers. Occupiers who had formerly sent in lists were also circularised, and the Health Visitor makes inquiries into the subject of homework in the course of her ordinary visits. The Council has done everything that is practically possible to obtain a complete and accurate list. 73 Altogether 153 lists were received; 136 of these were received from occupiers in the district, and 17 from other Councils. In 13 instances the place of employment was in another district, and the names and addresses were forwarded to the Council, in whose district the premises were situated. One hundred and forty of the lists referred to premises situated within the district, and these lists contained the addresses of 282 outworkers' premises. On the Table supplied by the Home Office will be found a list of the different kinds of homework carried on in the district, and it will be observed that 248 out of the 282 outworkers were engaged in the making, cleaning or washing of wearing apparel. In this class of work the Council may, if a case of infectious disease has occurred in a house where homework is done, prohibit an employer or contractor from giving out such work to any person living or working in the house during such time us the Council may fix. Four cases of Infectious Disease occurred in houses where home work was done, and although the Council made no order under Section no of the Act, the employers did not send work to the house until the patient had been removed to Hospital and the premises disinfected. In bringing this review of the year's work to a close, I beg to thank not only the other officials of the Health Department, but also of the ouier Departments, for their kindly assistance and co-operation. I remain, Your obedient servant, D. J. THOMAS. 74 FACTORIES, WORKSHOPS, LAUNDRIES, WORKPLACES AND HOMEWORK. INSPECTION. Including Inspections made by Sanitary Inspectors or Inspectors of Nuisances Premises. Inspections. Written Notices Workshops (Including Workshop Laundries) 77 31 Workplaces (Other than Outworkers' premises included in Part 3 of this Report). 4 —. Total 81 31 DEFECTS FOUND. Found Remedied Referred to H. M. Inspector. Nuisances under the Public Health Acts:— Want of Cleanliness 18 18 _ Want of ventilation 2 2 — Overcrowding 1 1 — Want of drainage of floors 2 2 — Other nuisances 2 2 — Sanitary accommodation insufficient 1 1 — unsuitable or defective 1 1 — not separate for sexes 9 9 1 Offences under the Factory and Workshop Act:— Breach of special sanitary requirements for bakehouses (ss. 97 to 100). 1 1 - Total 37 37 — HOME WORK. OUTWORKERS' LISTS, SECTION 107. Twice Yearly Once Yearly Outworkers received from other Councils. Outworkers forwarded to other Councils. Inspection of Outworkers' Premises Infected Premises, Instances. NATURE OF WORK. Lists Outworkers Lists Outworkers Wearing Apparel— (1) making, etc. 30 40 4 8 17 2 60 — (2) cleaning and washing 102 208 12 19 - 7 306 4 Brush making 2 8 — — — 2 15 — Stuffed Toys 2 26 — — — 2 45 — Total 136 282 16 27 17 13 426 4 75 REGISTERED WORKSHOPS. Workshops on the Register (s. 131) at the end of the year:— Laundries 288 Dressmaking 43 Millinery 8 Tailoring 5 Bakehouses 27 Others 37 Total number of Workshops on Register 420 OTHER MATTERS. Matters notified to H.M. Inspector of Factories:— Action taken in matters referred Notified by H.M. Inspector 10 by H.M. Inspector as remediable under the Public Healthy Acts, but not under the FacReports (of action taken) sent to tory and Workshop Act (s.5) H.M. Inspec tor 10 Underground Bakehouses (s. 101):— In use at the end of the year 8 Your obedient servant, D J. THOMAS. March 1st, 1997 76 ANNUAL REPORT OF CHIEF SANITARY INSPECTOR FOR THE YEAR 1906. D. J. THOMAS, Esq., M.R.C.S., L.R.C.P., D.P.H., Medical Officer of Health. Sir, I herewith present my seventh annual statement, showing the particulars of the actions taken in the suppression of Nuisances, etc., and various improvements effected during the year 1906. NUMBER OF INSPECTIONS, etc. 483 Complaints received 1,452 Premises inspected 1,452 Premises re-inspected 4,403 times. 138 House to House inspections 1,236 Nuisances reported 1,645 Nuisances abated 1,200 Preliminary Notices served 692 Statutory Notices served 51 Drains opened up for examination upon written complaint. The Volatile or chemical test was applied in numerous instances 108 Plans of new drainage systems submitted and approved by the Council 35 Workshops inspected 54 times. 78 Houses let in Lodgings inspected 236 „ 54 Furnished rooms inspected 218 „ 2 Common Lodging Houses inspected 112 „ 3 Cowsheds inspected 23 „ 69 Dairies and Milk Shops inspected 98 „ 28 Bakehouses inspected 189 „ 4 Slaughter Houses inspected 182 „ 6 Piggeries inspected 150 „ 3 Offensive Trades inspected 78 „ 4 Mews inspected 314 „ 7 Van Dwellings inspected 9 „ 179 Patients removed to Isolation Hospital 311 Rooms disinfected, also from which bedding, etc., was removed and steam disinfected 77 16 School rooms disinfected 12 Closets disinfected after Enteric Fever 54 Library Books removed from Infected Houses and dealt with 1,157 Letters received 1.060 Letters Written 4 Notices received from H.M. Inspector of Factories and satisfactorily dealt with 12 Notices to Water Company, re Waste of Water With regard to the Bakehouses, Dairies, Cowsheds and Milkshops, Common Lodging Houses, Houses Let in Lodgings, Mews, and Piggeries, I have no occasion to make special mention. Offensive Trades. There are 2 registered offensive trades in the district (fat extractors) and one licensed (Fertilizer Manufacturer). These premises have been frequently inspected during the year. In October serious complaints were received with regard to a nuisance emitted from the licensed premises, which complaints I can testify were not without foundation, and I understand the Council intend to take proceedings in the matter. Slaugnter Houses. I am pleased to be able to report that the number of slaughter houses (four) has diminished by one, viz., that of Mr. George Morris, 018 Enfield Road. The premises are now used as a carriers' depot. Public-house Urinals. In May, I presented a detailed report to the Council with regard to the offence against public decency caused by the situation of many of the urinals in connection with the Public-houses. You inspected all the premises with me upon a later occasion, and decided which should be dealt with. Circulars were sent to the Brewers, and in all but one instance our requirements were carried out. The Clerk, I understand, is at present dealing with the defaulter. 78 Cricket Pavilions. During the month of June, I visited all the Sanitary conveniences in connection with the cricket pavilions in the District, and am pleased to report that I found everything in a satisfactory condition. Dust Complaints. A complaint was lodged by the master of the County School with regard to the nuisance caused from the Carpet Beating Factory adjoining the ground. Upon investigation, I found that particles of fluff and hair were carried from the Works into the school hall and class rooms. The Factory owners were very anxious to carry out anything we could suggest, as they did not wish to cause any nuisance. As you are aware, certain remedies were suggested, and these were at once complied with, and I have not received any complaints since . Smoke abatement. All factories' and works' chimneys have been observed at frequent intervals, and several cautionary Notices and Statutory Notices have been served upon owners for emitting black smoke in such quantities as to be a nuisance. No police court proceedings, however, have been necessary. During the year two petitions have been received by the Council with regard to smoke nuisances. One in May, relating to the chimney of the St. Mary's Laundry, and the other in December, relating to the London United Tramways chimney. With regard to the former, immediate steps were taken by the Council, and the nuisance was at once abated. In the case of the Tramway's chimney, it is situated in the Chiswick district. This Council was not asked to take any active steps in the matter, as a similar petition had been presented to the Chiswick authority. During December, in consequence of complaints having been received, special observations (from 8 a.m. to 4 p.m.) were kept upon the chimneys of Messrs. Eastman (2), Stratton, Napier, and Thompson and Norris. One chimney was found to be particularly bad, and steps were taken in the matter, since when very little nuisance has been observed. 79 Water Supplies. In August, Mr. Morris, of Wells Farm, complained of losing a cow, the death of which he attributed was due to poisoning, caused by drinking water in the water course which runs through his field. I took a sample of the water and submitted it to the County Analyst, who reported that it was unfit for drinking purposes. This result I communicated to Mr. Morris, and he removed his cattle from the field. In another instance, Dr. Rudd complained of the well water which the occupiers were drinking at Heathfield Lodge, Gunnersbury Lane. I also took a sample of this water and had it analysed, and received a report that it was quite unfit for drinking purposes, and the necessary steps were taken to inform the occupiers concerned of the result of the analysis. Removal of Dead Body. In August, I received a complaint from an occupier in Hooper's Mews, stating that the dead body of his wife had been lying in the living room for some days awaiting the Poor Law undertaker. The weather being very hot, the smell from the body was unbearable, and I, therefore, had it removed to the Mortuary to await burial. Inspection of Meat and other Foods. The butcher's shops, greengrocer's shops, and other places where food is sold or prepared, were frequently inspected during the year, and in very few cases did.I find any unsound food, or was it necessary for me to call the occupier's attenting to any insanitary conditions or want of cleanliness. The cutting out of pharyngeal glands of pigs by slaughtermen and butchers has practically ceased on account of the steps the Council took in the matter, and also, I think, by the stringent measures taken by the City Corporation. Messrs. T. Wall and Sons' sausage and potted meat works in Warple Way are visited twice every week, and I can only report that great care and cleanliness is observed. All the carcases of pigs are accompanied by a veterinary surgeon's certificate to the effect that they are free from disease. Extensive cold storage is provided, so that in 8o the hot weather there is very litle chance of finding any meat in a decomposing state or unfit for human food. In August, I had a pint of milk brought to me by a resident, which she had purchased from her milkman. She complained that she had been ill for some time past and thought probably that the milk had been the cause of her illness. I found the milk to be sour, and had a peculiar appearance. Under Section 28 of the Public Health Acts' Amendment Act, 1890, I took it before a Justice, who gave me a condemnation Order, but before having it destroyed, I had it Analysed by the County Analyst, and he reported that, beyond being sour and containing a small quantity of boracic acid, there was nothing to complain of. During the year, the following were seized, or surrendered and taken before a Justice:— 1 Box of apples, 8½ Stone of plaice, 4 Boxes of haddocks, 8 Pigs' heads, 1 Trunk of codlings, 357 Rabbits (wild), 7. Lungs, 4 Livers, 2 Spleen. Food and Drugs. During the year I procured:— 56 Samples of New Milk, 2 Samples of Butter, 1 Sample of Margarine, 3 Samples of Soda Water. In 7 cases the Analyst reported that the milk samples submitted were inferior in quality and probably adulterated. No action was taken with regard to these samples, but in another case, the vendor was prosecuted twice for selling butter containing 7 per cent, of Margarine. In the first case he was fined a sovereign, and in the second 40s. and costs. 8 Legal Proceedings. Date. Offence. Fine. Jan. 10th. Depositing for the purpose of sale a Tubercular Cow's carcase. Fine £5 and costs. Jan. 10th. „ „ „ Fine £5 and costs. May 2nd. Butter adulterated with 70 per cent. Fined 20s., Analyst's of Margarine fee 10/6, and costs. May 30. Butter adulterated with 60 per cent. Fined 40s., Analyst's of Margarine. fees, and costs. The following Tabulated List gives particulars of the Sanitary Improvements effected during the year:— F. J. Fearns North J. J. Jenkins South District. District. .TI. House Drains taken up and reconstructed 91 45 136 „ repaired 15 26 41 unstopped and cleansed 28 66 94 „ provided with intercepting traps 69 49 118 „ manholes provided to 77 78 155 ,, ventilated 36 70 106 „ manholes to, cleansed — 22 22 „ manholes to, repaired 6 26 32 „ fresh air inlets repaired 3 14 17 fresh air inlets provided 68 45 133 Water Closets repaired 12 12 24 „ new, provided 103 73 176 „ new, pans provided to 1 17 18 „ unstopped and cleansed 11 11 22 ,, pan closets and containers replaced by efficient plans - 4 4 „ provided with new flushing cisterns 3 47 50 „ flushing cisterns repaired 19 33 52 „ flush, disconnected from drinking water cistern 2 10 12 „ additional provided to houses — 8 8 „ additional or separate, provide in Factories and Workshops - 9 9 apartments, foul and dilapidated 3 10 13 Soil Pipes repaired 18 6 24 „ ventilated 17 7 24 „ increased ventilation provided to 5 5 10 ,, reconstructed 24 9 33 Interceptors, want of stoppers to 3 10 13 Ventilating Shafts repaired 34 5 39 Waste Pipes disconnected from drain 4 4 8 „ stopped or repaired 11 8 19 82 Waste Pipes: sinks, baths ami lavatories trapped with lead traps 34 21 55 „ new, provided — 13 13 Rain Water Pipes disconnected from drain 28 48 76 „ repaired 4 2 6 „ provided 2 6 8 Eaves guttering provided 2 7 9 ,, repaired 7 11 18 Gully Traps replaced with stoneware gullies 2 10 12 „ removed from improper situation 4 12 16 „ unstopped — 31 31 „ provided — 10 10 „ grids provided to 1 7 8 „ cement work around, repaired 3 28 31 Yards or Passages, paving repaired 1 26 27 „ paved and drained 69 84 153 „ cleansed — 36 36 Bust Bins provided 21 50 71 Ashpits, foul arid defective, remedied 1 18 19 Cisterns repaired and covered 22 15 37 „ cleansed 14 14 28 „ removed from improper positions — 12 12 Cleansing, houses cleansed and whitewashed 221 127 348 „ plastering of walls and ceilings repaired — 7 7 „ houses dealt with under Housing Acts — — — Workshops cleansed and lime washed — 18 18 „ excessive steam in — 1 1 roofs repaired — 2 2 „ floors repaired - 4 4 „ overcrowding 1 — 1 Roofs of houses repaired 12 5 17 Floors of houses repaired or relaid 27 9 36 „ workshops repaired or relaid — 4 4 „ stables repaired or relaid — 3 3 Stables provided with drainage 12 4 16 „ ventilation — 1 1 Coachhouse floors repaired — — — „ ceilings repaired — — — Dampness of house walls remedied 45 4 49 Air space under floors of houses ventilated 31 2 33 Accumulations, refuse removed 18 10 28 manure removed 37 5 42 „ water in cellars removed 2 1 3 „ in ditches — — — Cess pools cleansed 1 — 1 Manure receptacles provided 2 2 4 Animals, fowls, etc., nuisances from, abated 5 6 11 Urinals cleansed — 8 8 „ reconstructed — 7 7 Smoke, nuisances abated 7 9 16 83 Overcrowding, number of cases abated — 11 11 Water, supply provided to houses 6 3 9 „ taps provided on Main — 15 15 Miscellaneous, nuisances abated 16 3 19 Inspections.—Number of premises inspected on complaint 483 „ Number of premises inspected in connection with infectious Diseases 276 „ Number of Premises under Periodical Inspection 286 „ Houses inspected from House-to-house 138 ,, Total number of inspections and re-inspections made 5,855 Notices.—Cautionary notices given 1,200 Statutory orders issued 692 ,, Summonses served 4 ,, Convictions obtained 4 Dwelling Houses.—Houses, premises, etc., cleansed, repaired, etc. 355 „ Illegal underground dwellings vacated 1 Houses let in separate dwellings or lodgings.—Number registered under Bye-Laws 132 Common lodging houses—Number registered under Bye-Laws 2 Movable dwellings, caravans, tents, etc.—Number observed during the year 7 ,, Number removed from district 7 Workshops and workplaces—Number in district 420 „ Contraventions of Factory Acts 37 Laundries.—Number in district 288 Bakehouses.—Number in district 28 „ Contraventions of Factory Acts 1 Slaughterhouses.—Number on Register 4 Cow-sheds.—Number on Register 3 Dairies and Milkshops.—Number on Register 69 Unsound Food.—Articles or Parcels seized and articles or Parcels surrendered 388 Adulterated Food.—Samples taken 62 ,, Found adulterated 9 Offensive Trades.—Number of premises in district 8 Contraventions of Bye-Laws 3 WATER SUPPLY AND WATER SERVICE. Wells.—Closed as polluted 1 Percentage of Houses supplied from Public Water Service 100 per cent. Cisterns.—New, provided 9 „ Cleansed, repaired, covered, etc 45 „ Overflow pipes disconnected from drains 1 Draw-taps removed from Cisterns to Mains 15 Percentage of houses supplied on constant system 100 per cent. Water Closets—New constructed 176 „ „ Repaired, supplied with water or otherwise improved 212 „ „ Percentage of houses provided with water closets 100 84 DRAINAGE AND SEWERAGE. Drains.—Examined, tested, exposed, etc. 187 , Unstopped, repaired, etc. 339 „ Waste pipes, rain water pipes disconnected, repaired, etc. 293 „ Soiled pipes and drains ventilated 164 „ Disconnecting traps or chambers inserted 273 „ Reconstructed 136 Cesspools—Rendered impervious, emptied, cleansed, etc. 1 Percentage of houses draining into sewers 100 Disinfection—Rooms disinfected 377 Dust—New bins provided 90 „ Periodical frequency of dust removal weekly Sundry nuisances abated—Overcrowding 12 „ „ „ Smoke 16 „ „ „ Accumulations of refuse 73 „ ,, „ Foul pigs and other animals 15 „ „ „ Dampness 49 „ „ „ Other nuisances 698 I am, Sir, yours obediently, MAURICE W. KINCH, A. R. San. I., (Chief Sanitary Inspector,) Public Health Dept., 130 Churchfield Road, Acton, W.