BEC 1 the Annual Report of the Medical Officer of Health foe the Urban Sanitary District of Beckenham for the year 1908 by George Carpenter, M.D. Physician to the Queen's Hospital for Children & Hon. Consulting Physician to the Children's Home Hospital, Barnet; Vice-President of the Royal Society of Medicine; Membre Correspondent de la Societe de Pediatre de Paris; Membre de la Societe d'Ophialmologie Francaise; Editor and Founder of the " British Journal of Children's Diseases"; Editor Vols. I. to VIII. of the "Report" of the Society for the Study of Disease in Children, and formerly Honorary Secretary and Chairman of Council of that Society. CONTENTS. PAGE. Beckenham Experiences and modern views on Scarlet Fever 30 Births 7 Chaffinch Brook 22 Daily Bread 21 Deaths 14 Diphtheria. 34 Enteric Fever 35 Factories and Workshops 22 General Sanitary Circumstances of the District 17 Glanders and Farcy 22 Infantile Mortality 9 Infectious Disease 24 Introduction 4 Management of Principal Notifiable Diseases 37 Measles 36 Midwives' Act 23 Milk as a Producer of Disease 17 New-Born Infants and 'Ophthalmia 12 Notification of Births Act 10 Population 6 Scarlet Fever 25 Scarlet Fever and Diphtheria 27 Tables of Vital Statistics 49 Whooping Cough 36 Zymotic Death Rate 16 Principal Features of the Vital Statistics for the Year 1908. Area of District 3.881 acres Census Population, March, 1901 26,331 Estimated Population to middle of 1908 33,061 Births 688 birth Rate per 1,000 of the Population 20.8 Deaths 280 General Death Rate 84 Zymotic Death Rate 0.4 Infantile Mortality Rate (under one year) per 1,000 births registered 71.2 Child Mortality Rate (under five years) per cent. of deaths registered 26.4 12, Welbeck Street, Cavendish Square, London, W. January, 1909. To the Chairman and Members of the Urban District Council of Beckenkam. Gentlemen, — In compliance with the Regulations of the Local Government Board, I have the honour to submit my 18th Annual Report on the Health and Vital Statistics of the Urban District of Beckenham for the year 1908. The Report of the Chief Sanitary Inspector, which this year appears under a separate cover, gives in detail the work of the Public Health Department in matters appertaining to Sanitary Administration. The general health of the District is about the same as that of the preceding year. But the Infectious Diseases are somewhat in excess of that reported to me during 1907. Thus Scarlet Fever was in evidence during the month of March, twenty-three cases being notified, but the disease could not be characterised as epidemic. Diphtheria also increased somewhat, there being 66 cases during the first half of the year, but from that time the disease declined, and in October, November and December there were only 8 cases in all. Measles also occasioned trouble, and I closed the Bromley Road Schools for two weeks on that account. Ten deaths were registered as being caused by Pulmonary Tuberculosis of people varying in age from 28 to 56 years, 5 while 17 other deaths were registered as due to some other tuberculous complaint. In regard to Tuberculosis the Council have passed a resolution by which Pulmonary Tuberculosis is now voluntarily notifiable. I am glad to find that this has been done because I have in several previous annual reports invited practitioners to voluntarily notify cases of tuberculosis to me, and I have offered them assistance in regard to disinfection in relation thereto. I cannot say that these offers have been taken advantage of on comparing applications for disinfection with the number of deaths from tuberculosis. The Local Government Board have also issued an Order, which took effect from the first of this year, whereby it became compulsory to notify Pulmonary Tuberculosis in the case of a poor person who is an inmate of a Poor Law Institution to the Medical Officer of Health for the area in which the poor person resided prior to his admission into that Institution. I doubt whether voluntary notification of Pulmonary Tuberculosis will be productive of such benefits as the Council anticipate. I am of opinion that good results could be •obtained by including all cases of Tuberculosis with discharges, together with such cases of the disease as are liable to cause contagion in the list of diseases which are compulsorily notifiable. The effort which was made by the Council to obtain the sanction of the Local Government Board to compulsory notification of Pulmonary Tuberculosis some years ago, with so little success, perhaps, with advantage to the District, might be repeated once again in relation to all cases of Tuberculosis with the above mentioned characteristics. 6 Area, Population and Rateable Value. Area, 3,881 acres; Population, 33,061; Rateable Value, £268,965. Population. The estimated population of the District up to the middle of 1908 is 33,061. For statistical purposes it is my usual practice to estimate the population of the District for the year under review. The estimate may be made in many ways, but the method which has always been adopted by me is to obtain the number of inhabited houses to the middle of the year in review, from the rate books, and multiply this by the number of the persons per occupied house, as demonstrated by the Census Returns for the preceding Census Year. This affords a very reliable means of determining the estimated population, and at the last Census my figures differed from those actually found by the statutory decennial enumeration of the people by only 270 persons. It is of interest also to review the steady growth ot the District for the past 18 years, and for this purpose, I give the population as has been estimated by me from year to year; and also the population of the various sections of Beckenham since the practice has been adopted of dividing the District into Ward areas. 7 Census Figures Year. Copers Cope Eden Park. Langley Park. Shortlands. Manor House. Kent House. Laurie Park. Total. 1891 20705 1892 21666 1893 21840 1894 22470 1895 Records not kept. 23070 I896 23579 1897 24300 1898 24730 1899 3022 3858 1737 1672 4343 4974 6499 26075 1900 3118 3776 1743 1696 4717 5016 6490 26556 Census Figures 26330 1901 2815 3432 1773 1785 5021 5027 6747 26600 1902 2836 3532 1842 1775 5902 5475 6887 28249 1903 2875 3555 1801 1781 6872 5967 6821 29672 1904 2906 3632 1848 1818 7654 6231 6612 30701 1905 2919 3610 1927 1769 8448 6550 6926 32149 1906 3000 2808 1927 1873 8426 6550 6651 32215 1907 3025 3821 1994 1915 8840 66l6 6998 32809 1908 3025 3737 2012 2019 9117 6428 6722 33061 Perusal of this Table will demonstrate that a steady growth of the District has been maintained, Manor House and Kent House Wards being the most populous. The increase of the people is due to an increased number of inhabited houses and not to an increase of persons per inhabited house. Beckenham is still growing and there is an estimated increase of the population of 252 persons. Upon the estimated population of 33,061, calculations have been made for the various Vital Statistics for the year 1908. Births. During the year in review 688 births have been registered, as against 664 for the preceding year: of this number 378 were Males and 310 Females. Thirteen infants were declared to be illegitimate. 8 This gives a birth rate of 20.8 for the year, and comparing this rate with that of former years, it is a fair average, and is 0.6 above the rate for last vear. The Birth rate for the last 3 years in the seven different Wards into which the District has been divided is given in the following Table:— Wards 1906. 1907. 1908. No. of Births Rate. No of Births. Rate. No. of Births. Rate. Copers Cope 31 10.3 32 10.5 31 10.0 Eden Park 48 12.6 63 16.4 60 16.0 Langley Park 23 11.4 33 16.5 35 17.3 Shortlands 29 10.1 24 12.5 23 10.1 Manor House 220 26.1 218 24.6 222 24.3 Kent House 162 24.8 152 22.9 147 22.8 Laurie Park 157 23.6 142 20.2 170 25.2 Totals 670 20.8 664 20.2 688 20.8 The Notification of Births Act, 1907, an Act which was optional for local Authorities, was adopted by the Council at its Meeting held on the 6th January, 1908. Under this Act all Births are required to be Notified to the Medical Officer of Health within 36 hours of birth. But although the Act makes it compulsory for the Medical Practitioner in attendance to notify, it makes no provision for payment of this service. This is not the only instance where medical practitioners are compelled by Law to render professional services to the public without payment. From 1st April (the date upon which the Act first became law in the District of Beckenham) to the end of the year, I have received notice of 362 births, but during this time 517 births had been registered with the Registrar, thus leaving 155 births which had not been notified to me as required. The 9 enactments of the Act will be defeated if announcements of births continue to be made in this imperfect fashion. That the Act provides for summary proceedings against offenders, and does not allow payment to be made for services in respect of notification is an anachronism for which Legislators are responsible, but it does not absolve the Council from carrying out the provisions of the Act that they have adopted, and after giving due warning to those concerned they will have no alternative but to institute proceedings in the ordinary way, therefore those medical practitioners who are not already acquainted with the provisions and obligations of the Act will do well to make a study of it. In regard to the application of the Act in Beckenham, it will doubtless prove a valuable adjunct to the efforts I have made from time to time to reduce Infantile Mortality, for it is only by instructions to poor parents at the earliest possible moment, respecting the proper feeding and care of their infants, that good results can be hoped for. Instructions given after the child has reached the age of some weeks and has passed a period of improper feeding and other aids to ill health and untimely decease, are either not required by reason of death or are much handicapped by lapse of time. Infantile Mortality. Reference to Table No. 5 will shew that of the 48 infants who died before the age of one year, 21 did not live one month. The Infantile Mortality rate has shown a steady decline since 1904, when it was 126.8 per 1,000 births registered. Now it is 71.2 per 1,000, the lowest by far since I have been Medical Officer of Health. Ten years ago it was 136.6, and nine years ago 144.4. For the following three years the lowest was 87.8 and the highest 129.6. I hope that my efforts in regard to this question, which have now extended over some years, are at last bearing fruit. But it is not wise to be carried away by enthusiasm over what appears to be a record year, as I have noticed before that a high infantile mortality rate has been followed by a period of low infantile mortality. What, however, is encouraging, 10 is the steady decrease, not a violent oscillation of figures for better or for worse. It is to be noted that during 1908 and the half of 1907, the district has had the advantage of a Lady Health Visitor's (Miss Moir's) services. Before the Notification of Births Act was adopted by the Council (April 1st, 1908), Miss Moir visited houses of all poor people who had recently been confined, delivered printed instructions to them, and assisted them in very many ways in the care of their newly born babies. Since the adoption of the Act the Health Visitor visits cases or not entirely at the discretion of the Medical man in attendance. In compliance with the Act stamped post-cards containing the form of notice have been supplied to all practitioners or midwives residing or practising in the district. Appended is a copy of the post-card which has been adopted together with the subsequent addition at the left- hand corner " The Health Visitor is requested to attend," and which is not required by the Act. The Health Visitor is requested to attend. THE NOTIFICATION OF BIRTHS ACT, 1907. CERTIFICATE OF BIRTH Urban District Council of Beckenham. To the Medical Officer of Health. In accordance with the provisions of the above Act I hereby notify you that a* child was born to † wife of ‡ residing at || on the day of 190 ... Dated the day of 190.... (Signed) . N.B.—(*) Insert" Male or Female." (+) Christian Name of Mother. (‡) Christian Name and Surname of Father. (||) Situation of premises where birth took place. But the system which has been adopted of leaving to the family practitioner the decision whether the Health Visitor shall or shall not visit recently confined poor mothers will 11 have to be seriously reconsidered, as experience has demonstrated that this concession has restricted her work, and therefore tends to defeat the aims of the Notification of Births Act, viz.:—the reduction of infant mortality. There is no desire on the part of the Public Health Department to come between the Medical Profession of Beckenham and their patients, but it is common knowledge that the poor cannot afford, for any lengthened period, skilled medical advice. Many women are strongly imbued with the notion that because Nature has ordained that maternity is their birth right, that She has at the same time endowed them with an unerring instinct as to what is best for the offspring—result disaster, frequently. Others base their claims to knowledge of infant dietetics by the number of children that they have lost—the more losses the greater their experience of infant rearing. Others again fly to equally incompetent though wellmeaning neighbour matrons for advice in their difficulties. The specious advertisements in the daily and weekly papers drawing attention to sure aids to infant feeding become the sheet anchors of others. When left to their own devices, whatever these poor people do is generally the wrong thing, but in their distress to whom are they to turn for free advice for their babies? There are no Children's Hospitals in the District to appeal to, London Children's Hospitals are too expensive to visit by reason of the travelling expenses, private Doctors are beyond their means, and the Children's Dispensary near by, which is out of the District, costs sixpence for medicine. But it is not medicine they require. What is necessary is advice and instruction, which does away with the compulsion for medicine. The Health Visitor carries to these poor people my "Advice to Mothers on the feeding and care of their Infants," which also tells them what they should not do. She explains any little difficulties they may have in regard to my instructions, and she gives them practical demonstrations on the care of their infants. Innovations are not received with open arms by English people—it is not their custom. The Health Visitor is an 12 novation, and the Notification of Births Act is an innovation, and when these novelties have become a habit, it will be realised by the members of the community for whom these innovations have been created and others, that there is really no harm in them, but on the contrary a great deal of good. It is unfortunate that greater advantage has not been taken of the Health Visitor's services in regard to Infant Management. Some Beckenham mothers must get into their heads that knowledge of babies has to be acquired by study like any other art; cooking for instance, which does not come by Nature, although it is man's necessity to eat. Nor is matrimony an essential preliminary to acquiring a knowledge of babies, and therefore no mother who has not studied the subject need feel ashamed of or disgraced by being instructed by an unmarried woman who has. On the contrary she should display her good sense by striving to learn how she can grow up a fine healthy baby instead of carrying in her arms a miserable, wizened infant, with one foot constantly in the grave, which is no credit to her and an object of sympathy for her neighbours. New Born Infants and Ophthalmia. But the adoption of the Notification of Births Act renders it possible to obtain prompt notice of, and to draw attention to, that terrible scourge of new-born infants known as Ophthalmia Neonatorum, and which is responsible for so large a proportion of the number of our sightless population. To efficiently deal with this malady, which infants contract during the act of birth from infected maternal parturient passages, treatment to be of any avail must be prompt. I have no present means of determining how many infants in Beckenham suffer in this way, but I have drawn up a memorandum of instructions relating to Ophthalmia Neonatorum, which will be immediately delivered to those parents who have provided the necessity for notification of Birth to the Public Health Department. It runs as follows:— 13 NEW-BORN INFANTS AND OPHTHALMIA. If the Baby's eyelids become red or swollen, or the eye. begins to run with matter within the first fortnight of birth, it is to be seen by a Doctor without a moment's delay. The disease, called Ophthalmia, is very dangerous, and if not treated may destroy the sight of both eyes. For those patients requiring hospital treatment, and hospital treatment is essential in all cases that cannot employ skilled medical supervision and efficient nursing, it is of importance that the mother and child should not be separated. Therefore provision for the admission into hospital of the mother as well as the infant must be made. In Beckenham it appears to me that there are two Institutions that could be made available for such a purpose should the occasion arise, viz.:—The Cottage Hospital or a special ward at the Infectious Diseases Hospital. To prevent blindness the aims must be, early recognition, followed by prompt and efficient treatment. The Notification of Births Act affords the ideal channel by which early recognition of Ophthalmia Neonatorum can be obtained-the machinery is at hand for the purpose. I do not know if the Council possess powers to make a slight but necessary addition, or should they not possess them, is the necessary powers can be obtained to enable them to make the Notification of Ophthalmia Neonatorum compulsory. But whether or no, I have no doubt that if such powers could be exercised it would be to the advantage of the Public Health. I urge the Council to take the necessary steps to obtain such powers forthwith. In my opinion the Public Health Department is the best machinery for obtaining early information of cases of Ophthalmia Neonatorum and also for making the necessary arrangements for its prompt treatment and isolation, and I therefore bring these matters to your notice for your consideration and deliberation. 14 Deaths. Two hundred and sixty-six deaths have been registered within the District during the year, of which 131 were males and 135 were females. This gives an actual Death Rate of 8.0 per 1,000. To this number must be added 14 deaths of former residents of Beckenham, who died at Locksbottom Infirmary, and 7 deaths occurring at the Infectious Diseases Hospital, while 7 deaths of non-residents which occurred at the Cottage Hospital or other Public Institutions within the District must be deducted. The sum total of 280 deaths, upon which figures the corrected death rate is based, gives a mortality rate of 8.4 per 1,000. I he particulars of the deaths of non-residents occurring in Public Institutions within the District are as under:— Sex. Age. Cause of Death. Institution. Female 47 Acute Pericarditis The Cottage Hospital Male 52 Suicide Do. Male 54 Stricture of Urethra Do. Female 60 Cerebral Hœmorrhage Do. Female 58 Suicide Do Male 58 Accident Do. Female 36 Ulceration of Stomach Brooklyn Nursing Home 15 The Death Rate for the last 3 years in the seven different Wards into which the District has been divided is given in the following Table:— Wards. 1906. 1907. 1908. No. of Deaths. Rate. No. of Deaths. Rate. No. of Deaths. Rate. Copers Cope 20 6.6 16 5.2 25 8.2 Eden Park 35 9.1 32 8.3 36 9.6 Langley Park 18 9.3 18 9.0 15 7.5 Shortlands 5 3.2 12 6.2 7 3.4 Manor House 71 8.4 72 8.1 79 8.6 Kent House 61 9.3 56 8.4 52 8.0 Laurie Park 48 7.2 57 8.1 66 9.8 Totals 268 8.0 263 8.0 280 8.4 The whole of the deaths, 280 in number, will be found on reference to Table No. 4, classified under the diseases assigned as the cause of deaths and to the period of life in which they occurred. The highest Ward Death Rate was in Lawrie Park Ward, which was g.8. The following Table shows the principal causes of death in 1907 compared with those under review:— Disease. 1907 1908 Heart Disease 37 28 Cancer 25 29 Bronchitis 22 12 Senile Decay 21 17 Diseases of the Nervous System 21 26 Pneumonia 18 15 Tuberculosis 13 27 16 Zymotic Death Rate. There have been 19 deaths from the seven principal epidemic or Zymotic diseases during the year, and these havebeen made up as under:— Disease. Number of Deaths. 1907 1908. Small-Pox — — Scarlet Fever 2 1 Diphtheria 4 5 Typhoid Fever — 3 Measles — 5 Whooping Cough 4 2 Diarrhoea — 3 Totals 10 19 The Zymotic Death Rate for the year is therefore 0.5 as against 0.3 in 1907, 0.2 in 1906. Summary. No. Treated at Home. No. sent to Hospital. Total. Fatal Cases. Scarlet Fever 25 107 132 1 Diphtheria 11 82 93 5 Typhoid Fever 3 4 7 3 Erysipelas 12 — 12 — Puerperal Fever — 1* 1 1 Total 51 193 245 10 * Sent to Infirmary. 17 General Sanitary Circumstances of the District. During the year I have made continual inspections in the District. I have visited from time to time the Dairies, Milkshops and Bakehouses, and many other such premises where food is prepared or sold. I find, perhaps, some slight improvement in the methods of cleanliness, but there is still much to be desired in this respect. Milk as a Producer of Disease. In regard to the management of milch cows in Beckenham by the Milk Trade, I have nothing further to add to the observations I made on this subject in my last Annual Report—the laws relating thereto are kept. But although the laws are observed, the arrangements for Cattle Management do not comply with the requirements of their health, on the contrary, they are conducive to the spread of Tuberculosis among the animals. To obtain sound milk healthy beasts are essential, and healthy beasts are not produced by unhealthy measures. Cows display signs of Tuberculosis either by wasting and cougning, or their udders are obviously involved, or the disease can only be detected by injection of vaccine. The milk obtained from tuberculous cattle becomes contaminated by tuberculous germs, either directly from the infected animals' blood vessels or indirectly from extraneous sources. Tubercle germs, be they obtained from human beings or from milch kine, are dangerous to human health and life, whether they be inhaled, or be taken into the bowels with the food. And bovine tubercle contaminated milk is especially dangerous to our child population, and tuberculous disease there from often occurs in them in the shape of tuberculosis of the bowels, because they are so dependent upon cow's milk for their nutriment. Enforce the existing regulations and whitewash cow sheds at stated intervals, see to it that they are kept with a 18 reasonable regard to cleanliness, and the tubercle bacillus will suffer no material damage. The existing regulations are totally inadequate for the purpose in view, viz.:—healthy cattle and a pathogenic germ free milk. The breath of cattle suffering from tuberculous lungs will infect the milk from aerial transmission, and the particles of hay and straw which find their way into the milk are vehicles for tubercle germs. To these sources of infection must be added the likelihood of milk contamination from dirty teats and udders, from dirty milkmen with manure-begrimed hands, and from the aerial currents which pervade infected cowsheds. Cows suffering from obvious tuberculosis of the udder are likely to be detected and weeded out, but cows with early tuberculosis of the lungs without wasting, and those which display no symptoms whatever of the infection, are equally dangerous, and perhaps even more so, because thev are not found out. Therefore milch cows destined to produce the public milk supply should be kept scrupulously clean, they should have a proper environment and be supplied with plenty of fresh air and sunlight, and above all things should be healthy. To safeguard the Public Health every such milch cow in the District ought to be branded and licensed, and a record kept of its health. Moreover those persons suffering from any tuberculous disorder likely to be conveyed to cattle or to milk, should not be permitted to tend milch cattle, or to milk them, or to engage in the milk trade in any capacity. The Council should, I think, pay serious attention to the following facts. Tubercle bacilli have been detected in a small percentage of samples of ordinary commercial fresh milk. A very large percentage of such samples contain organisms which occur in cows' excreta. According to recent researches of the American Government it is unsafe to use the milk of any tuberculous cow no matter where or what the lesion. Veterinary surgeons in the present state of knowledge cannot by the ordinary means of examination at their disposal detect all forms of tuberculosis; even when it 19 occurs in the udder. The best known means at the present time for the detection of tuberculosis in cattle is the use of the Tuberculin test. It has been realised for some years that tuberculosis in cattle in this country is by no means uncommon. There can be no doubt in the mind of any physician who has studied the question, or indeed in that of any layman who seriously considers the matter, that cows suffering from tubercle should not be pressed into the service of man as milk producers. If the flesh of sucn animals is not fit for human food, it is obvious to all that the milk, which is formed by the blood which nourishes the flesh, is equally unfit. It follows of course that if a cow responds to the Tuberculin Test it must be destroyed, and the serious side of this unfortunate but necessary deduction is, on whom in that event will fall the damage. It is obvious that a cowkeeper might be seriously crippled in his business and indeed ruined if he had to bear the expenses of such a rigorous though very necessary enquiry. On the other hand the ratepayer is not perhaps prepared to compensate cowkeepers for their losses should the verdict be against their cattle. These are questions, however, for the Council to study and do not come within the province of the Medical Adviser of the Sanitary Authority. But from the Public Health point of view some vigorous action should be taken by the Council. Perhaps the best way out of the difficulty would be to consider my suggestion of branding and licensing the beasts, all fresh cattle being pressed into the service being required to undergo the Tuberculin test before being approved by the Council. Veterinary Inspections could then be periodically made from that date, and the registered milch cows undergo a periodical Tuberculin test every three months. At the same time the present unsatisfactory housing and tending of the animals, and the no less unsatisfactory habits of the men engaged in the milk trade are subjects which will well repay attention. For some years past in my Annual Reports on the health of Beckenham and in my communications to Medical Science I have preached against dirty milk, pathogenic germ infected milk, and milk that has been commercially sterilized and 20 pasteurized. Are harmful bacteria in milk still to be fought by sterilization and pasteurization, those ancient and retrograde processes which are the salvation of the milkman, but which render that fluid less nourishing to many infants and actually harmful to some of them. Has not the hour arrived when the observance of cleanliness and the laws c f health should take the place of sterilizing dilute sewage, for this is what much of the milk now sold really is? Do the Council realize that there is a milk seller in their District who imports large quantities of milk there and unblushingly sterilizes it under the very noses of the Sanitary Officials? Perhaps it kills the germs in it, or, at any rate, sends to sleep those that are prone to render his milk unsaleable. But he does not kill the poisons that have been formed by these germs during transit, and he renders the milk by his culinary operation most undesirable for and harmful to infants. When milk has been sterilized or pasteurized, it should be sold as sterilized or pasteurized milk, and not as milk. Those who sell milk so treated without publicly announcing the fact should be proceeded against for vending an article which is not of the nature, substance and quality demanded by the purchaser. Sterilized and pasteurized cows' milk if given to infants for any length of time produces anaemia and malnutrition in many and scurvy in some. Therefore it there are no regulations in force by which the sale of such doctored milk as milk can be prohibited, then it is advisable in the interests of the Public Health that the necessary powers should be obtained. The death rate from Scarlatina in the district was .7 per cent., and the limited outbreak of Scarlet Fever, on which I shall presently offer remarks, has created some little exclamation in the Council Chamber. But what of the deaths from Tubercle? How many of these 27 deaths, not to mention the maimed and injured of which there is no account, can be proved to be not due to Tuberculous Milk? I should like the Council to take a very prominent part in the reformation of the cowkeeper and the milk trade, a reformation which is bound to come, and will come I hope at no very distant date. At present the milk trade enjoys far 21 too much license and at the expense of the Public Health. For how much longer will this state of affairs be tolerated? For quite long enough it has been recognised that reformation in the milk trade is desirable. The stage of expectancy has passed and gone, and now the demand for action on the part of local authorities has arisen and is imperative. Daily Bread. Judging from the great quantity of white bread displayed in the bakers' shops and the bakehouses of the District, the public do not realize that in the selection of white bread they are being carried away by appearances and are not getting the best value for their money in the way of a nourishing article. The grain of wheat, when ground whole is full of nutritious properties, mineral substances for the bones, the teeth, the brain and the nerves, and also flesh forming materials, together with the embryo or germ, which is rich in oil, in nitrogeneous matters and in phosphoric acid. Therefore brown bread is best. Further, flne brown flour is better than coarse, because more flesh-forming material can be extracted from a fine meal than a coarse one, and not only more fleshforming material, but more mineral substances are extracted by the human body from brown flour than from a similar weight of fine white flour. But for those who do not like brown bread, even if it be made from finely ground whole wheaten meal, the next best bread is the old-fashioned Household bread, which is cream coloured and retains 80 per cent. of the grain together with the chemical products of the embryo or germ. As so large a proportion of the food eaten by the working classes is bread, and the computation that has been made is that it amounts to 2-5ths of the weight of food consumed by them, it is obvious that nourishing bread and flour are of vital importance to those poor people of Beckenham who have families to bring up. And when ordering their bread they should stipulate that potatoes be not mixed with the wheat flour from the dough of which the bread is made. 22 The Chaffinch Brook. My attention was called by the Council to the practice of children bathing in this stream, and I reported specially thereon to your Committee. This stream is under constant observation because the effluent from the Croydon Sewage Farm is discharged into it. The naked eye appearance has in most instances been satisfactory, but in order to control these inspections, samples of the water have been submitted to the Public Analysts from time to time, who have pronounced favourably upon the specimens submitted to them An open stream which is of easy access to school children is not unnaturally a most attractive source of amusement, and so long as this stream remains of inviting aspect to them, so long will young bathers be found therein. The practice would become harmful if pathogenic germs invaded it, and the most effectual way of putting a stop to bathing there, is to have it efficiently covered in. Glanders and Farcy. Three cases of Glanders in horses have been notified to me by the County Inspector under the Contagious Diseases (Animals) Act as having arisen in this District. All three cases occurred in Shortlands, one in Station Road and two others in Kingswood Road. The horses were slaughtered and buried in quick lime, under the superintendence of the Inspector. The stables and the immediate surrounding premises were also disinfected to my satisfaction. Factories and Workshops. Section 132 of the Factory and Workshop Act, 1901, states:— "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 work-places, 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." There are now 132 Workshops on the Register. 23 A new Register has been compiled, and each of these premises has been entered therein. The cubic capacity of the workrooms has been obtained, but no case of overcrowding has been dealt with. Particulars respecting cleanliness, means of ventilation, and sanitary accommodation have also been recorded in the Register. A system for tabulating records respecting these matters at subsequent periodical inspections has been devised, and the following contraventions of the Act have been observed:— 10 Insufficient Sanitary Accommodation. 10 Want of Cleanliness. 1 Insufficient means of Ventilation. 6 Other Nuisances. 3 Want of drainage to floors. These contraventions of the Act have been brought to the notice of the Occupiers of the workshops, and all defects have been remedied by them. There are 15 Out-workers resident in the District, and without exception they are employed by people trading outside the District. Frequent inspection has been made of their premises and it has been found that they were for the most part in a cleanly condition. No case of Infectious Disease has occurred at any of these houses. Midwivos' Act. There are 3 qualified Midwives in the District, and these have been duly entered on the Register. I have kept close observation over these women during the year, and I have carefully examined from time to time their maternity bags and case books, and have given them instructions in respect of personal cleanliness together with suggestions as to the best and most simple appliances necessary for their requirements. For this purpose I obtained a maternity bag as recommended and used by the Royal Maternity Charity in order that they might be efficiently equipped for their duties. One of these nurses ceased work for some months during the year on account of nursing her husband who was then suffering from cancer. He has since succumbed to the disease 24 and she has again returned to her business. The Midwives' Act of 1902 constituted the County Council or County Borough to be the Local Supervising Authority over midwives, but this Act also provided that these bodies could delegate their powers should they so wish to Local Authorities. The Kent County Council in respect to the District of Beckenham placed the duty of inspection upon me. The County Council, however, have now decided to revoke their previous resolution, and I shall therefore cease to be responsible under this Act from 31st March, 1909. Infectious Disease. Table No. 3 gives detailed particulars of 245 cases of Infectious Disease notified during the year. It gives the age period for each disease, the Wards in which the Disease occurred, and the number of cases removed to Hospital from each of these Wards. The Schedule here appended gives interesting particulars for the last 10 years, of the Infectious Disease which occurred in the District:— Year. Disease. Total. Small-pox. Diphtheria. Scarlet Fever. Typhoid Fever. Erysipelas. Puerperal Fever. 1898 .. 22 29 6 19 .. 76 1899 .. 54 92 8 21 .. 175 1900 .. 45 77 13 25 1 161 1901 4 29 62 15 13 .. 123 1902 17 37 63 4 20 2 143 1903 .. 28 51 6 11 1 97 1904 .. 33 38 2 14 .. 87 1905 .. 47 57 7 17 .. 128 1906 .. 21 90 7 15 .. 133 1907 .. 73 115 .. 9 1 198 1908 .. 93 132 7 12 1 245 25 Reference to this Table discloses the tact that 1908 has presented more Infectious Disease than any one of the previous 10 years, and 47 in excess of 1907. Scarlet Fever. One hundred and thirty-two of the Infectious cases are attributable to Scarlet Fever: 35 of the cases occurred between the ages of 1 and 5 years, 78 between 5 and 15 years, 7 between 15 and 25 years, and 12 over 25 years of age. It will De seen that by far the greater number of cases were among children who had attained school age, and were pupils in the elementary or infants' departments of the Council's Schools. For the most part the disease was of a mild type, and of the number only one died. By order of the Council all persons residing in the house along with the Scarlet Fever patient and those children seated immediately to the right and left of the affected child at School, were medically examined, and the results of such examinations were reported to the Council. There has resulted from this order medical examinations of, and reports upon 202 people, and in all cases with a negative result, no cases of Scarlet Fever being detected among them. On a previous occasion in view of the prevalence of Scarlet Fever, it was suggested by the Council that single handed I should perform the Herculean task of examining all the School children of Beckenham. I expressed my willingness to undertake such an inspection, with the view of discovering presumed infected children, provided I were given assistance. I therefore placed before the Council the names of various local medical gentlemen for that purpose. But in view of the expense which would be incurred, their assistance was not forthcoming, and the proposed enquiry therefore fell through. Had such an enquiry been undertaken, to be of any value the medical examinations would have had to have been searching and thorough. In face of the recent outcry n regard to medical inspection of school children, this enquiry, if it had 26 been undertaken, would doubtless have been received with similar ungracious fervour by the ignorant. I shall take this opportunity of relating Beckenham experiences in regard to this disease, and of bringing to your notice modern ideas on the subject. On analysing the figures, there were 132 cases in 98 houses: in 3 houses there were 4 patients; in 2, 3 patients; in 21 houses, 2 patients; and in 72 houses, 1 patient. Thus in 72 houses the disease only occurred once, and it would appear that isolation of the patient and subsequent disinfection of the premises was successful. In the houses in which 2 cases arose, 4 failed within eight days of the first case. With regard to the others, failure of the second case took place at the following intervals of time: 2 failed within 9 days, 1 in 10 days, 1 in 13 days, 1 in 17 days, 1 in 48 days, 1 in 56 days, 1 in 63 days, 1 in 91 days, I in 94 days, 1 in 117 days. In six instances 2 cases were notified the same day. In the two houses in which three cases arose, in one of them the cases all occurred about the same time (October 17th, 18th and 24th), but in the other, two of them were notified on the same date, but the third was not notified until 80 days afterwards. Of two batches of 4 cases notified from two separate houses, the following was found: At both these houses the series of 4 cases were notified at one time. In one instance a child, who had been under medical care since February 17th, was notified on March 14th together with three other children as suffering from Scarlet Fever dating from March 11th. Here it would appear reasonable to suppose that one undetected case gave rise to three others. The third batch of four cases was notified on one day: In two of the cases the date of onset of symptoms occurred on the date of notification, in the third it happened 4 days before the notification, and in the fourth 17 days before. In this instance also it would appear that a mild undetected case of Scarlet Fever had given rise to the three other cases. 27 In neither of these cases of undetected Scarlet Fever did the disease spread byond the infected house nor were inmates there other than the children attacked. In regard to return cases from the Infectious Hospital at Bromley Common, the following facts were observed: — There were sent to that hospital 107 patients with Scarlet Fever, and who subsequently returned to their homes. All of these patients were examined on their return by their medical men, who gave certificates that these patients were free from infection except in one instance—a child was returned to hospital as being still infectious on account of peeling. On making further enquiry 1 find that in 6 cases the return home of the patient was followed by 6 cases of Scarlet Fever. These cases of Scarlet Fever occurred after the following intervals of time:—5 days, 13 days, 15 days, 17 days,. 49 days, and 56 days. Thus it would appear that 6 return cases which were certified as healthy by their medical men, were presumably capable of giving rise to the disease. Scarlet Fever and Diphtheria. There were 6 houses in various parts of the District at which both Scarlet Fever and Diphtheria were notified. In one case Scarlet Fever was notified, the premises were disinfected, and 48 days after a case of diphtheria was notified, and 7 days after that a fresh case of Scarlet Fever occurred and 56 days after the return of the original case of Scarlet Fever from the hospital. But the same thing happened previously, for in 1907 a case of Scarlet Fever was followed in 39 days by Diphtheria and in 89 days by Scarlet F ever. In another instance arising at the end of 1907, a case of Scarlet Fever was notified, this was followed in 11 days after the discharge of this patient from hospital by a case of Diphtheria. Twenty-one days after the Diphtheria patient was discharged from hospital a case of Scarlet Fever was notified. Nine days after the removal of the Scarlet Fever 28 case a further case of Diphtheria arose. That was discharged from hospital, and 17 days after reaching home there was notified another case of Diphtheria. The second Scarlet Fever and the second Diphtheria returned home on the same date, and 17 days later there was a fresh case of Diphtheria. At another house a case of Scarlet Fever was notified, it was discharged from the hospital, and a month later a case of Diphtheria was notified. The case was sent to the hospital, and ten days later a second case was notified. A neighbour living on the opposite side of the road nursed at the house, contracted Diphtheria and was sent to the hospital. At another house a case of Scarlet Fever was notified and sent to hospital, two months later after the return of the patient from hospital a case of Diphtheria occurred and was fatal. At another house a case of Diphtheria was notified and removed to hospital, but before its return a case of Scarlet Fever was notified. From another house a case of Diphtheria was removed to hospital and 7 months afterwards a case of Scarlet Fever occurred. There are certain known facts in regard to the behaviour of Scarlatina which merit attention, and on these I propose to dwell. While in many instances Scarlatina is quite obvious to the medical practitioner, in others it is impossible for him to pronounce a positive opinion owing to the absence of the characteristic appearances of the complaint. It happens sometimes in relation to the outbreak of Scarlet Fever in the house that illness arises among its inmates both before and after that event. But the illness is wanting in the usual symptoms which, when pieced together, are recognised as Scarlatina. Thus slight sore throat, trifling fever, headache, sickness and lassitude, in themselves of no special import, may occur and be followed by speedy recovery. Sometimes desquamation follows these indefinite illnesses. But some of these attacks are undoubtedly Scarlatina—abortive 29 cases of Scarlatina—and for this reason that the sufferers convey typical Scarlatina to others. In the absence of this close association with an obvious. Scarlatina, abortive cases are sure to pass unrecognised, on recovery mix with the public, and failing the onset of desquamation and its discovery, they escape detection. A diagnosis of a typical case of the disease is not easy even for the expert. Thus one child I have in mind, a convalescent in the Whooping Cough Ward of the Evelina Hospital for Children, had a Scarlatina-like eruption localised to the chest and a temperature of 99° F. It was seen by various members of the Medical Staff there, and the concensus, of opinion was that it was not Scarlatina. But is was Scarlatina for a child in the next cot contracted the disease from it. This is not an isolated experience, and it is obvious that cases where the signs are not distinctive are extremely likely to pass unrecognized. Therefore when dealing with a case of obvious Scarlet Fever at an infected house, it is advisable that medical enquiry should be made in relation to these matters to which I have just called attention, and that the medical practitioners of Beckenham should be invited to make observations in relation thereto, and report their results to the Sanitary Authority on the usual terms. That abortive cases should be isolated is an obvious deduction. To mention other phases of the behaviour of the disease: —Contact with Scarlet Fever patients by unprotected individuals may be of the freest possible kind, extend over a long period of time, and yet the contacts escape the disease. But should their general health suffer in any way, even though a considerable time, perhaps months, have elapsed since the last exposure to infection, they arc likely to develop Scarlet Fever. Thus a child may have been freely exposed to infection in a Scarlatina Ward and escape the disease, but under the home regime and lowered vitality in sequence to poor food and unhygenic environment, the child succumbs and the complaint runs a typical course. Or quite 30 nected with any traceable source of infection, a healthy person in sequence to a shock, or an injury without cutaneous involvement, or to a burn, or to some surgical procedure, in the throat and nose perhaps, or some plastic or other operation, develops Scarlet Fever. The onset follows the injury or operation after the usual incubation period, and the disease runs a typical course. It is thought that these cases carry the infecting material of Scarlatina in or on their bodies, that they are Scarlet Fever carriers, and that they are illustrations of Self Infection. Under some at present unknown conditions the specific particles of the disease lie dormant in certain constitutions, and are innocuous both to their host and to others for periods of time, but given circumstances favourable to their development they generate virulent qualities. Thus take return cases of Scarlet Fever from a Fever Hospital or private sources, these patients are discharged from hospital apparently free from infection. Perhaps they have developed rhinorrhoea or otorrhoea, or some other complication during their stay in hospital, or other pathological manifestation, but from which they are quite free on their discharge from that Institution. Perhaps they have escaped all complications during their treatment and isolation. Recent experiences at Beckenham, where medical inspection of cases returning to their homes from the hospital is now the custom, indicate that the patients leave there for the most part without discoverable lesions. But although patients are released from hospital free from nasal, ear or other discharges, in certain cases the discharges recommence or perhaps develop, and then the return case which was previously harmless, acquires harmful propensities and Scarlet Fever breaks out once more. The capacity for infecting others may arise in sequence to an ordinary cold in the head and have nothing whatever to do with the recurrence of a specific running from the nose. But in other instances, perhaps half the number, without signs of desquamation, eruptions, swelling of the glands, or inflammation of 31 the kidneys or any demonstrable disease, these discharged Scarlet Fever patients become temporarily actively infective to others. Thus certain individuals, some with and some without antecedent Scarlatina appear to be Scarlet Fever Carriers and to be subject to waves of infectivity associated with dormant periods of harmlessness. Sometimes operation for mastoid abscess in sequence to disease of the middle ear disturbs the concealed poison and infects with Scarlatina the nurses and attendants. That, at least, has been our recent experience at the Queen's Hospital for Children, and it is a method of infection that merits close attention. There is no doubt that the crypts of the tonsils, the nasal passages and sinuses, the eustachian tubes, the middle ear and the accessory cavities, and the mucuous, lymphatic and other glands in relation to these anatomical areas are apt to harbour the materies morbi. Exactly where these disease particles hide it is impossible to say, for as yet the germ of Scarlet Fever has defied detection. But the dissemination of the disease in sequence to inflammatory disturbances in these areas, e.g.: sore throat, colds in the head, discharges from the nose and ear and from the back of the nose, make it highly probable that these regions are its common habitation. Of all these situations the back of the nose, the nasopharyngeal cavity of young and other children theoretically affords the most favourable site. To find a really healthy mucous membrane in that situation is quite uncommon. In this region there is, together with a rudimentary third tonsil (Lushka's tonsil) a plentiful formation of separate lymph follicles. On inspection of these parts more or less hypertrophy of the contained glands (Adenoids), and a catarrhal and swollen condition of the mucous membrane there, accompanied by muco-purulent discharge which constantly trickles down the back of the throat is quite a common feature. These children are liable to colds in the head, they frequently present enlarged glands in the neck, and often in addition have diseased tonsils. It is possible, and indeed not unlikely, that some of these children act as Scarlatina Carriers, in any case 32 their unhealthy mucous membranes are ideal germ nurseries and render their hosts vulnerable not only to Scarlet Fever, but to other serious complaints such as Rheumatic Fever, Tuberculosis, and so on. In regard to this question of Scarlet Fever Carriers, I would suggest that an additional medical inspection of the cases returned from hospital be made at some future date, when the patients have settled down in their homes under the altered conditions of life. Certainly I think this medical inspection should be made in those cases where the disease has reappeared in the house, after the convalescent Fever patient's return from hospital regardless of the lapse of time in sequence thereto, even if many months have elapsed. But there are other puzzling features of the complaint. Thus it is not always infectious. A child was found to be desquamating and he was sent into the Scarlet Fever Ward from which he returned in due course. On enquiry it would appear that he attended School with the disease upon him, he associated with the unprotected, and no case followed. Another child was notified to be peeling and it was removed to hospital. There were six other unprotected children in the house, for only one of them had had Scarlct Fever, but no other case was reported from these premises. In another instance five children were found to be freely peeling. These children had attended school where there were many unprotected children, but no person apparently contracted the disease from them. A baby of twelve months; old who had not had the complaint also escaped. I do not wish to multiply instances of the above peculiarities of the disorder, those I have related will suffice. On the other hand it is recognized that cases similar to those I have drawn attention, will subsequently sometimes develop infective qualities. And this brings me to another feature, that of Desquamation. There is a strong feeling among the Medical Profession that the disease is not contracted by contact with the particles; 33 of dead skin thrown off from the body of the Scarlet Fever case. The cases which I have just related well illustrate the at least frequent innocuousness of these epetheliel scales, and my own experiences coincide with the observations of many others throughout the country. Not only is desquamation dethroned from the high estate into which it once entered but the infectivity of fomites—of infected articles—is regarded by many as an exploded notion. That for instance the doll of the deceased Scarlatina child which has been retreived from its seclusion, perhaps for years after the bereavement, to be placed in the hands of another child is not the cause of the Scarlet Fever to which that child quickly succumbs, but can be explained more rationally by human agency. In the present state of knowledge, however, it is not wise to ruthlessly abandon the notions which have prevailed in the past in regard to fomites. On the other hand to take a less stale infection the fact cannot be ignored that in certain cases where the contact with fomites has been free and continuous and harmless, the individuals have promptly succumbed to the malady on contact with infected persons. Scarlatina is a disease that is full of surprises. At one time it is very mild, at another very virulent; at another it is very contagious, and then again it is but very slightly or not at all so. Sometimes the power to infect is quickly dissipated, at others it clings to the person of the protected and unprotected (healthy) for months, perhaps years. Then again it is not constantly infectious but only intermittently so. Its occasional association with diphtheria has already been dwelt upon. It is always in our midst, and more or less prevalent everywhere throughout the Kingdom. The possibility therefore, of surrounding and throttling so fickle and so elusive an adversary does not seem hopeful in the present state of knowledge. When the virus is discovered, the study of its habits and the detection of its habitat will perhaps not only afford a satisfactory explanation for the capricousness of the disease, but will also give, it is to be hoped, increased control over its powers of infection. 34 As far as modern methods of disinfection are concerned, I am perfectly satisfied that all has been done and all continues to be done in that direction to prevent the spread of the disease by fomites. The only weak points in the Municipal Public Health armour that I can detect I have called attention to. But whether the suggestions made will be productive of commensurate beneficial results, time and experience will decide. In the meanwhile Scarlet Fever still remains a study for the experts, and the failure to completely subjugate it must not be ascribed to either lack of enthusiasm or want of efficiency on the part of the officials of the Public Health Department. Diphtheria. Ninety-three cases were notified under this head :— 59 were between 5 and 15 years. 18 „ „ 1 and 5 „ 8 „ „ 15 and 25 „ 7 „ „ 25 and 05 „ 1 under 1 year. There were in all 5 deaths arising therefrom :— 2 in Langley Park Ward. 1 in Manor House Ward. 2 in Kent House Ward. Of the 93 cases of Diphtheria I received 64 positive reports from the Clinical Research Association, the remaining 29 cases were doubtless so obvious clinically that bacteriological examination was not thought to be necessary. Eightytwo of the cases were removed to the Infectious Hospital, the remaining 11 cases being treated at home. Five deaths occurred; 4 of these were at the Hospital, and were 9 months, 4½ years, 5 years, and 5½years old respectively, the other case being that of a child of 12 years of age who was treated at home. Under the heading of Scarlet Fever I have already called attention to Return cases of this complaint and the association of Scarlet Fever with Diphtheria. 35 Enteric Fever. 1 regret to have to record that of 7 cases of Enteric Fever three died. One case came into the District with the disease upon her. She was removed to hospital. A probationer nurse contracted the disease from her patient at the Cottage Hospital. Another patient apparently was infected by eating oysters taken from a polluted oyster bed at Sheerness This patient was presumed to have acquired the disease at Beckenham at a banquet, but on making careful enquiries it was found that the complaint was evidently not contracted there. The purveyor of polluted oysters was prosecuted by the Fishmongers' Company, and was fined 15 guineas and 10 guineas costs. Another case dwelling at Sydenham was also supposed to have been attacked by the disease from oysters which were consumed in different parts of the country, his occupation being that of a traveller. The source of infection in the other cases could not be traced. I take this opportunity of drawing the attention of the medical profession of the District to Enteric Fever as met with in infants. During the many years that J have been Medical Officer of Health not a single case has been notified to me, and I cannot think it is because such have not occurred but rather from the fact that it has been overlooked. Enteric Fever in infants though uncommon even in my clinical experience with children, nevertheless has been occasionally encountered by me in them in hospital and private practice from time to time. It has been looked upon as a curiosity of medicine, but perhaps it would be nearer the truth to state that the disease is but rarely recognised in infants. Gastro-intestinal disturbance, an enlarged abdomen, with or without slight fever are so frequent in infants from simple causes that the possibility of the symptoms being due to Enteric Fever is overlooked. When it does arise in them it is apt to be wanting in essential symptoms and on that account it may be difficult to detect. The fever may be quite inconspicuous or the complaint may be a-pyrexial. The fever may 36 occur without rose spots, diarrhoea, without abdominal distension tenderness, and without enlargement of the spleen. Pyrexia and agglutinin in the blood may be the only signs. In one infant of 13 months under my care with rose spots and an enlarged spleen the highest temperature recorded whilst under observation was only 100.6° F. The examples of Enteric Fever in infants that have been brought to my notice arose where that disease was present in the house and they were obviously infected. In young children the disease suggests rather some cerebral affection than an abdominal complaint, for constipation, a retracted abdomen and brain symptoms are not uncommon in them. The disease is apt to be mild and shortened and a sudden onset is not uncommon with sickness, fever and prostration. The agglutination test cannot be relied upon always to assist the diagnosis. Therefore in the presence of Enteric Fever in the house, if any of the infants or young children are attacked by an ill-defined complaint, Enteric Fever should be suspected. In all doubtful or suspicious cases the same precautions must be adopted as in the declared disease, and they should be reported to me. Measles. The Bromley Road Schools, Infants' Department, was closed for Measles for two weeks during the month of May. There were 5 deaths notified. Whooping Cough. Two deaths were notified during the year from Whooping Cough between the age of 1 and 5 years. The previous year there were 4 deaths from this disease. 37 COMMON CHARACTERISTICS OF AND INSTRUCTIONS REGARDING THE MANAGEMENT OF THE PRINCIPAL NOTIFIABLE DISEASES. To better safeguard the Public Health I have drawn up the following memoranda in regard to these diseases together with instructions to householders and others as to the measures which must be adopted in regard to their management. It would be advantageous to the Public Health if copies of the Annual Report were sent to all medical practitioners residing or practising in the District. Scarlet Fever. The onset is very sudden. Vomiting, fever, a burning skin, sore throat, and a red rash within 24 hours which first appears on the body and quickly extends to the limbs. The mouth is pale, the cheeks are red and swollen. Take the following steps : — Place the sick person in a room alone, and no one must come in contact except the attendant until the Doctor has seen the patient. If there are children in the house. (1) Keep them from school and Sunday school and from contact with their school fellows and playmates. (2) If they remain healthy for a period of 7 clear days dating from the last contact with the sick person they may return to school. (3) If, however, in the meantime a child displays any of the above symptoms, put it to bed and send for the doctor. (4) Should any member of the affected premises have recently suffered from, or subsequent to the removal of the patient suffer from either sore-throat, sickness, headache, lassitude, and fever, the doctor should be sent for. Children so indisposed must on no account be sent to school. 38 (5) If the child's removal to hospital be directed the mother and relatives must abstain from kissing the patient. (6) Notice of removal must be delivered to the person in charge at the Public Health Office and not be deposited in the letter box, as it is only by this means that prompt removal can be assured. The office is open from g a.m. to 5 p.m. weekdays, except on Saturday, when it is open from g a.m. to 1 p.m. After the above hours and on Sundays communications must be made to the officer in charge at the Fire Station. (7) Should the patient on recovery and when medical attendance has ceased develop discharges from the nose and cars, the doctor should be sent for—this is important. PATIENTS NURSED AT HOME. The patient should go to hospital, but where home treatment is admissible, and that is at the discretion of the Medical Officer of Health and only in cases where (1) the Public Health will not suffer, (2) when the patient will run no risk to life or health by reason of the unsuitability of the premises for treating infectious or contagious diseases, the following precautions must be taken: — (a) All non-washable articles of clothing, books, etc., all soft materials, i.e., rugs, carpets, curtains, etc., must be gathered together and made ready for removal from the sick room. These infected articles will be collected by the Sanitary Officials, disinfected and returned to the house. The sick room should be on the top floor, where it can be readily quarantined. Avoid all unnecessary articles of furniture—they waste too much air space. (b) Place a sheet over the door outside and keep it constantly wet with an efficient disinfectant fluid such as Carbolic Acid 1 in 40, or 2 per cent. Solution of Formalin, or other chemicals authorised by the Medical Officer of Health, which can be obtained at the Public Health Office. During the summer months be most particular about flies and rigidly exclude them from the sick room, and take measures to destroy them if necessary. 39 (V) Provide a long white linen gown (overall) for the doctor to cover his out-door clothes when he visits his patient, and facilities for washing his hands before leaving the sick room. The overall should be hung outside the sheet-covered door. A bowl of disinfectant containing a 5 per cent Solution of Lysoform with a nail brush therein, should be supplied for the doctor to disinfect his hands and nails and stethoscope after use. (d) Fresh air is most important and the window sashes should be regulated in accordance with that view. A small fire in the grate at all seasons is an aid to ventilation and infected articles of no value should be at once burned there. {e) Nurses must avoid as far as possible contact with other members of the house. (/) Nurses must wear a washable dress and cover their hair with a washable cap of ample dimensions, great cleanliness and frequent ablutions are most necessary in the interests of the nurse, and disinfectants should be used by her as a matter of routine when she has attended to her patient. The use of an anti-septic gargle several times daily and a nose douche twice daily are recommended. (g) Nurses must have their meals apart from the family, All unused food coming from the sick room and from the nurses must be disinfected and passed down the closet or be destroyed by fire according to its liquid or solid nature. Spoons, cups and dishes which have been used by the patient should be boiled before being returned to the kitchen. The room should be dusted with damp cloths moistened with perchloride of mercury I in 2000. The floor should be washed with a similar solution. (h) Excreta from the patient must be voided into vessels containing suitable disinfectants, i.e., completely covered by carbolic acid 1 in 20, or other chemicals authorised by the Medical Officer of Health, and when not required for medical inspection should be discharged into the W.C., in which liquid disinfectants, which can be obtained at the Public Health Office, are to be freely poured, and the pan well flushed with water. 40 (i) All swabs or rags, pieces of gauze or dressings, or any things which contain discharges from the mouth, the teeth, the ears, the nose, the throat, the lungs, glandular, mastoid or other abscesses, peelings from the skin, etc., are best dealt with by being thrown into the fire. The water in which the patient has been washed should be disinfected and at once discharged into the W.C. (i) After use and cleansing place the tongue depressor and the thermometer in a solution of carbolic acid I in 20 and keep them there until required. (k) No one except the doctor or nurses can see the patient unless authorized by the doctor, who will ensure that proper precautions be taken, and will on no account give such permission unless the patient's state be so grave as to warrant it. (/) All washable clothes which have been in contact with the patient must be steeped for 6 hours in a suitable disinfectant (i.e., carbolic acid 1 in 20, or other chemical authorised by the Medical Officer of Health) before being washed. (m) While cases are being nursed at home the washing must not be sent to a Public laundry. (n) Those dwelling in the infected house whose business brings them in contact with articles of food, or articles of wearing apparel for the public use, or those who teach children, must discontinue their callings while occupying the infected premises. If at the expiration of one week dating from the last contact they be certified as free from all trace of illness, they can resume their occupations as public providers on taking up residence in uninfected premises. (o) At the removal of the sick person to hospital or at the termination of the illness, the sick room must be stripped of wall paper and the Public Health Department will fumigate the infected premises and disinfect the bedding. The playthings or books used during the illness must be destroyed. All books of trifling value and papers and periodicals will be destroyed. At the termination of the illness the sick persons and the attendants should take a hot bath and thoroughly cleanse the 41 body and the hair and scalp with soap and water. At the completion of the ablutions they should be clothed in uninfected garments from head to foot. Their infected clothing must be placed in suitable bundles in the sick room for disinfection. (p) The furniture and floors must be washed after fumigating, with perchloride of mercury (1 in 1000), or 5 per cent. carbolic acid, or other chemical authorised by the Medical Officer of Health, and the whole exposed to plenty of fresh air and sunlight. When that has been done to the satisfaction of the Medical Officer of Health, the sick room is ready for redecoration. Typhoid Fever. Enteric Fever comes on gradually as a rule, but the onset may be sudden, with sickness, fever and prostration. A feeling of being out of sorts, lack of interest in affairs, indisposition to work or play, loss of appetite, feverishness, headache, which increases day by day, perhaps nose bleeding, possibly a look of heaviness about the face; these are the symptoms during the first week of the illness. INSTRUCTIONS. (1) Put or keep the patient in bed and send for the doctor. If, when the doctor sees the patient, there be any suspicion that the illness be Enteric, the case must be treated as Enteric until the illness has been declared to be otherwise. If it be intended to remove the patient to hospital, notice must be delivered to the person in charge at the Public Health Office and not be deposited in the letter box, as it is only by this means that prompt removal can be assured. The office is open from 9 a.m. to 5 p.m. week days, except on Saturday, when it is open from Q a.m. to 1 p.m. After the above hours and on Sundays communications must be made to the officer in charge at the Fire Station. PATIENTS NURSED AT HOME. (2) The patient should go to hospital, but where home treatment is admissable, and that is at the discretion of the 42 Medical Officer of Health and only permitted where (a) the Public Health will not suffer, (b) when the patient will run no risk to life or health by reason of the unsuitability of the premises for treating infectious and contagious diseases, the following precautions must be taken:—The sick room should be on the top floor where it can be readily quarantined. Avoid all unnecessary articles of furniture—they waste too much air space. Suitable W.C. accommodation is essential, and should be within easy reach of the sick room. (3) Plenty of space, plenty of fresh air, a single high bedstead with a wire-wove and a hair mattress are necessaries. There should be a small fire in the grate for ventilation and for the destruction of infected articles. (4) Supply a large glass bowl containing 5 per cent. Lysol in it and a nail brush. After every service to the patient these articles should be used. (5) Be most careful to keep the patient's buttocks clean after every evacuation of the bowels. Wash the parts with soap and water, use a suitable disinfectant, e.g., 2 per cent. Lysol, and well dry with a piece of gauze. Burn the gauze, disinfect the water and place in the W.C., use plenty of disinfectant, which can be obtained at the Public Health Office, and well flush the pan. (6) The sheets must be kept spotless; if they become stained with the evacuations they must be changed at once. Discarded bed linen must be placed in 1 in 20 carbolic acid or other authorised disinfectant, and left to soak for 6 hours. It napkins or diapers are used they must be treated in the same way. The nurse must wear white washable oversleeves to protect the sleeves of her dress which must be removed before her meals. (7) All excreta must be passed into disinfectants, i.e., carbolic acid 1 in 20, or other chemicals authorised by the Medical Officer of Health. The motion must be completely covered by and incorporated with the disinfectant, and there should be 2 parts disinfectant and 1 part liquid motion. They must stand for 6 hours before being passed down the W.C, 43 The W.C. is then to be freely treated with disinfectant and well flushed. The sides of the pan must not become soiled. (8) The bed pan must be thoroughly washed inside and subsequently disinfected with carbolic acid I in 20, or other authorised chemicals, after use, and the washings discharged down the W.C. followed by the free use of liquid disinfectants. (9) The thermometer must be washed after use and transferred to carbolic acid 1 in 20, where it is to be kept. The tongue depressor, if required, must be treated in exactly the same manner. (10) Don't employ handkerchiefs, use gauze or rags instead. Any material that is used for cleansing the mouth and teeth, and discharges that come from the throat or nose, are to be received into some material which will admit of immediate destruction. Any discarded surgical dressings are to be at once burned. (11) For washing the patient use soap and water and gauze. Destroy the gauze and disinfect the water before passing down the W.C. (12) Be careful that flies do not gain admittance into the sick room or the W.C. Destroy those that do so. (13) Milk and beef tea and so on, and such solid food stuffs that have been in the sick room and that have not been used must be mixed with liquid disinfectant and passed down the W.C. Later on during convalescence unused solid foods must be destroyed by burning. (14) The spoons, forks and plates, etc., must be boiled before being returned to the kitchen. (15) Those in attendance must on no account take any food in the sick room or that has been in the sick room, and must never omit to thoroughly wash and disinfect the hands before eating. (16) Sheets, napkins, night garments, etc., when removed trom the disinfectant must be boiled for two hours apart from the family washing. All soiled clothes from the patient or the nurse must not go to the Public laundry. 44 (17) When the quarantine has been raised the patient should have a warm bath, get into fresh clothes, and be transferred to another room or elsewhere, and the Public Health Department notified. (18) At the removal of the sick person to hospital or at the termination of the illness, the Public Health Department will fumigate the infected premises and disinfect the bedding. The playthings or books used during the illness must be destroyed. All books of trifling value and papers and periodicals will be destroyed. (19) The furniture and floors must be washed after fumigating with perchloride of mercury (1 in 1000) or 5 Per cent. carbolic acid, or other chemicals authorised by the Medical Officer of Health, and the whole exposed to plenty of fresh air and sunlight. When that has been done to the satisfaction of the Medical Officer of Health, the sick room is ready for reoccupation. Diphtheria. (1) Diphtheria may attack the throat, the organ of voice, the nose, the eyes, or other parts. The usual situation is the throat. ONSET. (2) The onset of Diphtheria is gradual as a rule, and the child, for it more often occurs in children than adults, looks pale and is tired and sleepy, does not wish to play or want its food, and has probably hard swollen glands in the neck, and fever. (3) The throat is a little sore and there may also be noticed an unpleasant odour of the breath; or— (4) If the organ of voice be involved the voice will be altered, there will be huskiness, a hollow or barking cough, and later, difficulty of breathing; or— (5) If it attacks the nose it is like a bad cold in the head, the discharge is watery, abundant, often down one nostril only and often bloody; or— 45 (6) If the eyes be attacked the secretion from them is either profuse in matter or the lids are very red and swollen and stiffened or tightly closed. INSTRUCTIONS. (a) The doctor will determine the nature of the illness, and he must be sent for at once, because if the disease be Diphtheria the sooner the remedy is applied the greater are the chances of recovery. But in the meantime— (b) When in doubt isolate the sick person at once and keep the other children, if any, from school until the complaint is known. (c) When the illness is detected the following health precautions must be adopted :— (d) If the child's removal to hospital be directed the mother and relatives must abstain from kissing the patient. No time should be lost in leaving the doctor's notification at the Public Health Office. In regard to such notices they must be delivered to the person in charge at the Office and not be deposited in the letter box, as it is only by this means that prompt removal can be assured. The office is open from 9 a.m. to 5 p.m. week days, except on Saturday, when it is open from 9 a.m. to 1 p.m. After the above hours and on Sundays communications must be made to the officer in charge at the Fire Station. (e) Contacts will be allowed to go to school or adults return to their work, e.g., teachers, salespeople and food distributors, provided that they (a); obtain a medical certificate to the effect that they show no signs of Diphtheria, (b) that they were promptly isolated from the sick, and (c) that they have received a protecting injection of the Diphtheria antidote. PATIENTS NURSED AT HOME. The patient should go to hospital, but where home treatment is admissible, and that is at the discretion of the Medical Officer of Health and only permitted in cases where (1) the Public Health will not suffer, (2) when the patient will 46 run no risk to life or health by reason of the unsuitability of the premises for treating infectious and contagious diseases, the following precautions must be taken : — (a) All non-washable articles of clothing, books, etc., all soft articles, e.g., rugs, carpets, curtains, etc., must be gathered together and made ready for removal from the sick room. These infected articles will be collected by the Sanitary Officials, disinfected and returned to the house. The sick room should be on the top floor, where it can be readily quarantined. Avoid all unnecessary articles of furniture—they waste too much air space. (b) Place a sheet over the door outside and keep it constantly wet with an efficient disinfectant fluid such as carbolic acid I in 40, or 2 per cent. solution of Formalin, or other chemicals authorised by the Medical Officer of Health. During the summer months be most particular about flies and rigidly exclude them from the sick room, and take measures to destroy them if necessary. (c) Provide a long white linen gown (overall) which should be hung outside the sheet-covered door, for the doctor to cover his outdoor clothes when he visits his patient, and facilities for washing his hands before leaving the sick room. A bowl of disinfectant containing a 5 per cent. solution of Lysoform with a nail brush therein should be supplied for the doctor to disinfect his hands and nails and stethoscope after use. (d) Fresh air is most important and the window sashes should be regulated in accordance with that view. A small fire in the grate at all seasons is an aid to ventilation and infected articles of no value should be at once burned there. (e) Nurses must wear a washable dress and cover their hair with a washable cap of ample dimensions. Great cleanliness and frequent ablutions are most necessary in the interests of the nurse, and disinfectants should be used by her as a matter of routine when she has attended to her patient. Nurses must take their meals apart from the family and come in contact with them as little as possible. The use of an anti-septic 47 gargle several times daily and a nose douche twice daily are recommended. (/) Don't employ handkerchiefs. All swabs or rags, pieces of gauze or dressings, or any things which contain discharges from the mouth, the teeth, the ears, the nose, the throat, or lungs, or elsewhere, are best dealt with by being thrown into the fire. The water in which the patient has been washed should be disinfected and at once discharged into the W.C. (g) The throat can be inspected with less danger to the examiner by taking up a position at the side of and overlooking the patient. Inspection from the front should be conducted by viewing the throat through a pane. After use and cleansing place the tongue depressor and the thermometer in a solution of carbolic acid I in 20, and keep them there until required. (h) All unused food coming from the sick room must be disinfected and passed down the closet or be destroyed by fire according to its liquid or solid nature. Spoons, cups and dishes which have been used by the patient should be boiled before being returned to the kitchen. The room should be dusted with damp cloths moistened with perchloride of mercury 1 in 2,000. The floors should be washed with a similar solution. (i) No one except the doctor or nurses can see the patient unless authorized by the doctor, who will ensure that proper precautions be taken, and will on no account give such permission unless the patient s state be so grave as to warrant it. (j) All washable clothes which have been in contact with the patient must be steeped for 6 hours in a suitable disinfectant (i.e., carbolic acid 1 in 20, or other chemicals authorised by the Medical Officer of Health) before being washed. (k) At the removal of the sick person to hospital or at the termination of the illness, the Public Health Department will fumigate the infected premises and disinfect the bedding. Infected clothing must be placed in suitable bundles in the sick room for removal and disinfection. At the termination of the illness the patient and nurse should have a bath, well cleanse the whole of the body with soap, and be clothed in 48 uninfected clothing. The playthings or books used during the illness must be destroyed. All books of trifling value and papers and periodicals will be destroyed. (l) The furniture and floors must be washed after fumigating with perchloride of mercury (1 in 1,000) or 5 per cent. carbolic acid or other authorised chemicals, and the whole exposed to plenty of fresh air and sunlight. When that has been done to the satisfaction of the Medical Officer of Health, the sick room is ready for reoccupation. (l) Diphtheria germs have been found after months in books, toys, furniture, floors, walls, dishes, and so on in previously infected premises, therefore thorough disinfection is most necessary. Plenty of fresh air and sunlight kill these germs, while damp, dark places are favourable to their growth. I have the honour to be, Gentlemen, Your obedient servant, GEORGE CARPENTER. T. W. Thornton, Printer, Beckenham. TABLE I. DISTRICT OF BECKENHAM. Vital Statistics for whole District during 1908 and previous years. Year. Population estimated to middle of each year Births Total Deaths Registered in the District. Deaths in Public Institutions. Deaths of NonResidents registered in District Deaths of Residents registered beyond District. Deaths at all Ages. Nett. Deaths under One Year of Age. Deaths at all Ages. Total. Number. Rate. Number. Rates per 1,000 Births registered Number Rate.* Number. Rate. 1 2 3 4. 5 6. 7 8 9 10 11 12 13 1898 24,730 571 23.08 78 136.6 252 10.1 … 7 7 252 10.1 1899 26,075 554 21.25 80 144.4 271 10.4 … 4 17 284 10.8 1900 26,556 569 21.4 50 87.8 258 9.7 … 8 19 269 10.1 1901 26,600 625 23.6 81 129.6 249 9.3 12 3 22 265 9.9 1902 28,249 596 21.1 55 92.2 218 7.7 14 6 21 240 8.4 1903 29,672 629 21.19 61 96.9 230 7.7 9 5 17 234 7.8 1904 30,701 662 21.2 84 126.8 286 9.3 20 5 13 294 9.5 1905 32,149 660 20.5 64 96.9 281 8.7 4 3 18 296 9.2 1906 32,215 670 20.8 63 94.0 245 7.5 8 2 16 259 8.0 1907 32,809 664 20.2 50 75.3 240 7.3 9 2 25 263 8.0 Averages for years. 1898-1907) 28,975 620 21.4 66 108.0 253 8.7 8 4 17 265 9.1 1908 33,061 688 20.8 49 71.2 266 8.o 23 7 21 280 84 * Rates in Columns 4, 8, and 13 calculated per 1.000 of estimated population. Note.—The deaths to be included in Column 7 of this Table are the whole of those registered during the year as having actually occurred within the district or division. The deaths to be included in Column 12 are the number in Column 7, corrected by the subtraction of the number in Column 10 and the addition of the number in Column 11. By the term " Non-residents " is meant persons brought into the district on account of sickness or infirmity, and dying in public institutions there; and by the term " Residents" is meant persons who have been taken out of the district on account of sickness or infirmity, and have died in public institutions elsewhere. The " Public Institutions " to be taken into account for the purposes of these Tables are those into which persons are habitually received on account of sickness or infirmity, such as hospitals, workhouses and lunatic asylums. Area of District in acres (exclusive of area covered by water). 3,881 Total Population at all ages 26,331 Number of inhabited houses4,704 Average number of persons per house .5 74- At Census of 1901 TABLE 11. DISTRICT OF BECKENHAM. Vital Statistics of separate Localities in 1908 and previous years. Names of Localities Copers Cope Ward. Eden Park Ward Langley Park Ward. Shortlands Ward. Manor House Ward. Kent House Ward. Laurie Park Ward. Yeak. Population estimated to middle of each year. Births registered Deaths at all ages Deaths under 1 year. Population estimated to middle of each year. Bilths registered. Deaths at all ages. Deaths under 1 year. Population estimated to middle of each year. Births registered. Deaths at all ages. Deaths under 1 year. 1 opulation estimated to middle of each year. Births registered. Deaths at all ages Deaths under 1 year. Population estimated to middle of each year. Births registered. Deaths at all rgcs. Deaths under 1 year. Population estimated to middle of each year. Bii ths registered. Deaths at all ages. Deal lis under 1 year. vopulation estimated to-middle of each year. Births registered. Deaths at all ages. Deaths under 1 year. a. b. c. d. a. b. C. d. a. b. c. d. a. b. c. d. a. b. C. d. a. b. c. d. a. b. c. d. Records for Wards not kept previous to 1900. 1900 3118 ... 16 3 3776 ... 38 6 1743 ... 12 0 1696 ... 7 0 4717 ... 44 3 5016 ... 48 12 6490 ... 85 20 1901 2815 ... 18 4 3432 ... 26 8 1773 ... '3 3 1785 ... 14 1 5021 ... 48 26 5027 ... 46 15 6747 ... 78 24 1902 2836 ... 19 4 3532 ... 27 4 1842 ... 11 3 1775 ... 7 0 5902 ... 42 12 5475 ... 47 11 6887 ... 65 19 1903 2875 ... 16 2 3555 ... 26 4 1801 ... 10 3 cc ... 10 0 6872 ... 51 20 5967 ... 52 16 6821 ... 52 15 1904 2906 ... 21 4 3632 ... 29 3 1848 ... 14 3 1S18 ... 16 2 7654 ... 76 28 6231 ... 63 23 6612 ... 75 21 1905 2919 ... l5 0 3610 ... 36 6 1927 ... 15 1 1769 ... 10 I 8448 ... 70 22 6550 ... 72 18 6926 ... 78 16 1906 3000 31 20 2 3808 48 35 5 1927 23 18 3 1873 20 6 I 8426 220 71 27 6530 161 61 14 6651 157 48 11 1907 3025 32 l6 2 3821 63 32 3 1994 33 18 3 1915 24 12 3 8840 218 72 17 6616 !52 55 5 6997 142 57 17 Averages of Years 1900 to 1907. 2936 ... 17 2 3645 ... 31 4 1856 ... '3 2 1801 ... 10 1 6985 ... 59 19 5926 ... 55 14 6766 ... 67 17 1908 3025 31 25 3 3737 60 36 2 2012 35 15 2 2019 23 7 1 9117 222 79 23 6429 147 52 9 6722 170 66 9 Notes.—Deaths of residents occurring beyond the district are included in sub-columns c of this table, and those of non-residents registered in the district excluded. Deaths of residents occurring in public institutions are allotted to the respective localities according to addresses of deceased. table iii. DISTRICT OF BECKENHAM. Cases of Infectious Disease Notified during the Year 1908. Notifiable Disease. \ At all ages. Cases notified in Whole District. Total Cases notified in each Locality. No. of Cases removed to Hospital from each Locality. Total from Whole District. At Ages—Years Copers Cope Ward. Eden Park Ward. Langley Park Ward. Shortlands Ward Manor House Ward. Kent House Ward Laurie Park Ward. Copers Cope Ward. Eden Park Ward. Langley Park Ward. Shortlands Ward. Manor House Ward. Kent House Ward. Laurie Park Ward. Under 1. 1 to 5. 5 to 15. 15 to 25- 25 to 65. 65 and upwards. Small-pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cholera ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .. ... Diphtheria (including Membranous Croup) 93 1 18 59 8 7 ... 4 14 5 ... 45 8 17 2 12 2 ... 41 8 17 82 Erysipelas i 2 ... 1 ... ... 7 4 1 2 ... i 3 1 4 ... ... ... ••• ... ... ... ... Scarlet Fever 132 ... 35 78 7 12 ... 10 21 6 5 49 18 23 7 15 5 2 39 16 23 107 Typhus Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Enteric Fever 7 ... ... 1 2 4 ... ... 3 ... ... 2 ... 2 ... 2 ... ... 1 ... 1 4 Relapsing Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Continued Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Puerperal Fever 1 ... ... ... 1 ... ... ... ... ... ... ... ... I ... ... ... ... ... ... ... ... Plague ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Totals 245 1 5 4 i3« 18 30 4 15 40 11 6 99 27 47 9 29 7 2 81 24 41 193 Note.—The Isolation Hospital used by the Sick of this District is the Infectious Diseases (Joint) Hospital, Skym Corner, Bromley Common, in the Bromley Rural District. TABLE IV. DISTRICT OF BECKENHAM. 1 Causes of, and Ages at, Death during 1908. ses of Death. Deaths in or Belonging to Whole District at Subjoined Ages. Deaths in or belonging to Localities (at all Ages). Total Deaths in Public Institutions in the District All Ages. Under 1. 1 and under 5 5 and under 15 15 and under 25 25 and under 65 65 and upwards. Copers Cope Ward. Eden Park Ward. Langley Park Ward. Shortlands W7ard. Manor Hons Ward Kent HouseWard Laurie Park W ard. fell-pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... fesles 5 2 3 ... ... ... ... ... ... ... ... 4 1 ... 1 Brlet Fever 1 ... 1 ... ... ... ... 1 ... ... ... ... ... ... ... Hooping-Cough 2 ... 2 ... ... ... ... ... ... ... ... ... 1 ... ... Bhtheria (including Mem 5 1 1 3 ... ... ... ... ... 2 ... 1 2 ... ... B branous Croup up 1 ... 1 ... ... ... ... ... ... ... ... 1 ... ... ... l/er ( Typhus ... ... ... ... ... ... ... ... ... ... ... ... ... ... Enteric 3 ... ... ... ... 2 ... ... ... ... ... 1 ... 2 ... ( Other continued ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... lidemic Influenza r3 5 ... 1 ... 5 2 2 3 2 ... 2 3 1 ... lolera ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ague ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... iarrhue 3 2 ... ... ... ... 1 ... ... ... ... 2 ... 1 ... pteritis 9 6 ... ... ... ... 2 ... ... ... ... 6 3 ... ... lerperal Fever 1 ... ... ... 1 ... ... ... ... ... ... ... ... 1 ... iysipelas ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ???hisis (Pulmonary Tuber- 1 culosis) 10 ... ... ... ... 10 ... 1 ... 1 ... ... 5 3 ... Her tuberculous diseases 18 2 2 3 ... 10 ... 2 3 ... ... 5 3 5 1 Hcer, malignant disease 31 ... ... ... ... 25 6 1 8 1 1 8 4 8 2 Hnchitis 13 1 1 ... ... 2 9 1 1 ... 1 1 2 7 ... Bumonia 15 4 3 ... ... 2 6 1 2 ... ... 4 3 5 ... Birisy 2 ... ... ... ... 1 ... ... 1 ... ... ... 1 ... ... Her diseases of respiratory ???organs 9 4 2 ... ... I 2 ... 1 ... ... 5 1 0 ... Bholism i Bhosis of Liver 3 ... ... ... ... 3 ... ... ... ... ... 1 ... 2 ... Be real diseases ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ???nature birth 9 9 ... ... ... ... ... ... 1 ... I 3 2 2 ... Bases and accidents of ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... BParturition 2 1 ... ... 1 ... ... ... ... ... ... 1 1 ... Ht diseases 28 2 1 1 ... 12 12 4 3 3 1 8 5 4 3 Hdents 3 ... ... ... ... 3 ... 1 ... ... ... 1 1 ... 2 Hdes 3 ... ... ... ... 3 ... ... ... ... ... 2 1 ... 2 Br septic diseases 5 ... ... ... ... 3 2 1 1 ... ... 2 ... 1 ... He Decay 22 ... ... ... ... 22 3 5 2 I 5 3 3 ... Htry diseases 15 1 2 ... ... 6 5 4 5 ... I 4 1 5 Hases of the nervous system 28 1 3 ... ... 11 12 1 1 3 1 9 4 9 2 ???ther causes 21 8 2 3 ... 4 4 2 1 1 ... 3 6 8 5 All causes 280 49 25 11 7 103 8.5 25 36 15 7 79 52 66 23 Notes.—(a) The deaths of residents occurring beyond the limits of the district are included in this table, and deaths of non-residents occurring in the districts are excluded. See note on Table I. as to the meaning of "Residents" and "Nonresidents." (b) Deaths of residents occurring in public institutions are allotted to the respective localities according to the addresses of the deceased as given by the Registrars, and in addition, are classified under " Public Institutions." (c) Under the heading of " Diarrhoea " are included deaths certified as from diarrhoea alone or in combination with some other cause of ill-defined nature; and also deaths as certified from Epidemic enteritis; Zymotic enteritis; Epidemic diarrhoea ; Summer diarrhoea; Dysentery and Dysenteric diarrhoea; Choleraic diarrhoea, cholera, cholera nostras (in the absence of Asiatic cholera). Under the heading of "Enteritis" are included those certified as from gastro enteritis, muco-enteritis and gastric catarrh, unless from information obtained by enquiry from the certifying practitioner or otherwise, the Medical Officer of Health shall have reason for including such deaths, especially those of infants, under the specific term " Diarrhoea." Deaths from diarrhoea secondary to some other well-defined disease are included under the latter. recording the facts under the various headings of Tables I., II., III., and IV., attention has been given to the notes on the Tables. GEORGE CARPENTER, M.D., Medical Officer of Health. January, 1909. TABLE V. DISTRICT OF BECKENHAM. Infant1le Mortal1ty dur1ng the year 1908. Deaths Jrorn stated Causes 1n Weeks and Months under One Year of Age. (See Notes at Foot of Table IV.) 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. All Causes. Cert1f1ed - - - - - - - - - - - - - - - - - Uncert1f1ed - - - - - - - - - - - - - - - - - Common Infect1ous D1seases. Small-pox - - - - - - - - - - - - - - - - - - Ch1cken-pox - - - - - - - - - - - - - - - - - Measles - - - - - - - - - - - - - - - 2 2 Scarlet Fever - - - - - - - - - - - - - - - - - D1phther1a; Membranous Croup - - - - - - - - - - - - - - - - 1 Whoop1ng Cough - - - - - - - - - - - - - - - - - D1arrhceal D1seases. D1arrhoea, all forms - - - - - - 1 1 - - - - - - - - 2 Enter1t1s, Muco & Gastro-enter1t1s — — — — — 1 1 1 — 1 - 1 — 1 1 — 7 Gastr1t1s, Gastro-Intest1nal Catarrh - - - - - - - - - - - - - - - - - Wast1ng D1seases. Premature B1rth 9 - - 9 - - - - - - - - - - - 9 Congen1tal Defects - - - - - - - - - - - - - - - 1 Injury at B1rth 1 - — — 1 — — — — — - — — - - — 1 Want of Breast-m1lk, Starvat1on - - - - - - - - - - - - - - - - — Atrophy, Deb1l1ty, Marasmus — 1 — 1 2 1 1 1 — 1 - - - - - - 6 Tuberculous D1seases. Tuberculous Men1ng1t1s - - - - - - - - - - - - - - - - - Tuberculous Per1ton1t1s, Tabes — Mesenter1ca - - - - - - - 1 - - - - - - - - 1 Other Tuberculous D1seases - - - - - - - - - - - - - - - - 1 Other . Causes. Erys1pelas - - - - - - - - - - - - - - - - - byph1l1s - - - - - - - - - - - - - - - - -— R1ckets - - - - - - - - - - - - - - - - — Men1ng1t1s (not Tuberculous) - - - - - - - - - - - - - - 1 - 1 Convuls1ons 2 1 — - 3 — — — — — - — 1 - - - 4 Bronch1t1s - - - - - - - - - - - - - - - 1 1 Laryng1t1s - - - - - - - - - - - - - - - - 1 Pneumon1a - — - 1 1 — — — — — 2 — 1 - - 1 5 Suffocat1on, overly1ng - - - - - - - - - - - - - - - - - Other Causes 2 — — 2 4 1 — 1 - - - - - - - - 6 14 3 — 4 21 3 3 5 — 2 2 3 2 2 2 4 49