FIN 10 THE METROPOLITAN BOROUGH OF FINSBURY. ANNUAL REPORT on the PUBLIC HEALTH OF FINSBURY for the Year 1911. by A. E. THOMAS, M.A., M.D., D.P.H., Medical Officer of Health. Barrister-at-Law. London: Printed by Vail & Co., 170, Farringdon Road, E.C. 1912. Public Health Committee, 1911-1912. Chairman. Councillor The Rev. T. C. ELSDON, A.K.C. Vice-Chairman. Councillor Dr. LAUZUN BROWN. HIS WORSHIP THE MAYOR. (Councillor H. B. BARTON, J.P.) Alderman W. HOWES. Councillor W. F. ABRAHAMS. Councillor D. COOKSEY. Councillor F. FOULGER. Councillor A. W. HUMPHRIES. Councillor The Rev. Prebendary G. H. PERRY, M.A., J.P. Councillor LEWIS PHILLIPS. Councillor O. M. RICHARDS. Councillor The Rev, GEORGE SMITH. Councillor ERNEST TROTT. The Public Health Committee meets on the 2nd and 4th Tuesdays each month at 2.30 p.m. To the Mayor Aldermen and Councillors of the Metropolitan Borough of Finsbury. His Worship the Mayor: Councillor H. B. Barton, J.P. Gentlemen, I have the honour to submit to you the Annual Report on the Public Health and sanitary condition of the Borough of Finsbury for the year 1911. For the sake of uniformity, the method of arrangement adopted in previous reports has, in the main, been adhered to. During 1911 special investigations have been made into The Incidence of Phthisis in the Borough, Infant Births, Crowding and Overcrowding, and The Home Conditions of Outworkers and Homeworkers. The results of these inquiries are embodied in the present report. In presenting this review of last year's work I wish to thank the Council and the Chairman and Members of the Public Health Committee for their ever-willing help, their encouragement and support, and the Officials of the Health Department and of the other Departments for their kind assistance and co-operation. I am, Gentlemen, Your obedient Servant, A. E. THOMAS, Medical Officer of Health. Public Health Department, Town Hall, Rosebery Avenue, E.C. TABLE OF CONTENTS. page page Infectious Disease, Deaths and Summary 5 Notifications110 P°PuIation 5 Disinfection 113 Births 7 Protection of Food Supply 115 Notification of Births 9 Meat and Food Inspection 115 Health Visitation 10 Unsound Food Prosecutions 118 Weighing Centres 20 wholesale Meat Salesmen .. 119 Special Birth Enquiry 25 Cool Air Stores 120 Midwives' Act 42 slaughterhouses 121 Puerperal Fever 42 Milk Supply 122 Deaths and Death Rates 44 Milk Registration 123 Inquests 50 Milk Samples and Analyses 124 Infantile Mortality 50 Milk Samples in the Metropo- Infant Deaths (Table) 53 litan Boroughs, 1910 126 Deaths from Diarrhoea 54 Ice Cream Shops 127 Infant Deaths in previous Restaurants 127 Years 56 Butter Manufacturers 127 Cancer57 Sale of Food and Drugs Acts 127 Atcoholism 58 Housing 129 Consumption of the Lungs 60 Registered Houses 130 Phthisis . Common Lodging Houses 131 Notification and Deaths(Table) 61 House-to-House Inspection 131 Deaths and Death Rate's, Crowding and Overcrowding 133 1901-1911 82 Customs and Inland Revenue Deaths in Institutions, Acts 137 1901-1911 84 Verminous Houses 138 Death Rates, 1911 and Stable Dwellings 139 1906-1910 85 Factories and Workshops 139 Visits and Re-visits .. 87 Homeworkers 146 What more may be done. 90 Bakehouses 149 Glanders and Anthrax 92 Canal Boats 150 Plague and Cholera 92 Elementary Schools 151 Cerebro-Spinal Meningitis .93 Black Smoke 152 Polio Myelitis 93 Cleansing of Persons 152 Ophthalmia Neonatorum 93 The Mortuaries 153 Erysipelas 93 The shelter 153 Chicken Pox 94 Offensive Trades 154 Small-Pox 95 Staff of Department 151 Measles and Hooping Cough 96 Work of the Inspectors 155 Scarlet Fever 99 Work of the Lady Sanitary In- Diphtheria 101 spector 156 Typhoid Fever 104 Legal Proceedings 157 5 VITAL STATISTICS. SUMMARY.—The principal facts of the Vital Statistics for the year 1911 have been as follows :— Census Population—April 2nd, 1911 87,976. Registrar-General's Estimated Population—middle of 1911 87,566. Birth Rate 80.6 per 1,000 inhabitants. Death Rate 19.4 per 1,000 inhabitants. Infant Mortality 154 per 1,000 births. Death Rate from Phthisis 1.81 per 1,000 inhabitants. Death Rate from all forms of Tuberculosis 2.30 per 1,000 inhabitants. Death Rate from the seven Chief Zymotic Diseases 3.38 per 1,000 inhabitants. Matters of interest embodied in the present report are:— The still declining birth-rate. The lessened number of births—the lowest since the Borough was incorporated. The slight increase in the death rate. A continued diminution in the death rate from phthisis. The lessened number of deaths due to Diphtheria and Hooping Cough. The increase in the deaths due to Measles, Scarlet Fever and Typhoid Fever. The increased prevalence of the common infectious diseases. The increased Infantile Mortality. POPULATION.—The population of the Borough at the middle of 1911 was estimated by the Registrar-General to be 87,566 allocated as follows :— Clerkenwell 56,899 St. Luke 29,310 St. Sepulchre 1,357 87,566 6 This is the intra-mural or inlying population, and does not include the extra mural or outlying Finsbury residents detained in the following institutions outside the confines of the borough:— The Holborn Union Workhouse, Shepherdess Walk (986) ; the Workhouse Infirmary, Archway Road (279); the Holborn Union Workhouse, Mitcham (556) ; and the Holborn Schools, Mitcham (338), giving a total of 2,159. Adding these to 87,566, the Registrar-General's estimate gives a corrected population of 89,725 for the whole Borough in the middle of the year. The decennial census of England and Wales was taken on the night of Sunday, April 2nd, 1911. Every head of a family, and every occupier of a tenement, was required to state in respect of every occupant of the house or tenement, the name and surname, the relationship to the head of the family, the age and sex, particulars as to marriage, the number of children of each marriage, the personal occupation, the industry or service in which employed, the status whether as employer or worker, the birth place, the nationality, and any attaching infirmity. In Finsbury, the following figures were obtained :— Area in acres, Families or separate occupiers. Population 1911. Population 1901. Population 1891. Clerkenwell 317 14,042 57,166 63,704 St. Luke's 242.3 6,936 29,447 36,116 St. Sepulchre 27.3 300 1,363 1,643 Whole Borough 586.6 21,278 87,976 101,463 109,981 Since the last census in 1901, the populations of Clerkenwell, St. Luke and St. Sepulchre have diminished by 6,538, 6669, and 280 respectively. Taking the borough as a whole, between 1901 and 1911, the percentage diminution in population is 16.9; the corresponding decrease during the preceding 10 year interval 1891 to 1901 was 11.0 per cent. It appears, therefore, that the depopulation of the borough is being accelerated, or proceeding at an increased rate. 7 The reasons for this depopulation have been given in previous annual reports : briefly, it has been in progress during the last 40 years, and is due to the fact that the borough is becoming more and more a manufacturing and business centre and less and less residential. The number of inhabited houses in 1891 was 10,365 ; in 1901, was 9,287. In 1911, the number of persons per family or occupancy was for Clerkenwell 4.07, for St, Luke's 4.24, for St.. Sepulchre 4.54. The corresponding numbers for 1901 were 4.58, 5.20, and 5.47 respectively. In all the districts, therefore, the number of persons per occupancy has diminished since the last census. In previous years the death rates and birth rates have been callated on the basis of the inlying population as estimated by the Registrar-General; for the sake of uniformity and comparison, this method has been continued in the present report. The populations in the inter-censal years have been calculated by an improved method described in the Registrar-General's Annual Report for 1907 All these populations are, for the present, subject to future alteration, when the final revised census report for 1911 shall have been issued. At the time of writing only the preliminary census report is available. BIRTHS.—During 1911 there were registered 2,676 births of Finsbury residents, equal to a birth-rate of 30 6 per 1,000 living. This rate is less than it was last year, and, with one exception, the lowest yet recorded since 1901. The birth rate for Finsbury has not fallen to the same extent that it has diminished in the country generally. 8 The corrected rates and populations are given below:— CORRECTED BIRTHS AND BIRTH RATES. Year. Population in the middle of each year. Corrected Births. Corrected Birth Rates. 1901 101,141 3,254 32.1 1902 99,846 3,191 31.9 1903 98,538 3,162 32.0 1904 97,215 3,095 31.8 1905 95,880 2,886 30.1 1906 94,529 3,012 31.8 1907 93,165 2,884 30.9 1908 91,787 2,916 31.7 1909 90,394 2,857 31.6 1910 88,987 2,833 31.8 1911 87,566 2,676 30.6 The corrected rates for the several sub-registration districts 1911 were as follows :— Population. Births. Birth-rate. Clerkenwell 56,899 1,730 30.4 St. Luke 29,310 924 31.5 St. Sepulchre 1,357 22 16.2 The Borough 87,566 2,676 30.6 The corresponding birth-rates for the rest of the country for 1911 are attached :- England and Wales 24.4 London 25.0 Finsbury 30.6 77 Great Towns 25.6 136 Small Towns 23.4 Rural Districts 23.4 9 It will be seen that the birth-rate for Finsbury is greater than the rate for the whole of England and Wales, greater than the birth-rate for London, and greater than the rates in the 77 great towns, the 136 smaller towns, and the essentially rural districts. The birth-rate is greatest in St. Luke, least in St. Sepulchre. Sixty-one of the births in Finsbury children occurred in the City Road Workhouse, 153 were notified as having taken place in other metropolitan boroughs. At the City of London Lying-in Hospital there were 992 births during the year; of these 120 belonged to Finsbury, and the rest to other London boroughs. NOTIFICATION OF BIRTHS ACT, 1907.—This Act was adopted by the Borough Council on the 19th December, 1907, and came into force on the 9th March, 1908 All births, including still-births, must be notified to the Medical Officer of Health within 36 hours by the father or by any person who at the time of the birth or within 6 hours thereafter was in attendance on the mother. For the purpose of notification, stamped addressed envelopes are supplied free of charge to all Doctors and Midwives resident or practising in the Borough. The number of notifications received in 1911 was 3,441. There were 60 sets of twins, but no triplets or quadruplets. There were 92 still births. The percentage notified by parents was 12.0, by medical men 4.5, by midwives 18.0, and by others—chiefly medical students and professional assistants, was 65.5 per cent. The mothers in this last percentage (65 per cent.) were all attended gratuitously in their confinements. This means that approximately 2,200 Finsbury mothers, or 2 out of every 3, were cared for during child-birth and the subsequent 10 lying-in for no charge whatever, chiefly by the medical students of the various hospitals. This gratuitous treatment is so much appreciated, that mothers poor, and occasionally even the moderately well-to-do, living in the outlying districts 10 or 15 miles away, have been known to move their home temporarily into Finsbury so as to be attended in child-birth (without payment) by the students. One expectant mother, the wife of a "jockey," resident near Paris, is stated to have come to Finsbury from France for this purpose. The institutions whose students learn their midwifery in the district are: — 1. St. Bartholomew's Hospital; West Smithfield. 2. The Royal Free Hospital, Gray's Inn Road. 3. The City of London Lying-in Hospital, City Road, 4. The Maternity Nursing Association, 63, Myddelton Square. 5. The Royal Maternity Charity, 31, Finsbury Square. Dinners are provided for expectant and suckling mothers, at a nominal charge, or, in special cases, free of charge, by 1. Mrs. Lamond, The Home of Service, King Square. 2. Mrs. Dr. Willey, 26, Cumming Street. By the provisions of the Notifications of Births Act, local Registrars are allowed to inspect the notifications received, and to compare them with their own lists of births registered. By this means it is possible to trace those parents who have not sent information to the Public Health Office. To these a printed form is sent drawing attention to the omission and asking that the notice shall be sent. This has always been effective. The number of notices of omission sent out to parents have been in 1908, 277; in 1909, 181; in 1910, 196; and in 1911, 189 letters. HEALTH VISITATION.—The visitation of infant births was begun in Finsbury in 1909. The methods adopted and the scope of the work done, have been fully described in the Annual Reports for 1909 and 1910. 11 Briefly, they consist in defining those streets in the Borough in which infant deaths chiefly take place, in visiting every household in such streets in which a birth occurs on the eleventh day after the birth, or as soon as convenient, and giving suitable advice to the mother. The following is the list of the streets in which 10 or more infant deaths have occurred in 7 recent years :— DISTRICT No. 1. Infant Infant Deaths. , Deaths. Affleck Street 19 Myddelton Square 19 Amwell Street 10 Noble Street 22 Albert Street 26 Northampton Buildings 65 Bakers Row 15 Northampton Road 26 Berkley Street 17 Penton Place 11 Busaco Street 14 Penton Street 20 Buxton Street 13 Pentonville Road 36 Chapel Street 12 Pine Street 14 Clerkenwell Close 16 Red Lion Street 16 Coldbath Buildings 11 Risinghill Street 61 Coldbath Square 18 Rodney Street 25 Collier Street 19 Rosebery Avenue 11 Corporation Buildings 14 Rosoman Street 25 Gumming Street 28 St. Helena Street 30 Donegal Street 18 St. James Street 11 Easton Street 31 St. John Street 35 Farringdon Road 30 Sadler Street 10 Gloucester Street 12 Southampton Street 46 Godson Street 12 Victoria Dwellings, Goswell Terrace 10 (Clerkenwell Road) 23 Gt. Bath Street 12 Vineyard Walk 15 Gt. Percy Street 14 Warren Street 35 Hermes Street 21 Whiskin Street 13 James Gardens 13 White Lion Street 40 Kings Cross Road 23 Wilmington Place 10 Little Sutton Street 27 Wilmington Square 17 Margaret Place 32 Wynford Road 19 Margaret Street 32 12 DISTRICT No. 2. Infant Infant Deaths. Deaths. Baldwin Street 34 Leage Street 11 Bartholomew Square 10 Lever Street 48 Bastwick Street 39 Little Northampton Beckford Square 11 Street 12 Brewer Street 15 Lizard Street 15 Brunswick Close 15 Macclesfield Place 10 Central Street 39 Macclesfield Street 19 City Road 22 Mitchell Street 24 Compton Buildings 17 Murton Street 13 Compton Street 10 Peerless Street 28 Costers Dwellings Percival Street 16 (Dufferin Street) 10 President Street 19 Cyrus Street 18 Radnor Street 37 Dingley Road 19 Rahere Street 27 Dufferin Street 22 Rawstorne Street 10 Galway Street 33 Richmond Street 11 Gee Street 43 Roscoe Street 24 George Yard 18 St. Bartholomew's Goswell Road 30 Buildings (Seward Guest Street 10 Street) 52 Guinness Buildings St. Clement's Buildings (Lever Street) 66 (Lever Street) 12 Hatfield Street 20 Sidney Grove 10 Henry Street (Old Sidney Street 11 Street)17 Smith Street 14 Ironmonger Row 34 Spencer Street 10 Ironmonger Street 26 Waterloo Street 15 In the above streets every birth that occurs is visited ; in other streets only those births are dealt with where the mothers are very young, ill-treated, deserted, or living in poor and domestically squalid surroundings, or where the children are first children, wasting, debilitated, illegitimate, or twins. Other households are visited on request, or on complaint as to ill-treatment, neglect or exposure. 13 The policy of the department is primarily to watch over and help the children who are in the way of becoming weaklings or "wasters," and secondarily to prevent the healthy children from becoming ill or debilitated. As a general rule it is considered unnecessary to visit mothers with large families who have successfully reared all their children or very nearly all of them. So, too, it is thought to be inexpedient to visit mothers who live in better-class houses, or mothers who are known to be clean, careful, and industrious. At each visit the yard is inspected for sanitary defects which may react adversely upon the child's progress, and any defects, such as a broken gully grid, choked water closet, or a broken or absent dustbin, are referred for amendment to the district sanitary inspector. The Health Visitors refrain entirely from diagnosis, and, as much as possible, from all treatment, save in simple and urgent matters. The mothers, in the first instance, are referred to their own medical men, or, if too poor to pay for medical advice, to the various hospitals and dispensaries in and near the borough. Out-patients' letters are supplied, or, if not available, exact information is given to the mothers as to where they may be obtained and as to the times at which the institutions are open for out-patients. A tubeless feeding-bottle and a special teat are provided by the Public Health Department at cost price to those who can pay, but free of charge to the very poor mothers. In addition, the Department supplies "Finsbury Cream," a special form of fat-food to wasting and debilitated children. This has been found of great service. The babies take it. readily ; the mothers buy it at cost price. It is given gratis to those mothers who cannot afford to pay. A list is appended of Creches and other Institutions in and around the borough, which are available for the help of Finsbury mothers and infants. 14 Creches.—There are four creches in Finsbury affording accommodation for 136 children, and situated as follows :— 1. Claremont Hall Creche is in Pentonville, has room for 50 children, and is affiliated to the National Society of Day Nurseries. It receives infants and children under five years, and is supervised by a trained nurse. The charge is threepence a day for each child. 2. St. Agnes Creche, 48, Amwell Street, belongs to the Sisters of Bethany, Lloyd Square. It can receive 30 children under school age, and is managed by one of the Sisters. The charge is fourpence per day, but two children in one family are taken for sixpence. 3. The Hope Mission Creche, Banner Street, belongs to The London Congregational Union, and accommodates 40 infants under school age. A few school children, however, who have been brought up in the Creche are admitted for the mid-day meal and again from 4 p.m. to 9 p.m. It is controlled by a Sister, and the charge is threepence per day per child. 4. The Guinness Buildings Creche, 97, Guinness Buildings, Lever Street, is exclusively for the use of the Guinness Trust tenants, and preference is given to the children of widows. It is managed by one of the tenants and has room for 16 children of various ages ranging from two months to ten years. The children attending school come in to the mid-day meal and from 4 p.m. to 8 p.m. The charge is twopence per day for children under five years, and threepence per day for those over five years. Day Foster Mothers.—In addition to the four creches given above, in which an honest attempt, more or less successful, is made to help the children, there are in the Borough many women who, for a small pittance, take charge, during the daytime, of the children of poor mothers while these are out at work. 15 Many of these day foster-mothers are most unfitted and unsuitable for this self-imposed task. Some are infirm, or crippled, others are dirty, filthy, domestically squalid and offensive. In effect, they keep modified creches, but evade the provisions of the Children Act, 1908, by supervising the children only during the daytime. Under the Children Act, notice to the local authority is only necessary if the infant is received for 48 hours or longer. Some of these modern Mother Gamps were found to be living in very dirty domestic surroundings—in a few instances the yards where the children played were strewn with the excrement of many days and decaying vegetable matter. The children on the premises were in very poor condition and ricketty. Notices were served for the various public health nuisances and abatements effected. It must be realised, however, in this connection, that public health intervention is only palliative—true prevention lies in the readjustment of labour and economic conditions which have rendered it necessary for the mothers to work in order to support the family and an ailing, unemployed, unemployable, or dissolute husband. ILLUSTRATIVE CASES. 1. Improper Reception and Difficulties of Accommodation.-An illegitimate child was left for payment, soon after its birth, in the care of a woman and her husband, wl.o already had 12 children—girls, 20, 17, 14, 11, 7, 6, 4 years, and a baby 10 months; and boys, 26, 25, 23, and 9 years of age. No notice of the reception of the child was given to the Local Authority as required by law. The family occupied a three-roomed tenement in Finsbury consisting of one out kitchen, one small front room hardly ever used, and one bedroom. The rooms were all dirty and verminous. The adopted child was undersized, had its face covered with sores, and suffered from ophthalmia. It was fed on condensed milk. 16 It got ill and eventually died at the age of ons month from tuberculosis meningitis. The disposition of the family for sleeping purposes was as follows:— The mother, the six younger children, and the adopted child all slept in one bed at night. The father, who worked at night, slept in the same bed by day. The son 26 years, a widower, occupied a room in another borough, worked at night and slept by day. When he got up for night work, the three eldest girls got into his bed and slept there for the night. The second son lived in "lodgings,'' the third son was a private in the army. It will be observed that this mother, despite the dire and acute difficulties of accommodation necessitating two Box and Cox arrangements, in spite of the fact that she was suckling her own child 10 months old, still had the colossal effrontery to accept for reward the care of a delicate and undersized infant less than a fortnight old. The family disappeared soon after the death of the adopted child. 2. Creche mother paralysed and crippled.—A married woman, crippled, and paralysed in both legs, occupied a oneroomed tenement, and received babies and older children for payment to care for them while their mothers were at work. Her husband was in casual employment as an odd man. She herself took in sewing as an outworker. She was personally dirty and sat on the floor, being only able to move with the use of her hands. The mothers prepared the children's food in the morning before taking the children to this most unsuitable creche. The food so prepared was then supposed to last each child during the whole day—it was sometimes found to be sour in a few hours. Here we have a woman, well meaning no doubt, dirty, crippled, unable to move save by crawling along the floor, struggling to 17 support herself and her husband on the sorry pittance paid for home-sewing and on the beggarly doles received from mothers as poor as herself—mothers who also had to go out to work, leaving their children in her care, until their return later in the day. As the children were only received during the daytime, notice to the local authority was not necessary. Institutions of this kind, therefore, unless there is reason to believe that cruelty or neglect has occurred, are free from municipal supervision and do not, at present, fall within the scope of preventive administration. It is obvious, too, that public health sanctions do not, in effect, closely apply to such cases as these; the true prevention, as has already been indicated, lies in the readjustment of the industrial and economic conditions which have transferred the burden of supporting the family from the father on to the mother. Dinners for poor nursing and expectant mothers.— These may be obtained at 26, Cumming Street and the Home of Service, 36, King Square. The Cumming Street dining room was established by the League of Service in 1910. It provides a nourishing and attractive dinner for twopence, a payment which barely covers the cost of the food alone. About 35 Finsbury mothers are fed daily. There are knitting and sewing classes in connections with this centre. The Home of Service was founded by the League of Liberal Christianity and provides dinners for nursing mothers at twopence each. It has a boot and clothing fund, and a milk fund for providing milk for sick children. Medical, Nursing and Maternity Institutions and Associations. 1. The Finsbury Dispensary, Brewer Street, has a Resident Medical Officer, Dr. Warwick, who visits patients daily at their own homes. 18 2. The Leysian Medical Mission, City Road. Patients are seen by the Staff on Tuesdays and Fridays, and are charged 1d. for medicine, 1d. for a bottle, and 2d. for cod liver oil and malt. 3. Bunhill Medical Mission, Memorial Buildings, Roscoe Street. Patients attend on Mondays and Thursdays. 4. The Northampton Estates Sick and Provident Society has a maternity self-help branch. The Marquis of Northampton maintains a nurse for the help of tenants on the Northampton Estate. 5. The St. Barnabas Home, Lloyd Street, Lloyd Square, W.C., is conducted by the Sisters of Bethany for the medical and surgical treatment of in-patients and outpatients who are expected to contribute according to their means. Six beds are reserved for the poor of the Parish of the Holy Redeemer. Cases sent in by the Sisters are received without payment. 6. The Peel Mission, 32, St. John's Lane, has a Mothers' Guild, and is opened on Thursday afternoons as a Weighing Centre, when nursing mothers may obtain suitable advice for themselves and for their babies. 7. The Home for Wasting Babies, Brunswick Place, Hoxton (Hon. Physician, Dr. Stanley Simpson), received 18 Finsbury babies in 1911, and has been of very great service in rearing delicate and motherless infants. 8. Gough Street Medical Mission is associated with the Baptist Deaconesses' Mission, 37, Mecklenburgh Square, W.C. The Hon, Medical Officer is Dr. Fercy Lush. It is open on Friday afternoons only, and is much resorted to by Clerkenwell mothers. The Sisters from the Baptist Deaconesses' Home, some of whom are trained nurses, visit the homes of the sick poor. 19 9. The Field Lane Institution lies outside the Borough. It possesses a day nursery accommodatin; 26 children at a charge of twopence per day for each child. These infants are chiefly the children of widows, deserted wives, or of those mothers whose husbands are ill or out of work. It employs a trained nurse, and distributes much broken food amongst the Finsbury poor. 10. The Royal General Dispensary, 26, Bartholomew Close, is open daily at 12 mid-day. The Resident Medical Officer is Dr. Kearney. 11. Nursing Facilities.—There are nurses in conmection with the following Churches and Chapels :— St. Silas, Pentonville. All Saints Mission, White Lion Street. St. John's, Clerkenwell. St. Paul's, Peartree Street. Claremont Hall. Queen's Nurses for the sick poor can always be obtained by applying to the Superintendent of the Queen Victoria Jubilee Nurses at the local branch, 23, Bloomsbury Square, W.C. Birth Visitation.—The number of visits paid by the Lady Health Visitors and Mrs. Greenwood was as follows:— Visits. First Births. Total Births. Miss Macqueen 2,337 101 890 Miss Tubbs 2,559 110 708 Mrs. Greenwood 327 15 119 Totals 5,223 226 1,717 The number of births in the Borough was 2,676, so that these figures show that in 1911 seventy per cent, of all the births in Finsbury came under the supervision of the Public Health Staff. 20 As a rule, the ladies are well received -occasionally a little resentment is shown. "We ain't paupers and don't want no charity. When we wants advice, we can pay for it." One mother had quite a clean and well-ordered home, but considered herself "too superior to require the Lady Health Visitors, as she was the wife of a policeman." In another household the baby fell, hurt its head, and was taken to a doctor. The mother, however, was not satisfied with the treatment "until one of the health ladies had seen it" and approved of it. The efficiency of the work is much lessened from the difficulty of following up the births owing to the frequent removals of the families concerned, in and out of the borough. In addition to seeing infant births, the ladies also visited expectant mothers for advice, children with rickets, and investigated a few infant deaths, Weighing Centres.—There are four weighing centres in the Borough, held in the afternoon at 2..30 p.m., at the following times and places. Wednesday : The Branch Library, Penton Street. Thursday : The Mothers' Guild, 65, St. John Street. Thursday : St. Luke's Institute, Radnor Street. Friday : The Committee Room, The Town Hall. The weighing centre at 65, St. John Street, is supervised and controlled by the Peel Mission of the Society of Friends. A summary of the work done is appended:— Centre. No. of Meetings. Attendances. Average Attendance. No. of Children. Penton Street 50 693 14 137 Radnor Street 47 1,022 22 176 Town Hall 46 953 21 168 Totals 143 2,668 19 481 21 The largest average attendance and largest number of children both belong to St. Lukes. The Penton S'reet Centre suffers probably from the fact that many of the mothers prefer to attend the Dinner Centre at 26, Cumming Street. The weights of the babies at birth are given below : — Weights at birth in pounds. Centre. Under 4 lbs. 4-5 5-6 6-7 7-8 8-9 9-10 10 + Penton Street — 4 16 13 35 10 15 8 Radnor Street 2 4 11 29 40 33 29 4 Town Hall — 4 9 33 42 35 9 4 Totals 2 12 36 75 117 78 53 16 Most of the infants weighed between 7 and 8 pounds—16 were over 10 pounds at birth. Sixty-seven per cent, of the children, that were weighed, were over 7 lb.—this shows that twothirds of all the children, as far as this factor is concerned, start life with a reasonable prospect of surviving, or, if we include the children between 6 and 7 lb., then 87 per cent, have a similar expectation. Feeding—The feeding of the infants when first attending the centre is annexed in tabular form :— Centre. Breast. Breast and Bottle. Cows Milk. Condensed Milk. Patent Foods. Penton Street 70 17 29 16 1 Radnor Street 121 11 26 8 4 Town Hall 99 8 37 15 4 Totals 290 36 92 39 9 22 The children breast fed are nearly twice as many as those fed in other ways. The number of children fed exclusively on patent food is very small. Fifteen children were being fed on boiled bread, biscuits, and other unsuitable foods. There is reason to believe that the use of boiled bread either alone, or in combination with other foods, is far too common amongst Finsbury mothers for their babies. Here is a method of preparing it given by one of the mothers affected :— "Take one slice of bread, and boil it in a pint of water until it becomes a pulp. Strain through linen or muslin, and then beat up with a little butter. Give a baby of three months half a teacupful twice or three times a day." This boiled bread for infants is a most unsuitable food, and cannot be too severely condemned. The large number of mothers who breast-feed their children, is matter for much congratulation. One mother, whose husband was unemployed, returned to her work three weeks after her confinement, and, though debilitated, jaundiced, and anaemic, came home at every meal-time to breast feed her baby. Another mother had rheumatic gout when she was 17 years, had since married, and had 5 children, all living. Later she became so crippled that she was unable to hold her baby to the breast, but had to get her husband or a neighbour to do it for her. These examples of maternal devotion and selfsacrifice could be multiplied many times in Finsbury. Condition when first brought. —Six of the children were premature and consequently very delicate: 261 or 55 per cent, were fat, 76 were thin, and 138, or nearly one-third, were definitely wasting, due to irregularities of feeding, improper or unsuitable food. The large percentage of wasting children is very deplorable, and shows the need there still is for sound, practical, common sense supervision and instruction. Age when first brought.—41 were under 1 month, 210 were between 1 and 3 months, 103 between 3 and 6 months, 112 between 6 and 12 months, ana 15 over 12 months old. 28 More than half the children were brought before they were 3 months old, the rest were, in very many cases, brought because they were already ailing or wasting. It would be better if all the babies were brought during the first or second month. Nearly 30 per cent, of the children were the first born of their mothers. These are the children it is sought to get hold of; if the mothers can be taught thoroughly how best to deal with their first children, the instruction survives for the benefit of succeeding children. Work and Status of Parents.—These are included to exhibit the social status and character of the parents who resort to the weighing centres. The occupations show that the fathers are mainly of the working class and chiefly General Labourers, Porters, and Carmen. These occupations were as follows :— General Labourers (99), Porters (51), Carmen (41), Packers (27), Printers (15), Window Cleaners (14), Painters (9), French Polishers (8), Clerks and Timekeepers (7), Costermongers (7), Lift Attendants (7), Gas Fitters (6), Hawkers (6), Policemen and Firemen (6), Barmen (5), Cabdrivers (5), Cooks (5), Horsekeepers (5), Shop Assistants (5), Tailors (5), Fish Friers (4), Hairdressers (4), Jewellers' Assistants (4), Leather Bag Makers (4), Bootmakers (3), Silver Polishers (3), Stick Dressers (3), Tobacconists (3), Turners (3), Bacon Driers, Basket Makers, Bookbinders, Bricklayers, Card Embossers, Caretakers, Fruiterers, Gilders, Office Cleaners, Packing Case Makers, Piano Key Makers, Scavengers, Stonemasons, Tinplaters (2 each), Bath Attendant, Bat Maker, Billiard Marker, Bill Poster, Blindmaker, Boilerman, Box Repairer, Butcher's Assistant, Cloth Shrinker, Cocoa Roaster, Cycle Enameller, Gas Collector, Glass Blower, Insurance Agent, Leather Dresser, Metal Sorter, Milkman, Mosaic Worker, Newsvendor, Optician, Organ Grinder, Plasterer, Platelayer, Postman, Sailor, Scene Shifter, Skin Sorter, Sweep, Teacher of Languages, Tiler, Umbrella Maker, Waiter, Water Inspector, Wheelwright (1 ach). Two of the mothers were widows. Nearly 20 per cent, of the parents were out of work, 25 per cent, were in casual employment, 55 per cent, only were working 24 regularly. This is where the crux lies. It is idle to enjoin good food and to preach high sanilary ideals to those who have little or no food in the home, to those for whom the prospect of work is vague and illusory. The main problem is the problem of poverty, and it is unfair, irrational, almost ridiculous to attempt to solve it by added public health legislation or keener sanitary administration. A more critical system of public health inspection, an increased number of municipal inspectors, will not add one loaf to the cupboard, or one thread to the child's raiment. Regularity of Attendance.—None of the mothers attended regularly week by week—22 per cent, came every two or three weeks, 42 per cent came casually and occasionally, 17 per cent, came twice only, 19 per cent, came once only. The reasons for this irregularity are various. Some mothers bring their babies when the child is ailing—but stop coming if the baby begins to improve. Some, again, come as long as their husbands are in work, but when their husbands are unemployed have themselves to go to work to support the family. Occasionally the mother ceases to attend because she has no "respectable clothing" or no "proper boots." It is great pity that the attendances are not more uniformly regular ; the cause of this irregularity, however, is, in the main, an industrial one, and lies outside the scope of public health measures. Average gain per week—Amongst those who attended regularly, the average gains per week were at the— Minimum Maximum gain. gain. Penton Street Centre 3½ ozs ⅓ oz. 7¼ ozs. Radnor Street Centre 3½ ozs ⅔ oz, 8 ozs. Town Hall Centre 4¼ ozs 1½ oz 9½ ozs. 25 The larger gains in the Town Hall babirs are correlated to the better social status of the mothers who attend there. For purposes of comparison, it is found as the result of many enquiries that the average Finsbury baby, fed on good food and born of a careful mother, gains, during the first few months of life, at the rate of 5 ozs. weekly. SPECIAL BIRTH INQUIRY—In 1911 a special investigation was made into 200 Finsbury births, taken consecutively as they occurred in the poorest streets of the borough. There weie 108 male children, and 92 females; 146 were under one month at the time of the first visit ; 24 were over one month and under two months of age. One hundred belonged to Clerkenwell and the same number to St. Luke's. Cleanliness of Children.—On the first visit 169 of the children were found to be distinctly dirty and unwashed between 11 a.m. and 12 mid-day ; 108 of the children—or more than half— were vermin bitten, some excessively so. This disregard for the personal cleanliness of their babies is only too manifest in the poorer streets. It is not due to poverty— homes may be found where the direst poverty prevails, and yet where the walls, floor, ceiling, household utensils, and children are scrupulously clean. It is sometimes due to sheer weariness; mothers who have to return to work hard to maintain the family a week or two after their confinements are apt to delegate the washing to a neighbour, or to one of the other children, often an immature girl of 10 or 12 years. The presence of vermin is looked upon almost as a necessary evil. Insect powders are very rarely used. The method of extermination usually adopted is to squash the bug between the forefinger, the thumbnail, or the handle of a kitchen utensil, and the subjacent wall, leaving the wallpaper stained red in patches, and discoloured. A more drastic procedure is to apply a lighted match to the insect. This leaves the wallpaper or the whitewash 26 charred and disfigured. Both these methods bespeak an utter disregard for house cleanliness, and inflict an added hardship upon the owner, who may be called upon to strip, cleanse, and purify the rooms three or four times a year. When verminous rooms are found, the Lady Health Visitors see that the bedding is all turned out and disinfected. The personal clothing is steam-disinfected. The floor and woodwork are scrubbed. The room is then sulphur fumigated by the Borough officers. Some municipalities supply a disinfecting soap, gratis, to poor people, on request, for such a cleansing. It would tend to prevent houses becoming verminous if the rooms were distempered and not papered. House owners, how ever, state that tenements that are only distempered are let with great difficulty. The poor have an obssssion for papeied walls. In Finsbury, the walls may be covered with only one wall paper. When re-papering takes place, all the old wall papers are stripped off. Illustrative Cases. - 1. A baby, 4 weeks old, very dirty and unwashed, was left in sole charge of a girl 9 years of age while the mother went out to her work in the early morning. 2. The mother was a machinist "to keep the home together." The father was " always out of work." There had been 7 children, of whom now only 4 were alive, all dirty and neglected, and left in charge of the eldest boy, 10 years. All the children were thin, and suffered from ophthalmia. 3. A family consisted of the parents and two children. The father earned 16s. weekly. The mother was unable to get sufficient food. In spite of the great poverty, the home and the children were exceedingly clean and well cared for. 4. The father was in prison. The mother had been out all night, and was returning home where she had left her child of 2 weeks in bed the previous evening. The baby was very dirty and unwashed. 27 5. The baby was dirty and unwashed at 3.30 p.m., and left in the sole charge of a child 10 years of age. The mother was a street flower seller and fad been out since 8 a.m. 6. The baby was dirty. The mother was ill, but was "drinking a pint of stout so as to get up her strength and be strong enough to wash the baby." 7. The baby was 2 weeks old, filthily clad, and had inflamed eyes. The mother explained that she was unable to wash the child because she had lent her soap and washing-basin to a neighbour, who had refused to return them. Condition of the Eyes.—In 80 babies, or 15 per cent., the eyes were sore. In 7 additional cases there was a yellow discharge from one or both eyes. All these were referred by the Lady Health Visitors to Hospitals for treatment, or were already being treated there. The very poor recognise three affections of the eyes— the black eye, the squint, and the "blight," which includes all the rest. Squint, it is alleged, is not a disease, but is "due to ignorance," though sometimes accredited to "stubbornness." It is not surprising that, with this primitive register of diseases, serious conditions of the eyes may be treated as trivial. The notification of ophthalmia in the newly born, made compulsory in March, 1911, will do much to remedy this. In all the above cases the Lady Health Visitors saw that the treatment prescribed was persevered in, and properly carried out. Condition of the infant.—Of the 200 no less than 129 were found to be suffering from thrush. This is a complaint that ought not to occur, provided the mother washes her breasts daily, and cleans her teats and the baby's mouth before and after each feed. It is an index of carelessness and uncleanliness. The Lady Health Visitors saw that the proper treatment was adopted. One mother insisted on curing her baby by taking crude soot from the chimney and rubbing it on her child's tongue. "She 28 always did that, and as she had had seven children, all living, she thought she knew what was best." The child survived her mother's rough but well-meant methods. One child had a sore navel, 84 had sore buttocks, and in 195 the supply of available napkins was quite insufficient. It is a matter for much regret that in nearly all the children the supply of napkins was inadequate. A mother who has at most only two or three napkins cannot possibly keep her child even moderately clean, or free from sores. In this connection it is interesting to note that the use of the discredited Fuller's earth is declining, and that the employment of vaseline, or of the more rational starch and zinc oxide powders is increasing. Clothing.—Only one child was clothed completely in flannel; 26 children were dressed in wool and cotton; the rest, 173 in number, were clothed in cotton or flannelette. In 180 cases the clothing was dirty and fouled, in 197 instances the clothing was insufficient. Sixty-three of the children were found to be cold and blanched, 14 were blue with cold, 9 were exposed with little or no clothing. It is sad to think that though the dangers and shortcomings of flannelette have been preached incessantly now for many years, that the very poor mother still chooses it for her baby's clothes. Possibly its attractive pink colour and its cheapness may have some influence with her in fixing this preference. In 119 babies the binder was too tight, to the great discomfort of the child. In two instances the babies had too much clothing. Illustrative Cases.— 1. A baby four months old was found lying on the floor, clad in a vest only. 2. A baby six months old was placed on the doorstep, clad only in a pinafore and a flannelette shirt. A very keen cold wind was blowing. 29 3. The father was out of work. There was no fire in the grate. The mother had wrapped the baby, which was otherwise naked, in its father's coat, and was nursing it to keep it warm. 4. A baby two weeks old was cold, crying, exposed with its chest uncovered. It had on two tight cotton binders and nothing else. It was wasting, and had cough and diarrhoea. The mother was clean, tidy, and presumably intelligent. Her home was very clean and orderly. Her clothes were clean and well kept. She had left off the baby's clothes so that "it might breathe and cough easier." The two binders had apparently been placed on very tightly for the same reason. 5. A baby was blue and very cold from the pressure of excessive clothing. It had on four flannelette petticoats, one flannelette shirt, a cotton frock, and a pinafore. It had then been wrapped in a woollen shawl folded double in three turns, and over all these was placed a blanket folded four times. Feeding.—At the first visits, 172 babies or 86 per cent, were breast-fed exclusively, 6 were partly breast-fed and bottle-fed, 20 were wholly bottle-fed, 2 were fed on patent foods and boiled bread. The large number of children breast-fed is much to be commended. Most Finsbury mothers breast-feed their children for the first month of life and only give this up not because it is their desire but because necessity compels them. This has been discussed in previous reports. One mother stated "she could never breast feed her children as the milk got into her own head." Some mothers feed their children whenever the babies cry; others try everything and anything the neighbours suggest. On such a recommendation one mother tried 8 different patent foods in one month. 30 These examples will suffice to show the place that still remains for practical common-sense instruction. Sixteen mothers were using cow's milk, 7 used condensed milk, diluted with water or barley water. Five mothers were using the condemned type of bottle with a long tube. The Public Health Department supplies an approved bottle to mothers at cost price, and gratis to those who cannot afford to pay. Fourteen of the babies 'bottles were dirty. The milk, for the household generally, was in 158 cases stored in dirty uncovered milk jugs; in 176 households the kitchen feeding utensils—the cups, saucers, plates and jugs were dirty. In 93 cases the milk was kept continuously on the table, the mantelshelf, or on the "dresser," in 36 cases in a cupboard. It appears then, that whereas much and increasing attention has been given to the cleanliness of the babies' bottles, much still remains to be done in improving the domestic cleanliness in poor homes. Not uncommonly it was found that the baby's milk was being kept in what may be termed the official beer-jug, and when this was wanted to fetch ale, the milk was placed temporarily in an empty jam-pot or basin. It was quite rare to find the household milk covered in, not even while sweeping and dusting were in progress. The Public Health Department now supplies milk jug covers to poor mothers and specially distributes them in June of each year to fend off flies during the hot months. As long as breast-feeding continues, the baby is comparatively safe, but when the mother returns to the strenuous household duties or to her task as an outworker—and the baby is in consequence partially or entirely weaned, then the situation becomes a dangerous one for the infant. Very few of the children were breast-fed until the ninth month, The reasons given for early weaning were various—worry, illness, insufficient food, return to work, no breast milk, and insufficient breast-milk. 31 The examples given below refer to this period. One hundred and forty-four children used comforters or dummy teats, and in all but six instances these were dirty and a source of danger. In nearly every case the mother only possessed one comforter. I Illustrative examples.— 1. A baby four months old suffered from indigestion. The mother was giving the child semolina pudding, tea, sponge fingers, breast milk, and in the intervals between the feeds—some fried fish to suck and chew. The mother had plenty of breast-milk. 2. A mother fed her twins on brandy and water. She herself drank gin. She explained that "brandy was better than gin for . babies.'' 3. A child two months old, was eating a raw unripe tomato. The mother said "she didn't know it was bad for them—she thought tomatoes were good for the children." 4. The father had been out of work for ten months. The mother was a bookfolder working two days a week. She took in for the baby a half-penny-worth of milk in the morning and the same amount in the evening. This was kept in a dirty broken jug used also for ale. The family occupied one ground floor back room and consisted of the parents and two children aged three years, and ten months respectively. Sleeping Accommodation.—Only ten of the babies slept in a separate cot. The rest slept with their parents. When it is remembered that last year 15 Finsbury children were overlain in bed by their parents, the importance of separate sleeping accommodation cannot be over estimated. A cheap cot can easily be made out of a banana crate or an orange box. In one house the child slept in an ordinary galvanised washing vessel, and in another case in the bottom drawer of a chest ot drawers. It is quite common to find that even though the baby sleeps in a separate cot by day, yet at night it usually sleeps with its parents. 32 By the Children Act, 1908, where the death of an infant under three years is caused by suffocation while the infant is in bed with some other person over 16 years, and that other person was, at the time of going to bed, under the influence of drink, then proceedings may be taken against such other person for neglect of the infant and thereby causing its death. Miscellaneous details.—Ninety-eight (or nearly half the children) were insured ; 21 were ailing during the time they were under supervision. In nearly all the houses flies were present and allowed free access to the household milk. In 24 homes they were present in excessive numbers. One father insisted on rubbing his baby, a few weeks old, with cheap paraffin oil from head to foot to keep the flies away. As a result the child's neck, chest and face became extensively inflamed and blistered. He had seen it stated in the Press that paraffin was being used to destroy the larvae of mosquitoes, and concluded it would be equally effective in warning off the common house fly. The Mothers.—All except five of the mothers were attended in their confinements gratuitously, chiefly by students from St. Bartholomew's and the Royal Free Hospitals, and by midwives and student-midwives from the various charitable institutions in and near the borough. At the time of the first visit, 140 mothers were thin and in poor condition, 182 were personally and domestically dirty, 129 had insufficient food, 4 had been deserted by their husbands, and 8 were definitely ill, including one case of phthisis; 195 were said to be careless, 161 to be slovenly. Special attention was paid to the breasts; 75 mothers had dirty teats, 55 had sore and cracked nipples, 29 had insufficient or little breast milk. Fifty-eight mothers, or 29 per cent., attended the weighing centre, all did the usual housework at home, 8 were homeworkers, chiefly cardboard box makers, 15 went out to work as charwomen, street hawkers, costermongers, paper sorters and laundry women. Ninety-eight of the mothers, or nearly one half, had already lost 33 children under one year of age—two mothers had lost 6 such children, one mother had lost 5 babies, six had lost 4 children, and 13 mothers had had 3 infant deaths. Counting in older children over one year of age, one mother had lost 8 children, one had lost 7, four had lost 6 children, and three had lost 5 children. Reviewing the above facts— the large number of mothers in delicate health, insufficiently fed, ill, and deserted, results for which the mother is not to blame, and the numerous slovenly mothers personally and domestically dirty, with sore and dirty breasts, matters for which the mother is directly responsible, demonstrate the terrible odds with which their infants have to contend during the early months of existence. And, unfortunately, this personal filth and this domestic nastiness are evils which public health measures are almost powerless to amend or to abate. Further, the many mothers, who had already lost their young ones in previous years, shows the heavy toil that is paid in infant life for this noisome carelessness, and personal uncleanliness. In this connection it is interesting to note that when an infant dies, it appears to be a source cf satisfaction to the parents to say that they took the child to four or five hospitals, to a couple of dispensaries, and to three or more medical men. They then feel that they have done the best they can. In some cases the treatment advised by these various institutions is not carried out at home, and the medicines are not administered. In appraising these results, it must be remembered that they refer exclusively to the very poorest parts of the Borough—they must not be taken to apply to Finsbury as a whole. Illustrative examples.— 1. A mother had had nine children; only three were now alive. The other six had died from convulsions after passing their twelfth month. The mother seemed to be proud of this fact, and said, "You see I have brought them all up to their twelfth month." 2. A mother and her children were in bed at mid-day because " there was nothing to get up for." 34 3. A mother and her three children were found lying in an underground cellar. The father was in the workhouse. 4. A mother was so slovenly and dirty in her habits that her husband refused to live with her, but allowed her 15s. per week. 5. A mother suffering from anaemia resumed her work of making artificial flowers on the twelfth day after her confinement. The father was out of work. There was no money to buy milk in the house. 6. A mother had eight children. Five were still-born owing to the fact that the mother had to work exceedingly hard as a bookfolder, while still pregnant, "to keep the home together." The husband was out of work. The three living children were born during the period when her husband was in work, and she had merely her own household duties to attend to. 7. The father, mother, and five children lived in one room. The father came home at two in the morning, woke the mother up to cook him some supper ; she was quite worn out. The father, mother, baby and a child 2 years all slept in a bed four feet wide. Going back to bed, the mother breast-fed the baby and went to sleep suckling the child. The baby died overlain. The mother begged some cow dung from a neighbouring cowshed and put a "manure poultice" on her breasts to "dry up the milk." The Fathers.—The occupations of the fathers were as follows:—Labourers 73, Carmen 35, Porters 23, Street Hawkers, 15, Packers, Opticians, Organ Grinders, Potmen 3 each, Horsekeepers, Newsvendors, Fish Friers, Window Cleaners 2 each, the rest were employed in various other callings one in each. Of the labourers, 27 were out of work, only 21 were in regular work, 19 were employed casually. Of the carmen, 23 were in regular work, 12 were unemployed. The total number of unemployed amongst the 200 was 57, or 28.5 per cent. The unemployment record was as follows :— 35 Fathers idle during the twelve months preceding the first visit. Duration of Unemployment. Weeks 1-5 Weeks 5-10 Weeks 10-15 Weeks 15-20 Weeks 20-30 Weeks 30-40 Weeks 40-50 Totals. Labourers 3 10 14 5 5 6 1 44 Carmen 1 6 8 1 6 1 .. 23 Others 6 19 15 6 7 3 2 58 Totals 10 35 37 12 18 10 3 125 Illustrative cases.— 1. The father was an undersized man, with defective eyesight, who played an organ at street corners. The mother had recently been confined of twins, and was left at home in bed uncared for, unattended, and able to do very little for herself. One twin was subsequently found dead in bed. The father had been given a ticket to obtain the services of a Queen's nurse gratis, but had neglected to send. When the first twin died the priest was called in to baptise the second twin. The public health staff obtained the help of a nurse and were able to secure food for the mother. 2. The father was not yet 17, and had been out of work for 6 weeks. The mother was 19, the paternal grandmother 33 years. The first child was born when the father was 15 years 9 months. The mother had worked before marriage and continually ever since her marriage, save for the lying-in period. She worked up to within a few hours of her confinement hand colouring picture post cards. 3. The father was in prison, two children were in the workhouse. The mother was at work, and on her way home was taken in labour in the street, and removed to hospital. 4. The father blind and sold matches, or went out with a street organ. The mother was a charwoman. The baby was found at 36 home lying in bed with damp clothes on, and being looked after by a neighbour. 5. The father was out of work and was given employment in the country through the aid of the Distress Committee. At its completion he returned home to find his wife living with another man, the home almost entirely pawned, and the baby and the other children dirty and grossly neglected. 6. The father's wages ranged from 10s. to 12s. weekly. The family consisted of the parents and 5 children and occupied one back room. The walls and bedding were dirty. The room was overcrowded. The baby was nearly twelve months old, was undersized and insufficiently fed—it was having half-a-pint of cow's milk daily. Home circumstances and condition of the other children.—Of the mothers 196 were stated to be moderate drinkers, as compared with 190 fathers; one mother and five fathers drank to excess. In 174 homes there was evidence of poverty, in 18 households evidence of destitution. Not unfrequently when the Lady Health Visitors call on Monday morning they are unable to get access to the tenement but are informed by a neighbour that the mother has gone "to the pawnshop." It occasionally happens that on other days they may be shown by the mother pawntickets representing £2, £3, or £4 obtained in this way. Sometimes even the children's boots are pawned. In 124 families, the other children were thin and in poor condition, in 107 families they were ricketty, in 167 homes they were dirty, in 148 households they were badly clothed, in 65 families the other children were verminous. Illustrative cases.— 1. One back room was occupied for living and sleeping by a father, mother, and two children, aged respectively 19 months and 12 days. The room was clean, the bedding was clean. The baby was fat, smiling and clean. The only household utensils were four cups without handles and three saucers. There were no jugs, no knives, no forks, no spoons. 37 The husband was in casual employment. When out of work he caught birds and sold them at street corners. The tenement contained many chaffinches and linnets when the home was visited shortly after the birth of the baby. 2. The parents and 5 children—8 years, 7 years, 5 years, 3 years and 9 months respectively—occupie 1 one small room whose cubic content was 800 cubic feet. The room was dirty, although it had recently been stripped and cleansed. It was overcrowded. The window was kept shut, the room smelt very offensively, the floor was littered with household refuse and rags and grimed with dirt. The children of 8 and 7 years were at school clad in rags. The child 5 years of age was extremely badly clothed, and its face was covered with sores. The child 3 years old was very dirty and had sore eyes. The baby was unwashed at mid-day. The mother did not know her husband's age or his wages ; she received 8s. 6d. weekly from him. The father was seen and spoken to as to the dirty and neglected condition of his children and the home. He said, "The Distress Committee ought to find him work. They did in 1910, but only for four months." His employer stated the man's "wages were 10s. to 12s. per week and his food. He was not worth more, but he was honest.'' 3. A family consisted of the parents and 4 children all living. The father was a music street artist and had been out of work for 2 years. The tenement contained one bed, one chair bed, but no chairs or tables. The mother had a severe confinement and was very ill. Her medicine was placed on an inverted tub near the bed. 4. A family consisted of the parents, and 4 children, 8 years, 7 years, 4 years, and 7 months, all exceedingly dirty and neglected and occupying a two-roomed tenement. The mother was out at work. Access was obtained to the rooms after very great difficulty and many visits. The father was then found in bed at mid-day and stated he had been ill in bed for 8 weeks. The floor was 38 filthy to such an extent that the dirt could be shovelled up in flakes 1 to 2 inches thick. The owner was seen and stated that the tenant paid no rent, was under notice to quit, was employed by a neighbouring borough council, and that he had been unable to obtain access to the rooms for some considerable time. When the Lady Health Visitor made her re-visit, the tenement was empty. The family had removed secretly during the night time. The Tenements.—The use and occupation of each tenement is given in the attached table:— Occupants. 1 Room. 2 Rooms. 3 Rooms. 4 Rooms. Parents, 1 child 14 – – – „ 2 children 19 5 – – „ 3 „ 31 15 – – „ 4 „ 18 20 1 – ,, 5 ,, 3 24 2 – „ 6 ,, 3 22 2 2 „ 7 „ – 4 4 1 „ 8 „ – 5 2 – „ 10 „ – 1 1 1 Totals 88 96 12 4 Eighty-eight families or 44 per cent, lived and slept in one room only. In 192 tenements the kitchen was also used as a sleeping room owing to the lack of other suitable accommodation. Twelve of the tenements were damp, 189 were dirty, 66 were dark, and 192 were stuffy and badly ventilated—the windows were rarely opened. In 130 instances the walls were verminous, in 116 homes the vermin had invaded the picture frames in profusion. The bedding was dirty in 185 cases, insufficient in 179, and verminous in 99 39 holds. There was a fireguard in 82 homes. The cupboard accommodation for food was insufficient in 190 tenements; in 165 there was no separate provision for the storage of coal or coke. This absence of proper cupboard accommodation presses very hardly upon the poor. It is difficult for them to keep their food clean or milk unpolluted when they have to keep their clothes, food and coke in one and the same cupboard. The cupboard has then to be used as wardrobe, larder, and coal-cellar. When this is the case, it is usual to find the women's hats on the top shelf, the food on the middle shelf, and the coke in the lowest compartment. The men's best clothes are then placed between the mattress and the palliasse, where they harbour vermin until these are shaken out on Sunday preparatory to being worn. Sometimes when the cupboards are provided, the occupants will not use them alleging that they are over-run by mice ; in other cases there are no shelves— these are stated to have been burnt for firewood by previous tenants and not to have been replaced. In one house the family kept chickens in the top compartment, food and household utensils in the middle part. In another house, not connected with the present enquiry, ducks were kept in a similar situation. In 119 tenements there was a separate washhouse, in 67 cases the washing was done in the yard, in 9 instances in the basement, and in 4 households in the living room. One family used the public baths of a neighbouring borough. It is very important that washing accommodation should be available for every tenement, easy of access and convenient. In some houses, however, the washing coppers are placed in very unsuitable situations—as for example under a basement, the approach to which is by means of steep steps under a low floor—too precipitous for a woman to use with safety or comfort even when not burdened with a basket of clothes, and so constructed that it would be difficult for her to bring the clean clothes out without soiling them against the ground floor joists or basement ceiling Further there is sometimes no water laid on in such a basement, so that as a consequence the copper is hardly ever used. In these circumstances the woman boils a few things in a pail or bucket on her own kitchen fire. 40 Unfortunately, even when suitable washing coppers are provided, they are liable to be grossly misused or wilfully damaged. It is not at all uncommon to find the washing copper used for boiling beetroot with a minimum amount of water. "The steam is kept in" by covering the top of the copper with the fouled lid of the ash-bin. The copper may crack in the process. The beetroot is subsequently sold from hawkers' barrows or from baskets in the market streets. In 3 houses, not connected with the present investigation, the coppers were being used for melting waste fat, for ham boiling, and for fish boiling, so that the other occupants of these houses were deprived of the use of the coppers for purposes of washing. In addition to the various nuisances described in the foregoing pages— 21 other sanitary defects were found. Notices were served for all these and abatement obtained. Length of residence in Finsbury.—Thirty-seven families, or 18.5 per cent., had lived in the borough for one year or less; 83, or 41.5 per cent., for five years or less. Removals, however, from one address to another were quite common in a large number of cases. These removals add a great deal to the work of watching over the progress of the babies. Reasons for cessation of visits.—These were various and as follows:—The baby's condition was satisfactory and improving. The family removed and was lost sight of—75 babies were withdrawn from supervision in this way, a larger number than that due to any other cause. In a few cases the mother was always out, or was ignorant and apparently unable to understand the instruction given. Fifteen of the babies died. Others were received into hospital or infirmary. In three instances the visits were said to be merely a "waste of time." 41 Action taken.—The Public Health Department supplies some details at cost price to mothers, gratis to poor mothers, e.g. lubeless milk bottles, special rubber teats, milk jug covers, bristle brushes for milk bottles, "Finsbury cream," woollen vests, and pneumonia jackets. The vests are knitted by school children in the district, by the kindness and courtesy of the head-teachers. A small book on the management of children is left with each mother, and its use explained. An invitation is given to her to attend the weighing centres and have her baby weighed regularly. Special attention is paid to the abatement of certain matters which may react adversely upon the progress of the infant— phthisis, overcrowding, domestic dirt, house refuse disposal, the condition of the gullies and the water-closets. Definite instruction is given as to the best feeding, clothing, and washing of the child. Mothers who are ill are referred to their own doctor, or tickets are given available at hospitals or dispensaries. Mothers who are poor are directed to the various religious and philanthropic institutions, and occasionally in urgent cases to the poor law authorities, who have on every occasion proferred ready help. Summary — the problem stated.—The present enquiry showed that amongst the very poorest households in the borough many mothers and their children were personally dirty, clad in dirty clothes, and living in domestically dirty and squalid surroundings. For these matters, though education, sympathy, moral suasion, willing help and better housing may do much, yet in the end the appeal must be a personal one. Fresh public health legislation in bulk will not cleanse the bodies of the unclean, or remove the grime from their clothes. 42 The effort for advancement, the will and the desire for improvement must emanate from the individual. On the other hand the number of mothers insufficiently fed, deserted, ill, or working in workshops, or at home as outworkers shows that there is in these poorest homes another and a more acutely pressing and insistent trouble. Mothers who are not supported by their husbands, mothers who have to work hard to keep the home together, cannot reasonably be expected to rear healthy, sturdy and smiling infants. It must sooner or later be realised that in these poor homes the successful upbringing of children is largely, if not chiefly, an industrial problem and only, possibly, in the second instance a matter of public health and education. Public health measures are only palliative ; the problem is that of the prevention of poverty. MIDWIVES ACT, 1902. In London this Act is administered by the London County Council as the Local Supervising Authority. In 1911, twenty midwives resident in Finsbury gave notice of their intention to practise. The following institutions train and educate midwives for work in the Borough :— The City of London Lying-in Hospital, City Road. The Maternity Nursing Association, 63, Myddelton Square. The Royal Maternity Charity, 31, Finsbury Square. The Royal Free Hospital, Gray's Inn Road. In addition to the above, the medical Students of St. Bartholomew's Hospital and the lady medical students of the Royal Free Hospital attend Finsbury mothers, under the supervision of qualified resident medical officers. PUERPERAL FEVER. This disease is compulsorily notifiable by Section 55 of the Public Health (London) Act, 1891. In 1911, there were 4 notifications and 3 deaths. 43 The number of notifications and deaths in previous years are appended. Puerperal Fever. Year 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 Notifications 5 6 8 5 6 7 3 4 6 7 4 Deaths 4 5 4 5 0 5 1 3 2 6 3 This year both the number of deaths and notifications are less than in 1910. In 1911 there were registered in the district 8441 births, and in only four cases were the mothers notified to be in peril owing to puerperal fever. It may, therefore, be confidently asserted that the work of attending women in their confinements is, on the whole, carried out extremely well in Finsbury. The four cases in the present year were attended—two by student midwives of the Royal Free Hospital, one by a registered midwife, and one by a medical student from St. Bartholomew's Hospital. The associated causes were stated to be prolonged labour (2), retained portions of the afterbirth (1), and in one instance presumed infection from a previous case attended by a student from St. Bartholomew's Hospital. Every case was made the subject of a special enquiry by the Lady Sanitary Inspector, the premises were visited and disinfected ; the sanitary defects were ascertained and made the subject of subsequent notice for amendment. 44 DEATHS AND DEATH RATES. The number of Finsbury residents who died in 1911 was 1,697, equivalent to a crude death rate for the whole Borough of 19.4 per 1,000 inhabitants living. The corrected death rate for the whole of London was 15.8, as compared with 12.7, 14.03, 14.0, and 14.6 for the years 1910 to 1907 respectively. The crude death rates for previous years are given in the attached table. They have all been re-calculated on the basis of the new populations estimated on the results of the recent census. CRUDE DEATH RATES. Year. The Borough. Clerkenwell. St. Luke. St. Sepulchre. 1901 21.4 20.1 23.5 19.1 1902 22.8 21.8 24.7 21.3 1903 20.2 19.0 22.3 19.7 1904 21.4 20.6 22.8 24.0 1905 19.3 18.1 21.1 26.3 1906 21.4 21.1 21.5 26'.1 1907 I9.1 17.3 21.8 26.6 1908 19.2 18.7 20.6 11 .1 1909 20.1 19.1 21.6 24-.0 1910 18.4 17.7 19.6 17.3 1911 19.4 19.3 19 .45 11.7 It will be observed that this year the general death rate shows a slight increase which is to be correlated in part to a larger number of deaths ascribed to Diarrhoea, Enteritis, and Measles. The table shows that the death rates in St. Luke are generally higher and in Clerkenwell lower than the rates for the whole of the Borough. It will be seen, too, that with one or two slight variations the death rate in St. Luke tends to show a progressive diminution during the last eleven years. 46 The Clerkenwell death rates, however, are rather uneven from year to year. This difference between St. Luke and Clerkenwell is possibly to be associated with the fact that the population in St. Luke is, as compared with Clerkenwell, believed to be more stable, less migratory. At the time of writing the factor for age correction derived from the recent census is not available. This factor enables one district to be compared vith another, and smooths down the irregularities which depend upon differences in the ages and sexes of the populations of the different areas. The old factor for correction in Finsbury was 1.0355. Multiplying this number by 19.4 the crude death rate gives a corrected death rate ot 20.08 per 1,000. There is, however, still another correction to be made in the case of Finsbury due to the number of residents detained in institutions outside the Borough. When these are taken into account the crude death rate becomes 18.9 per 1,000. This, multiplied by the factor 1.0355, gives a fully corrected death-rate of 19.6 per 1,000. The corrected death rate for Finsbury calculated by the Registrar General is 20.5 per 1,000 inhabitants. Adopting for Finsbury the fully corrected death rate of 19.6 per 1,000 given above, then for the present year, Finsbury has the second highest death rate amongst Metropolitan Boroughs, being placed below Shoreditch alone, which has a corrected death rate of 211 per 1,000. Poplar comes third with a corrected death rate of 19.5 per 1,000. The comparison of Finsbury with the rest of the country may be seen below:— Corrected Death Rates for 1911. England and Wales 14.6 London 15.8 Finsbury 19.6 77 Great Towns 16.4 136 Smaller Towns 14.4 Rural Districts 13.1 46 The Finsbury deaths were apportioned as follows—Clerkenwell, 1,101; St. Luke's, 570 ; St. Sepulchre, 26 deaths. The deaths from the following causes are less this year than last year:—Diphtheria, Hooping Cough, Influenza, Puerperal Fever, Phthisis, Bronchitis, Pneumonia, Alcoholism and Cirrhosis of the Liver, and Premature Birth—whereas in the case of Enteric Fever, Measles, Scarlet Fever, Diarrhoea, Enteritis, Bright's Disease and Tuberculous diseases other than Phthisis, the number of deaths is increased. The deaths of residents in public institutions were : In general hospitals, 238 (252); in special hospitals, 34 (42) ; in fever hospitals, 50 (23) ; in poor-law institutions, 558 (533); in asylums, 44 (24); in various hostels, homes of rest, and homes for babies, 22 (18); the figures in brackets are the corresponding numbers for the previous year. It will be observed that 558, that is over 32 per cent, or nearly one-third ot the whole number of deaths occurred in poor-law institutions. The following table gives the numbers of deaths of Finsbury residents that have occurred in public institutions since 1901. Deaths in Public Institutions Year. Total Deaths. Deaths in Public Institutions of Finsbury Residents. Percentage. 1901 2,161 876 40. 1902 2,283 908 39.8 1903 1.993 870 43.6 1904 2,084 965 46.3 1905 1,855 886 47.8 1906 2,020 1,020 50.5 1907 1,774 911 51.3 1908 1,767 891 50.4 1909 1,814 988 54.4 1910 1,636 889 54.3 1911 1,697 946 55.7 47 These deaths in public institutions are in Finsbury mainly "transferable" deaths, that is, deaths of persons who, having a fixed or usual residence in England or Wales, die in a district other than that in which they usually reside. Persons who die in Institutions for the sick or infirm (saving almshouses) are regarded as residents of the district in which they had a fixed or usual residence at the time of admission. If the person dying in an Institution had no fixed residence when admitted, his death is not transferable, and is accredited to the district in which the Institution is situated. If the patient has been transferred from one Institution to another, the death is accredited to the district of residence at the time of admission to the first Institution. The deaths of infants born and dying within a year of birth in an Institution to which the mother was admitted for her confinement are referred to the district of fixed or usual residence of the parent. Deaths from violence are referred :— (a) To the district of residence. (b) If this is unknown, or if the deceased had no fixed abode, to the district where the accident occurred, if known. (c) Failing this, to the district where death occurred, if known. (d) Failing this, to the district where the body was found. These are the rules of the Registrar General. Let us see how they operate in practice. 1. A male 28 years died in February, 1911, at Folkestone. He had given a Finsbury address and his death was therefore being accredited to Finsbury. On enquiry it was found that the deceased had never lived in the Borough—the address given was a business address only. No one lived on the premises. His permanent address was refused. 2. A male 54 years died in the West Ham Hospital. He had given a Finsbury address where he had lived for six months prior 48 to his admission to hospital. Previous to this, he had lived for some years in Islington. His death was accredited to Finsbury. 8. A child nine months old died in the Holborn Infirmary in August, 1911. The mother had given a Finsbury address; she had never resided in Finsbury and had lived and was still living iu St. Pancras when her child died. The child had been put out to nurse in Finsbury a short lime before its deatn. It is alleged that a false statement was made to the Relieving Officer as to the domicile of the mother so that the child was buried by the Holborn Guardians. The death was attributed to Finsbury. 4. A child died in the City Road Workhouse. The mother had given a Clerkenwell address where she had been a servant. The mistress of the house had noted her condition, and gave her notice to leave before her confinement. She then went to live in Holborn. She was confined in the City Road Workhouse. She obtained admission here by wrongly asserting she lived in Clerkenwell. Had she given her correct address, she would have been confined in the Endell Street Workhouse, Holborn. There was an objection to this course. She had already, it is stated, had a previous illegitimate child in the Endell Street Workhouse. The child's death was accredited to Finsbury. 5. A male 77 years of age died in Walthamstow. He had given a Finsbury address, and his death was being counted amongst the Finsbury returns. It was found that he had lived for 72 years in the City of London, then for four years in Finsbury, and subsequently for six months in Walthamstow, where he died. When these facts were brought to the notice of the RegistrarGeneral the death was then attributed, not to the City of London, where he had lived for 72 years, but to Walthamstow, where he had stayed for six months. The above cases show the difficulties, the inequalities, and the public health odium which may attach to a district through the 49 present method of transferring deaths from one district to another. The method has one advantage—it prevents disputes as to settlement and length of residence, and, as a rule, easily achieves finality. It may, however, react unfairly in the case of those areas which possess hospitals or other humane institutions, and equally unfairly in the case of districts like Finsbury which adjoin such areas. In Finsbury many young children are brought into the borough and, shortly after, are received into the neighbouring hospitals or into the poor law infirmary. Later, although they may have resided in this borough for a very short time, their deaths are counted in the Finsbury returns. Reference has been made in previous reports to the frequent occurrence of this matter in cases of phthisis. This method, then, of transferring deaths may lead to a considerable increase in the number of dumped deaths and thereby burden the district with a fictitiously heavy death rate. This unreal death rate is of no moment if the correct cause is remembered, but, unfortunately, the general public have come to regard the official regional death rates as infallible and incontrovertible and as defining with the utmost nicety and precision the efficiency of the public health administration in the impugned district. The belief that the inhabitants of the district are now generally poorer than they were years ago is confirmed by the fact that the percentage of deaths which occur in public institutions is slowly, and with slight remissions, continuously increasing. The percentage of the total deaths— 32.8 per cent, of the whole, which occurred in the wcrkhouse or workhouse infirmary—is a fair criterion of the poverty which exists among many inhabitants of the district. Deaths from Exposure and Destitution.—There were three deaths in the district which were accelerated by destitution and exposure. Two were widows—one was a male. Two were from Clerker well, ere from St Luke's. They all died in poor law institutions, two from pneumonia, one from Bright's disease. 50 INQUESTS. During the past year 198 inquests were held in the Borough. This number includes the inquests on six non-residents who died in Finsbury. The causes of death were as follows : — Adults and Children over 5 years— 2. Other causes (89). 135 deaths. Heart Disease 20 1. Accidental causes (46) comprising:— Suicide 16 Accidental falls 28 Bright's Disease 13 Accidental burns and scalds 6 Alcoholism 8 Run over by motor cars 3 Pneumonia 7 Accidental poisoning 2 Phthisis 6 Accidental suffocation 2 Bed sores 3 Run over by van or engine 2 Cirrhosis of liver 3 Accidental crush between rail- Disease of blood vessels 3 way trucks 1 Peritonitis 3 Accidental injuries causing blood poisoning 1 Accidental shooting 1 And the following one each : Gangrene of Buttock, Strangulation of Intestines, Tuberculous Meningitis, Diarrhœa, Heat Stroke, Murder; and Gastric Ulcer. Children under 5 years of age—63 2. Other causes (33). deaths. Pneumonia and Bronchitis 10 1. Accidental and violent causes (30) Diarrhœa 3 Overlain in bed by parents 15 Measles 3 Accidental falls 5 Premature Birth 3 Accidental burns and scalds 3 Tuberculous Meningitis 3 Accidental suffocation 2 Distended stomach pressing on Run over by horse and van 2 heart 2 Accidental blood poisoning— Heart Disease 2 buttocks chafed by a napkin 1 Strangulated Bowel 2 Accidental blow on head from cricket ball 1 Accidental haemorrhage 1 And the rest one each: Phthisis, Want of attention at birth, Marasmus, Haemorrhage into brain at birth, and Internal Haemorrhage. INFANTILE MORTALITY. The infantile mortality of any district for any stated year means the number of deaths of children under one year per 1,000 51 births. The corrected number of births of Finsbury children for 1911 is 2,676. In the same year 411 children died under one year of age and belonging to the Borough. The infantile mortality is obtained by multiplying the number of deaths under one year (411) by 1,000, and dividing the result by the number of births (2,676) for that year. The infantile mortality of the Borough for 1911 is 154; expressed in popular manner this means that out of every 1,000 children born during the year 154 died before reaching their first birthday. The corresponding figures for previous years are annexed : — Infantile Mortality, 1901-1911 Year. Corrected Births. Corrected Deaths. Infantile Mortality. 1901 3,254 533 163 1902 3,191 558 174 1903 3,162 503 159 1904 3,095 522 168 1905 2,886 429 148 1906 3,012 474 157 1907 2,884 368 127 1908 2,916 400 137 1909 2,857 366 128 1910 2,833 342 121 1911 2,676 411 154 The number of infant deaths in 1911, and the corresponding infant mortality were both last exceeded in 1906. This increase in 1911 was foreshadowed in the annual report for 1910. 52 The following table compares Finsbury with London and England and Wales generally:— Infantile Mortality * for 1911. England and Wales 130 Whole of London 128 Finsbury 154 77 Great Towns 140 136 Smaller Towns 133 Essentially Rural Districts 118 The Infantile mortality of Finsbury is 20 per cent, greater than the figure for the whole of London, and 10 per cent, more than the infantile mortality prevailing in the 77 great towns. From the Registrar General's returns it appears that among metropolitan boroughs, Finsbury and Bermondsey have an equal infantile mortality, which is surpassed by the corresponding figures for Shoreditch and Poplar which are 170, and 157 respectively. In 1911 the infant mortality was increased throughout the whole country chiefly owing to the excessively hot summer. The deaths of infants allocated to the various diseases are given in the following table, which contains the records for the last five years:— 53 Infant Deaths. 1911. 1910. 1909. 1908. 1907. Measles 20 14 23 10 12 Diphtheria 1 4 1 – 2 Scarlet Fever – – – – 1 Hooping Cough 10 12 21 7 16 Gastritis 2 – 2 – 42 Diarrhœa 75 85 46 59 Enteritis 40 7 16 21 Premature Birth 69 83 60 62 61 Congestion Defects 2 7 7 14 13 Atrophy, Marasmus 43 33 50 42 55 Tuberculous Meningitis 8 4 7 9 3 Other Tuberculous Diseases 2 5 5 10 7 Erysipelas – 1 1 – 2 Syphilis 8 9 9 7 3 Convulsions 8 7 3 18 14 Bronchitis 24 15 21 21 36 Pneumonia 38 63 47 50 49 Suffocation in bed 15 18 21 29 20 Other Causes 46 25 26 41 32 Totals 411 342 366 400 368 This year there is an increased number of deaths due to measles, diarrhœa, enteritis, marasmus and wasting conditions; a diminished number due to diphtheria, hooping cough, premature birth, chest complaints, and overlying. The deaths from diarrhœa and enteritis are excessive, and are referred to below. 54 The deductions which may reasonably be made from the foregoing tables have been given at full length in previous annual reports. Deaths from Diarrhoea and Enteritis.—There were 115 deaths due to these causes, in children under one year, 24 deaths in children between 1 and 2 years, and 13 deaths at other ages. Confining our attention to the children under one year, 7 of the children died under one month, 19 between 1 and 3 months, 42 between 3 and 6 months, 21 between 6 and 9 months, and 26 between 9 and 12 months of age. The largest number died in Finsbury between the ages of 3 and 6 months. Eighty-six per cent, of the children died during the very hot weather in July, August and September—the number of deaths during these months were 19, 47 and 33 respectively. Fifty-four or nearly half the infants died in hospitals or poor law institutions. Ten of the children were illegitimate. The methods followed in dealing with the epidemic arc outlined below. The Notification of Births Act has been adopted in Finsbury, and all the births in the poorer parts of the Borough are visited by the Lady Health Visitors. Special attention is given to those births in streets where the infant mortality is excessive. Leaflets on infant feeding and on the prevention and treatment of summer diarrhoea are distributed and explained by the public health staff, and suitable practical advice given to the mothers. Sanitary feeding bottles, appropriate teats, and milk-jug cloth covers are given gratis or sold at cost price. During the hot summer months a special watch is kept over the disposal of household refuse, and notices for the abatement of nuisances served at once. 55 In 1911, the Lady Sanitary Inspector paid rapid visits to the areas where the stress was greatest to offer advice, to distribute dispensary tickets, to secure the prompt amendment of nuisances, and to impress upon parents in affected households the absolute necessity of immediate treatment. Re-visits were paid to see that this last course was taken. In 1912 it is proposed to distribute bristle brushes for the more efficient cleansing of the feeding bottles. The general measures applicable to these cases of diarrhoea, and also to the supervision of all infants, whether ill or not, are detailed at sufficient length in the earlier part of this report. The distribution of the deaths was fairly equable over the whole Borough, and affected the better and the poorer districts involving altogether families in 77 different streets. The largest number of deaths were in the following localities : — Lever Street and Guinness Buildings (9), Penton street (4), Baldwin Street (3), Cumming Street (3), Parrs Place (3), Pentonville Road (3), Risinghill Street (3), Albert Street (2), Bartholomew Buildings (2), Dingley Road (2), Donegal Street (2), Galway Street (2), Gee Street (2), Hatfield Street (2), Holford Square (2), Macclesfield Street (2), Radnor Street (2), Rahere Street (2), Roscoe Street (2), Skinner Street (2), Smith Street (2), White Lion Street (2), Wilmington Place (2), and Winchester Street 2 deaths. In the other affected streets the deaths were one in each street. A priori, one would have expected to have had more deaths in Warren Street, Easton Street, Margaret Street, St. Helena Street and other streets inhabited by the very poorest. The explanation of their comparative immunity is to be found in the constant and continuous supervision by the public health staff of all the births in these streets. This supervision means the adoption of preventive measures, the securing of prompt medical treatment, and the early removal to hospitals and infirmary of infants definitely ailing. 56 Infant Deaths in previous years.—The number of infant deaths and the infant mortality rates for the period 1901-1911, arranged according to districts, are given in the annexed table :— Infant Deaths and Infant Mortality Rates. † Year The Borough. North Clerkenwell. South Clerkenwell. St. Luke. St. Sepulchre. No. of Infant Deaths Infant Mortality No. of Infant Deaths Infant Mortality No. of Infant Deaths Infant Mortality No. of Infant Deaths Infant Mortality No. of Infant Deaths Infant Mortality 1901 *533 163.8 158 149.2 124 139.6 172 137.0 6 162.1 1902 588 174.9 183 173 .3 152 172.7 217 178.4 6 157.9 1903 503 I59.1 163 153.8 125 142.2 2IO 176.5 5 151.5 1904 522 168.6 191 177.2 123 147.8 206 178.7 2 60.6 I905 429 148.6 146 148.2 98 121.7 178 165 .5 7 333.4 1906 474 I57.3 183 172.5 116 I35.9 166 157.0 9 219.5 1907 368 127.0 119 116.5 105 I35.1 136 128.3 8 307.7 Clerkenwell 1908 400 137.0 Infant Deaths. Infant Mortality. 163 150.1 1 34.5 1909 366 128.0 236 131.0 131 1300 6 300.0 219 I35.0 1910 342 121.0 219 122.0 120 1200 3 71.0 1911 411 154.0 251 145.0 156 1690 4 181.0 *The return for 1901 includes 73 infant deaths taking place outside the Borough but belonging to Finsbury, and which cannot now be distributed in districts. Throughout the table, births taking place in the City of London Lying-in Hospital, but not belonging to Finsbury have been excluded and the births taking place in City Road Workhouse and other places belonging to Finsbury have been included. † Contains the Corrected Rates calculated by the Medical Officer. Distribution of Infant Deaths.—In 1911 the largest number of infant deaths occurred in Risinghill Street (11), Baldwin Street (10), Gee Street (9), Bartholomew Buildings (9), White Lion Street (9), Lever Street (8), Donegal Street (7), Dufferin Street (7), Easton Street (6), Peabody Buildings, Dufferin Street (6), Peabody Buildings, Roscoe Street (6), Radnor Street (6), Rahere Street (6), Rodney Street (6), Roscoe Street (6), Albert Street (5), Bakers Row (5), Cumming Street (5), Hermes 57 Street (5), King's Cross Road (5), Macclesfield Street (5), Northampton Buildings (5), Pentonville Road (5), St. Helena Street (5), Warren Street (5), Wilmington Square (5), Buxton Street (4), Coldbath Square (4), Dingley Road (4), Galway Street (4), Ironmonger Row (4), Little Sutton Street (4), Myddelton Street (4), Parrs Place (4),Penton Street (4), Percival Street (4), President Street (4), Vineyard Walk (4), and Wynford Road 4 deaths. CANCER. In 1911, death was accredited to cancer in 81 persons, of whom 42 were males and 39 females. The death rate was 0.92 per 1,000. The deaths in previous years from 1901 onwards were 72, 72, 92, 79, 65, 84, 86, 87, 88 and 79, respectively. The following table shows the deaths distributed according to sex and age:— Cancer Deaths, 1911. Ages. Under 10 years. 10 and under 20. 20 and under 30. 30 and under 40. 40 and under 50. 50 and under 60. 60 and under 70. 70 and upwards. Total. Males 1 — — 3 7 12 13 6 42 Females 1 I — 1 5 16 5 10 39 Totals, 1911 2 I — 4 12 28 18 16 81 Cancer Deaths, 1901-1911. Ages. Under 10 years. 10 and under 20. 20 and under 30. 30 and under 40. 40 and under 50. 50 and under 60. 60 and under 70. 70 and upwards. Totals. Males 7 8 10 20 51 116 140 84 436 Females 4 5 29 85 125 109 90 449 Totals 9 12 15 49 136 241 249 174 385 58 Most of the deaths occur between 50 and 70 years;—between 40 and 50 the females exceed the males, between 50 and 60 the sexes are very nearly equal—after 60 the males are the more numerous. The parts affected are set out below:— Cancer of various parts of the body. 1911. 1901-10. Total. Face, Tongue and Jaw 6 75 81 Throat, Neck and Gullet 9 77 86 Stomach 5 107 112 Intestines 16 154 170 Liver 8 92 100 Pancreas 3 18 21 Breast 11 67 78 Womb 13 116 129 Various 10 98 108 Totals 81 804 885 The sites of the disease differ in the two sexes—in man they are chiefly those parts concerned with feeding and assimilation of food, the mouth, tongue, liver and intestines, in woman the parts concerned with child bearing and reproduction, the womb, and the breast. ALCOHOLISM. Alcoholism and Cirrhosis of the Liver caused 29 deaths in 1911. Cirrhosis of the liver is the euphemism under which, in deference to the susceptibilities of relatives and friends, alcoholism is masked on death certificates. It is quite uncommon to find alcohol entered as a cause of death, except in the case of those who are friendless, homeless, unknown, destitute, or who die in the workhouse or workhouse infirmary. 59 The deaths from both these are appended :— Years. Alcoholism and Delirium Tremens. Cirrhosis of Liver. Total. 1901 11 22 33 1902 27 21 48 1903 22 29 51 1904 19 25 44 I905 8 22 30 1906 21 31 52 1907 20 26 46 1908 10 21 31 1909 12 34 46 1910 14 26 40 1911 11 18 29 Totals 1901-11 175 275 450 In addition to the numbers given above there will be other deaths due to alcoholism, but in which it has been omitted as the primary cause from the certificate and the secondary cause or terminal disease alone inserted. Thus many of the deaths of young adults from pneumonia, many of the cases of Bright's disease of the kidneys, some of the deaths due to " influenza " or bronchitis, many street and night accidents, and possibly some of the cases of overlying are attributable directly or indirectly to alcohol. It will be noticed that in the above table the deaths from cirrhosis of the liver much outnumber the deaths from alcoholism. This alone is eloquent of the desire to exclude the presence of alcoholism from the certificates of the causes of death. 60 The ages at death are shown in the following table: — Age. 10-20 20-30 30-40 40-50 50-60 60-70 70-80 Total. No. of Males 0 0 4 3 3 2 0 14 No. of Females .. 0 0 0 5 6 2 2 15 The youngest was a man aged 33, the oldest a woman aged 73 years. As far as these results go, only three of these cases were connected with the trade. Eight of the cases died in poor law institutions. CONSUMPTION OF THE LUNGS. Notification.—Finsbury was one of the very first boroughs to adopt the voluntary notification of phthisis. This was in 1900, or eleven years ago. From the very first the cases were visited by the public health staff, suitable enquiries made and advice given. A leaflet of instruction was left with the patient, and disinfection of the premises was offered. The notification of patients in Poor Law institutions was made compulsory under the Public Health (Tuberculosis) Regulations of the Local Government Board, which came into force on tie 1st of January, 1909. By the Public Health (Tuberculosis in Hospitals) Regulations, 1911, phthisis from the 1st May, 1911, was made compulsorily notifiable in all hospitals, dispensary and institutional patients. Finally by the Public Health (Tuberculosis) Regulations, 1911, a general order was issued by the Local Government Board making all cases of pulmonary tuberculosis compulsorily notifiable from the 1st January, 1912. The notifications and deaths of Finsbury cases of phthisis since 1901, ara appended : 61 Phthisis Notifications and Deaths, 1901-1911. Total No. of Notifications. No. of Cases notified per 10,000 of inhabitants. Total No. of Deaths Death Rate per 1,000. 1901 70 6.9 216 213 1902 121 12.1 240 2 40 1903 219 22.2 223 226 1904 2IO 21.6 251 2.57 1905 178 18.5 215 2.24 1906 217 22.9 232 2.45 1907 217 23.2 243 2.60 1908 220 23. 9 221 2.40 1909 359 39.7 228 2.52 1910 319 35.8 166 1.86 1911 419 47.8 159 1.81 The actual number of notifications received in 1911, was 1,183; in 1910, 1,033, but of these many refer to the same patient. In 1911 there were 419 primary notifications, of which 152 were poor law cases, in 1910, the corresponding numbers were 319 primary notifications, of which 188 were derived from poor law sources. In reference to the 152 poor law cases in 1911, there were received 916 notifications, re-notifications, and notices of discharge. This means that on an average 6 notifications were received in respect of each poor law case. In 1910, the poor law cases were 188 in number, and 902 notifications, re-notifications and notices of discharge were received. From private doctors were received 62 notifications; under the Tuberculosis Regulations, 1908 and 1911, the notifications received were 152 and 161 respectively. Two hundred and sixty-three gave a Clerkenwell address, 151 St. Luke, and 5 St. Sepulchre. Forty-four cases were notified in school children by the London County Council school doctors. Institutions.—The institutions and the number of notifications from each are appended :— 62 Holborn Union Workhouse and Infirmary, 140; the Finsbury Dispensary, Brewer Street, 57; St. Bartholomew's Hospital, 50; the Royal Chest Hospital, City Road, 49; Mount Vernon Hospital, Hampstead, 7; Brompton Chest Hospital, 5; Royal Free Hospital, 5; Royal General Dispensary, Aldersgate, 5; University College Hospital, 5; St. Catherine's Hospital, Ramsgate, 4; Fairlight Sanatorium, Hastings, 3; Margaret Street Dispensary,W., 3; National Sanatorium, Benenden, Ke it, 2; Royal Sea Bathing Hospital, Margate, 2; and one each from the following:—Bloomsbury Dispensary; Darenth Asylum; Eversfield Chest Hospital, St. Leonards; Farringdon General Dispensary, Holborn; Firs House Hospital, Bournemouth; Friedenheim Hospital, Hampstead; Hendon Asylum; Kensington Poor Law Infirmary; Leavesden Asylum; Metropolitan Hospital, Kingsland; Middlesex Hospital; National Hospital, Isle of Wight; North Eastern Hospital, Hackney; St. Anthony's Hospital, Cheam; St. George's Hospital; St. John's Hospital, Paddington; St. Joseph's Convalescent Home, Bournemouth, St. Luke's House, Kensington; St. Pancras Dispensary, rnd Victoria Park Hospital, London. The list shows that 29 Finsbury patients received institutional treatment in a sanatorium. Finsbury Cases.—A patient is said to belong to Finsbury by residence when he has resided in the Borough for at least 5 years, or, if not yet 5 years of age, since his birth. The period 5 years has been arbitrarily assumed as one of a reasonable duration entitling to a public health settlement, and also because it is generally asserted that the average duration of a case of phthisis from early demonstrable clinical signs to death is about 5 years. A case is accredited to Finsbury by infection when the presumed duration of the disease, as e'icited by enquiry, is less than the length of the patient's residence in the Borough. Adopting these definitions, the cases may be grouped as follows 63 1. Finsbury cases by residence and infection 225 2. Finsbury cases by infection 31 3. Finsbury cases by residence 18 4. Cases from common lodging houses 13 5. Cases homeless, or giving false addresses or about whom no information could be obtained 29 6. Cases probably not phthisis 6 7. Not Finsbury cases 97 419 The cases, which may be definitely associated with the Borough, are the first two groups, and amount to 256, that is, to 61 per cent, of the whole number. The Finsbury cases by residence had definite signs of the disease before living in the Borough. Very little information could be obtained about the cases from common lodging houses. These patients are generally nomadic and homeless. Here are the movements of one such case:—He lived in Battersea for 15 years and then took to the road for a few years, staying in common lodging houses for one or two days at a time. Then he settled down in Bristol for 8 weeks, went on to Plymouth for 6 weeks, tramped to Liskeard and stayed 6 weeks. Next he came to the Salvation Army Home, Bermondsey, and remained 3 weeks, came on to the Church Army Home in Finsbury and stayed 3 days. Twenty-nine of the cases were homeless, or gave false Finsbury addresses, sometimes the address of a brother, sister, daughter, brother-in-law, friend, or casual acquaintance. They sought by this means to achieve a Finsbury settlement, so as to obtain admission to the local workhouse infirmary. The " cases probably not phthisis " were those notified by school doctors and thereafter re-examined by experts in the large general hospitals,who failed to find evidence of the disease. 64 The cases which were "not Finsbury " were those which had the disease when they first came into the Borough, and who had also lived here for less than 5 years.. Some cases live in common lodging Houses, Rowton Houses, or in other philanthropic institutions, and wilfully give a fictitious address in order to escape the supervision which naturally follows notification. Very many of the poor law cases do this, and it is only after repeated enquiry and much difficulty that the permanent address is obtained, or, if this is not available, where the patient has recently been sleeping. Sometimes when the correct address is given, the present occupant of the house denies that the patient ever stayed there. In one such case, a woman was a domestic servant and had clandestinely harboured her husband who suffered from phthisis on the premises unknown to her master. From time to time the man left his wife and stayed at Rowton House, and with his sister at a Finsbury address. His sister at first denied that the patient had ever stayed there and concealed her relationship. One hundred and fifty-six beds are set apart in the Holborn Poor Law Infirmary for the treatment of males with phthisis, and 56 beds for the treatment of females so suffering. Sex and Age.—The notified cases, classified according to sex and age are given below : — Years 1-2 2-5 5-15 15-25 25-45 45-65 65 and over Males 2 2 43 24 113 66 6 Females ... o 4 38 20 64 29 8 Totals 2 6 81 44 177 95 14 It will be seen that the males exceed the females, and that 65 per cent., or nearly two-thirds of the cases are between 25 and 65 years, that is, in adults during the period of maximum working efficiency. 65 Bed-ridden Cases. — Sixty-five of the patients were bed-ridden at the time of notification, and included 44 males and 21 females. Six had been confined to bed less than one week, 44 less than one month, 9 between one and three months, 1 between three and six months, 5 between six and twelve months. Patients who are not notified until they become bed-ridden are patients generally with long-standing disease, who may presumably have taken few or no precautions to prevent infecting others. These cases, where the circumstances are suitable, are urged to enter the Holborn Infirmary. Distribution by streets and blocks of dwellings.—The largest numbers were notified from the following places :—Gee Street, 13; Roscoe Street, T2; St. Bartholomew's Buildings, 10; Northampton Buildings, 10; Risinghill Street, 9; Coldbath Buildings, 8; Margaret Street, 8; White Lion Street, 8; Central Street, 7; Farringdon Road, 7; Pentonville Road, 7; Southampton Street, 7; Wynyatt Street, 7; Clerkenwell Green, 6; Compton Street, 6; Northampton Street, 6; Warren Street, 6; Waterloo Street, 6; and Donegal Street, Mitchell Street, Northampton Road, Penton Place, 5 cases each. Length of residence.—The duration of residence in the Borough and of residence at the notified address were ascertained in over 370 cases, with the following results :— Duration O-1 week 1 week1 month 1-3 months 3-6 months 6-12 months 1-5 years 5 years and over Finsbury Residence 11 4 7 8 18 89 236 Present Address 11 15 37 29 56 156 71 Nearly 40 per cent, of the patients had lived less than one year at the addresses given when they were notified. 66 The fact is that phthisis is chiefly a disease of poverty, and these poor people, as their savings get exhausted and their sick benefit gets less, are for ever moving from one house to another, infecting them all, in their endeavour to get cheaper accommodation and to stave off the ultimate request for poor relief. Place of Birth,—This was ascertained in 846 cases as follows :—Finsbury, 146; other parts of London, 163; England, 29; Ireland, 3; Scotland, 2; West Indies, 1; Italy, 1; and Australia one case. It is interesting to find that 42 per cent, of these cases were born in Finsbury, and that 89 per cent, were Londoners by birth. Family History.—Out of 377 cases there was a clear history in 158 households of other previous cases—that is a definite family history in 42 per cent, of the cases investigated. In one family there had already been 14 deaths from phthisis, in other families, 12 deaths, 7 deaths, 5 deaths (2 families), 4 deaths (6 families), and 3 deaths in 6 families. In two families there were six cases of phthisis still living and 3 dead from phthisis, in another family 3 cases living and one death, in another family 2 cases living and 4 deaths, in another household one case living and 4 deaths from phthisis. This list does not exhaust the number, and bears witness to the potential ravages of this fell disease, and to the manner in which it may infect all or many of the members of the same household. Early Signs—The early signs which first induced the patients to seek medical advice are appended :—Cough, or a prolonged cold on the chest, 160; cough associated with pain in back or front of chest, 17; cough associated with difficulty of breathing, 5; cough and wasting, 5; cough and pain in the back, 1; pain in the chest, 47 ; haemorrhage from the throat, 28; bronchitis or bronchitis and asthma, 18 ; excessive weakness, 8; wasting, 3; "influenza cold," 4; lumps in the neck (enlarged glands, 1; huskiness and pain in the throat (tuberculous laryngitis), one case, 67 By far the largest number, 65 per cent., went to consult a medical man in the first instance for persistent cough, either alone or associated with pain, wasting, or difficulty of breathing; 16 per cent, first saw a doctor because they suffered from severe pain in the chest, probably due to a tuberculous pleurisy. In 9 instances the phthisis was discovered during the progress of an attack of pneumonia. In 376 cases enquiry was made as to whether the patient knew the nature of the disease from which he was suffering—out of all these, only 149, or less than 40 per cent., were aware that they had phthisis. It would appear that with many doctors there is a disinclination to inform the patient that he has consumption. Instead of this, he is told that his "lungs are touched," or that his "chest is slightly affected." For this course the following reasons are urged in explanation : —If the patient is told he has phthisis, he may become alarmed, exicited, or depressed, and this may react adversely on his condition. If poor, he knows that to be affected with phthisis means prolonged treatment, and he consequently becomes an out-patient at a hospital or dispensary, and is treated gratuitously. The very poor often think that their own private doctor may safely treat their simple aches and pains, their stomach ache and neuralgia, but consider, quite wrongly, that consumption is too serious to be treated by a private doctor, and go to a hospital to have the diagnosis confirmed, and for free treatment. When, therefore, the patient is informed that he has phthisis, the result often is that the doctor loses the case. From a public health standpoint this is much to be deplored—it is a great pity that the poor do not have more confidence in their docto-s in this respect. It will be obvious that, if the patient is not told he has phthisis, it is useless to expect him to observe the precautions which are necessary to prevent the infection spreading to others. 68 Duration of the Disease.—The presumed duration of the disease when the case was first notified is given in the attached table, which records the results in 349 patients :— Source of Notification 0-3 months 3-6 months 6-12 months 1-5 years 5-10 years 10-20 years 20 years and over Poor Law 5 3 11 53 20 15 6 Hospital 7 2 14 69 27 24 6 Voluntary 2 4 4 25 7 10 2 School 3 2 2 21 5 — — Totals 17 11 3' 168 59 49 14 It will be seen that comparatively few cases are recognised in the early stage—83 per cent., or 5 out of every 6 had been ill for periods over one year before notification—14 had actually been ailing for 20 years and more. The early signs of phthisis may be so slight and may appear so unimportant to the general public that their suspicions are not aroused. Further, phthisis, even when well marked, is often characterised by quiescent periods which lull suspicion. This explains why it is so difficult to deal with the disease from a public health standpoint, and also why it is so very important to search for slight, missed, and suspicious cases amongst the contacts in the households of notified and recognised cases. Previous addresses in the Borough.—Out of 386 cases— 172 had lived in 2 or more Finsbury addresses while definitely known to be consumptive. Sixteen had lived in four different houses in the Borough during their illness. Out of these 172 cases—66 lived in houses from which cases of phthisis, numbering 82, had already been notified, and in which 54 deaths from phthisis had occurred prior to their occupation. Owing to their poverty and inability to pay rent, these very poor phthisical patients are continually moving from one tenement 69 to another, and presumably infecting them all. There is no power to enforce systematic disinfection, and in practice it would be found difficult to perform it owing to the demand for tenements, the short times the rooms are empty, and the large number of removals which are unknown to the public health department. I'urther, it appears that 17 per cent, of the cases went to live in houses already infected with the tuberculous taint before their arrival. It is quite possible that these latter patients may have been infected with the disease from their surroundings. The practical outcome of this is that it is very desirable that when a death from phthisis occurs in a tenement, or when a tuberculous family removes, means should be taken to disinfect the premises and to give the rooms a good scouring and scrubbing out. In order the better to achieve this, many public health departments supply a disinfectant soap gratis to the inhabitants. There is no special virtue in a disinfectant soap—many, probably most of them, do not disinfect in actual practice. The poor, however, will not scrub out their rooms with ordinary white soap. But if a nauseous, evil-smelling soap stamped with a coined word and labelled "disinfectant" is supplied, they scrub with the zeal, the earnestness and alacrity born of wholesome faith and a good cause. Residence in other boroughs.—During their illnesses and before they were notified, 40 patients had lived in one other London Borough, 9 in two other metropolitan boroughs, and one in 3 other London boroughs. These patients may have infected not only houses in Finsbury but also in other metropolitan districts. Reasons for Finsbury.—The patients were asked why they had chosen to live in Finsbury. The answers are summarised below :— 70 Finsbury convenient for work— " Easy to get to and from the City. Living with their parents 24 " House rent is cheap in Finsbury 6 "So as to get into the Holborn Infirmary 4 Other reasons given were :— Finsbury is as good as anywhere else in London " " Finsbury is healthier than Holborn " " Recommended to some of the Finsbury ' buildings.' " One patient had lived in St. Pancras, and had been oft-times ejected for non-payment of rent. He had tried to get a oneroomed tenement elsewhere, but failed owing to his lacking a "respectable reference." Finsbury was the only borough he knew where one could rent a room " without giving the landlord any reference whatever." He came to this Borough, and, although ill, and without any " landlord's reference," obtained a room at once. OCCUPATIONS. 1. Food. —In 66 cases the occupation of the patient brought him or her into close relationship with the preparation of food, either for the household, or for public consumption, or with the distribution of food. Four were domestic servants, 3 were street hawkers of fruit, vegetables and confectionery, 2 were waitresses in a restaurant, 1 was a chef in an hotel, 1 made confectionery, 1 was a milk carrier, and 1 was a milk seller. In one case a girl of 13 years had been excluded from school on account of phthisis. Arrangements were made to send her to a sanatorium for treatment, but her father refused to allow her to go. Her father was addicted to drink ; her mother was in the Holborn Poor Law Infirmary. The girl had to do all the household cleaning, and when this was finished had to help her father to sell from a stall in a market street; the condition of the child was, therefore, worse than if she were allowed to remain at school. 71 2. Attended by poverty and exposure. —Nineteen were general labourers, 18 were carmen, 14 were porters, 9 were charwomen, 7 were window cleaners, 4 were packers, 3 were strett flower-sellers, 2 were costermongers, 2 were street newsvendors, and 1 sold firewood. Most of the carmen were out of work through illness; the general labourers were all in casual employment and led a precarious hand to mouth existence ; the rest, 9 in number, were all in very poor circumstances. 3. Sedentary and Confined.—These were printers, 9; clerks, 5; shop assistants, 4; bookbinders, 2; book-folders, 2; boot makers 2; clock makers, 2; dressmaker, 1; envelope maker, 1 ; and tailor, one case. 4. Dusty.—It has long been known that certain dusty occupations favour the onset of consumption. Two Finsbury cases were feather makers, 2 were meital polishers, 2 were upholsterers, 1 was a brass finisher, 1 was a brush maker, 1 was a chaff-cutter, 1 was a fur worker, 1 was a mantle maker's assistant, 1 was a pattern card maker, and another was a skirt finisher. Among the remainder there were 5 horsekeepers, 5 warehousemen and packers, 4 washerwomen, 3 glass blowers, 3 glass workers, 2 house decorators, 2 leather bag makers, 2 signwriters, and 33 others all possessed in more or less degree of facilities for furthering the spread of this disease. Homeworkers.— Eight patients were homeworkers. Their occupations were as follows :—One brace maker, 1 brush maker, 1 clock maker, 1 collar ironer, 1 glass blower, 1 leather worker, 1 milliner, and 1 washerwoman. The stress of poverty, which compels the parent, weighted and exhausted with phthisis, to undertake work at home, is one which does not promise well for his own progress or recovery, or for the health and nourishment of those dependent upon him. 72 Unemployment and Insurance.—Enquiry was made as to the unemployment or absence from school during the 52 weeks preceding notification. Information was obtained in 365 patients, comprising 321 adults and 44 school children. Taking the adults first—86, or 26 per cent, of the whole number had been in regular employment without losing a single day; 87, or 27 per cent., had been employed for periods ranging from a few days to 1 month ; 37 had been out of work from 1 month to 2 months; 65, or 20 per cent, had been out of work from 2 months to 6 months. The rest, 46 in number, had been out of work from 6 months to 12 months—one had been unemployed for 2 years, and 1 for 15 years. Of the school children, 24 had not been absent a single day— the rest, 20 in number, had been absent for periods varying from 1 week to a year. Information was obtained as to thrift and insurance in 372 families. One hundred and ninety-nine were insured at the time of the first visit, 30 had been formerly insured but had allowed the policies to lapse owing to poverty, 7 were members of friendly societies, 6 were members of trade unions, 6 belonged to shareout clubs, 128 were definitely not insured, and 6 were formerly members of a trade union, but had been unable to keep up their subscriptions. Treatment.—One hundred and forty had been treated ait the Holborn Poor Law Infirmary or Workhouse. Twenty nine patients received sanatorium treatment during the year—and thereby obtained a training which is of great preventive and educational value. Each patient, when visited, was asked whether he would like to have sanatorium treatment or not—237 stated that they would 73 be very glad to have the opportunity of entering a sanatorium, 102 did not wish to accept. Home Circumstances and Social Conditions.—Ninetynine families were in great poverty, 20 others were destitute, that is to say, 119 households, or 28 per cent, of the whole number, bore evidence which convinced the casual visitor of the existence of very straitened circumstances. This raises an important issue. Public Health measures can, and will, prevent the spread of phthisis to others provided the home circumstances are favourable and the patients are willing. Progressive sanitation will help to prevent fresh cases in the comparatively well-to-do, but, in its larger sense, the prevention of phthisis in the poor is a social problem—the relief and prevention of poverty. Eighty-seven patients were total abstainers, 170 were said to be moderate drinkers, 33 drank to excess. Ninety-seven families, comprising 325 children and adults, lived and slept in one room. For these, the prevention of infection would be a matter of great difficulty, if not almost impossible. Overcrowding was discovered in 21 households. In 348 homes, excluding common lodging-houses, there were 1,399 other members of the family besides the patient—these would be naturally in close contact with him and very liable to be infected. In addition to these close contacts, there were 2,211 remote contacts living in these houses, so that there would be altogether 3,610 persons more or less exposed to infection from the phthisis patients living in their houses. In making this estimation in the case of tenements in buildings, regard is only had to the patients in the affected households. This number does not include the occupants of the tenements on the same landing as the patient. 74 Illustrative Cases. - 1.—The family, consisting of the father, mother and three children, 8 years, 6 years and 4 years, occupied a two-roomed tenement. The father was ill with phthisis and out of work; the mother was a box maker before marriage, but was now a charwoman. The children slept in the back room. The father was unable to enter the Infirmary because the mother went out to work at 5 p.m. and returned home at 11 p.m., so that during these hours the children would be without supervision. 2.—A woman, a spinster, 72 years, feeble and short of breath, suffering from phthisis, lived in a one-roomed tenement on the top floor. The patient was exceedingly dirty and verminous, and too weak to carry water for washing to her room—the furniture and bedding were filthy and verminous. She paid 4s. per week rent. She had three pennyworth of meat and some vegetables on Sundays only : she lived on bread and butter, coffee or tea during the rest of the week. She had no money for washing or cleaning : she lived on her old age pension. She formerly worked as a dressmaker—she was referred for help to one of the churches. 3.—A family consisted of the mother, boys 18, 12 and 7 years, girls 16 and 14 years. They lived in a three-roomed tenement which was extremely dark, necessitating the constant use of artificial light. The boy 18, suffering from phthisis, was sent to a convalescent home, but discharged himself at the end of two weeks, dissatisfied with the restrictions imposed, and because he worried about his mother. The earnings of the family were as follows :— The mother, 6s. to 7s. per week as a charwoman; the girl 16, 4s. 6d. per week; the girl 14, 5s. per week; the husband and three other daughters had died of phthisis. 4.—A father, mother and eight children, girls 15, 10, 8, 6, boys 14, 12, 4 and 2 years, lived in a two^roomed tenement. The father was phthisical and went into the infirmary. The mother, shortly about to be confined, was making cardboard boxes at home. She received 8s. 6d. and two loaves weekly from the Poor Law. 75 5.—The family consisted of father, mother, five girls, 14, 12, 7, 4 and 2 years, and 2 boys, 9 and 10 years. They occupied a two-roomed tenement, but had only two chairs and insufficient beds and bedding-. The second girl, 12 years old, was phthisical. The father was an odd man earning 9s. or 10s. per week : the mother was a homeworker making children's coats and costumes and was thin and ill with bronchitis, the eldest girl had just left school and the head teacher had offered to obtain a situation for her as a domestic servant. This offer was refused. The rooms were overcrowded. 6.—A family, consisting of father, mother and 9 children—boys 17, 15, 13, 11, 9, 7, 5 and 2 years, and a girl 8 years—occupied a four-roomed tenement. The mother was out at work and not expected back until 6 p.m. The father was at work and came in to dinner daily, went out to work again, and returned late in the evening. The boy 13 years had phthisis, was in rags, had no boots ; the boy 7 years had sore feet and no shoes or stockings ; the boy 5 years had no shoes or stockings ; the boy 2 years was naked except for a woollen vest and was sitting on a chair in front of the fire. The two eldest boys were working. The boy 13 years stated that he had been taken to the hospital by his mother, but when asked for his out-patient's letter, he produced an unused one and then admitted that his mother had not taken him to the hospital because she had no clothes to put on him. This boy with phthisis had been excluded from school for 12 months, and meantime nothing had been done for him. It is quite usual to find that when phthisical children are excluded from school, that they are kept at home by their parents and made to do the house-work, to look after the other children and sometimes to help their parents street trading. It is not uncommon to find that school children with phthisis and sometimes adults with phthisis go " hopping " in August and September, and, when they return, express themselves as being much improved in health. 76 Tenements.—Out of the whole number, excluding common lodging houses, 97 were one-roomed tenements, that is to say, the patient and family lived and slept in one room only; 146 were two-roomed tenements—the rest had three to eight rooms. Twenty-one tenements were overcrowded. It is difficult to conceive a condition which favours the spread of infection more than overcrowding. In phthisical families the abatement of overcrowding is insisted upon forthwith. Fifty-three tenements had one cupboard only for food, clothes and coal. Fourteen had no cupboard accommodation at all. These are very unsatisfactory conditions for a phthisical household. When the household utensils of the patient are kept in the same cupboard as the other household utensils, when his clothes are hung on the common peg, the spread of infection from person to person is favoured. When, in addition to these, the tenement is overcrowded, the conditions for promoting the spread of the disease are as pernicious as they possibly can be. Ninety-one tenements were on the list of houses-let-in- lodgings ; sixty-seven tenements were in the so-called model buildings, which, with their common landings and their many points of contact between the families who occupy them, are only too well adapted for the spread of phthisis. Homework was carried on in eight tenements. A sanitary survey was made of every tenement and the nuisances found made the subject of subsequent notice. The following defects were ascertained :—Insufficient lighting 65, insufficient headroom 56, dirty rooms 31, dilapidated floors and roofs 8, verminous rooms 2, deficient ventilation 5, and damaged waste-water preventer in one tenement. The Patient's Bedroom.—The number of beds in the patient's bedroom, the number of persons occupying the patient's bedroom and the number of families affected are given in the attached table. 77 Persons and beds in the patient's bedroom :— One Bed. Two Beds. Three Beds. Persons. Families. Persons. Families. Persons. Families. i 80 — - — — 2 130 3 21 — — 3 46 3 41 3 3 4 5 4 26 4 2 5 1 5 6 9 5 1 — — 7 2 — — This list excludes common lodging-houses. Only 80 patients out of 419 were able to have a bed and bedroom all to themselves. In the other households where only one bed was available, 241 persons slept in the same bed with the consumptives and were consequently closely exposed to infection. This number refers to those families which only possessed one bed. In addition to these, there were 265 persons who occupied the same bedroom as a phthisical patient and in some instances the same bed. Forty-seven bedrooms had no fireplace, so that ventilation in them was absent or impossible. The ventilation was insufficient in 61 other bedrooms, making a total of 108 bedrooms, or 25 per cent, of the whole number. This defective ventilation and absence of ventilation favours the spread of the disease. It is difficult sometimes to suggest means by which it may be overcome—occasionally owners have been induced to place gratings in the walls. The absence of fireplaces bespeaks very bad housing—in some instances these 78 rooms without fireplaces were not originally built for human habitation, but were attached to the tenements as lumber rooms or as odd rooms. In some places in the Borough it is found that tenements which originally contained three rooms have been in recent years converted into three one-roomed tenements. With this degradation of the tenement the old-time lumber room comes to be used as a living room and sleeping room. It is extremely important that every room used for human habitation should have a fireplace or means of communication with the outer air in addition to the window frame. Twenty-five bedrooms had dirty walls and ceilings. In 15 tenements the walls and bedding were verminous. The kitchen.—In 219 instances, or 52 per cent, of the whole number of cases the kitchen was being used as a living room and a sleeping room. This is one index of poverty, and also shows the difficulties of accommodation which accrue in these poor households. Sometimes the patient himself occupies the kitchen by day and night. The conditions found in the kitchens were as follows:—Fortysix had dirty walls and ceilings, 16 were verminous, 6 were damp, and in 9 houses the kitchen and feeding utensils were extremely dirty. The presence of dirt or vermin may be taken to connote carelessness, and carelessness in the family of a consumptive means increased risk of exposure for the rest of the family. The House. —Thirteen houses in which cases occurred were being used for the purpose of sale or manufacture of food as follows :—Restaurants, 6 ; food preparation, 2 ; milkshops, 2; public houses, 2 ; and sausage making one house. Three houses were workshops. 79 Notifications of phthisis had been previously received from 104 houses, or 24 per cent, of the whole number. Deaths from phthisis had occurred in 43, or 10 per cent, of the houses affected. Whenever a case is visited the whole house is made the subject of critical sanitary inspection. As a result the following defects were ascertained and notices were served for them :—Dirty walls, ceilings, staircases and passages, 50; leaking and broken water closet cisterns, 12; choked and foul water closets, 10 ; no water supply to the upper storeys of the house, 10; yard paving broken, 10 ; leaking roofs, 9; insufficient and absence of dustbin provision, 8 ; damp walls, 4; broken flooring, 3; and insufficient water closet accommodation, two houses. The Street.—The number of previous notifications of phthisis in the affected streets since 1904, and the number of cases notified in 1911 from these streets, the number of deaths in these streets since 1904, and the corresponding deaths in 1911 from these same streets are indicated in the table given below : — Comparative Statement of Street Notifications and Deaths since 1904, and of the Cases and Deaths In 1911. Notifications since 1904 1-5 5-io 10-20 20-30 30-40 40-50 50-60 Cases in 1911 71 85 112 31 41 6 2 Deaths since 1904 1-5 5-10 10-15 15-20 20-25 25-30 3o-35 Deaths in 1911 95 113 65 45 35 7 1 From this table the following inference may be made :—That the largest number of cases and the largest number of deaths are now occurring in the streets which since 1904 have had the 80 minimum incidence of notification and of phthisis deaths. In other words this means that fresh streets are being invaded, and that the disease is tending to spread into streets and parts of the Borough hitherto unaffected. This may possibly be associated with the lower standard of living now prevailing in the Borough, with the increasing poverty of many of its inhabitants, and with the conversion of houses for human habitation into workshops, a change which forces the former inhabitants to seek accommodation elsewhere. In 1911, seventeen cases occurred in streets in which there had been no previous notification, and 21 deaths occurred in streets in which there had been no previous deaths from phthisis. Disposal of Sputum.—Eighty-two, or nearly 20 per cent., used a special spit-cup ; 51 were said to spit into pieces of paper or rag, which were subsequently burnt ; 12 spat into the Pre or into the fireplace, whenever this was convenient, but were stated to be very careless by the other members of the family. The rest, 179 in number, about whom information was obtained, may be confidently assumed to have taken few or no precautions in disposing of their sputum. As this is such an important matter, the Public Health Committee have now sanctioned the purchase and distribution of spit-cups to all suitable cases. The Borough Council examines gratis the sputa of patients suspected to have phthisis. In 1911, 52 specimens were examined with positive results in 18 cases. Search for missed and unrecognised cases.—As the result of special enquiry, in 23 affected families, 24 suspicious cases of chronic cough and wasting were discovered and put in the way of obtaining treatment. By investigation into the other families inhabiting the same houses as the consumptives, 12 81 other suspicious cases of phthisis were referred to hospitals and dispensaries. This is one of the most important purposes of visitation, to enquire after missed and unrecognised cases. These patients, unless captured early, are possessed of infinite possibilities of spreading phthisis. Disinfection and Preventive Measures.—The room, bedding, kitchen, and feeding utensils, towel, handkerchiefs and linen were disinfected in 176, or 41 per cent, of the households. In 147 affected homes the responsible head of the family refused any disinfection whatever ; in 2 cases only the bedding was disinfected ; in 2 other homes only the rooms were allowed to be disinfected. In every case it is urged that the room, the bedding, sheets, pillow-slips, curtains, valances, towels, handkerchiefs, feeding utensils, knives, forks, spoons, cups, plates, saucers, clothe3 for wearing week-day, and Sunday clothes, should all be disinfected. The feeding utensils used by the patient are boiled for ten minutes in boiling water containing a little washing soda. The water must be boiling before the utensils are placed in it. After disinfection, it is advised that the room should be well scrubbed out with soap and water. Twenty patients took no special precautions whatever to prevent the infection spreading to the rest of the family, and were apparently indifferent as to whether this occurred or not. One father, a consumptive, insisted upon his children drinking tea out of the same vessels that he did himself, alleging that the disease was not infectious, and that he meant to prove it in this way. Five patients thought that by using a spittoon they were doing all that could be reasonably expected of them—they refused to put themselves to any further trouble. 82 Deaths.—In 1911 the number of Finsbury persons who died of phthisis or consumption of the lungs was 159, as against 166 in the previous year ; in addition to these 31 died from tuberculous meningitis, and 12 from other forms of tuberculosis. The deaths for previous years are given in the subjoined table: — Phthisis Deaths and Death Rates, 1 901—1911. Year. Finsbury Deaths from Phthisis. Finsbury Deaths from other forms of Tuberculosis. Phthisis Death Rates per 1,000 inhabitants. Finsbury. England and Wales. 1901 216 30 213 1.260 1902 240 23 2.40 1.230 1903 223 39 2 .26 1.200 1904 251 67 2.58 1-230 1905 215 52 2.24 1.140 1906 232 48 2.46 I.I50 1907 243 42 2.60 1.140 1908 221 39 2.40 I.115 1909 228 31 2.52 1.081 1910 166 31 1.86 1.015 1911 159 45 1.81 — The death rates for Finsbury have been re-calculated on the basis of the recent census. The corrected figures for England and Wales are not yet available. It will be observed that in Finsbury the deaths this year and the death rate from phthisis are both less than they have been since the Borough was formed, 83 I hey are, however, still much in excess of the corresponding rates prevailing in the whole of England and Wales. Enquiry was made into the length of residence of each case in the Borough, and as to the duration of the disease. Adopting the classification indicated in an earlier part of this report, it was found that out of the 159 deaths, 90 patients were Finsbury cases by residence and infection, that is, they had lived in the Borough for five years, and had presumably been infected with the disease since their arrival in Finsbury. Fourteen patients had lived in the Borough less than five years, but had been infected since they had come to reside in the district, that is to say, they were Finsbury cases by infection, and not by residence. Forty persons were considered on this basis to be not Finsbury cases, that is, they had definite signs of phthisis when they came into the Borough, and had not lived here five years. In nine instances no information could be obtained—the addresses given were false ones. Four patients died in Finsbury common lodging houses and were otherwise homeless. If we include only the Finsbury cases by infection, and by residence and infection, these amount to 104, adding in the deaths in Finsbury common lodging houses and the doubtful Finsbury cases, gives a total of 115 deaths, which may reasonably be associated with the Borough, and a corresponding death rate from phthisis of 1-31 per thousand inhabitants. Of the whole number of deaths in Finsbury in 1911, 9-3 per cent, were due to phthisis, as against 10 and 12 per cent, in 1910 and 1909 respectively. Three-quarters of the deaths due to phthisis took place between 25 and 65 years, the period of maximum working efficiency in men—the "working life " period when their earnings are most needed and their usefulness greatest. Seventy-four died in the poor law institutions. The deaths from phthisis in institutions for previous years are appended 84 Phthisis Deaths in Institutions, 1901—1911. Year. Total Number of Phthisis Deaths. Phthisis Deaths in Holborn Union Infirmary. In other Institutions. Total in Institutions. Percentage of Deaths in. Institutions. 1901-6 1.377 572 195 767 55.7 1907 243 108 51 159 65.4 1908 221 8l 5° 131 59.3 1909 2l8 87 59 I46 67.0 1910 166 63 25 88 53.0 1911 159 74 14 88 55.3 It is a great advantage to have cases of phthisis removed to an institution, especially in the later stages when the expectoration may be very profuse. This measure removes a possible source of infection to others. Unfortunately, however, it is difficult to secure the removal of these poor law cases until they are helpless or sometimes almost moribund. Under these circumstances the removal, although still advisable, is not nearly as salutary as if it were done earlier. The method adopted by the Registrar-General, of allocating deaths in institutions to the districts in which the patients reside immediately before admission, makes the Finsbury death rate from phthisis higher than it otherwise would be. As was pointed out last year, many consumptives come into Finsbury a short time before death for four chief reasons :— 1. They wish, when eventually they break down in health, to get into the local poor law infirmary, which, amongst poor 'aw patients north of the Thames, has a high reputation for the humane and considerate treatment of its inmates. 2. There are very many charitable, philanthropic, and nursing associations, missions and institutions in the Borough. 3. There is a considerable market for unskilled labour. 85 4. There are four large general hospitals close to the Borough, which give gratuitous treatment. These patients who are received as in-patients into the hospitals and infirmary, when they die are accredited to Finsbury even although they may have lived in the district only a few days or a few weeks. The phthisis death rates per 1,000 calculated by the RegistrarGeneral are as follows :— Phthisis Death Rates 1911, and 1906 1&10. 1911. 1906-1910. England and Wales, 1910 1.015 — County of London 1.35 1.40 Finsbury 1.87 2.21 Holborn 2.08 2.31 Shoreditch 1.84 I .90 St. Pancras 1.57 1.67 Islington I.24 1.30 In 1911, Finsbury is second highest on this list, being exceeded by Holborn. The death rate from all forms of tuberculosis for 1910, was in England and Wales 1-434, in Finsbury in 1911, 2 30 per 1,000 inhabitants. The 1911 figures for England and Wales are not yet available. It may be asked whether the tabulated number of deaths accurately represents the number of deaths from phthisis in the borough. To this the answer is in the negative. There is very little 86 doubt that other deaths from phthisis occur in the borough and are wrongly entered up on the death certificates. To take an actual example : a patient, 45 years, was examined by three medical men in September and November, 1911, and was notified by each one to the public health department as suffering from phthisis. The patient died in December, 1911, and the cause of death was entered on the death certificate as " bronchitis " by one of the doctors who had previously notified the case as one of phthisis. In another case a patient, 41 years, was notified as phthisis in February, 1911. He died the next day, and the death was certified by the assistant of the first doctor to be due to bronchitis. In both these instances the deaths should have been accredited to phthisis following the rule that when a death is associated with two or more causes—the primary cause of death—the one cause for statistical purposes, must be the disease which has lasted longest and the disease which has an infectious basis. In Finsbury the number of deaths attributed to bronchitis in 1911 was 161. Now it is quite true that very young children may, and do, die of acute bronchitis. It is very difficult sometimes in infants to say whether the case is one of acute bronchitis or broncho-pneumonia. But young adults rarely, if ever, die of bronchitis, and the so-called chronic bronchitis of older people is hardly ever the primary disease. In both these cases a death from bronchitis very often means that the primary cause of death has been overlooked or could not be ascertained. The bronchitis is then due to heart disease, phthisis, Bright's disease, gout, alcoholism, emphysema, or to arterio-sclerosis—a disease of the blood vessels. These diseases quite commonly produce changes and effects in the lungs which give rise to a secondary bronchitis. It would appear then that, out of the 161 deaths due to bronchitis, 29 may possibly be correctly so attributed, but of the 87 remaining 132 many, probably 10 or 20 per cent., of these deaths are due to phthisis. This matter is not peculiar to Finsbury—the same argument and considerations hold for all other towns. In New York since the notification of phthisis was made compulsory there has been a gradual decline in the number of deaths attributed to bronchitis in adults and a transference of a fair proportion of these deaths to the phthisis column. Visits and Re-visits to patients.—Every case of phthisis in Finsbury is visited in the first instance by one of the district sanitary inspectors. This has been done continuously since the year 1900. It is well that this should be clearly known, as it is sometimes alleged that these visits are of recent adoption. The Finsbury cases of phthisis have been visited by the staff of the public health department for the last 11 years. The cases are re-visited by the lady sanitary inspector. The first visit is paid as soon as possible after the receipt of the notification. Re-visits are paid whenever it is thought desirable. In the absence of any indications to the contrary, the re-visits take place at intervals of one to three months. Cases already under local medical men or under local nurses are not taken up except with the approval and consent of the doctor or nurse concerned. Disinfection is, however, offered in these cases, and a sanitary survey of the premises is made if the patient does not object. At each visit, enquiry is made into the following matters, as affecting the patient, and suitable advice given :— The provision of a separate room, a separate bedroom, a separate bed, a separate towel, a separate handkerchief, separate utensils and separate facilities for washing, 88 The importance of cleansing and disinfecting patient's own utensils after each meal, and the means to be adopted. The provision of a spittoon, wet dusting and wet sweeping, the value of open air and fresh air, open windows, sunshine and its curative and disinfecting importance, the sufficiency of lighting and ventilation, and the food value of milk and eggs. Leatlets of instruction are always left and their terms explained. The visits are made practical and educational. It often happens that some of the measures above indicated are, in actual practice, found to be impossible of achievement. In such a case the patient is shown how, under the circumstances actually prevailing, he should best order his life for his own benelit and for the protection of those around him. Enquiry is made from the head of the household as to the existence in the family or house of other alleged cases of phthisis, wasting, chronic cough, blood spitting, bloodlessness, bronchitis, asthma, or other alleged chest complaint. Persons suffering from one or more of these conditions are referred primarily to their own doctor. If they are unable to afford medical advice, then they are advised to go to the Chest Hospital, City Road; St. Bartholomew's Hospital, the Royal Free Hospital, Brewer Street Dispensary, The Royal General Dispensary, or the Farringdon Dispensary. Letters of recommendation are given to the patients, or, if these are not available, the patients are instructed in exact terms where and how to get them. The premises are carefully inspected for sanitary defects which re-act adversely upon the patient's complaint, and notices served for their abatement. In effecting this, every care is taken to avoid offending the patient's susceptibilities, and to interfere as little as possible with his personal comfort. In this connection the abatement of overcrowding is considered to be extremely important. 89 Cases of poverty or destitution are referred to the churches and chapels, the Charity Organisation Society, the Distress Committee, the Home of Service, the Leysian Mission, or the Relieving Officer. Very valuable help and extra nourishment are obtained, if the distress is urgent, from the churches and the religious organisations in the Borough. In a few instances single beds for the use of the patients themselves have been provided through these agencies. Steps are taken to put the patient in the way of getting sanatorium treatment by referring him to one or other of the Medical Missions in the Borough, to his Friendly Society, to his Trade Union, or to the Charity Organisation Society. On this head, exact information is given to the patient ; a short list of sanatoria is supplied, with the weekly charges made for treatment. As a rule, it is thought inadvisable to refer the patient to his employer. In sending patients to any charitable society, much tact and discretion are exercised in choosing a suitable type of case. It is definitely ascertained that the patient will not object to such a reference, or to the enquiries that are made by the society. Tradespeople, or workmen in the enjoyment of a moderate wage, are not so referred. No pressure whatever is made in this matter. The patient is left a perfectly free hand as to whether he will go or whether he will not go. The name of any such patient is not sent to the society unless the patient requests that this step shall be taken. These considerations only apply to those patients who are not being treated by their own private doctors. If a patient is already under the supervision of his own medical man no steps whatever are taken. At each re-visit enquiry is made as to the progress reported, and further help is offered. 90 1 he rest of the family are instructed how best to avoid infection from the case of phthisis already existing. Great care is taken to avoid friction with the local medical men. In order to achieve this, the visitor does not take the patient's temperature, or the patient's pulse rate, and carefully abstains from anything that may verge upon medical or .surgical treatment. It is no part of the inspector's work to treat cases, or to diagnose cases of phthisis. This is left to the doctor in attendance. The supervision of cases not under medical treatment is not undertaken. These patients are referred to their own medical adviser, or to an institution. Cases are not investigated at the casual request of outside organisations or committees. If such cases are received they are referred, in writing, to the Medical Officer of Health. Visits are visits of necessity, not visits of convenience. Any difficulties that are encountered in the work are immediately reported, in writing, to the Medical Officer of Health. What more may be done. 1.—There is great need of a tuberculosis dispensary in the district, modelled and working on Edinburgh lines, and equipped with the facilities for the modern tuberculin treatment. 2.—The retention of " educational beds " in a sanatorium is very desirable. 3.—The loan and distribution of wooden municipal shelters for open-air home treatment is very helpful, and is already being accomplished in some London boroughs. 4.—It is impossible in many Finsbury households to attempt even a modified or incomplete form of isolation owing to the lack of bedsteads and bedding. It is obviously absurd to tell a father of a family to sleep by himself when he rents only one 91 room and lias only one ramshackle bed and insufficient bed-clothes for himself, his wife, and his children. In some instances, extra beds have been provided by the help of employers and institutions at the suggestion of the Lady Sanitary Inspector. This provision of extra beds and spare bedding offers an excellent opportunity for voluntary and charitable effort in the Borough. 5.—The free distribution of disinfectant soap to phthisis cases in poor households would certainly help to achieve a higher standard of cleanliness in their homes. 6.—The investigation of tubercle in the milk supplies is at present undertaken by the London County Council. Unfortunately the County Council does not inform the local authorities of tuberculous supplies which come into their districts. The Borough Council receive no information whatever on this head. It ought to be possible to promote co-ordination of effort and more active co-operation in this matter. Now, when all this has been accomplished, shall we be able finally to stamp out phthisis? Probably not. It must be remembered that phthisis and its prevention are not solely matters of public health. Phthisis is only too often an expression, one of the protean manifestations, of poverty. The prevention of phthisis is, in the main, the prevention of poverty, and is as much a social and industrial problem as it is a public health issue. Twenty years ago it was hoped that the notification of fevers, the building of fever hospitals, and the isolation of patients would, within a generation, abolish the common infectious diseases. The tardy recognition of extremely mild and missed cases, and their infective character have now shown this hope to be illfounded. In like manner, it is very probable that the many mild missed cases of phthisis, and the cases with long quiescent periods, both classes infective and easily overlooked, will prevent the ultimate extinction of the disease. 92 GLANDERS AND ANTHRAX. Both these diseases in men are notifiable in London to the Medical Oilicer of Health of the local authority under orders of the London County Council, made in pursuance of Sections 55 and 56 of the Public Health (London) Act. Outbreaks amongst animals are notified to the Medical Officer of Health concerned, by the London County Council Veterinary Inspector of the Public Control Department. The premises are disinfected, and precautionary measures carried out under the supervision of the County Council staff. In 1911, no case of anthrax or glanders occurred in man in Finsbury, but notice was received of six outbreaks of glanders in different mews in the Borough, and of one case of anthrax in a horse. PLAGUE AND CHOLERA. The names and Finsbury addresses of eleven persons who had been in contact with cases of cholera were received from various Port Medical Officers. These contacts were visited at intervals while they remained in the Borough. In one instance the contact was not known at the address given, nor did he arrive there ; in another case the contact did not come to the hotel he had named as his destination in Finsbury. These two were, therefore, not visited by the Public Health staff. Three plague contacts arrived in the borough in 1911, and were kept under supervision for 10 days. 98 CEREBRO-SPINAL MENINGITIS. POLIO-MYELITIS AND POLIO-ENCEPHALITIS. Two cases of cerebrospinal fever were notified in infants, 5 months and 9 months respectively. Both died in St. Bartholomew's Hospital. One of the tenements was reported to be dirty and verminous—the other clean. No source of infection was found. Acute polio-myelitis and acute polio-encephalitis were both made temporarily notifiable from September 1, 1911, up to and including March 12, 1912. No case of either of these diseases was notified in Finsbury in 1911. OPHTHALMIA NEONATORUM. Inflammation of the eyes in the newly-born was made notifiable in 1911. Seven cases were notified by medical men, and in addition 2 other cases were reported by the London County Council Inspector of Midwives. Of the 9 cases, in two infants the sight of one eye was said to be permanently destroyed in each case. Both these cases were attended by medical students from St. Bartholomew's Hospital. As far as could be ascertained, the eyesight of the other 7 babies was said to have been ultimately recovered without damage. ERYSIPELAS. Notifications to the number of 223 were received, distributed as follows:— 94  Under 1 year 1-10 10- 20- 30- 40- 50- 6o- Total all ages. Males 2 5 6 2 14 9 12 13 63 Females 1 6 14 19 28 30 33 29 160 Totals 3 11 20 21 42 39 45 42 223 Disinfection is done after erysipelas only on request and not as a routine measure. There were 7 deaths due to the disease, all in adults. CHICKEN POX. Owing to the prevalence of small pox in London, chicken pox was made temporarily notifiable for three months, from the 22nd March, 1911. One hundred and thirty-one cases were notified. These were all visited and a special investigation made into 100 consecutive cases. Forty-four were school children. Two were in school on the day before the rash was notified ; 26 were absent from school 2 to 7 days before being notified. Of the whole number only 27 were kept in bed—these were the very youngest children. Contact with other cases was ascertained in 87 instances. Seventy-nine were vaccinated, 21 were unvaccinated. In only 30 cases were there symptoms at the onset—these were headache, 16; slight disinclination for food, 11; pain in the legs, 2; pain in the back, one case. 95 These aches and pains were very mild and transient. This is in striking contrast to small pox, where the onset is always well marked and fairly severe. The rash was first noticed by the parent on the face in 39 cases, on the back in 33 cases, and on the chest in 21 cases. The instances in which the rash was first noticed on the face are those in which the appearance of the rash first indicated that the child was ill. The rash was out before the parent realised there was anything amiss with the child. In 21 instances the rash was first seen simultaneously in 2 or more situations. Vesicles were noticed in 92 cases, in 90 within 24 hours of the appearance of the rash, in two others within 48 hours. No vesicles were seen in 8 patients. The chicken pox with vesicles is popularly known as the water pox or glass pox. The amount of malaise before the rash was noticed, was very slight, and was described as fretfulness, peevishness, languor, irritability, or slight feverishness. SMALL-POX. One case of small pox was notified in Finsbury in 1911. On investigation it proved to be a case of chicken pox. In addition the Medical Officer of Health was asked to see two cases suspected to be small pox. They were both chicken pox. Notice was received from Port Medical Officers of 8 oversea small pox contacts proceeding to Finsbury. Four of these came into the borough, and were visited daily until the incubation period was well passed. Of the other four—one gave a wrong Finsbury address. When the correct address was found, the contact had left for Ireland. 96 Another contact came into the borough, stayed a very short time, and left for Cornwall before he was visited. His address in CornwaJl could not be obtained. The remaining two—a man and his wife, gave a false Finsbury address—at a factory. The four contacts therefore were not seen. It would certainly appear that further powers are desirable to deal effectively with this violation of precautionary sanitary procedure. MEASLES AND HOOPING COUGH. Measles.—This disease is not notifiable. In 1911 notice of 384 cases was received from the London County Council Education Department, from head teachers of schools, from school visitors, from doctors, from other borough councils, from relieving officers, from registrars of births and deaths, from sanitary inspectors, superintendents of dwellings, and from parents and guardians. The sections of the Public Health (London) Act, 1891, which refer to the cleansing and disinfection of premises and materials, and to contact with, or exposure of, infected persons and things, have been extended to measles. These are Sections 60-65, 68-70, and 72-74. By the Metropolitan Asylums (Measles) Order, 1911, dated May 30th, 1911, the hospitals of the Metropolitan Asylums Board were made available for the reception of non-pauper cases of measles. The age incidence and the ages at death from 1903 to 1911, are shown in the subjoined tables :— Age Incidence of Cases of Measles, 1903-1911. Under 1 year of age in months. 1- 2- 3- 4- 5-10 10-15 Total 1903-1911. 0-3 3-6 6-9 9-12 2 38 106 155 619 610 758 1,077 1,984 68 5.417 97 The actual numbers notified year by year were 577, 802, 561, 1,036, 478, 245, 436, 898, and 384 from 1903 to 1911 respectively. Ages at Death in Cases of Measles, 1903-1911. Under I year of age in months. Total 1903-1911. 0-3 3-6 6-9 9-12 1- 2- 3- 4- 5-10 10-15 1 13 48 72 275 91 61 17 19 3 600 The deaths year by year were 69, 60, 31, 115, 43, 38, 86, 73, and 85 from 1903 until 1911. The largest number of cases and deaths were in 1906, when the disease was very prevalent. The cases are visited by the Lady Sanitary Inspector, who gives the parents suitable advice as to nursing and feeding the patients. A leaflet of instruction is left at the house, and dispensary tickets given for those children needing treatment. The dirtier tenements are disinfected at the end of the case. The rooms were disinfected in 156 tenements. The number of cases visited was 250, the number of visits 397. From 1909 to 1911, deaths from measles occurred chiefly in the following streets :—Baldwin Street (4), Bastwick Street (7). Cumming Street (4), Donegal Street (11), George Yard (4), Guinness Buildings (6), Lever Street (5), Margaret Street (4), Risinghill Street (6), Southampton Street (4), St. Helena Street (6), Warren Street (5), and White Lion Street 4 deaths. Hooping Cough.—This is not a notifiable disease. Information of cases is generally received from schools and from other bodies and persons who send notice of measles. In this way, the addrisses of 119 cases were obtained in 1911. The deaths numbered 27 ; all except one were under five years of age. Disinfection is not done as a routine after recovery. 98 From 1909-1911, the deaths have chiefly occurred in Hermes Street (5), and Collier Street, Hatfield Street, Lever Street, Northampton Buildings, Peerless Street, Penton Place, Penton Street, Risinghill Street, Rodney Street, Southampton Street, and St. Bartholomew's Buildings 3 deaths each. Comparative Table. In 1911 Measles caused 85 deaths, hooping cough 27 deaths. These two diseases are very fatal to children under five years. The following table compares the deaths in chi'dren under five years from measles and hooping cough with the deaths from certain other diseases. Deaths in Children under 5 years—1 901-1911. Year. Measles. Hooping Cough. Small Pox. Scarlet Fever. Diphtheria. Enteric Fever. 1901-5 278 211 13 53 80 — 1906-10 347 202 — 39 80 I 1911 82 26 — 4 14 — Totals 707 439 13 96 174 I From this table it appears that the deaths in 11 years due to scarlet fever, diphtheria, enteric fever, and small pox, all taken together numbered 284, to hooping cough 439, to measles 707. In children under five years, therefore, it is seen that measles kills more than twice the number of children whose deaths are caused by small pox, scarlet fever, diphtheria, and typhoid all included. Hooping cough causes a little more than one and-a-half times the number of deaths accredited to the four remaining diseases. 99 SCARLET FEVER. The number of notifications, 171, and the number of deaths, 6, are, with the exception of 1910, less than they have been in any previous year since the Borough was formed. With the exception of 11 cases, all the rest, 160 in number, were in children between one and 15 years. The deaths were 3-5 per cent, of the total number of cases, or one in every 29 children affected, died. Four cases were treated at home—suitable measures were taken to ensure the isolation of the patient. The rest, 167, were treated in hospital. The particulars with regard to previous years are appended. Scarlet Fever, 1901-1911. Year. Actual No. of cases. No. of Deaths. Case Mortality No. of Deaths per 100 cases notified. No. of cases per 10,000 of Population. No. of Deaths per 10,000 of Population. 1901 495 19 38 48.9 1.8 1902 381 15 39 38.1 1.5 1903 283 12 4.2 28.7 1.2 1904 323 17 5.2 33.2 1.7 1905 456 21 46 47.5 2.1 1906 422 13 6.1 446 1-3 1907 471 l6 34 50.5 1.7 1908 387 12 3.1 42.1 1.3 1909 231 9 3.89 25. 5 .9 1910 126 4 3.17 14.1 .4 1911 171 6 3.5 19.5 .6 100 Probable Source. -In 19 instances the infection was derived from previous cases in the same family, in another 16 there was reason to believe that the disease had been contracted by visiting cases in the same house and in houses in the vicinity. In 10 persons the disease was probably contracted from schoolfellows while in school or on the way home. Four patients had been infected when visiting the houses of friends or relatives—two others by attending- places of entertainment just previously to their illness. One patient had caught the disease while sitting by a scarlet fever patient awaiting examination in the out-patient department of a general hospital. One case of scarlet fever was not discovered until 16 days after the rash had appeared. The patient was then peeling. Three developed scarlet fever while detained in hospital for other causes. These are called cross infections and occur when a patient is being treated in hospital for one disease and contracts another disease having been infected from some other hospital patient. They occur in nearly all fever hospitals and are a serious blemish upon their administration. All the houses where cases occurred were visited and inspected. Nuisances that called for remedy were made the subject of notice and amendment. The rooms, the bedding and the clothing were disinfected. There were 5 return cases. Cases discharged from Home.—In Finsbury every case discharged from the fever hospital is visited soon after return home and carefully examined. The possibility of further infection is explained to the mother, suitable measures suggested, and a leaflet of instruction left with her. 101 Special attention is paid to children who develop a discharge from the nose after their return home, to children with adenoids, and to children with sores on their lips or faces. Thirty-one such cases were kept under the supervision of the Medical Officer for periods varying from one to three months before they were certified as being free from infection and fit to resume school attendance. The cases examined after their return home from fever hospitals had the following complications : enlarged neck glands 22, general weakness of limbs 15, discharge from nose 11, sores on lips, face, mouth, or nostrils 11, conjunctivitis 9, discharge from ears 6, peeling on hands or feet 4, sore throat 4, shortness of breath 4, and sores on ears 2 cases. DIPHTHERIA. The number of cases notified was 175, of which 16 were subsequently sent home as not suffering from the disease, leaving 159 true cases. There were 17 deaths, so that 11 per cent, of all patients died. The number of cases is 33 more than it was last year. Sixty were between 1 and 5 years, 68 were between 5 and 15 years, compared with 58 and 41 in 1910. The cases treated in the fever hospitals of the Metropolitan Asylums Board were 131, with 9 deaths, that is 6-8 per cent. Nine cases were treated at home with 1 death. Nineteen cases were treated in general hospitals with 7 deaths—or 37 per cent, of the whole number. The cause of the excessive fatality amongst diphtheria patients treated in general hospitals was discussed at length in last year's report. 102 The particulars of cases in previous years are appended :— Diphtheria, 1901-1911. Year. No. of Cases. No. of Deaths. Case Mortality. No of Deaths per 100 cases notified. No. of Cases per 10,000 of Population. No. of Deaths per 10,000 of Population. 1901 289 36 12'5 28.5 3.5 1902 216 37 171 21.6 3.7 1903 119 12 10.1 12.0 1.2 1904 123 14 11.4 12 6 1.4 1905 126 11 8.7 13.1 l.l 1906 151 25 165 15.9 2.6 1907 127 15 11.8 13.6 1.6 1908 130 16 123 14.1 1.7 1909 152 13 8.5 16.8 1.4 1910 126 19 15.1 14.1 2.1 1911 159 17 107 18.1 1.9 All the cases arc investigated, and the source, if possible, is ascertained. The premises are inspected and notices served for sanitary defects. Out of 159 tenements visited in 1911, no less than 119, or 75 per cent., were found clean, free from vermin, and without sanitary defects. In the remaining 40 houses, there were 14, or 8-8 per cent., with defective drainage, or defective water closets. The smallness of this percentage shows what little foundation there is for the popular reference of every case of diphtheria to faulty drainage. Source.-In ten cases the disease had been contracted from members of the same family already suffering from diphtheria, in 8 other cases from previous cases in the same house or near by. Eight patients were infected after they had been admitted to hospital suffering from another disease. 103 Two patients caught diphtheria while on a visit to relatives. There were 6 return cases. Cases discharged cured from Hospital.—Within a few days after their arrival home from the fever hospitals, all these patients are examined very carefully and a record kept of their condition. A leaflet is given to the parents, its terms explained, and precautionary measures are advised. If a child has a discharge from the nose, or if for any other reason the infection is believed to persist, the mother is advised to take the child to her own doctor, or if poor to bring it to the public health department. The conditions found amongst these convalescent patients after their return home are shown below. Neck Glands enlarged 17 Sore Throat 2 Nasal Discharge 11 Difficulty of swallowing 3 Nasal Voice (Paralysis of Vomiting 5 Palate) 12 Weakness of limbs, proSore Nostrils 2 bably slight paralysis Sore angles of the mouth 2 following diphtheria 20 Ear Discharge 2 Shortness of breath ... 8 Conjunctivitis 7 Rashes, possibly due to Anaemia 19 the serum 1 It is quite possible that some of the cases in the above list were discharged from hospital rather a little too soon. Thirty-one of the cases referred to were examined by the Medical Officer of Health and swabs taken from their throats. In fifteen of these the diphtheria bacillus was still present. The cases were kept under supervision and excluded from school until they were considered to be free from infection. Throat swabs are examined bacteriologically free of charge from medical men by the Public Health Department; 221 were submitted in 1911, and in 50 specimens the diphtheria bacillus was found present. Diphtheria Anti-toxin (London) Order, 1910.-For the purposes of this order medical men may, on request at the Public 104 Health Office, obtain a supply of antitoxin scrum for the treatment of suitable cases. In 1911, eight medical men availed themselves of these facilities. The fees paid amounted to £1 12s. 6d. TYPHOID FEVER. The number of cases notified was 74, with 9 deaths. All except one were removed to hospital. The numbers in previous years are given in the accompanying table:— Enteric Fever, 1901-1911. Year. No. of Cases Notified. No. of Deaihs. Case Mortality. No. of Deaths per 100 cases notified. No. of Cases per 10,000 of Population. No. of Deaths per 10,000 of Population. 1901 65 11 16.9 6.4 1.08 1902 77 9 117 77 09 1903 47 11 23.4 4.7 1.1 1904 40 8 20.0 4.1 08 1905 42 9 21.4 4.3 0.9 1906 44 14 31.8 46 i'4 1907 22 2 210 2.3 02 1908 41 12 292 44 1.3 1909 15 3 20.0 1.6 0.3 1910 28 4 143 3.1 04 19II 74 9 12.2 8-4 1 02 The deaths occurred in four males, aged 10, 13, 20 and 21, and in five females, aged 7, 13, 13, 18 and 21 years. Source.—During the latter end of August and the month of September, Finsbury suffered from a smal' epidemic of enteric fever. Five of the patients had recently been to the seaside, may have consumed shell fish there, and may, possibly, have been in this way infected previous to their return to the Borough. For 105 the rest, an analysis of the enquiry cards used in the investigation of the cases excluded milk and most of the usual sources of infection, but showed that many of the patients had eaten ice cream and fried fish during the presumed period of infection. Attention was, therefore, chiefly directed to these two articles of food. All the cases, omitting those such as late family cases, almost certainly due to contact, cannot even now be satisfactorily explained 011 the basis of one or other of these two impugned food substances. In another report, the epidemic has, on statistical grounds, been attributed to fried fish. In the Finsbury Public Health Department the early cases were attributed to ice crCam. In the house of one ice cream vendor there was an early concealed case. The daughter of another ice cream vendor contracted the disease early in September. Some of the early cases were missed. The diarrhoea of which they complained was considered to be summer diarrhoea, at that time very prevalent, or an attack of " liver and headache." Some of these missed and early cases fed and ate in the neighbouring ice cream shops and fried fish and other restaurants and possibly infected the feeding utensils. The method of cleansing these utensils is very unsatisfactory. In ice cream shops the glasses are momentarily dipped into a bucket of water, swabbed out with a wet cloth used for hours at a time, and then inverted on the ice erean. cart. In August and September, 1911, the weather was extremely hot. The bucket of water for cleansing ice cream glasses would form an excellent medium for the growth of the typhoid germs left on the edge of the glass by infected purchasers, and by the end of the day might contain very large numbers. Each time the glass was washed it would carry with it numbers of the typhoid germ ready for the next purchaser. 106 Somewhat similar considerations apply to fried fish and other restaurants, where the methods of cleansing are equally unsatisfactory, and may explain the explosive character of the onset of the epidemic. The Fried Fish Hypothesis.—This was discussed in last year's report. The following additional observations are now adduced. 1.—This hypothesis depends upon the statements of the patients, chiefly young persons who might very well be inclined to assent to the consumption of fried fish under the pressure of examination when ill. 2.—This theory is one which impugns the fried fish on statistical grounds—it raises a "statistical probability." It would be quite easy by pursuing an investigation, similar in form, though not in detail, to raise an equally violent presumption in favour of attributing the epidemic to the consumption of bread from a particular shop, or to the burning of coke. Fried fish is, like bread, a staple article of diet in the district of the epidemic. Something more is required—it shoukl be shown how the fried fish can produce typhoid fever in fact. The possibility of such an origin must now be demonstrated. 3.—The number of persons who feed daily at the suspected fried fish shop ranges from 950 to well over 1,000. The number of cases bears quite a small ratio to the persons exposed to the infection. At least three weeks intervened between the dates of onset in the early and late cases, known to have fed at the suspected fried fish shop. 107 During this three weeks 18,000 dinners and suppers were served, and yet there were only 74 cases of enteric fever, counting every case. 4.—The following particulars were obtained in respect of the fish frying :—The pans are cleaned out thoroughly once a week. For frying, the best cotton seed oil at 27s. per cwt. is used—from 1£ to 2 cwt. daily. The fish takes 4 to 5 minutes or more to fry. The temperature of the oil in the vat during frying ranged from 406 to 424 degrees Fahrenheit. Some large fish were taken and a thermometer pushed through the mouth so as to be well imbedded in the flesh, and then fried in the oil with the other fish. Care was exercised that the oil did not have direct access to the thermometer bulb. The minimum steady temperature, recorded in this wa), was 230 degrees Fahrenheit. If, therefore, the bacteriological origin of typhoid is accepted, it will be necessary to postulate some sort of salamander germ or fire bacillus to enable it to withstand this high temperature and maintain its virulence unimpaired. It may be alleged that the disease is due to a chemical poison elaborated in the fried fish. The natural history of typhoid, and the progressive development of its signs in man, are incompatible with this suggestion. A chemical poison taken into the body is eliminated once and for all. In typhoid fever the poison is being continually produced and manufactured inside the patient's body, and for this, as far as we now know, the presence of a living organism is necessary. The temperature in the abdominal cavity of the fish was very much higher than the temperature given above for the fleshy part. 108 5.—The fried fish vendor states that no difference was made in the quality of the fish served at mid-day and in the evening. Only one quality fish was bought, and the hampers containing them were used indiscriminately. No fish and no hampers of fish were specially put by for the evening's frying. It is, therefore, difficult to explain the immunity of the large number of Finsbury non-residents who took their mid-day dinners daily at this shop. 6.—It is practically certain that some of the patients did not eat fried fish, and some others ate fried fish from shops other than the impugned shop. Measures.—The following measures were adopted in dealing with the epidemic :— 1.—All the cases except one were removed to hospital. 2.—The tenement, the bedding and the patient's clothes were disinfected. The premises were inspected and notices served for sanitary defects. 3.—The contracts wee kept under supervision and enquiry made for missed, suspected, or carrier cases, both in the affected tenement, and in the whole house. 4.—Lists of contacts known to be ailing and resident elsewhere, were sent to the Medical Officers of other boroughs. 5.—Enquiry was made at the large general hospitals, and especially at the Italian Hospital to find out whether there had been any Finsbury cases of diarrhoea, enteritis, or suspected typhoid in attendance at the out-patient department. 109 6.—The common lodging houses were searched for missed cases. 7.—The urine and freces of suspected cases were investigated bacteriologieally. The blood was examined for the Widal reaction. 8.—A boys' club, to which many of the patients belonged, was temporarily closed. 9. Samples of ice cream were examined bacteriologically and chemically. 10.—A circular letter was delivered by hand to all the ice cream vendors in the Borough, requiring them to scald and scour daily the ice cream container, the churn, the freezer, and its cover. The use of the smalf conical glasses for the sale of ioe cream was prohibited. " Tasters " from a common spoon were not allowed—they might be given on paper. The conical glasses referred to, were disinfected and put away. Power to enforce these provisions is given by Part VIII., Section 42 of the London County Council General Powers Act, 1902. 11.—Leaflets of instruction were distributed and re-distributed to every tenement in a street on every occasion when a fresh case occurred in that street. 12.—The Registrar-General's weekly death returns were watched for deaths attributed to gastritis, enteritis, diarrhoea, pneumonia, and influenza. Some of these, near the affected area, were visited as possible cases of typhoid fever, and enquiry made into the circumstances. 110 13.—By the courtesy of the Wharf and Cleansing Department and of the Cleansing Superintendent, arrangements were made for the daily removal of household refuse in the affected area. 14.—The use of common wash-houses was discouraged. Householders were advised to do the weekly washing in their own kitchens. 15.—All the cases discharged cured from hospital were visited and instructed as to the precautions to be observed. A suitable leaflet was left with each patient explaining the circumstances. Diagnosis.—Specimens of blood in suspected cases of typhoid fever are examined free of charge at the Public Health Department. In 1911, nineteen specimens of blood were received—ten gave a positive Widal reaction, the rest were negative. INFECTIOUS DISEASE. General Considerations.—The diseases now notifiable under Section 55 of the Public Health (London) Act, 1891, are small pox, cholera, diphtheria or membranous croup, erysipelas, scarlet fever, typhus, relapsing, continued and puerperal fevers. Cerebro spinal fever, polio-myelitis, polio-encephalitis, ophthalmia neonatorum, glanders, anthrax and hydrophobia in man are likewise notifiable in London, under an order of the London County Council, under Sections 55 and 56 of the Public Health (London) Act. 111 Sections 60-63, 68-70, 72-74 of the same Act, referring to the cleansing and disinfection of premises and materia's, and to contact with, or exposure of infected persons and things have been made applicable to measles. Chicken pox was made temporarily notifiable for the three months ending June 22nd, 1911. Cases of anthrax, or poisoning by mercury, arsenic, lead and phosphorus, must be notified to the Chief Inspector of Factories, Whitehall. Phthisis is voluntarily notifiable in Finsbury in the case of private patients, and compulsorily notifiable in the case of poor law, hospital, and dispensary patients. On and after January 1st, 19-12, all cases of phthisis become compulsorily notifiable. Outbreaks of glanders and anthrax are notifiable to the Health Authority by the Inspectors appointed under the Diseases of Animals Act, 1894, in pursuance of the provisions of the Anthrax Order, 1899, and of the Glanders and Farcy Order, 1907, of the Board of Agriculture. Notifications.—The number of notifications of infectious diseases received in 1911, was as follows :—Small pox none (none), scarlet fever 170 (126), diphtheria 159 (126), cerebro spinal fever 2 (4), typhoid fever 74 (28), erysipelas 223 (164), puerperal fever 4 (7), and ophthalmia neonatorum 7 cases. The figures in brackets refer to the year 1910. 112 he numbers for previous years are appended : — Notifications of Infectious Disease, 1901-1911. Year. Number of Notifications Received. Notifications per 1,000 of the population. Percentage of Cases removed to Hospital. 1901 1,101 10.8 85.5 1902 1,026 10.2 82.4 1903 566 5.7 788 1904 609 6.2 72'.5 1905 745 7.7 81.8 1906 764 8.08 76.9 1907 735 7.8 83.4 1908 654 7.1 83. 6 1909 534 5 .9 74.7 1910 455 5.1 63.5 1911 640 7.3 61. 4 The above table excludes notifications of Chicken-Pox—there were 203 in 1907 and 181 in 1911. The amount paid in fees this year for notifications was £70 8s. 6d. The highest was £175 16s. in 1902, at the time of the small pox epidemic. The lowest was £43 14s. 6d. in 1910. Diagnosis.—In 31 cases out of a total number of 410, the patients after admission to a fever hospital were returned home as not suffering, at the time of admission, from any notifiable infectious disease. Sixty-seven per cent, of these mistakes were made at the large general hospitals. The errors were chiefly in connection with diphtheria—out of 175 cases removed, 16 were returned home as not having the disease. The diagnosis of typhoid fever was sustained in hospital except in 5 cases. 113 Nine cases of scarlet fever were returned home as incorrect. Deaths.—The number of deaths certified in 1911 as due to the infectious diseases named in the accompanying table, was 299. The corresponding death-rate was 3-4 per 1,000 inhabitants. Deaths from Infectious Disease, 1901-1911. Small-Pox. Scarlet Fever. Diphtheria and Membranous Croup. Enteric Fever. Puerperal Fever. Measles. Hooping Cough. Diarrhoea. Total. 1901 8 19 36 11 4 49 37 95 259 1902 32 15 37 9 6 83 68 84 334 1903 — 12 12 11 4 69 52 100 260 1904 3 17 14 8 5 60 26 145 278 1905 — 21 11 9 — 31 32 111 215 1906 — 13 25 14 5 115 55 144 371 1907 — 16 15 2 1 43 44 66 187 1908 — 12 16 12 3 38 22 126 229 1909 — 9 13 3 2 86 51 68 232 1910 — 4 19 4 6 73 36 5° 192 1911 — 6 17 9 3 85 27 152 299 The increase this year is due to the large number of deaths from diarrhoea in infants during the exceedingly hot summer months. DISINFECTION. In Finsbury there are two disinfecting stations—one at 49, Northampton Road, Clerkenwell, and the other at Warwick Place, Whitecross Street, St. Luke. At each station there is a mortuary and a coroner's court. The mortuary keepers, who reside on the premises, are also chief or foreman disinfectors. 114 At 49, Northampton Road, provision is made for the housing and accommodation of families during the disinfection of their premises after infectious disease, and for the reception of small pox contacts during the incubation period. It was used in 1911 by four families from Finsbury (17 persons) and one family from Holborn (3 persons). The Holborn Metropolitan Borough is allowed to use this shelter by an agreement made between the two boroughs, dated October 4th, 1911, and terminable at the pleasure of either Council. The borough has two steam disinfectors—a Washington-Lyons high-pressure steam apparatus and a Thresh current steam machine. For the disinfection of rooms, formic aldehyde gas, liberated by an Alformant lamp burning 30 tablets per 1,000 cubic feet, is used, or sulphur fumigation, or a spray of chloride of lime dissolved in water and having a strength of 1-2 per cent., whichever is considered suitable. During the year 882 separate rooms were disinfected, of which 146 were for measles, 156 after notification of phthisis, 74 after deaths from phthisis, 34 on account of vermin, and 9 on request. In addition, bedding and mattresses were steam disinfected for the following institutions :— The City of London Lying-in Hospital, the Clarcmont Hall Creche, St. Barnabas' House, St. Luke's Hospital, and The Royal Ophthalmic Hospital. Altogether 6,556 articles were disinfected in connection with cases of infectious disease and phthisis—these were chiefly mattresses, pillows, bolsters, sheets, blankets, quilts, cushions, curtains, carpets, tablecloths, and clothes. Besides these, 10,556 articles of wearing apparel were disinfected for 3 city firms at a price agreed upon, prior to exportation to South Africa. 115 PROTECTION OF FOOD SUPPLY. General Considerations.—Each of the five district inspectors is responsible in his own district for the inspection of foods, of restaurants, of restaurant kitchens, of fried fish shops, of ice cream shops, and generally of all places used for the preparation of food for human consumption. The three street markets are kept under close supervision, and are continuously and specially inspected throughout the year on every Saturday evening and Sunday morning. The latter duty is done by every inspector in turn. Each inspector takes samples under the Sale of Food and Drugs Acts in his district. These purchases are nearly always made by deputy. Meat and Food Inspection.—The Borough Council have appointed Mr. Billing as a special meat inspector to inspcct systematically butchers' shops, food-stuffs, shops for food preparation, and cold stores throughout the whole district. In addition he pays special attention to the meat deliveries in the wholesale market in Charterhouse Street, St. John Street, and Cowcross Street, all adjacent to Smithfield Market. Each district inspector holds a certificate of competency in meat inspection. The attached table is a summary of the diseased and unsound meat and offal confiscated during the year ending 31st December, 1911. All the unsound meat is removed under agreement by Messrs. C. & H. Webb, bone and tallow melters, 155, Bow Road, London, E. Messrs. Webb have their factory in Bow Common Lane, and pay the Borough Council one penny per stone of eight pounds for all the meat removed. 116 Diseased and Unsound Meat Confiscated in 1911, Diseased. Sides of Beef 21 Beef Udders 3 Quarters of Beef 16 Sheep's Livers 27.798 Carcases of Pork 1 ,, Lungs 2,864 „ Veal 2 ,, Plucks 60 „ Stirks 8 ,, Heads 2 Beef Livers 1.567 Pig's Plucks 23 „ Lungs 1.743 ,, Mesenteries 7 „ Heads 50 „ Omentums 7 „ Tongues ,, Spleens 7 „ Hearts Bundles of Beef Casings 52 „ Tripes 2 Tons. Cwts. Qrs. Lbs. Total Weight 48 12 1 11 Decom posed. Quarters of Beef 95 Sheep's Plucks .. 2.532 Pieces of Beef.. 156 ,, Livers.. 10,488 Carcases of Mutton .. 137 ,, Kidneys 206 Pieces of Mutton 78 Cases of Sheep's Sweet-breac 4 Carcases of Lamb 137 ,, Kidneys 108 Pieces of Lamb 3 Casings 4 Carcases of Veal 12 Bags of Sheep's Offal 8 Pieces of Veal 17 Calves' Plucks.. 44 Pork 10 ,, Heads.. 42 Sides of Bacon 102 Pigs' Plucks 361 Pieces of Bacon 492 ,, Livers 56 Cases of Bacon 2 „ Mesenteries 128 Hams 17 Saveloys 80 Beef Lungs 18,844 Barrels of Pigs' Plucks 129 „ Lirers • 4.416 „ ,, Kidneys 7 „ Hearts .. 159 „ ,, Chitterlings. 16 „ Heads 49 ,, Pork Trimmings . 1 „ Tongues .. 574 „ „ Feet .. 1 „ Tails 570 Tins of Sausage Meat 3 „ Spleens .. 10.753 „ Minced Veal 1 „ Tripes Turkeys 7 lt Kidneys .. 1.123 Pheasants 6 Bags of Beef Spleens 3 Partridges 61 „ Tripes .. 3 Ptarmigan 4 Cases of Beef Kidneys 206 Plover 3 „ Sweet-breads 54 Ducks 10 ,, Tails .. 4 Cases of Rabbits 138 ,, Brains .. 2 Eggs 24 „ Palates.. 5 Barrels of Sprats 3 „ . Livers .. 12 ,, Grapes 24 ,, Cheeks.. 177 Bag of Oysters 1 ,, Pieces .. 2 Cheddar Cheese 1 „ Heels .. 2 Barrels of Mackerel 8 ,, Suet 2 Railway Truck of Cabbage . 1 Sheeps' Heads 536 Tons. Cwts. Qrs. Lbs. Total Weight (Decomposer 1) 164 18 2 0 Total Weight (Diseased) 48 12 1 11 Grand Total Weight 213 10 3 11 117 The amount of meat confiscated in 1911 was very much more than that for any previous year. This was due to the very hot summer and to the railway strikes. Australian Beef.—During the first four months 1,318 hindquarters and 2,100 fore-quarters of Queensland beef were delivered into Finsbury cold air stores and were here examined for " worm nests." Of the hind-quarters, 673, or 51-6 per cent., were found to have worm nests in the parts adjacent to the stifle joint. These parts were removed under the supervision of Mr. Billing and sold by the owners for soap making. The hind-quarters deprived of these worm nests were then passed into circulation for human consumption. The 2,100 fore-quarters had been examined and cut by another authority previous to delivery into Finsbury, but were found, on examination here, still to possess worm nests. The whole number were therefore carefully and thoroughly re-examined in this borough and the affected portions excised. 118 UNSOUND FOOD PROSECUTIONS —1911. Date of Trial. Name and Address. Article. Where seized and Name of Inspector. Penalty and Costs Inflicted. 1911. June 1st. Albert Hieleman, 70, Askew Road, Shepherd's Bush, Lcndon. W. A quantity of saveloys, minced veal, prepared sausage material, scrap meat, 5 loins of veal, 7 pairs of calves' lungs and a piece of pork, weighing in all 203 lbs The saveloys were mouldy. The loins of veal and calves' lungs were slimy and discoloured. The pork was slimy and mouldy. All tbe details smelt rery offensively. This meat was actually being made into sausages at the time of the Inspector's visit. No. 5, Cyru? Street. London, E.C. Inspector Billing. Fined £20 and £5 5s. costs. October 19th, Joseph Blake, 51, Victoria Dock Road, London, E. 214 pieces of bacon and 118 pigs' feet, weighing about 762 lbs. The pieces of bacon were discoloured, some pieces were slimy and mouldy. The pigs' feet were very slimy. All the st ized material smelt vtry c ffensively. No. 164, Whitecross Street, London, E.C. Inspector Billing. Fined £100 and £5 5s. costs. This was a difficult and intricate case. The defendant asserted that the business and the bacon belonged to another. An unstamped agreement was produced to confirm this statement. A summons was issued against this alleged owner, but was withdrawn on the conviction of the original defendant. October 29th. Thomas Rimmer, 2, White Lion Buildings, White Lion Street, N. and Thomas Holt, 57, White Lion Street, London, N. One barrel and two half-barrels of sprats. The sprats were very soft, the eyes were sunken, the gills dull in colour, and the whole of the fish smelt offensively. On a coster's donkeybarrow in Hermes Street, London, N. Inspector Davis. Fined 20s. each and 2s, costs, or 7 days' imprisonment Defendants went to prison. December 29th. Giovanni Clerico, 35, Lloyd's Row, London, E C. 6½ lbs. of liquid eggs. The liquid eggs were discoloured and smelt offensively. No. 35, Lloyd's Row, London, E.C. Inspector Rees. Fined £5 and 12s. 6d. costs, or one months' imprisonment. Defendant went to prison for 3 days. The fine was then paid and the defendant liberated. 119 Since 1901, there have been 103 meat prosecutions, with 99 convictions. The largest number was 24 in 1901, with 24 convictions. During this period the meat confiscated has amounted to 1,148 tons. In recent times the average number of prosecutions has been three yearly. Certification of Meat Food Products.—The Medical Officer of Health, with the consent of the Council, was designated the certifying officer by the Local Government Board, for certification of these products for export to the Argentine Confederation, to the United States of America and to the Phillipine Islands. Certificates were granted in 1911 to Messrs. Bovril, Ltd., 152 to 166, Old Street, Finsbury, E.C. Wholesale Meat and Offal Salesmen.—There are 23 wholesale meat firms in Cowcross Street, St. John Street and Charterhouse Street, all adjoining the Smithfield Market. Of these, 15 are wholesale meat contractors, the remaining eight expose meat for sale to regular or casual customers. The firms are as follows:— 2, Cowcross Street, Mr. I. Legrand. 90, Cowcross Street, Messrs. W. Simpson & Co., Ltd. 93, Cowcross Street, Messrs. C. & F. Corne Bros. I, St. John Street, Messrs. F. & W. Warman. 3, St. John Street, Messrs. W. Harris & Son. 7, St. John Street, Messrs. Pepper & Co. 11, St. John Street, Messrs. Sproat & Co. 10 & 12, St. John Street, Messrs. Sproat & Co. 18, St. John Street, Messrs. Woodhouse & Stead. 20, St. John Street, Messrs. Woodward & Co. 85, Charterhouse Street, Messrs. Johnson & Co. 85, Charterhouse Street, Messrs. T. J. Farrell, Ltd. 85, Charterhouse Street, Messr. Rowbotham. 91, Charterhouse Street, Messrs. Fraser & Co. 93a, Charterhouse Street, Messrs. Vanderhage & Philp. 120 95, Charterhouse Street, Mr. H. Hyde. 97, Charterhouse Street, Mrs. J. L. Henson. 99, Charterhouse Street, Messrs. T. Kendon & Sons. 101 & 103, Charterhouse Street, Messrs. G. & W. Burchill. 107, Charterhouse Street, Mr. John Reynolds. 109, Charterhouse Street, Mr. John Palmer. 117, Charterhouse Street, Messrs. R. Wilson & Co. 119, Charterhouse Street, Messrs. Cramp & Gresmar. Cold Air Stores.—There are four Cold Air Stores in Finsbury, whose addresses and proprietors are given below:— Port of London Authority, 19-33, St. John Street, E.C. Premier Meat Company, 14-17, St. John Square, E.C. Messrs. Eastman's Ltd., 91, Charterhouse Street, E.C. Mr. John Palmer, 111, 113, Charterhouse Street, E.C. The first two deal exclusively with frozen meat, the third and fourth with frozen and chilled or refrigerated meats. The wholesale meat establishments and the Cold Air Stores are inspected daily. Street Markets.—These are three in number, and situated in Chapel Street, Pentonville; Exmouth Street, Clerkenwell; and VVhitecross Street, St. Luke's. The barrows, shops and food stalls in these streets are regularly inspected on week-days by the inspectors in whose districts they lie, and on Saturday nights and Sunday mornings by each inspector in turn throughout the whole year. Bacon Curing Establishments.—There are 11 of these in the Borough, situated as follows:— Messrs. Lipton, Ltd., Cayton Street, City Road, E.C. Messrs. Pearks, Ltd., 1, Basterfield Street, Golden Lane, E.C. Messrs. J. D. Link, Greenhill's Rents, Cowcross Street, E.C. Messrs. E. Puxon & Sons, Bull Yard, St. Peter's Lane, Cowcross Street. 121 Messrs. E. Puxon & Sons, Radsworth Street, City Road, E.C. Messrs. Harris Bros., 44 & 46, St. John Street, E.C. The Globe Bacon Co., 48, St John Street, E.C. Messrs. Sloane, Wells & Taylor, 24, St. John Street, E.C. The Danish Bacon Co., Ltd., 9-13, Cowcross Street, E.C. Messrs. Pratt & Cane, 5-8, St. Peter's Lane, Cowcross Street, E.C. Messrs. E. J. Harvey & Son, 29 & 30, Cowcross Street, E.C. Faggot Shops.—There are 12 in number; the addresses are attached:— Mr. Lemming, 138, St. John Street. Mr. Miller, 149, Whitecross Street. Mr. Henne, 152, Whitecross Street. Mr. Firmin, 141, Whitecross Street. Mr. Ching, 93, Central Street. Mr. Spencer, 9, Central Street. Mr. Smith, 28, Bath Street. Mr. Cush, 55, Exmouth Street. Mr. Barnett, 29, Exmouth Street. Mr. Deitz, 93, Chapel Street. Mr. Robinson, 30, Chapel Street. Mr. Saur, 229, Goswell Road. The bacon curing establishments and the faggot shops are periodically and systematically inspected. Slaughter houses.—In Finsbury there are three slaughter houses ; the owners' names and addresses are as follows:— Mr. A. E. Spink, 20, Amwell Street. Mr. Thos. Webb, 191, Goswell Road. Mr. J. A. Mobbs, 14, Penton Street. The Goswell Road slaughter house is licensed for the slaughter of small animals only. The average number of animals slaughtered in the Finsbury slaughter houses is 24 per week—2 head of cattle and 22 sheep. 122 The Greener humane killer is used. The quality of meat is distinctly good. Occasionally a few livers, affected with the liver fluke, are confiscated. There are no knackers' yards in the Borough. The slaughter houses were inspected in 1911, on 95 occasions. No defects were ascertained, and consequently no notices were served. MILK SUPPLY. There are in Finsbury only three sets of premises licensed for cowkeeping. The addresses are annexed:— Name of Occupier. Situation of Premises. Actual No. of Cows. Licensed for. Mrs. Elizabeth Davies Mrs. Nancy Evans 19a, Baldwin Street 15 17 Messrs. John James & Son 40, Rawstorne Street 15 15 Mr. J. H. Jenkins.. 230, St. John Street 28 30 The premises were inspected by the district inspectors on 12 occasions. They are also periodically inspected by the London County Council staff and their veterinary inspector. No notices were served in 1911. Dairies and Milkshops.—The number of persons registered during the year as purveyors of milk was 31, of which 5 were new registrations. During the same period 34 names were removed from the register for various reasons, chiefly on transfer of business. The total number left on the register was 260. Of these, 217 are milkshops, as distinguished from dairies, and sell milk in driblets, for a farthing or a half.penny at a time, in this way disposing of three or four quarts per day. These milkshops, which are also small general or grocery shops, were inspected on 242 occasions, and 38 notices served for various sanitary defects. 123 Registration for the Sale of Milk.—In 1911 there were four prosecutions of milk vendors for selling milk without being registered for this purpose. There were convictions in all cases, but at the time of writing an appeal has been entered in one case. The defendants were in all instances restaurant keepers. In restaurants in this Borough the following milk containing commodities are usually available for customers:— 1.—An ordinary cup of tea, in which the milk is added by the proprietor in small amounts. The usual charge is a penny per cup. 2.—"Tea and milk," "Special tea," or "Tea, half-and-half," in which the milk and tea are roughly in equal proportions —the usual charge is 1½d. or 2d. per cup. 3.—A pot of tea. In this case the milk is in a small jug, and is sometimes, but not always, charged for separately. 4.—Bread and milk. 5.—Porridge and milk. The milk is served in a jug, and may be charged for separately. Enquiry was made from the other metropolitan boroughs as to the practice observed in the registration of restaurants for the sale of milk in connection with the sale of the above articles, Nos. 1, 2, 3, 4 and 5. The cases of restaurants avowedly selling milk, hot or cold, and of public houses selling rum and milk were excluded from the enquiry. It was found that in three boroughs all restaurants were, in fact, registered for the sale of milk, whether they supplied it only in small quantities in tea, or otherwise. That is to say, all restaurants in these three boroughs supplying articles, Nos. 1, 2, 3, 4 and 5 were registered for the sale of milk. The following reasons were given for such registration—that in such shops the milk must necessarily be stored, and it is very 124 important that the means adopted for such storage should be regulated and supervised. Further, the shops, which sell bread and milk, should be registered for the sale of milk, because in this case milk is distinctly one of the main items in the food. In one borough, the registration, for the sale of milk, of all public-houses selling rum and milk was then being considered by the Public Health Committee. In nearly all the boroughs restaurants were entered on the register of workshops and workplaces and cleanliness of working and utensils secured under the Factory and Workshop Act, and the London County Council (General Powers) Act, 1908. There are in Finsbury 237 restaurants. Of the whole number 49 sold milk, and of these 34 were registered in the usual way for such sale. Notices were served on the remaining fifteen and registration effected, or the sale of milk given up. One hundred and twenty-seven sell "Tea and Milk," or one or other of the commodities, Nos. 2 to 5, given in detail above. In respect of these latter restaurants, further action by the Public Health Committee is in abeyance, pending a judicial decision in the case raised for appeal. The restaurants were inspected on 293 occasions: seventy-seven notices were served for various sanitary defects. Milk Samples and Analyses.— The total number of milk samples taken was 373, of which 43, or 11.5 per cent., were found to be adulterated on the standard adopted by the Board of Agriculture—that is not less than 8.5 per cent, of non-fatty solids and not less than 3.0 per cent. of fat. The percentage of adulterated samples is still slowly increasing and is in all probability to be attributed to the increased prevalence of milk "toning" adopted by large distributing companies. 125 This "toning," or "standardising," is one of the drawbacks attaching to the fixing of a definite standard for milk constituents. The following table gives the statistics for the last 12 years :— MILK SAMPLES, 1900-1911. No. of Samples Analysed. No. of Samples Adulterated. Percentage of Adulterated Samples. Added Water. Percentage of Watered Milks in Samples Analysed. Removal of Fat. Percentage of Milks with fat removed on Samples Analysed. Under 5% 5% or over. 10% or over. 15% or over. 20% or over. Under 5% 5% or over. 10% or over. 15% or over. 20% or over. 1900 228 36 15.8 5 12 6 4 2 12.8 — — 4 I 2 3.0 1901 251 56 22.3 17 13 2 3 2 14.7 2 7 4 3 3 7.6 1902 269 53 19.7 15 15 3 2 3 14.2 2 6 3 2 2 5.5 1903 348 58 16.7 19 20 6 1 1 13.5 3 5 3 — — 3.2 1904 346 48. 13.9 14 4 2 1 1 6.0 2 8 6 2 2 5.5 1905 349 38. 109 16 1 1 — 1 5.4 7 8 1 1 1 5.1 1906 377 51. 13.5 10 11 1 2 — 6.3 9 8 1 — 1 5.0 1907 329 38. 11.5 7 4 4 — — 4.5 5 9 4 .— 2 6.0 1908 365 32 8.7 11 2 1 1 1 3.6 7 5 2 1 1 4.3 1909 365 33 9.0 6 2 2 — — 2.7 7 8 1 2 3 5.7 1910 362 38 10.8 5 3 4 1 — 3.7 2 16 5 1 1 7.1 1911 373 43 11.5 4 12 — 1 — 4.6 8 7 7 2 2 6.9 *These figures include samples of milk which were adulterated with preservatives. 126 During the year 22 prosecutions were instituted for milk adulteration : there were 18 convictions. The warranty defence was successfully pleaded in four instances. From 1901 to 1911, and including both years, there have been 184 convictions in milk cases. The fines have amounted to £370 4s. 0d., the costs to £159 6s. 0d. The following table compares the milk vigilance of Finsbury with that of the other London boroughs. MILK SAMPLES, 1910. Borough. No. of Samples. No. Adulterated. Percentage. Battersea 651 59 9.0 Bermondsey 774 76 9.8 Bethnal Green 382 29 7.5 Camberwell 509 29 5.6 Chelsea 147 3 2.0 Deptford 272 31 11.39 Finsbury 354 42 11.8 Fulham 295 36 12.2 Greenwich 191 23 12.0 Hackney 471 52 11.0 Hammersmith 231 31 13.4 Hampstead 310 11 3.5 Holborn 229 21 9.1 Islington 632 58 9.1 Kensington 276 34 12.3 Lambeth 661 50 7.5 Lewisham 296 18 6.0 London (City of) 526 33 6.2 Paddington 337 31 9.1 Poplar 178 9 5.0 St. Marylebone 577 50 8.6 St. Pancras 397 53 13.3 Shoreditch 848 90 25.8 Southwark 953 78 8.1 Stepney 900 130 14.4 Stoke Newington 77 8 10.3 Wandsworth 586 45 7.6 Westminster(City of) 1009 131 12.9 Woolwich 318 15 4.7 Whole of London 12,887 1,276 9.9 127 It will be noticed, that with regard to the percentage of adulteration estimated on the whole number of milk samples in each borough, Finsbury is ninth on the list. Ice Cream Shops. These are all registered and periodically inspected. The list was revised in 1911, and the names and addresses of the proprietors of 97 shops entered on the register. These were inspected on 142 occasions, and, as a result, 17 notices were served for sanitary and other defects. There were no prosecutions. Restaurants.—There are 237 restaurants in the borough. These are regularly inspected. In 1911, the number of notices served was 77, the number of inspections 293. These premises are not included in the sum total of workplaces given on another page. Butter Manufacturers and Wholesale Margarine Dealers.—At the end of 1911, there were on the register six butter manufacturers and one margarine manufacturer. Two additional names of wholesale margarine dealers were registered during the year. The number on the register at the end of the year was 25. Ninety-five samples of butter were taken for analysis, and five found to be adulterated: 25 samples of margarine were obtained, all genuine. Sale of Food and Drugs Acts.—In Finsbury 500 food samples are taken for analysis each year, and, in addition, 100 samples of milk are taken in the evening, or on Sundays at irregular and unusual hours. A rota is arranged at the beginning of the year, but each inspector may also take samples at his own discretion. All the shops in the Borough are sampled from time to time—no exception is made. In 1911, 600 samples were taken, of which 51, or 8.5 per cent." of the total were adulterated. The tables given below show the number and nature of the samples collected and the number adulterated in each case. 128 Substance. Samples taken. Adulterated. Substance. Samples taken. Adulterated. Milk 373 43 Ground Ginger 4 0 Butter 95 5 Ice Cream 4 0 Margarine 25 0 Lemonade 3 0 Coffee 26 2 Cheese 2 0 Cocoa 22 0 Coffee Mixture 1 0 Pepper 21 0 Flour 1 0 Mustard 14 1 Separated Milk 1 0 Lard 8 0 Total 600 51 The statistics for previous years are subjoined:— Year. Total Examined. Genuine. Adulterated. Percentage of adulterated samples. Percentage of adulterated samples for the whole of London. 1901 501 413 88 17.56 11.4 1902 556 475 81 14.56 11 9 1903 6lO 524 86 14.10 10.8 1904 6lO 537 73 11.96 10.2 1905 620 547 73 11.77 10.2 1906 602 527 75 12.42 12.1 1907 603 551 52 8.62 10.0 1908 601 547 54 8.94 9.9 1909 600 553 47 7.83 7.8 1910 600 541 59 9.83 8.5 1911 600 549 51 850 — 129 HOUSING. Bastwick Street.—The proprietor of some of the houses in Bastwick Street wrote a letter in June, 1910, to the President of the Local Government Board suggesting that Bastwick Street and its houses might well be considered to be suitable premises for action under the Housing and Town Planning Acts. A copy of the letter was sent to the Borough Council asking for the observations of the Council thereon. Every house in Bastwick Street, therefore, was very carefully inspected by the Medical Officer of Health, and a report on the conditions found presented to the Public Health Committee. A digest of the report is presented below. The width of the street varies from 15 ft. to 21 ft. 6 in., the carriageway ranges from 8 ft. to 8 ft. 6 in. At the time of inspection there were in the street 392 rooms for letting, of which 90 were empty. Those accommodated 175 families, consisting of 473 adults and 239 children. There were 87 one-roomed tenements. The average death rates for eight recent years were for the whole street 35.5 per 1,000, for Nos. 16-34 inclusive 41.6 per 1,000. During the same eight years, the borough general death rate had ranged from 19.1 to 22.8 per 1,000. The average phthisis death rate for the whole street was 5.61 per 1,000, for the special group of houses 7.06 per 1,000. The phthisis death rate for the borough for the same period had ranged from 2.13 to 2.60 per 1,000. The infectious disease notifications were for the whole street equal to a rate of 15.1 per 1,000, for the special group 15.7 per thousand. The corresponding rate for the borough was 7.5 per 1,000. The special group, Nos. 16-34 inclusive, was represented to the Public Health Committee as unfit for human habitation, each house on its merits, apart from the foregoing general considerations based on disease incidence and death rates. Briefly, the conditions found were as follows:— 130 The rooms were dilapidated, damp, leaking, dirty and verminous, dark, ill-ventilated, or of insufficient height. The accommodation for food storage was absent or insufficient. There was often no separate accommodation for the storage of coal or coke. The staircases were dark, dangerous, dilapidated or broken. Some of the roofs were leaking. Some of the basements were dirty, dark, low, or dangerous. There was insufficient accommodation for drying clothes. Some of these defects were found in some of the houses, and some in others—they were not necessarily all present in any one house. The external brickwork generally was in a good state of repair and showed evidence of recent pointing. In a few cases there were open joints, bulgings, cracks and settlements. Internally the structure was what, for want of a better term, might be called "worn out" and showed evidence of much patching. The owner and his agent interviewed the Public Health Committee and a scheme was proposed by which the houses were to be repaired and made habitable. This scheme was, however, eventually dropped and the owner voluntarily closed Nos. 16 to 34, Bastwick Street. Registered Houses let in Lodgings.—During 1911, no fresh houses were placed on the register and none were removed, so that the number on the books, 1,209, was the same as in 1910. For purposes of cleansing, 996 intimation notices and 172 statutory notices were served. For overcrowding there were 49 notices. The number of visits paid was 8,824. There were no prosecutions. At the end of the year new bye-laws are in process of being drafted. In the present bye-laws there are no sex clauses dealing with indecent occupation. The need for these clauses will be apparent from the following Finsbury cases chosen at random out of the many available for this purpose:— 1.—A back underground kitchen—one room—was occupied for living and sleeping by a father and his daughter, aged 19 years. 131 2.—A front room on the ground floor was occupied for living and sleeping by the father, mother, and a daughter, 18 years. 3.—A family, consisting of a mother, two sons, aged 25 and 19 years, and 2 daughters, 28 and 6 years, occupied a one. roomed tenement for living and sleeping. The room contained one ordinary bed and one floor bed. 4.—A family, consisting of the father, mother and six children —males 15, 9 and 6 years, and females 30, 17 and 13 years—occupied a three.roomed tenement. The father, mother and the three boys occupied the same bed. Common Lodging Houses.—The common lodging houses in the Borough are given in the following table:— Address. Registered Owner Registered Number of Occupants. Average Attendance. Pentonville Road, 19-23 Mrs. Shuttleworth 93 55 White Lion Street, 57 Mr. Shuttleworth 98 70 Clerkenwell Green, 35 Mr. J. H. Claytor 73 34 St. John's Lane, 34 Mrs. Holland 48 25 Old Street, 97 Mr. W. H. Hatch 80 62 Banner Street, 6 Mr. C. Fitzwm. Campbell 140 105 Totals 532 351 They are administered by the London County Council, and are licensed annually at a special meeting held in June of each year. Notice of objection to the licence of any common lodging house must be sent in duplicate to the Clerk of the London County Council, at least a week before the date of the special meeting. Systematic House to House Inspection.—The details of the work done under The Housing (Inspection of District) Regulations, 1910, are indicated briefly in the subjoined table:— 132 SYSTEMATIC HOUSE TO HOUSE INSPECTION, 1911. Street, Place, or Buildings. No. of houses inspected. No. of houses in which defects were found. Percentage of houses with defects to houses inspected. Families occupying. Number of rooms. Total. Occupied. Empty Over. crowded. Anns Place 10 7 70.0 11 20 20 — — Bartholomew Square 7 7 ioo.o 23 43 43 — — Berkley Street 11 9 81.8 43 69 62 7 — Bowling Green Lane 6 5 83.3 24 41 40 1 — Busaco Street 11 5 45.4 29 70 65 5 — Church Row 10 10 1oo.o 28 55 53 2 — Coldbath Square 12 11 91.6 60 100 94 6 1 Compton Passage 9 1 11.1 15 41 38 3 — Cottage Lane 7 7 100.0 13 33 33 — — Crawford Passage 9 7 77.7 30 45 43 2 — Cumming Street 73 44 60.2 252 575 548 27 1 Dundee Buildings 23 11 47.8 23 46 46 — — Eagle Dwellings 28 10 35.7 28 73 73 — — Elizabeth Place 9 9 100.0 15 27 27 — — Easton Place 9 4 44 .4 22 26 26 — — Easton Street 32 6 18.7 115 126 124 2 14 Frederick's Row 3 3 100.0 6 12 12 — — Galway Street 26 22 85.7 64 137 132 5 1 Gloucester Street 1 1 100.0 4 12 12 — — Granville Square 22 15 68.1 58 192 180 12 — Hat and Mitre Court 11 3 27.2 11 22 22 — — Howard's Place 11 7 63.6 26 63 61 2 — Langton Avenue 11 5 45.4 30 55 53 2 2 Langton Street 12 7 58.3 25 64 64 — 1 Little Sutton Street Buildings 42 16 38.1 42 75 75 — — Lock's Gardens 13 6 46.0 24 50 49 1 — Ludlow Street 12 5 41.6 19 32 32 — 7 Macclesfield Place 12 5 41.6 12 38 38 — — Margaret Place, Margaret Street 4 4 100.0 4 8 8 — — Mason's Place 15 8 53.5 15 30 30 — 1 Memel Street 6 1 16.6 22 36 31 5 — Mitre Court 4 4 100.0 13 15 14 1 — Moreland Street 32 20 62.1 89 208 199 9 — New Buildings, Margaret Street 9 6 66.6 9 18 18 — — New Street 22 4 18.1 49 92 92 — — Northampton Road 11 8 72.7 31 66 53 13 — Paton Street 9 5 55.5 18 44 41 3 — Peerless Street 22 4 18.1 61 130 129 1 — Pine Street 25 10 40.0 60 147 145 2 — Pump Court 9 6 66.6 20 29 28 1 — Red Lion Street 33 14 42.4 92 229 191 38 1 Rodney Street 28 16 57. 1 96 306 264 42 2 Sidcup Place 9 6 66. 6 9 26 26 — — Sidney Grove 5 5 100.o 10 19 19 — — Sidney Place 12 11 91.6 14 41 41 — — Southampton Street 80 59 73.7 239 603 567 36 2 Spa Cottages 9 6 66.6 14 36 36 — — Stewart's Place 5 2 40.0 11 18 18 — — Valetta Street 14 9 64.2 20 65 65 — — Whitecross Street 50 15 30.0 58 240 235 5 — White Horse Alley 13 5 38.4 30 67 58 9 1 Wither's Place 10 10 100.0 18 30 30 — — Vineyard Gardens 4 1 25.0 7 18 18 — — Young's Buildings 6 3 50.0 8 19 19 — — Totals 888 490 55.1 2,069 4,682 4.440 242 34 133 The number of houses inspected similarly in preceding years were 1746, 1501, 1447, 1548, 2250, 1341, 806, 534, 789, and 1355 from 1901 to 1910 respectively. Crowding and Overcrowding.—During the year 121 cases of overcrowding were dealt with and abated: 49 of these were in registered houses. Thirty-four were discovered as the result of house to house inspection. Thirty-one complaints of overcrowding were received, but only 21 of these were substantiated on enquiry. As a result of these visits, however, 13 other cases of overcrowding were discovered in the houses complained of. In the area covered by the systematic house to house inspection, 2,069 families occupied 4,440 rooms, or 2.14 rooms per family. Of the total number of rooms inspected, 5.1 per cent. were empty —this shows that the crowding is not due to lack of accommodation. Special Investigation.—In 1911 a special enquiry was made into 50 consecutive cases of overcrowding, 35 in Clerkenwell, 15 in St. Lukes. Two of the families consisted of 11 persons each, and occupied two-roomed tenements. Four families consisted of 10 persons each, and also occupied two-roomed tenements. In these cases the kitchens were used for living and sleeping. The numbers in each family are given in the annexed table:— Persons in family. 11 10 9 8 7 6 5 4 3 No. of families 2 4 4 8 11 7 9 3 2 Two of the families, although they were already otherwise overcrowded, were actually taking in lodgers. The occupations of the fathers were as follows:—Carmen, 11; labourers, 9; street hawkers, 4; porters, 4; ice cream vendors, 134 2; and other occupations, one each. One lather was employed by a London Borough Council. Three fathers were dead, one was in an asylum, and one had deserted his wife. Thirty-six out of the fifty were in casual employment, 15 had been idle for some considerable time. The reasons given for the casual nature of the work and for unemployment were "Work slack," 10; "Unable to get work," 8; "A strike on," 5; illness, 3; and dismissal, one case. Five of the mothers were homeworkers, tailoring, or making artilicial flowers or cardboard boxes. Thirteen mothers worked in a factory or workshop. In 19 families the children were working and were the chief source of support—the wages of the children ranged from 2s. 6d. (a domestic servant) to 8s. 6d. per week. Twenty-six families, comprising 141 persons, lived and slept in one room—the rents ranged from 2s. 6d. to 5s. 6d. per week. One such single room at 4s. 6d. per week was occupied by nine persons—the father, mother, girls 14, 9, 5 and 1½ years, and boys 11, 7 and 3 years. There were two beds. The content of the room was 990 cubic feet, which was too small by 1,610 cubic feet. Twenty-two of the families occupied two-roomed tenements at rents ranging from 4s. to 7s. 6d. per week. Two families occupied three-roomed tenements; the rents were 7s. 6d. and lis. 6d. respectively. Some of the tenements were remarkably small—thus a two-roomed tenement contained only 800 cubic feet and was occupied by nine persons. In all the households there was evidence of poverty, in onethird of the whole number, evidence of destitution. One of the families had removed five times during the preceding 12 months, two families four times, two families three times. Twenty-three families had resided in their present addresses for 12 months. 135 In 19 households both parents were addicted to drink, in 10 other families one or other of the parents was alcoholic. The sickness records of the families since they had been living under these overcrowded conditions were ren arkably good —there were three families with phthisis, two families with scarlet fever, and one with pneumonia. The rest had merely experienced the usual children's ailments. The total deaths in these families were 45, and nearly all of these had occurred before the overcrowding was established. The explanation of this anomaly may be that now, owing to their poverty, these families had perforce to live on simple lare, and to avoid excesses. Many of the previous deaths were due to pneumonia, probably to be attributed to insufficient clothing and exposure, while the families were still having a hard struggle to keep up appearances before becoming submerged. The original reasons for the overcrowding were stated to be poverty, unemployment, the casual or irregular nature of the employment, increase in family, drink, and the illness or death of the chief wage-earner. Additional reasons for its continuance were inability to pay more rent, and, in one instance, a definite refusal to pay more rent though well able to do so. This latter was the family of nine, who lived in one room, rented at 4s. 6d. per week. The father earned 26s. per week, and gave his wife 10s. to provide for the household. In order to supplement this pittance the mother worked as a charwoman. In 13 families, although the overcrowding was well established, children were still being born. In one instance the mother left the father because she did not wish to have any more children. It is interesting to note that when the circumstances of these overcrowded families improve, their first concern is for more and better food. It is only under pressure that they seek to abate the overcrowding. Sometimes such a family has become so 136 accustomed to its settled overcrowded arrangements, that much objection is raised to any change. The conditions of the tenements were: Walls verminous (15), bedding verminous (16), pictures verminous (14), and walls dirty in 31 cases. Notices were served for these and other nuisances. It is difficult sometimes to appreciate the stress on room accommodation that is experienced in the poorer quarters of the Borough. By way of il'ustration the rooms, occupants, cubic space, and disposition for sleeping purposes are given below in such a house where each floor is occupied by one family, and consists of a back and a front room. Each tenement, therefore, consists of two rooms, and the kitchen is used for living and sleeping:— Floor. Room. Cubic Space. Occupied at night by Basement Front 1,008 c. ft. Father and mother. Basement Back 536 c. ft. Girls 16, 13, 5 years. Ground Front 926 c. ft. Father, mother, boy 1 year. Ground Back 684 c. ft. Girls 13, 9 years. Boys 11, 7, 4 years. One bed. First Front 1,287 c- ft- Father, mother, baby 3 weeks. First Back 684 c. ft. Girls 11,9 years boy 10 years. Second Front 1,160 c. ft. Father, mother, boy 1 year. Second Back 622 c. ft. Boys 13, To, 3 years. It is difficult to know how to deal effectively and satisfactorily with overcrowding. It is contrary to all humane considerations to have the family ejected at a few days' notice. The practice in this Borough is to exercise pressure to secure abatement as 137 soon as possible. In cases of phthisis or of infectious disease, abatement is required straightway. Customs and Inland Revenue Acts, 1890 and 1903.— Applications for the certificates of the Medical Officer were received in respect of seven houses, containing 35 tenements, and for blocks of model buildings comprising 346 tenements. These were all carefully inspected, but no certificates were granted. These certificates enable the owners of certain classes of houses to obtain exemption from inhabited house duty, provided the Medical Officer of Health is prepared to certify that the pro— perties are so constructed as to afford suitable accommodation for each of the families or persons dwelling therein and that due provision is made for their sanitary requirements. In inspecting houses for such certificates weight is attached to the following matters :— 1.—Each tenement must be self-contained. 2.—The lighting and ventilation of rooms, staircases and passages. It is considered important that every room occupied for living and sleeping should have a fire-place or some other form of ventilation in addition to the window opening. In this connection it is not uncommon to find an unventilated lumber room or other room converted into a children's sleeping room. 3.—Sufficient cupboards for separate food storage. 4.—Separate coal storage accommodation. 5.—Accessible and sufficient water supply. 6.—A wash-house with convenient coppers, or other sufficient provision for washing clothes and for drying them. 7.—A damp proof course. 8.—A minimum height of rooms—a standard of 8 ft. 6 in. has been adopted in accordance with the terms of section 70, part 5, of the London Building Act, 1894. 138 The above details are in addition to the usual sanitary requirements as, for example, the provision of sufficient water closet accommodation, and of facilities for the disposal of household refuse. Certificates are not issued in respect of buildings containing one-roomed tenements. Verminous Houses.—When school children are found to be verminous in school by the London County Council medical officers in the course of their official inspections, the names and addresses of such children are sent to the Public Health Department. Their homes are then visited by the sanitary inspectors, and notices for cleansing are served on the occupiers where the premises are dirty or verminous. The parents are offered steam disinfection for the verminous bedding and clothing, and sulphur fumigation for the rooms. The number of verminous children notified in 1911 was 536. The number of homes found clean on the first visit was 304, or 56 per cent. This confirms the view tiiat, while the presence of head lice or body lice discovered in school children may suggest the presence of bugs in the home, the association is not a close one. Of the rest, 183 tenements were dirty or verminous. Seventy of the addresses were inaccurate and in 49 instances the correct addresses could not be obtained. In 39 cases the tenements were disinfected by the Borough Council. Of the 183 dirty or verminous homes, the walls and bedding of 135 were verminous, and of 48 dirty but not verminous. In 60 instances the bugs had invaded the wall picture frames. The number of registered houses affected was 64 as against 119 unregistered houses. It is not unreasonable to infer that this smaller incidence on registered houses is to be attributed to the regular annual cleansing and closer supervision which obtains in them. Underground Rooms.—In seventeen instances underground rooms were found to be separately occupied in contravention of the provisions of the Public Health (London) Act, 1891, Section 96. 139 Notices were served and the illegal occupations were discontinued. Stable Dwellings.—The stable dwellings remaining in the Borough are given in the following list. They are all frequently inspected. Premises. No. of Occupancies. No. of Persons. Total. Adults. Children. Baker's Row 1 5 3 8 82, Bath Street 1 2 — 2 93a, Charterhouse Street 1 3 2 5 Claremont Mews 10 22 15 37 14. Clerkenvvell Close 1 3 — 3 Davis Yard 1 2 — 2 Garnault Mews 1 1 — 1 Holford Mews 3 8 7 15 Holford Yard 3 8 — 8 Jay's Buildings 13 42 40 82 119, Lever Street 1 2 5 7 1, New Court, Peter's Lane 1 2 4 6 Sidney Grove 2 3 4 7 Complaints are occasionally received of the nuisance in the streets caused by the open cartage of manure from the stables in connection with these dwellings. FACTORIES AND WORKSHOPS. The number of workshops and workplaces on the Register at the end of 1911 was 1,960, compared with 1,970 at the end of 1910. During the year 323 entries were removed from the register owing to the closing or removal of the workshops and workplaces, and 313 reopened or newly-established workshops and workplaces were placed on the register. The factories on the register at the end of 1911 numbered 936, compared with 895 at the end of 1910. During the year 110 factories were removed from the register, and 151 were added. 140 The factories on the register include 7 tenement factories, in which there are 32 occupiers, carrying on different trades or processes, and supplied with mechanical power by the owners of such factories. Each of these occupiers and his tenement is individually and separately subject to the provisions of the Factory Acts, but the whole premises are treated as one building. During the year 3,442 inspections and re-visits were made by the Council's Inspector. A summary of the defects found is appended:— Summary of Defaults and Defects in Factories, Workshops and Workplaces for which Notices were served during 1911. Work- shops. Factoiies. Workplaces. Tuotals. Dirty workshops and workplaces 165 5 9 79 Damp and dilapidated premises 48 10 ... 58 Dirty passages and staircases 19 5 1 25 Overcrowded workshops 11 ... ... 11 Insufficient ventilation 23 1 ... 24 Fumes from stoves, gas stoves and gas 8 2 ... 10 Drainage of floors. 3 8 ... 11 Water supply inadequate 9 4 2 15 Sanitary conveniences, cleansing 74 81 9 164 Sanitary conveniences, defects 113 115 19 247 No sanitary convenience. 6 ... 3 9 Insufficient sanitary convenience accommodation 1 8 ... 9 Improper use of sanitary con— veniences by both sexes 22 13 5 40 Defective soil pipes ... 6 ... 6 Yards cleansed, paved, or paving repaired 14 10 1 25 Defective sinks, gullies and wastepipes 39 34 2 75 Water cisterns dirty and defective 45 23 5 73 Accumulations of refuse 13 11 1 25 Dustbins, defective or absent 49 28 7 84 Drainage defective 8 14 7 29 Rain-water pipes choked or broken 6 5 ... 11 Stables in need of limewashing 1 ... 1 2 Stable paving defective ... ... 1 1 N uisance from rats and dead mice 2 1 ... 3 Improper keeping of dog ... 1 ... 1 Food utensils and fittings dirty 2 2 ... 4 Black smoke emission ... 1 ... 1 Totals 681 388 73 1,142 141 In connection with these defects 514 intimation notices and 63 statutory notices were served, and 2 summonses were issued. Infectious Disease.—Notice was received of the occurrence of 6 cases of infectious disease (scarJet fever 3, small pox 1, diphtheria 1, and typhoid fever 1), in the homes of out-workers and of workers employed in Finsbury and resident in other districts. These were inquired into, and suitable precautions adopted. Special enquiries.—Investigations were made into the death of a horse from anthrax, and into outbreaks of glanders in stables and mews in the Borough : these are referred to elsewhere. Enquiries were conducted into the practice of caramel wrapping and into the use of unventilated gas heaters in workshops. The caramel wrapping in Finsbury is not done at home, it is confined to factories, where it is carried out under good sanitary conditions. With regard to the gas heaters, it was felt that the conditions actually prevailing were not such as to justify the requirement of special means of ventilation; Dangerous Structures.—In seven instances serious structural defects were found by the workshop inspector during his official visits to work premises. These were referred to the London County Council to be dealt with as dangerous structures under the London Building Acts. Overcrowding.—Eleven cases of overcrowding were discovered and dealt with during the year. One case was very gross. The 142 firm occupied three workrooms affording sufficient accommodation for 17 persons—allowing the official minimum of 250 cubic feet for each person. The number of persons actually found working was 42, or two and a-half times the permissible legal number. One room contained more than three times the maximum number of persons allowed. In this room the amount of air space per person was only 83 cubic feet for each adult. Notices were served on the firm, and they took an adjoining house, thereby abating the overcrowding. Prosecutions.—There were two prosecutions—for failing to provide sufficient w.c. accommodation and for failing to provide a proper dustbin. There were convictions in both cases. The following matters are presented in the form required by the Home Office:— Inspection of Factories, Workshops and Workplaces. Premises. Inspections. Written Notices. Prosecutions Factories (Including Factory Laundries.) 1,190 169 — Workshops.. (Including Workshop Laundries ) 1,932 361 2 Workplaces (Other than Outworkers' premises included in Part 3 of this Report) 320 47 — Total 3,442 577 2 143 Defects found in Factories, Workshops and Workplaces. Particulars Number of Defects. Number of Prosecutions. Found Remedied Referred to H.M. Inspector. Nuisances under the Public Health Acts.— Want of cleanliness 225 204 21 ... Want of ventilation 31 24 7 ... Overcrowding 13 11 2 ... Want of drainage of floors 11 11 ... ... Other nuisances 587 587 ... 1 Insufficient. Unsuitable Sanitary accommodation or defective. Not separate for sexes 18 18 ... 1 247 247 ... ... 40 40 ... ... Offences under the Factory and Workshop Act— Illegal occupation of underground bake— house (S. 101) ... ... ... ... Breach of special sanitary requirements for bakehouses (SS. 97 to 100) ... ... ... ... Other offences (excluding offences relat— ing to outwork which are included in Part 3 of this Report) 86 ... 86 ... Total 1,258 1,142 116 2 144 145 HOME WORK. OUTWORKERS LISTS, SECTION 107 OUTWORK IN UNWHOLE SOME PREMISES, SECTION 108. OUTWORK IN INFECTED PREMISES, SECTIONS 109, 110. NATURE OF WORK. Lists received from Employers. Notice; served on Occupiers as to keeping or sending Lists. Prosecutions. Sending twice in the year. Sending once in the year. Instances Notices served. Prosecutions. Lists Outworkers Lists Outworkers Failing to keep or permit inspection of Lists. Failing to send Lists. Instances. Orders made. (S. 110) Prosecutions Contractors Workmen. Contractors Workmen. Wearing Apparel— Nil. Nil. Nil. Nil. Nil. Nil. Nil. (i) making, &c. 176 456 3773 48 33 438 Circular letters and forms are sent to all employers when the lists are due. All the forms are promptly returned without the necessity for further action. (2) cleaning and washing .. .. .. .. .. .. Household linen .. .. .. .. .. .. 2 Lace, lace curtains and nets .. .. .. .. .. .. 2 Curtains & furniture hangings .. .. .. .. .. .. .. Furniture and upholstery .. .. .. .. .. .. .. Electro-plate 4 .. 14 2 5 .. .. File making .. .. .. .. .. .. .. Brass and Brass Articles .. .. .. .. .. .. .. Fur pulling .. .. .. .. .. .. .. Cables and chains .. .. .. .. .. .. .. Anchors and grapnels .. .. .. .. .. .. .. Cart gear .. .. .. .. .. .. .. Locks, latches and keys .. .. .. .. .. .. Umbrellas, &c. 4 .. 15 1 .. 3 .. Artificial flowers 10 .. 145 3 .. 35 .. Nets, other than wire nets 4 .. 15 .. .. .. .. Tents .. .. .. .. .. .. .. Sacks .. .. .. .. .. .. .. Racquet and tennis balls .. .. .. .. .. .. .. Paper bags ind boxes 32 .. 612 5 .. 35 .. Brush making 16 126 1 8 .. Pea picking .. .. .. .. .. .. .. Feather sorting .. .. .. .. .. .. .. Carding, &c., of buttons, &c. .. .. .. .. .. .. .. Stuffed toys .. .. .. .. .. .. .. Basket making .. .. .. 1 .. 6 .. Total 246 456 4700 61 38 525 .. .. .. .. .. .. 6 .. .. 146 OTHER MATTERS. Matters notified to H. M. Inspector of Factories Failure to affix Abstract of the Factory and Workshop Act (s. 133 66 Action taken in matters referred by H. M. Inspector as remediable under the Public Health Acts, but not under the Factory and Workshops Act (s. 5) Notified by H. M. Inspector 45 Reports (of action taken) sent to H. M. Inspector 45 Other 50 Underground Bakehouses (s. 101):— Certificates granted during the year None In use at the end of the year 34 Registered Workshops.—The workshops on the Register at the end of the year were in connection with the following trades: Clocks and Watches 118, Jewellery 97, Cabinet Making and Polishing 76, Leather Goods and Trunks 62, Tailoring and Clothing 61, Engraving, Embossing, and Chasing 60, Provisions, Bacon, Grocery and Food Preparation 52, Building Trades 44, and Furriers and Skin Dressers 41 workshops. There were in addition 1,349 workshops, making a grand total of 1,960. Outworkers and Homeworkers.—At the end of 1911 there were on the register the names of 585 homeworkers consisting of 38 men and 547 women. During the year 120 names were removed. Four died, 93 left the district, and 23 gave up homework. Fifty of the homeworkers, returned on employers' lists, could not be traced because the stated addresses were incorrect. Of the whole number, 585, who were visited, two men and 16 women were over 70 years; six men and 47 women were between 60 and 70 years. The oldest homeworker was a man aged 86—very bent and engaged in making wicker flasks. 147 They were employed as follows Cardboard box and paper bag making 171, ties, braces and belts 58, artificial flowers 50, tailoring 49, blouses, aprons, skirt and mantlemaking 40, millinery 26, umbrella making 26, ladies' and children's outfitting 28, brushmaking 19, dressmaking 18, collars and shirts 13, furriers and furliners 9, embroidery 9, bookfolders 8, burnishers 5, bootmakers and boot repairers 7, and various other trades 47. Some of the women had become homeworkers for the first time when well over 50 or 60 years. These were generally engaged in making artificial flowers— often a buttercup or other very simple flower. One woman with five young children, who helped in some measure, was able to make 30 gross a week at 3d. per gross. Some of the box makers, when work became scarce, went out as monthly nurses. " Nursing paid better than box making, but was more difficult to get." Sometimes women were found doing men's work—one woman, when her husband died, had continued for years to do the French polishing for her husband's firm in her husband's name. One old lady had been in the workhouse for some considerable time, but on attaining her seventieth birthday, came out, obtained her old age pension, entered her name in the books of the Labour Bureau, and very soon got work to make artificial flowers. Eighteen homeworkers were in receipt of old age pensions : 10 others had poor law relief. Some of the homeworkers worked as charwomen, or at some other occupation during the day-time, and did their homework at night. One of the outworkers was a postman, who, in the intervals of letter-carrying, repaired clocks and watches in his bedroom. Of the women 118 were widows, 92 were spinsters. 148 Of the whole number 140 lived, worked and slept in one room, 216 occupied 2 rooms. Sixty-three women suckled their children during the intervals of work. Many of the women only became homeworkers when their husbands fell out of employment, and expressed themselves as hopeful of relinquishing the work when their husbands began again. Eighty per cent, of the whole number appeared to be in good heajth : the other twenty per cent, were ailing, nine were cripples, and four had phthisis. In 51 cases the work was being done in a basement room; in 146 instances the room was of insufficient height, in 53 homes the lighting was deficient, and in 26 others the ventilation was inadequate. In 50 households the floors and bedding were very dirty. As a class, it was found that the box-makers had a lower standard of cleanliness than the others, and their homes were more frequently verminous. Eighteen notices were served for overcrowding, and 73 for dirty and dilapidated rooms. In 324 cases there was marked poverty in the home. This number comprised 87 widows, 36 spinsters, 3 deserted wives, 7 women with crippled and invalid husbands, 26 women with husbands out of work, 150 women with husbands engaged in very irregular, or badly paid work, and 15 old men, feeble and decrepit. Some of the old ladies over 60 with great difficulty supported themselves and their crippled or paralysed husbands and children entirely out of their earnings as homeworkers. On the other hand, one old man over 70 years, a bootmaker, alert and quick witted, occasionally earned as much as 30s. per week. Of the total number, 163 were entirely dependent on their work. 149 On these people, the bulk of whom are women, the pressure is very great. The married woman homeworker with a family often depends on what she makes in the intervals of housework to provide food and clothing for the children, and when the husband falls out of work she becomes the sole support of the family. In a district like Finsbury it is quite rare to find a woman working for pin-money. Under the Trade Boards Act a minimum rate of 3d. per hour has been fixed for box-making. The prices paid in Finsbury for making card-board boxes ranged from 9d. per gross for making boxes for Christmas cards, to 3s. 9d. per gross for making large perfumery boxes and bottle cases. Most of the box-makers were being paid from 1s. It 1s. 9d. per gross. The average earnings of the homeworker box-makers, not dependent upon the work, amounted to 4s. 6d. per week. Three box-makers, entirely dependent, earned 12s. 6d. per week Bakehouses.—At the end of 1911 the total number of bakehouses in the Borough was 60, of which 24 are above ground and 36 below ground. All the bakehouses are periodically inspected; in 1911 the number of visits paid was one hundred and eleven. Notices for cleansing and dilapidations were issued in 13 instances. These were all complied with. At one visit of inspection the baker was found taking cakes out of the oven with hands very much soiled with coal and grease. The floor of the bakehouse and the utensils were all dirty, There was no water supply. In another bakehouse the premises and utensils were clean, but the walls were covered with cob-webs. There was one prosecution. Mr. G. Clerico, 35, Lloyd's Row, was prosecuted for having deposited and in preparation for sale, 150 intended for the food of man, a quantity of liquid eggs, unsound, unwholesome and unfit for the food of man. He was fined £5 and 2s. costs. Canal Boats Acts, 1877 to 1884.—During the year the total number of boats inspected was 106. The Acts and Regulations were contravened in seven instances, and for this three complaint notes were sent to the owners and four to masters requiring abatement within a specified time. The details of the contraventions are as follows :— Boats not painted in accordance with the requirements of the Acts 3 Boats being worked without registration certificates 3 Fore-cabin overcrowded 1 These defects were all remedied within the times specified. No legal proceedings were taken. The following table gives statistics relating to the inspection of boats for the past 5 years:- Year. Boats inspected. Persons found on Boats. Totals. Registered. Men. Women. Children. 1907 103 181 40 43 264 322 1908 101 267 18 36 321 353 1909 105 261 28 47 336 370 1910 112 299 29 36 364 412 ½ 1911 106 270 39 50 359 377 Of the 106 boats inspected, 73 were occupied by men only, 9 by men and women, and 24 by men, women and children. The children accompanying their parents on the boats appeared to be strong and healthy. 151 No case of infectious disease was notified or discovered in the Canal Boats, therefore isolation of the patient and detention of the boat have not been necessary. The inspection of Canal Boats is part of the duty of the Sanitary Inspector whose district includes that portion of the Borough in which the canal is situated. This year the duties were carried out by Inspector Davis (January and February) and Inspector Norman. There is no separate remuneration for this work. Elementary Schools.—There are in Finsbury nineteen Public Elementary Schools—14 provided and 5 non-provided, affording accommodation for nearly 18,000 children. The average daily attendance is approximately 14,430. The school premises are visited from time to time by the Medical Officer and the Sanitary Inspectors. The greater part of the work, however, in connection with these schools lies with the Medical Department of the London County Council Education Committee. Infectious Disease in Schools.—During the year 394 children were excluded from school owing to the presence of notifiable infectious disease in their homes. In addition, 1,475 children were kept at home in connection with outbreaks of measles, hooping cough, chicken pox, and other infectious or contagious disorders in their households. The names and addresses of the children concerned were sent to the Public Health Department by the school teachers. 152 The figures for the year have been as follows :— SCHOOLS. Average Attendance. NOTIFIED BY MEDICAL MEN. INFORMATION FROM SCHOOLS. Total. Scarlet Fever. Diphtheria. Enteric Fever. Measles. Hooping Cough. Chicken Pox. Other Diseases Albion Place 580 6 5 22 4 8 72 117 Amwell Street 570 1 1 1 4 4 10 12 33 Ann Street 880 11 21 — 14 4 12 47 109 Baltic Street 580 7 7 — 11 27 28 20 75 Bath Street 1,280 3 14 — 16 — 20 56 109 Bowling Green Lane 690 — — — 1 — — — 1 Central Street 730 17 9 — 14 1 17 55 113 Chequer Street 740 8 6 — 13 4 42 38 111 Compton Street 1,080 17 17 4 9 5 1 25 75 Hugh Myddelton 1,440 30 25 4 68 34 8 89 68 258 Moreland Street 1,020 6 11 — 7 9 35 136 Risinghill Street 1,240 39 6 — 87 16 36 4 188 Winchester Street 1,225 57 14 — 56 18 32 84 261 White Lion Street 850 35 1 — 39 18 37 71 201 St. John Street 145 4 — — 2 — 10 1 17 St. Luke's 690 1 1 — 6 — 5 7 20 St. Mark's 130 2 — — 10 — 5 3 20 St. Joseph's 370 — 1 — 5 — — 10 16 St. Peter & Paul 190 - 5 - - - 1 3 9 Total 14,430 244 144 6 384 119 307 665 1,869 Black Smoke.—During the year 67 black smoke observations were made by the district and workshop inspectors. Notices of 10 infringements were received from the London County Council. One complaint was made by a private person. In 25 cases, the black smoke was emitted for 3 minutes or longer and, in respect of these, cautionary letters and notices calling upon the occupiers to prevent the recurrence of the black smoke were issued. Summary proceedings for the abatement are taken under Section 24 of the Public Health (London) Act, 1891. Where the black smoke lasted less than three minutes no action was taken. There was one prosecution—the details are given at the end of this report. Cleansing of Persons Act, 1907. In 1909 an arrangement was entered into with the Holborn Board of Guardians to provide 153 for the cleansing of Finsbury cases under this Act, at a cost of six shillings per person. This cleansing is effected and the clothes of applicants are freed from vermin at the Casual Wards, in Little Gray's Inn Lane, Holborn. During the year applications were received from 11 persons, for whom orders were duly issued. All except four availed themselves of the facilities offered. The Mortuaries. There are two mortuaries in the borough, one at Warwick Place, St. Luke's, and one at 47, Northampton Road, Clerkenwell. At each place there is a disinfecting station, and 'a Coroner's Court. The returns for 1911 are as follows:- Northampton Road Mortuary. Warwick Place Mortuary. Total. Inquest cases 79 40 119 Infectious Diseases 5 4 9 Bodies deposited by Borough Orders 2 2 4 Bodies brought for convenience of relatives 69 59 128 155 105 260 At the Warwick Place Mortuary 27 post mortem examinations were made; at Northampton Road 69 examinations. The Shelter.—The Council's shelter is situated at 47, Northampton Road, Clerkenwell, in connection with the Disinfecting Station 154 In 1911, 7 families, 26 persons in all, availed themselves of its accommodation. Offensive Trades.—In Finsbury there is only one registered offensive trade—Mr. Joseph L. Henson, Tripe Dresser, 137, Whitecross Street. This was inspected on 6 occasions in 1911. It was not found necessary to serve any notice for sanitary defects. A complaint was received of fat melting in the Borough. The premises were visited, and it was found that 4 lbs. of beef fat were being melted daily in a gas stove in the basement. Notice was served upon the owner, and the practice discontinued. Staff of the Public Health Department.—The staff consists of:— A Chief Sanitary Inspector, five District Sanitary Inspectors, a special Meat Inspector, a special Factory and Workshop Inspector , one Lady Sanitary Inspector, two Lady Health Visitors, one Chief Clerk, and two Clerks. In addition there are two Disinfectors, one Van Driver, who may assist with disinfection, and two Keepers of the Mortuaries and Coroner's Courts. One of the Mortuary Keepers assises in disinfecting rooms ; the other works the steam disinfector, and his wife attends to those who are temporarily housed in the Council's shelter. The following table summarises the work done during 1911 by the Sanitary Inspectors :— 155 WORK OF SANITARY INSPECTORS, 1910. Inspector Davis. Inspector Longden. Inspector Norman. Inspector Jackson. Inspector Rees. Totals. Houses dirty, damp or dilapidated remedied 343 178 123 194 234 1072 Doors, windows, floors, walls, ceilings; sash cords repaired 50 104 63 55 57 329 Overcrowding cases abated in other than Registered Houses 26 11 22 4 9 72 Illegal occupation of underground rooms 2 4 - 3 8 17 Water closet defects remedied 245 119 149 196 129 838 Water closets erected 69 15 102 53 27 266 Urinal defects remedied 1 5 5 1 1 13 Urinals erected 3 2 4 5 — 14 Soil pipe and ventilating shaft defects remedied 2 - 2 5 4 13 Soil pipe and ventilating shafts erected 36 2 34 15 12 99 Yard defects remedied 173 117 58 68 79 495 Waste pipe defects remedied 27 20 12 16 11 86 Waste pipes erected 29 — 32 13 2 76 Water cistern defects remedied 31 15 7 11 18 82 Rubbish, manure accumulations removed 29 20 10 15 13 87 Dust or Dung receptacles repaired or renewed 78 63 90 47 49 327 Drains relaid or amended 84 13 36 41 24 198 Drains cleared 78 37 53 77 59 304 Rain water pipes repaired or renewed 14 13 28 22 23 100 Water supply to houses re-instated 4 1 — 4 2 11 Roofs and Gutters repaired 61 73 67 55 46 302 Area defects remedied 37 18 4 8 21 88 Washhouse defects remedied 149 82 41 47 57 376 Animal Nuisances abated 2 7 3 3 7 22 Floor space unventilated 2 4 - — 1 7 Stables cleansed or repaired 1 3 — — 8 12 Smoke observations 5 8 28 16 8 65 Water Supply laid on to upper storeys of house 30 41 25 25 10 131 Miscellaneous Nuisances abated 54 27 7 37 20 145 Bakehouses cleansed or repaired 3 5 4 5 4 21 Restaurants cleansed or repaired 6 10 32 23 6 77 Milkshops cleansed or repaired 5 14 12 7 — 38 Public Houses cleansed or repaired 4 3 8 4 1 20 Ice Cream Manufactories cleansed or repaired 2 7 5 3 3 20 Butchers' shops cleansed or repaired — — 4 4 1 9 Fish Purveyors' Shops cleansed or repaired 6 - 3 1 1 11 Registered Houses - Overcrowding cases abated 10 3 8 12 16 49 Registered Houses-cleansed 212 180 158 164 254 968 Registered Houses-Intimation (Cleansing) Notices served 217 191 156 164 268 996 Registered Houses - Statutory (Cleansing) Notices served 18 11 29 63 51 172 First visits (complaints, casual visits) 1134 1240 1364 1512 1288 6538 Revisits 2896 3268 3010 3014 2306 14494 Intimation Notices served 535 444 505 516 507 2507 Statutory Notices served 72 67 42 101 64 346 Infectious disease investigations 343 258 204 281 310 1396 House inspections 393 411 379 410 519 2112 House to house inspections 168 182 196 199 143 888 Canal Boats inspected 8 - 106 - - 114 156 Work of Mrs. Greenwood, Lady Sanitary Inspector, 1911. First Visits. Births 189 Infant Deaths 32 2 Measles 250 Outworkers (Home-workers) 574 Factories 8 Workshops 32 Phthisis 123 Laundries 267 Re-visits. Births 138 Infant Deaths 212 Measles 147 Outworkers (Home-workers) 322 Factories 4 Workshops 11 Phthisis 167 2,766 Number of Notices served 160 Dirty rooms and tenements 52 Defective flooring and broken sash cords 16 Dirty floors and bedding 22 Workshops dirty 2 Overcrowding 27 Rooms illegally occupied 4 Sanitary convenience dirty 28 Sanitary conveniences defects 40 Insufficient w.c. accommodation 7 Yard walls dirty 22 Defective paving of yard or drain choked 12 Defective sink pipes or water cistern 14 Defective dustbin or absence of dustbin 20 Defective roofs or guttering 7 Area walls or basement dirty 8 Dirty walls and ceiling of washhouse, defective paving and roof 11 Miscellaneous nuisances 20 Nuisances referred to District Inspectors 43 157 LEGAL PROCEEDINGS UNDER THE PUBLIC HEALTH (LONDON) ACT 1891. Date. 1911. Name and address of Defendant. Offence. Result. June 20th F. Frost, 29, Alwyne Road, Canonbury, N. Failing to supply a dustbin at 49, Rosoman Street Ordered to pay £1 3s. costs. June 20th Sarah Shoard, 9, Old Park Villas, Palmers Green. Failing to alter and amend a defective dustbin at 35 Corporation Row Fined £1 and 2s. costs. July 6th Northampton Institute Allowing black smoke to issue from boiler shaft Fined £4 and 2s. costs. July 21st Alfred Jos. Brown, River Cottage, Barrowell Green, Winchmore Hill, N. Failing to alter and amend dilapidated dustbin at 6, Risinghill Street Ordered to pay £1 3s. costs. Dec. 22nd S. J. Soames, 6, Harpur Street, Theobalds Road, W.C. Failing to provide additional water closet accommodation at 154, Farringdon Road Adjourned to Jan.22nd,1912 Dec. 27th Pisa Barnett, 58, Moorgale Street, E.C. Failing to alter and amend a dustbin at 18, Sidney Street Adjourned to Jan.10th, 1912 158 SALE OF FOOD AND DRUGS ACTS. Date. Name and Address of Defendant. Offence. Result. 1911 Jan, 19th Bartholomio Fabrizi, 60, Golden Lane, EC. For selling milk with 14 3 per cent. of added water and with 25·3 per cent. of its cream abstracted Fined £2 and 12s. 6d. costs „ 19th Mrs. Emily Smith, 5, Helmet Row, E.C. For selling Pepper containing 50 per cent. of foreign starch Fined £1 and 12s. 6d. costs „ 28 th Mrs. Ann Davies, 318, St. John Street, E.C. For selling butter adulterated with 40 per cent. of foreign fat Fined £2 and 12s. 6d. costs Mar, 2nd Arthur Scott, 8, Southampton Street, N. For selling milk from which 14 per cent. of its cream had been abstracted Fined 10s. and 12s. 6d. costs Apr. 28th John Morgan, 114, Clerkenwell Close, E.C. For selling milk containing 7·1 per cent. of added water Fined £1 and 12s. 6d. costs „ 28 th John Evans, 15, Gt. Bath Street, E.C. For selling milk containing 16·8 per cent. of added water Fined £5 and 12s. 6d. costs May 4th Harry Schnelderman, 13, Fleur-de-lis St., Spitalfields, E. For selling butter adulterated with 40 per cent. of foreign fat at No. 83 Lever Street Fined £2 and 12s. 6d. costs „ 26th Isaac Joel, 30a, Gt. Sutton Street, E.C. For exposing Margarine for sale without a label Fined 10s. and 12s. 6d. costs „ 26th Clara Roberts, 4, Collier Street, N. For selling milk adulterated with 9 per cent. of added water and from which 8 per cent. of its fat had been abstracted Fined 5s. and 12s. 6d. costs. June 8th William Jones, 13, Percival Street, E.C. For selling milk containing 5·4 per cent. of added water Fined £2 and 12s. 6d. costs July 4th John T. Howell, 3, St. John's Lane,E.C. For selling milk from which 14·3 per cent. of its fat had been abstracted Dismissed. Warranty proved „ 6th H. D. Pugh, 124. Whitecross Street. E.C. For exposing margarine for sale by retail without a label Fined £3 „ 6th G. W. Copeland, 14, Playhouse Yard, E. C. For selling milk from which 22 per cent. of its cream had been abstracted Dismissed. Warranty proved ,, 18th Robd. Wm. Barfield, 23, Northampton Road, E.C. For selling milk from which 6·6 per cent. of its cream had been abstracted Fined £2 and 12s. 6d. costs. 159 Date. Name and Address of Defendant. Offence. Result. July 20th Albert & Wilfred Hall, 307, Liverpool Road, N. For selling milk from which 10 per cent. of its cream had been abstracted Dismissed. Warranty proved „ 20th Myer Cohen, 11, Mitchell Street, E.C. For selling milk from which 10 per cent. of its cream had been abtracted Fined £2 „ 20th W. Francis Grove, 52, Ironmonger Row, E.C. For selling milk from which 10 per cent. of its cream had been abstracted Fined £1 „ 21st Annie Gilliver, 12, Penton Street, N. For selling milk from which 10 per cent. of its cream had been abstracted Fined £2 and £1 3s. costs ,, 21st Albert Edward Sharpe, 25, Baron Street, N. For selling milk from which 16·6 per cent. of its cream had been abstracted Fined £2 and £1 3s. costs Aug. 18th Mrs. A. E. Dibsdale, 21a, Easton Street, W.C. For selling milk containing 9 per cent. of added water. Fined £1 and 12s. 6d. costs. „ 18th Louisa Shackshaft, 162, Kings Cross Road, W.C. For selling milk containing 6·9 per cent. of added water. Fined £1 and 12s. 6d. costs Oct. 9th George Hughes, 43, Whitechapel Road, E. For selling milk adulterated with 71 per cent. of added water and from which 30 per cent. of its cream had been abstracted Fined £5 and 12s. 6d, costs. „ 27th G. C. Bull, 270, St. John Street, E.C. For selling milk containing 8·6 per cent. of added water Fined £1 and 12s. 6d. costs. „ 27th Jane Jones, 57, Rosoman Street, E.C. For selling milk from which 6·6 per cent. of its cream had been abstracted Fined £1 and 12s. 6d. costs Nov. 30th Oliver John Cole, 37, Chiswell Street, E C. For selling butter adulterated with 8·03 per cent. of added water Fined £3 and £1 3s. costs Dec. 27th Rowland Thomas, 113, Whitecross Street, E.C. For selling butter adulterated with 8·1 per cent. of added water Fined £1 and 12s. 6d. costs „ 29th F. J. Pettitt, 57, Percival Street, E.C. For selling milk from which 6·6 per cent. of its cream had been abstracted Fined £2 and 12s. 6d. costs „ 29th Peter Puncia, 10 Garnault Place, E.C. For selling milk from which 11·3 per cent. of its cream had been abstracted Fined £1 10s. & 12s. 6d. costs „ 29th J. Humphreys, 48, Northampton Road, EC. For selling mustard adulterated with 10 per cent. of starch. Fined 10s. and 12s. 6d. costs ,, 29th Gt. Western & Metropolitan Dairy Co., Ltd.,9,Harrow Road, Paddington, W. For selling milk from which 4·6 per cent. of its cream had been abstracted Dismissed. Warranty proved. 160 DAIRIES, COWSHEDS AND MILKSHOPS ORDER. Date. Name and Address of Defendant. Oflence. Result. 1911. Nov. 30th Gino Ferrari, 71, Old Street, E.C. Carrying on the trade of purveyor of milk without being registered as such Ordered to pay £1 3s. costs Dec. 22nd Messrs. Lipton, Ltd., City Road, E.C. Carrying on the trade of purveyor of milk without being registered as such Adjourned to Jan. 11th, 1912. „ 29th G Capane, 125, Aldersgate Street, EC. Carrying on the trade of purveyor of milk without being registered as such Fined 10s. and 2s. costs ,, 29 th G. Capane, 125, Aldersgate Street, E.C. Carrying on the trade of purveyor of milk at 7, Carthusian Street, without being registered as such Fined 10s. and 2s. costs „ 29th Messrs Spiers & Pond, Ltd., 35/38, New Bridge Street, Blackfriars, E.C. Carrying on the trade of purveyor of milk at Farringdon Street Station, without being registered as such Adjourned to Jan. 19th, 1912. LOCAL GOVERNMENT BOARD AND OTHER TABLES. 162 TABLE I. Vital Statistics of Whole District during 1911 and previous Years. Metropolitan Borough of Finsbury. Year. Population estimated to Middle of each Year. Births. Total Deaths Registered in the District. Transferable Deaths.‡ Nett Deaths belonging to the District. Uncorrected Number. Nett. of Nonresidents registered in the District. † of Residents not registered in the District. † Under 1 Year of Age. At all Ages. Number. † Rate. Number. * Rate. Number. * Rate per 1,000 Nett Births. Number. * Rate. 1 2 3 4 5 6 7 8 9 10 11 12 13 1906 94,529 3,464 3,012 31·9 1,032 10·9 32 1,020 474 157 2,020 21·4 1907 93,165 3,361 2,884 30·9 912 9·8 49 911 368 127 1,774 19·1 1908 91,787 3,474 2,916 31·8 931 10·1 55 891 400 137 1,767 19·2 1909 90,394 3,427 2.857 31·6 882 9·7 56 988 366 128 1,814 20·1 1910 88,987 3,566 2,833 31·8 819 9·2 69 886 342 121 1,636 18·4 1911 87,566 3,441 2,676 30·6 839 96 67 935 411 154 1,697 19·4 "Transferable Deaths" are deaths of persons who, having a fixed or usual residence in England or Wales, die in a district other than that in which they resided. (1) Persons dying in Institutions for the sick or infirm, such as hospitals, lunatic asylums, workhouses, and nursing homes (but not almshouses) must be regarded as residents of the district in which they had a fixed or usual residence at the time of admission. If the person dying in an Institution had no fixed residence at the time of admission, the death is not transferable. If the patient has been directly transferred from one such institution to another, the death is transferable to the district of residence at the time of admission to the first Institution. (2) The deaths of infants born and dying within a year of birth in an Institution to which the mother was admitted for her confinement should be referred to the district of fixed or usual residence of the parent. (3) Deaths from Violence are to be referred (a) to the district of residence, under the general rule; (b) if this district is unknown, or the deceased had no fixed abode, to the district where the accident occurred, if known; (c) failing this, to the district where death occurred, if known ; and (d) failing this, to the district where the body was found. Area of District in acres Total population at all ages 87,976 (exclusive of area 586·6 Number of occupancies, 21,278 At Census of 1911. covered by water). Average number of persons per occupancy, 4·13. 163 TABLE II. /Cases of Infectious Disease notified during the Year 1911. Notifiable Disease. Number of cases notified. Total cases notified in each locality. At all Ages. At Agest-Years. 1 2 3 Total cases removed to Hospital. Under 1. 1 to 5. 5 to 15. 15 to 25. 25 to 45. 45 to 65. 65 and upwards. Clerkenwell. St. Luke. St. Sepulchre. Small Pox - - - - - - - - - - - - Cholera - - - - - - - - - - - - Diphtheria (including Membranous croup) 159 3 60 68 24 4 - - 103 51 5 150 Erysipelas 223 3 5 15 20 80 76 24 176 47 - - Scarlet Fever 171 - 57 103 7 4 - - 115 55 1 167 Ophthalmia Neonatorum 7 7 - - - - - - 3 3 1 - Enteric Fever 74 - - 34 24 16 - - 68 6 - 73 Relapsing Fever - - - - - - - - - - - - Varicella 131 16 50 59 2 4 - - 70 61 - - Puerperal Fever 4 - - - - 4 - - 3 1 - 1 Cerebro Spinal Meningitis 2 2 - - - - - - 1 1 - 2 Phthisis Under Tuberculosis Regulations, 1908 152 - 3 16 10 70 44 9 96 55 1 152 Under Tuberculosis Regulations, 1911 161 - 3 10 28 74 41 5 105 55 1 66 Others 106 - 2 55 6 33 10 - 72 34 - 4 Totals 1190 31 180 360 121 289 171 38 812 369 9 615 164 TABLE III. Causes of, and Ages at, Death during Year 1911. Causes of Death. Nett Deaths at the subjoined ages of "Residents" whether occurring in or without the District. Total Deaths, whether of "Residents" or " Non-Residents" in Public Institutions in the District. All ages. Under 1 year. 1 and under 2 years. 2 and under 5 years. 5 and under 15 years. 5 and under 25 years. 25 and under 45 years. 45 and under 65 years. 65 and upwards 1 2 3 4 5 6 7 8 9 10 11 All causes Certified 1696 410 159 90 54 48 209 341 385 62 Uncertified 1 1 - - - - - - - - Enteric Fever 9 5 4 - - - Small-pox — — — — — — - — — - Measles 85 20 39 23 3 - - - - - Scarlet fever 6 1 3 2 - - - - - Hooping-cough 27 10 9 7 1 - - - - - Diphtheria and Croup 17 1 9 4 3 — — — — 1 Influenza 7 - - - - - 4 3 — - Erysipelas 7 - - - - - - 5 2 — Cerebro-Spinal Fever 2 2 - - - - - - - - Phthisis (Pulmonary Tuberculosis) 159 3 4 4 5 15 69 49 10 - Tuberculous Meningitis 31 8 7 6 10 - - - - - Other tuberculous diseases 12 2 4 3 1 1 1 - - 1 Rheumatic Fever 5 - - 1 1 2 1 — — - Cancer, malignant disease 81 - - 1 1 1 10 44 24 8 Bronchitis 161 24 4 1 — 1 7 42 82 — Broncho Pneumonia 91 31 30 16 3 — 3 2 6 — Pneumonia (all other forms) 96 7 11 3 3 4 22 25 21 2 Other diseases of Respiratory organs 3 - - - - 1 - 2 - - Diarrhœ and Enteritis 152 115 24 4 - - 1 2 6 - Appendicitis and Typhlitis 6 - 1 - 3 - - 2 - 2 Alcoholism 11 - - - - - 5 5 1 - Cirrhosis of liver 18 - - - - - 3 12 3 1 Nephritis and Bright's 137 - - 1 - 2 20 61 53 3 Puerperal Fever 3 - - - - - 3 - - - Other accidents and diseases of Pregnancy and Parturition 3 - - - - - 3 - - 4 Congenital Debility and Malformation, including Premature Birth 118 114 4 - - - - - - 17 Violent Deaths, excluding Suicide 77 23 4 5 4 4 8 16 13 1 Suicides 15 - — — — 1 7 4 3 1 Murder 1 - — — — 1 — — — - Senile Decay 84 - — — — — — 84 1 Other Defined Diseases 240 41 5 8 9 9 40 62 66 15 Diseases ill-defined or unknown 33 10 3 — — 2 2 5 11 5 1697 411 159 90 54 48 209 341 385 62 165 TABLE IV. Infant Mortality cause of death. Under 1 week. 1-2 weeks. 2-3 weeks. 3-4 weeks. Total under 1 month. 1-3 months. 3-6 months. 6-9 months. 9-12 months. Total Deaths under 1 year. All causes Certified 64 24 12 15 115 78 85 69 63 410 Uncertified 1 .. .. .. 1 .. .. .. .. 1 Small-pox .. .. .. .. .. .. .. .. .. .. Chicken-pox .. .. .. .. .. .. .. .. .. .. Measles .. .. .. .. .. .. 1 11 8 20 Scarlet Fever .. .. .. .. .. .. .. .. .. .. Diphtheria and Croup .. .. .. .. .. .. .. 1 .. 1 Whooping Cough .. .. .. .. .. .. 3 5 2 10 Diarrhœa .. 1 3 1 5 10 28 15 17 75 Enteritis .. .. .. 2 2 9 14 6 9 40 Tuberculous Meningitis .. .. .. .. .. 1 3 1 3 8 Abdominal Tuberculosis .. .. .. .. .. .. .. 1 .. 1 Other Tuberculous Diseases .. .. .. .. .. .. 1 .. .. 1 Congenital Malformations 1 .. .. 1 2 .. .. .. .. 2 Premature Birth 45 12 2 2 61 8 .. .. .. 69 Atrophy, Debility, and Marasmus 1 .. 2 3 6 19 10 7 1 43 Atelectasis 2 .. .. .. 2 .. .. .. .. 2 Injury at birth 4 .. .. .. 4 .. .. .. .. 4 Erysipelas .. .. .. .. .. .. .. .. .. .. Syphilis .. 1 .. .. 1 3 2 1 1 8 Rickets .. .. .. .. .. .. .. 1 .. 1 Meningitis (not Tuberculous) .. .. .. .. .. 1 1 1 2 5 Convulsions 2 2 .. 1 5 .. 2 .. 1 8 Gastritis .. .. .. .. .. 1 1 .. .. 2 Laryngitis .. .. .. .. .. .. .. .. .. .. Bronchitis 1 2 .. 1 4 10 3 4 3 24 Pneumonia (all forms) .. 1 1 3 5 6 7 10 10 38 Suffocation, overlying 2 .. 2 .. 4 4 5 1 1 15 Other Causes 7 5 2 1 15 6 4 4 5 34 65 24 12 15 116 78 85 69 63 411 Nett Births in the year legitimate 612 illegitimate 64 Nett Deaths in the year of legitimate infants 378 illegitimate infants 33