FIN 12 THE METROPOLITAN BOROUGH OF FINSBURY. ANNUAL REPORT on the PUBLIC HEALTH OF FINSBURY for the Year 1913 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. 1914. Public Health Committee, 1913-1914. Chairman. Councillor Dr. LAUZUN BROWN. Vice-Chairman. Alderman L. PHILLIPS. HIS WORSHIP THE MAYOR. (Councillor W. R. CORKE, J.P.) Alderman W. HOWES. Councillor The Rev. T. C. ELSDON, A.K.C. Councillor F. FOULGER. Councillor A. W. HUMPHRIES. Councillor Miss F. M. LINDSEY. Councillor The Rev. Prebendary G. H. PERRY, M.A., J.P. Councillor W. R. PUTTERILL. Councillor O. M. RICHARDS. Councillor Dr. W. F. ROE. 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 W. R. Corke, 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 1913. For the sake of uniformity, the method of arrangement adopted in previous reports has, in the main, been adhered to. 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 Summary 5 Infectious Disease, Deaths and Population 6 Notifications 103 Census Returns 6 Disinfection 106 Births 9 Food Supply 106 Notification of Births 11 Meat and Food Inspection 107 Health Visitation 14 Unsound Food Prosecutions 108 Weighing Centres 30 Ox Tongues with Actinomycosis 108 Mothercraft Competition 32 Slaughterhouses 111 Maternity Benefit 34 Milk Supply 111 Dinner Centres 36 Milk Registration 112 Puerperal Fever 37 Milk Samples in the Metropolitan Boroughs, 1912 113 Ophthalmia Neonatorum 38 Deaths and Death Rates 38 Milk Samples and Analyses 114 Inquests 43 Warranty Defence 116 Infant Mortality 44 Sale of Food and Drugs Acts 122 Cancer 54 Ice Cream Shops 124 Alcoholism 55 Restaurants 125 Tuberculosis:— Butter Manufacturers 125 Phthisis 57 Bakehouses 126 Notifications and Deaths Housing 128 (Table) 58 Registered Houses 128 Finsbury cases 59 Common Lodging Houses 129 Milk Supply 81 House-to-House Inspection 129 Deaths and Death Rates, Crowding and Overcrowding 131 1901-1913 83 Inland Revenue Acts 134 Death Rates, London Verminous School Children 136 Boroughs 86 Stable Dwellings 137 Tuberculosis—other forms 87 Factories and Workshops 137 Glanders and Anthrax 89 Rag Flock Act 142 Small-Pox 89 Canal Boats 146 Cerebro-Spinal Meningitis 90 Black Smoke 147 Polio Myelitis 90 The Mortuaries 147 Measles and Hooping Cough 91 The Shelter 148 Street List of Deaths 93 Offensive Trades 148 Diphtheria 96 Staff of Department 148 Scarlet Fever 99 Work of Inspectors 149 Typhoid Fever 101 Lady Sanitary Inspector 150 Law Proceedings 150 5 ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH FOR 1913. VITAL STATISTICS.—A summary of the principal facts of the Vital Statistics for 1913 is given below:— Estimated Population at the middle of 1913 84,679. Finsbury Residents in outlying Institutions 2,056. Birth Rate 29.4 per 1,000 inhabitants. Death Rate 18.4 per 1,000 inhabitants. Infant Mortality 139 per 1,000 births. Phthisis Death Rates Crude 1.78 per 1,000 inhabitants. Corrected 1.74 per 1,000 inhabitants. Death Rates from all forms of Tuberculosis Crude 2.52 per 1,000 inhabitants. Corrected 2.46 per 1,000 inhabitants. Death Rate from the seven Chief Zymotic Diseases 2.13 per 1,000 inhabitants. In comparison with the returns for 1912, the following matters are of interest:— The birth rate is still diminishing. The number of births is less—the number is lower than it has ever been since the Borough was incorporated. The death rate is lowered. The death rate from Phthisis is still further reduced. The deaths from Diarrhoea and Enteritis are much inccreased. The deaths from Diphtheria and Measles are less. The Infant Mortality is increased. Scarlet Fever and Enteric Fever have been more prevalent; Diphtheria less prevalent. 6 POPULATION.—The population of the Borough at the middle of 1913 was estimated by the Registrar-General to be 84,679, distributed as follows:— Clerkenwell 55,024 St. Luke 28,843 St. Sepulchre 1,312 84,679 This estimate does not include the Finsbury residents detained in the following outlying institutions: the Holborn Union Workhouse, Shepherdess Walk (943), the Workhouse Infirmary, Archway Road (305), the Holborn Union Workhouse, Mitcham (481), and the Holborn Schools, Mitcham (327), giving a total of 2,056. Adding these to 84,679, the estimate of the Registrar-General, gives a corrected population of 86,735 for the whole Borough. The day population is estimated to be 180,000. The various rates in the present report are calculated on the estimates of the Registrar-General. The intra-mural population in 1913 is less by 1,451 than the population for the preceding year. The gradual depopulation of the borough has now been in progress for some considerable time, and is due to the fact that inhabited houses are being demolished and are being converted into factories, workshops and warehouses. CENSUS RETURNS, 1911.—The following details are extracted from, or based upon, the report of the recent census. The highest average numbers of persons per inhabited house in London were: Holborn 13.15, and Finsbury 11.52 persons. The Finsbury census population distributed according to age and sex was as follows:— 7 Age. Male. Female. Totals. 0-1 1,114 1,067 2,181 1-2 948 1,008 1,956 2-3 1,052 1,043 2,095 3-4 1,039 1,063 2,102 4-5 963 1,029 1,992 0-5 5,116 5,2.0 10,326 5-10 4,695 4,888 9,583 10-15 4,474 4,579 9,053 15-20 4,211 4,373 8,584 20-25 3,791 4,151 7,942 25-45 12,570 12,813 25,383 45-65 6,473 7,254 13,727 65 + 1,325 2,000 3,325 Totals 42,655 45,268 87,923 The records of marriage are appended:— Unmarried. Married. Widowed. Males 26,085 15,215 1,355 Females 25,680 15,498 4,090 Totals 51765 30,713 5,445 The highest percentages of one roomed tenements in the principal cities of the United Kingdom were in Dublin (33.9), Glasgow (20.0), and London (13.4). In Finsbury 279 out of every 8 1,000 tenements consisted of only one room: this was the highest figure for London, and means that 3 out of every 11 families in the borough lived and slept in 1 room each. For London the proportion of persons living more than 2 in a room was highest in Finsbury, and amounted to 399 per 1,000. The next highest in order were Shoreditch, Stepney and Bethnal Green. In Finsbury, 5,880 families, ranging in numbers up to 8 persons per family, lived and slept in one room each; 7,160 families of 1 to 12 persons each lived and slept in two rooms per family. There were 2,606 Italians in Westminster, 1,488 in Holborn, 1,267 in Finsbury, and 1,155 in St. Pancras. The numbers of females in the borough and the numbers engaged in trades and occupations at specified age periods are annexed:— Age Period. No. of Females No. employed. Percentage. 20-25 4,151 2,986 72 25-45 12,813 4,900 38 45-65 7,254 3,008 41 Totals 24,218 10,894 45 The foregoing table shows what a large number of Finsbury women at "marriageable and married" ages were engaged in various trades and occupations, and incidentally throws a depressing light upon the women's "added burden" in the district. Some of the numbers of women at all ages employed in specified occupations were: Dressmakers, Milliners and Tailoresses (1,844), Charwomen (1,270), Paper bag makers (1,204), Servants, waitresses and hotel hands (1,167), Shirt makers (856), Bookfolders (845), Cardboard box makers (815), Artificial flower makers (633), Feather curlers and feather dressers (602), Laundrywomen (468), Cabinet makers and French polishers (203), Street hawkers 9 (176), General dealers and Pawnbrokers 155 women. Of all the women, at work, 624 were aged 65 years or more : they were chiefly employed as charwomen, laundrywomen, bookfolders, paper bag and cardboard box makers, tailoresses, milliners, dressmakers, seamstresses, and makers of artificial flowers. BIRTHS.—During 1913 there were registered 2,494 births of Finsbury residents—equal to a birth-rate of 29.4 per 1,000 inhabitants. This is the lowest birth-rate since the borough was formed. The number of births is also the lowest yet recorded. The birth-rate for Finsbury still keeps higher than the birth-rate for the whole of England and Wales, and does not fall to the same appreciable extent. The corrected rates for the Borough are appended:— 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 1912 86,130 2,579 29.9 1913 84,679 2,494 29.4 10 The corrected rates for the several sub-registration districts, 1918, were as follow:— Population. Births. Birth-rate. Clerkenwell 55,024 1,606 29.1 St. Luke 28,343 863 30.4 St. Sepulchre 1,312 25 19.0 The Borough 84,679 2,494 29.4 The corresponding birth-rates for the rest of the country for 1913 are attached:- England and Wales 23.9 London 24.5 Finsbury 29.4 96 Great Towns 25.1 145 Small Towns 23.9 Rural Districts 22.3 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 96 great towns, the 145 smaller towns, and the essentially rural districts. The birth-rate is greatest in St. Luke; least in St. Sepulchre. Of the total number of Finsbury births, 205 occurred in outlying institutions; 823 births of non-residents took place in the borough. For comparative purposes, the birth-rates of the Metropolitan Boroughs are annexed :— 11 BIRTH RATES, 1913. Borough. Rate. Borough. Rate. Battersea 25.3 Lambeth 23.9 Bermondsey 30.7 Lewisham 20.3 Bethnal Green 31.3 City of London 9.4 Camberwell 25.1 Paddington 19.4 Chelsea 18.2 Poplar 32.4 Deptford 28.0 St. Marylebone 18.6 Finsbury 29.4 St. Pancras 24.7 Fulham 26.9 Shoreditch 31.5 Greenwich 26.0 Southwark 31.5 Hackney 24.7 Stepney 29.7 Hammersmith 24.6 Stoke Newington 22.0 Hampstead 15.0 Wandsworth 20.8 Holborn 16.7 Westminster 14.1 Islington 25.1 Woolwich 22.5 Kensington 19.3 NOTIFICATION OF BIRTHS ACT, 1907.—This Act came into force on the 9th March 1908, having been adopted by the Borough Council on December 19th, 1907. The effect of its adoption may be seen from the accompanying table. Year 1910 1911 1912 1913 Births notified 3,566 3,441 3,401 3,285 Percentage attended by Doctors 3.0 4.5 3.5 4.5 Percentage attended by Midwives 13.0 18.0 18.7 17.0 Still births notified 89 92 105 55 Births registered 2,833 2,676 2,579 2,494 12 Notifications were received of 54 sets of twins. The percentage of births notified by parents was 10.8, by medical men 4.5, by midwives 17, and by others—chiefly medical students and lady midwifery students—was 67.7 per cent. The mothers in this last group were all attended gratuitously in their confinements. This means that in 1913, 2,322 Finsbury mothers, or 2 out of every 3, were cared for during child-birth, and during the subsequent lying-in period for no charge whatever, chiefly by the medical students of St. Bartholomew's Hospital, University College Hospital, the Royal Free Hospital, and by the midwives and midwifery students from the City of London Lying-in Hospital the Maternity Nursing Association, and the Royal Maternity Charity. This free treatment is so much appreciated that it is quite common for mothers in the outlying suburbs to move their homes temporarily into Finsbury so as to be attended in child-birth, without payment, by the students. This is especially the case with expectant mothers who originally lived in Finsbury within the spheres of work of the various institutions, or whose parents still live within these districts. This gratuitous maternity attendance has its drawbacks as well as its advantages. The mother, who is unable to pay for a doctor or a midwife, supplements the services of the student by engaging a neighbour, or a self-styled "nurse" to attend to her during the lying-in. These "nurses" are often dirty, offensive, grimy sluts, arrogant, self-assertive and excessively ignorant, and chiefly found caring for women who are attended by medical students. One of them pertinently observed:— "I follers the young 'orspital doctors and they follers me." They live in or near all mean streets. It is stated that their numbers have increased since the State has paid "maternity benefit." 13 As a rule they have no equipment—although some, greatly daring, have been known to produce enema syringes—faulty, leaking and repaired with string or sealing wax, and to give vaginal douches. They appear to wash themselves occasionally, but to wash their patients only on request. They regard the use of a nail brush as an unnecessary and crazy refinement, verging on the metempiric and transcendental. They consider as their special perquisite the care of the baby's navel, with dire results to the infant. By their rough and ready methods they have prematurely pulled the cord away, leaving an open wound, which they dress improperly with Fuller's Earth or with burnt rag. They leave the diapers in the bedroom until the mother notices their offensive character, and requests their removal. They are paid six or eight shillings per week. Some have their food in addition. They have one cure-all—gin—for the ailments of a lying-in mother, and if gin fails—more gin. One attended a mother in her confinement, and did not notice that the after-birth had not completely come away. It was expelled on the fifth day. She stated that she had "brought thousands of children into the world." Another lived in a slum, was consumptive, dirty, short of breath and "weak on her legs." She went out "nursing" whenever her strength permitted of it. It is a pity that the hospitals which now work in the district do not establish an efficient service of maternity nurses to displace some of these noisome and unsavoury "Gamps." By the provisions of the Notification of Births Act, local Registrars are allowed to inspect the notifications received, and to compare them with their own lists of registered births. 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. In 1913, the number of notices of omission sent to parents was 199. 14 HEALTH VISITATION.— The duties of the Lady Health Visitors are, briefly:— 1. To visit systematically all the births in the poorer streets and some of the births in the better class districts. 2. To instruct the mothers, and especially young mothers with first children or twins, in the feeding and proper care of their babies. 3. To pay revisits and to carefully watch over the child's health and progress, and to take the necessary steps by advice or by reference to medical or philanthropic agencies to safeguard the child's prospects and the mother's nourishment and circumstances. 4. To improve the home conditions of the mothers domestically by help, advice and suggestion, hygienically by referring defects of structure or environment to the Public Health Department. For these purposes, the Borough has been divided into two districts, mapped out as containing those streets in which infant deaths have chiefly occurred in recent years. One district is assigned to each Lady Health Visitor, and in the special streets so named and defined every household in which a birth occurs is visited on or about the eleventh day after the birth if the mother is up, or earlier on request, or if there is reason to believe that the mother is unattended by doctor, midwife or nurse. It is important to notice that, in these streets referred to, every birth is visited, and not merely births in those households where the parents aie ostensibly poor or dirty. In other streets only those births are supervised where the mothers are very young, careless, negligent, ill-treated, alcoholic, deserted, living in poor and domestically squalid surroundings, or are known to be the chief or sole wage-earners for their families, or where the children are first children, wasting, debilitated, ailing, illegitimate or twins. 15 Other households are visited on request, or on complaint as to ill-treatment, neglect or exposure. While the first visits are made in a general way all over the borough, revisits and supervision of a minute character are chiefly directed to the babies who are not thriving, babies who are debilitated, ill, neglected, dirty, badly fed or clad, "wasters," twins, and others who need careful watching and attention. Very few visits are paid to those mothers who have successfully reared large families and have lost none, or only earlier children. It is astonishing sometimes to see how these children of large and entire families thrive in spite of dirt, neglect, exposure and the violation of every sanitary precept by a careless, fool-happy and slatternly mother. Some of these babies, as soon as they are able to crawl or even before, are placed on the kerb early in the day, watched or nursed by a girl of 4 or 5 years. In a few hours both the baby and the "nurse" may be filthy and gutter-stained: they are true gutterchildren. Sometimes both are asleep. Sometimes the immature nurse sleeps, wearied with a task far above her strength, while the baby crawls to the other side of the road, heedless of the traffic. It is believed that in such families the members possess or have achieved a resistance to the commoner ailments of childhood. The stock from which they have sprung rises superior, and is immune to the ordinary diseases of children. Such a resistance, such an immunity is known to exist amongst animals; without doubt it may also be present in human beings. In the case of a reference to a philanthropic agency, the method adopted is to urge the mother to attend for a personal interview with the Secretary or the executive officer of the society or organisation. 16 Thus the mother learns, by actual trial, the trouble involved in dealing with the matter and the labour which underlies the subsequent effort for her betterment. The Health Visitor advises. It is for the mother and her friends to take the necessary steps and to do the work. In this way the mother's self respect is saved. The policy of the Health Department has been to inculcate a spirit of robust independence in the parents—to tell them what to do, how to do it, and to let them do it. The experience and instruction gained in personal application survive for the benefit of neighbours and other mothers. In the case of failure, the offer is made of tactful help and of unobtrusive co-operation. Every effort is made to avoid overlapping with the work of poor-law officials or of charitable associations. The duties of a Health Visitor are kept quite distinct from those of a district visitor or of a relieving officer. Letters of reference are not sent from the Public Health Office save in very pressing or knotty circumstances. This saves the time of the staff from being wasted on clerical work, and enables more time to be devoted to home visits. For home visitation is considered to be by fair the most important work of the Health Visitor. For Finsbury purposes the instruction and attendance at Weighing Centres and Schools for Mothers are, in this connection, deemed to be of third-rate or even of fourth-rate importance. Everything else is subordinated to home visitation, and any part of the work which, in any way, interferes with the efficiency, scope, or extent of home visitation is discarded. Visits are not paid to children over one year or to borderland children who live in or who have removed into other boroughs. As a rule, the health visitors are exceedingly well received and welcomed by parents. It is an extremely rare event for a visit to be resented. 17 Birth Visitation.—The number of visits paid by the Lady Health Visitors was as follows:— First Births. Total Births. Total Visits. Miss Cumming 152 962 3,073 Miss Pearson 132 1,120 2,891 Totals 284 2,082 5,964 The numbers for 1912 were 312 first births, 2,209 total births, and 7,239 visits. In 1913 the total number of births in the Borough was 2,494, so that these figures show that during the year eighty-three per cent, of all the births that occurred in Finsbury came under the supervision of the Public Health Staff. In the poorer districts of the borough—in the "slums"—all the births are visited. The number of twins born and visited was 42 sets, or one set for every 59 births. For the whole country it is usual to find that twins occur in one out of every 60 to 80 births, and triplets in one out of 0,000 to 7,000 births. Method of Feeding.—Nearly all the Finsbury mothers breast feed their children wholly or partially until the baby is four weeks old. Many mothers then return to work, but still endeavour to continue breast feeding by coming home at meal times or by suckling the baby in the house of a "minder," where it has been deposited earlier in the day near the factory or workshop. Otherwise, when the mother works, the baby is left with its grandmother, with a neighbour, or, quite commonly, with a young girl, aged from 10 to 16 years, who may be dirty, careless and negligent, and whose ideas of feeding may be summed up in the words of one such girl: "I feeds 'im when 'e cries—if'e don't cry, 'e don't get none." 18 Most mothers, by this time, know that babies should preferably be fed on the breast, and if breast milk is lacking, scanty, or of poor quality, on diluted cow's milk or diluted condensed milk. The proffering of unsuitable substances like raw baoon, raw mutton fat, toffee apples, fine oatmeal, boiled bread, or chipped potatoes, is often due to laziness, weariness, carelessness or poverty. The mother is too tired or too lazy to breast feed, or having- no breast milk is too poor or worn out to buy cow's milk, so, taking the line of least resistance, she gives the baby the "first thing that comes handy." On the other hand, there are still a few mothers who are obsessed by preconceived ideas that breast milk is "not strong enough," that cow's milk is "never twice alike," that breast milk and cow's milk "will not mix," that cow's milk for babies should be "from one cow," and until that one errant and belated cow has been defined and stalled, no cow's milk should be used. They are influenced by these and other crude notions which move uncensored from mind to mind in London's underworld. These are the mothers who buy patent foods, "tops and bottoms," rusks, or patent biscuits. If these commodities are expensive and alleged to be used by royalty—the more the mothers value them and foolishly use them. Many Italian mothers use patent foods sent specially to London from Italy. Exact ideas as to how and when the baby should be fed are very important. Some mothers feed their babies "little and often," and assert that it suits them better. One mother had very vague notions as to the degree of dilution to which she should Sibject the cow's milk. She just made it a "little bluish." Another, who preferred the "rich, yellow milk of London," used to add water until the mixture was the "same colour as the fog." Some mothers, when the child does not take its food well, endeavour "to help the baby" by giving it repeated doses of castor oil. 19 Illustrative Cases — 1. The baby was four months old. It had been left in charge of its grandmother, who was giving it raw fat bacon to chew. "There was nothing like it; it was good for babies and for canaries." 2. The mother boiled cow's milk with a proportionately large amount of patent barley. The mixture was semi-solid, and could with difficulty be placed in the milk bottle. The mother explained that the baby was hungry and required "substance and thickness." 3. A mother was giving her baby, three weeks old, "stout and aniseed for the wind." 4. The family occupied one room. There were two children, both alive and both ricketty. The baby was nine weeks old. The mother fed the baby chiefly on weak tea. "The only thing he fancies is tea—and he won't go to bed till we go!" 5. The family occupied one room. There were six children, but only two now lived. The baby was two weeks old, very hungry, and cried continuously. Its abdomen was very tender. The mother was feeding it on fine oatmeal. It had diarrhoea. 6. The family occupied two rooms. There were six children, but only four now lived. The baby was one month old, and had been left in charge of two children—10 years and 9 years—while the mother worked from 7 a.m. until 1 p.m., and from 2 p.m. to 6 p.m. The baby was fed on condensed milk, prepared by the children. It was washed by the mother at night time. The rooms and the baby were very cleara. 7. The baby was two weeks old, ill and vomiting, and was having one pint of "sterilised" milk daily. This milk had been placed on the window ledge, and was covered by a teacup. When the milk was inspected it was very dirty and much contaminated by "smuts." The mother was an organ-grinder, and used to take the baby out in a cradle fastened to the organ from 5 p.m. to 11 p.m. Each evening she made on an average 5s., and was 20 occasionally given good bundles of clothes for the baby. These she sold. She said it was "no good going out with an organ unless you had a child with you—you might just as well stay at home." The mother had already been imprisoned for exposing another child. Cape and Condition of Baby.—Many of the babies when first seen were wasting, improperly or irregularly fed, insufficiently, improperly or too tightly clothed, or occasionally suffered from exposure or neglect. For some babies the parents possessed no clothes Very few slept throughout in a separate cot, nearly all slept with their parents at night, even though they slept elsewhere during the day time. Some babies were premature and delicate. Others were dirty, and savaged and blood-raked by vermin. Some of the babies were ill, suffering from measles, bronchitis, pneumonia, diarrhoea, thrush, sore eyes, sore navels, sore buttocks, rickets, rupture, harelip and cleft palate. Many of the infants were left during the mothers absence in the care of quite young girls, from 10 to 16 years, or of their grandmothers, blind or infirm. Where the course is possible, the mothers are advised to put the babies out in the back-garden in a perambulator or push cart in the afternoon. This is not without its risks, because boys from adjoining houses throw stones at the pushcart. Some parents do more for their children when they are dead than when they are alive. One mother fully clothed her dead baby in flannel for burial, and sewed on its flannel binder. Another mother bought socks and woollen vests for her dead child in order that it might be buried "decent and comfortable." During life both these children had been very sparingly clothed in cotton, had never had socks, and had never worn woollen clothes. When the child becomes ill, some mothers imagine they have done all that is necessary when they have "fetched a bottle of 21 medicine from the sixpenny doctor." When death occurs, they assert that their children died "of no particular disease," or from "fretting inwardly." They rejoice when their children get an infectious disease, and are removed to hospital to get good food, a good cleaning up and good nursing. "It is the making of the children." When children get colds or bronchitis, the mothers abstain from washing them until they are convalescent. Nearly every skin eruption of the baby is attributed by the poor to teething or to a "spring breaking out," or is called a "gum rash," and considered thereby to need no further explanation. The usual treatment is to rub it with "nine oils," camphorated oil, or other liniment, according to the taste and fancy of the mother. Many—far too many—of the babies were clothed in cotton. The mothers usually knew this was wrong, but were unable to buy woollen clothes, because they could not afford them, or because the fathers were out of work. One mother objected to knitted woollen vests because they were too "area ted." Illustrative Cases. 1. The family occupied two rooms, and consisted of the parents and twins, 6 weeks old. The mother had insufficient clothes for the twins. One was sent into a home, and the clothes in which it was wrapped were brought back for the other. They consisted of a cotton shirt, a stiff cotton binder, a flannelette coat and a piece of carpet used as a shawl. 2. The family occupied three rooms. The baby was two months old. There were five children, all alive. The baby had a slight cold, and the mother was attempting to clear the nostrils by means of a camel-hair brush dipped in camphorated oil. She thought that as the oil was a good liniment for the chest, it must be a good application for the nose. 22 3. A grandmother rubbed the baby every day from neck to foot, during the cold weather, with tallow and camphorated oil to "keep the cold out." 4. The baby was a first child, illegitimate, and sent into hospital for "the blight," due, it was alleged, to a "distemper of the father." The grandmother said she "put it on a penny insurance for burial, and hoped the Lord would see fit to take it when it was teething." 5. A baby was attending hospital for sickness and diarrhœa. It had been left in the care of its grandmother, and, when seen, was unwashed and in a filthy condition. It was sucking a dummy teat, which was extremely dirty. The milk bottle was foul, and the teat smelt very offensively. The child was being fed on condensed milk, although the grandmother admitted that she had been told at the hospital to feed the baby on cow's milk, and not to give it condensed milk. It is quite a common occurrence to find that parents or others are taking a child to hospital, but are ignoring the advice they have received. Sometimes they carry out no treatment, and allege that "they did not understand what the hospital doctors said." 6. The mother and her illegitimate child occupied one room. When the health visitor called, the grandmother was seen, and stated that the mother had gone to work, and had "put the baby out." It was found on the second floor back room, lying asleep on a very foul bed. In the same room lived a dirty woman—a reputed widow—her two children, a crippled, tuberculous girl, 10 years, and a child of 2 years, and her grandchild of 2 years. The house was said to be a den of thieves. Some of the male adult occupants returned home between 2 and 3 in the morning, "bringing with them bags of stuff," and prevented the others from sleeping. 1 hey had never been known to work, but were always well dressed and well fed. The Mothers.-In the poorer parts of the borough the mother is sometimes the chief or even the only support of the family. She feeds and clothes the children; she pays for feeding and 23 clothing her husband. As soon as possible after her confinement she resumes her usual occupation as a bookfolder, laundry hand, street hawker, charwoman, office cleaner, ironer, machinist, or making cardboard boxes, paper bags, or artificial flowers. Many mothers arc homeworkers, and continue their work, for example, mounting artificial flowers, even when lying-in, on the third or fourth day after they have been confined. On a previous page, it has been shown that forty-five per cent, of all the women in Finsbury, between 20 and 65 years, are employed in some occupation ; between 20 and 25 years of age the proportion of the women employed is 72 per cent. In 1913, 430 mothers resumed work within eight or twelve weeks of the date of birth of the last child in each case. Some have to do this in order to pay for the furniture and equipment which they have purchased for their confinements. Many work right up to the day on which they are taken in labour; some work during the lying-in. Too often it happens that the mother is the only one in the family who has regular employment; the husband is an odd man or casually employed. The mother is out at work, the father is out, and stated to be looking for work. It is not at all uncommon for a mother to say that her "husband keeps rowing her because she hasn't gone back to work." It is the mother who has to work to pay all the back debts that have accumulated during her lying-in. When the mother works it sometimes happens that the husband "stops" the amount she earns from the money he gives to his wife. But when the husband is out of work the mother has to support the whole family. The mother's work and its attendant worry frequently result in the loss of her breast milk, and the child's nutrition suffers. Many mothers did not know where their husabnds worked or what they earned. 24 In slum districts the mothers often worsen their prospects by marriage. Before marriage they may earn from twenty to twentyfive shillings per week. After marriage they may have a very hard struggle to keep out of debt. Mothers with six or eight children may receive from their husbands exactly the same money as they did when they were first married and had no children to keep. These are the mothers who pawn their own or borrowed goods on Monday and redeem them on Saturday. These are the mothers who have recourse to the women money-lenders of mean streets. The usual charge is one penny per week for every shilling lent. Several mothers were insufficiently fed during pregnancy, during the lying-in, and during the period of suckling. During the lying-in some were entirely dependent upon the good services of neighbours who brought them occasional cups of tea. Some mothers were ill-treated, and disfigured by their husbands. Some were thin,, anæmic, consumptive, overworked, and overdone with child bearing. Nearly all the mothers drank ale or stout "to keep and improve their breast milk." It is very likely that hot water would be equally efficacious. Some of the wages paid to mothers for homework were as follows :— Box making for tooth picks 1s. 6d. per gross. Box making for laces 1s. 9d. per gross. Bookfolding l0d. per 1,000 sheets. Tie making 5d. and 6d. per doz. ties. Blouse making 3s. per dozen blouses. Mantle making 7d. each. Making knickerbockers l½d. each. Making one pint paper bags 6d. per 1,000. Putting 20 press studs on a card 5d. per gross of cards. Sewing leather ends to braces 5d. for 6 dozen. The lot of the home worker is sometimes very hard and grievous. Burdened with housework, with the care and feeding of young children, worried with the arrears of rent and the prospect of 25 possible ejectment, sorrowing over the unemployment of her husband, distracted with the slow progress of her homework and its merciless remuneration, with no immediate hope of betterment or of relief from her task, she deserves much sympathy and quick, generous material help. Hood's "Song of the Shirt is sung to-day in strident, lancinating tones in many a Finsbury home. Illustrative Cases. 1. The family consisted of the parents, and the baby 2 weeks old, breast fed. They had lost one child. They occupied one room. The father was out of work. The mother was a flower mounter, and had continued her employment during the lying-in period. She had been sitting up in bed, working to earn money for "food and firing." The family owed several weeks' rent, and were under notice to quit. Their landlady proposed to get rid of them as soon as the mother got up. 2. The baby was 3 weeks old. The mother made artificial flowers during her lying-in, and was helped by the father and 2 children, 12 and 10 years. Both parents sold the flowers in the street. At one time the father alone sold them, and the mother was able to " wash the children all over " on Saturday—but now, owing to the fact that both sold in the streets on Saturday, the children had to be washed on Sunday. 3. The family consisted of the parents, four children, and the baby, and occupied one room. The father, formerly a soldier, had been out of work for 16 weeks. The mother had borrowed 24s., and had during this time paid 32s. interest to a woman slum moneylender, without paying off any of the original loan. The mother was afraid to tell her husband, but the moneylender threatened to do so unless the interest were paid promptly. The mother was sent to the South Coast to recruit for two weeks. On her return she was met at the station by her drunken husband. He had a quarterly pension of 45s.; he gave the mother 5s. and drank the rest. The mother now pawned her husband's Sunday clothes "to pay him out," and meant to let him redeem them with his overtime money, which he never gave her. The mother kept her room extremely clean. 26 4. The baby was three months old. The mother was found to be personally dirty. She explained that her mother had told her on no account to put her feet in water or to take a bath until the baby was 6 or 7 months of age. 5. The family occupied one room. The baby was the first child, four weeks old and breast fed. The father had been out of work for six months. The mother was twenty years of age, and had been living on one meal a day, brought in by her own mother. The room was very clean. The table and bed were clean and free from vermin. The bed had only one small borrowed blanket. There was no fire. The only food in the tenement was ¼-lb. of sugar. 6. The parents occupied one room. There had been 4 children, but only two were now living. The mother and the baby were ill in bed, and were cared for by neighbours who brought in occasional cups of tea. The father was a blind man, who was taken out with a piano-organ at week-ends. 7. The mother was a widow. The baby was illegitimate, and 16 days old. The mother kept herself and her children by selling beetroot, celery and lemons in a market street. She made 1s. a day. She declined to marry the baby's father because she found out that " he was terrible in drink." The Fathers.— In the poorer parts of the borough, the fathers are chiefly employed as labourers, carmen, porters and street hawkers. Lowest in the scale are cart minders, odd men messengers attached to "pitches" outside public-houses, organ grinders, and bird catchers. Many were out of work, many were only in casual employment. Many of these odd men had been in regular work, but had never learnt a trade scientifically or technically. They were rule of thumb men, and when the firms changed hands, or competition became keen, they were the first to be discarded and discharged. They then took to street selling or to selling in public-houses on Friday and Saturday evenings. Some were consumptive, epileptic, paralysed, or otherwise ailing, blind, 27 youthful, ill-developed or undersized. Some were in the poor law infirmary or workhouse. Some were in prison for stealing or illtreating their wives. In the slums it is not uncommon to find that the fathers contribute little or nothing towards the support of their wives or families. Illustrative Examples. 1. The mother was a cook, and ill with severe hæmorrhage. There were 4 children and the baby. The father had never worked, but was said to make a living "by backing horses." He stated that he would like "to get the older children put into a home." Both parents smelt of ale. 2. The baby was a few weeks old. The mother was married one month before its birth. Her husband was a "handy man in the building line," and worked two days a week. He was not the father of the baby. He married the mother because he was " sorry for her." The family occupied one very dirty small room, containing one bed, one chair, one table, a basin for washing, and nothing else. 3. The father was a cripple, and accompanied coal porters on their rounds to help them load the sacks of coal on their backs. He made 6d. to 1s. per day by tips from householders who bought the coal. The mother was a charwoman, who, during her confinement, had severe haemorrhage, and was now very ill. The only bedding consisted of one sheet, one quilt, and two discarded coats. She was given tickets for free dinners. 4. The father had been out of work 18 months, and now assisted a woman who sold old clothes in a market street on Friday and Saturday. He earned 8s. to 10s. a week. The parents and their three children, 6 years, 4 years and 3 weeks old, lived in one small, dark, dirty basement room. There was no fire. The room contained only one bed and one table. The elder child had ringworm, and could not go to school because it had no boots. 28 5. The baby was a few weeks old, and breast fed. There were twelve children. The mother worked as a laundress. The lather had been in the infirmary for four months suffering from some chest complaint. He had been home for three months, but had done no work because he thought " it would be a pity to outdo his strength." 6. The baby was two months old. There were five children, but three had died. The family occupied one room, which contained one chair and one bed covered with rags and odds and ends. The father was consumptive,, had been to a sanatorium, did not work, and spent most of the day in smoking cigarettes. The mother was a street flower seller, but was unable to start, because she could not borrow money, and could get no credit. 7. The family consisted of the parents, four children living, and occupied two rooms. They had lost six children. The baby was six weeks old, thin and coughing. The father was a labourer, and "fed and clothed himself, and just managed to pay the rent." The mother was a charwoman, and fed and clothed herself and the four children. One child of five years was extremely thin, and had a cough, The mother said: "He gets fat when he's away to the infirmary, but it melts off him when he comes back home." 8. The family consisted of the parents and seven children, and occupied two rooms. Two children had died, so that only five now lived. The baby had no clothes. The mother had no sheets or nightdress for her confinement. She was given grocery tickets, and was lent a maternity bag. The husband, an old soldier, out of work, turned his wife out on to the stairs for five nights. The family owed 11 weeks' rent. Home Circumstances. —In many of the homes there was evidence of poverty — sometimes verging on destitution. Occasionally there was no food, no coke, coal or wood in the house. Some of the homes had very little furniture— perhaps a table, a bed and a chair—very little bedding, and scanty 29 food. The older children were ricketty, underfed, badly clothed and badly shod. Some families lived in dark, dilapidated, domestically dirty basements. These the family are sometimes unable to leave because they cannot pay the arrears of rent, and if they attempt to move, the landlord will "sell them up." In other tenements the parents may receive two or three pounds a week, and yet live in a dirty, slatternly home with every appearance of extreme poverty. Some of the mothers in the poorer parts were homeworkers, or took in washing or mangling. Many of the tenements were verminous—many were crowded. Some families took in relatives or lodgers, so that their homes became overcrowded. Nearly all the parents drank ale or stout—some drank to excess. Illustrative Cases. 1. The baby was two months old. There had been eight children, but only five now lived. The family occupied two rooms, which were almost bare. The father had been out of work for three years, and the family went into the workhouse. Latterly, they had come out, and the father got work as a carman at 25s. a week, which was just enough to keep the family in food. They were unable to buy any furniture. 2. The baby was five weeks old. There were three children, all living. The family occupied one room. The father did odd jobs, and earned from 10s. to 18s. per week. His average earnings were 12s. 6d. With this he paid 5s. rent, and provided firing, food and clothes for the family of five. The mother was helped from time to time by her father, a blind man who sang to theatre queues and at the doors of public-houses. 3. The baby was a few weeks old. There were eight children, but only five now lived. The family occupied two rooms. The parents lived on their wits. They obtained tickets for food and clothing from clergymen and from missions. They stole wood and coal. Their children were sent away to institutions and convalescent homes by kindly disposed and well-meaning people. 30 The father had never been known to work. The mother occasionally did a little washing-. 4. The baby was 10 months old. The mother had an abscess in her right breast. The family occupied one room, containing a bed, a small table and a broken chest of drawers. There were no chairs. The baby had no clothes, was quite naked, and was being cared for by a child of 10 or 11 years. The family had been ejected from their last tenement. 5. The baby was fat, and six weeks old. There were three children, all living. The family occupied two rooms. The father was a carpenter, and gave his wife from 6s. to 9s. per week ; some weeks he gave her nothing. The mother was very weak and anaemic. She was a homeworker, and made ties for 6d. a dozen. She was able to do one dozen in 1½ hours if she was quick. 6. The baby was 4 weeks' old. There had been 9 children, but only 5 were now living. The family occupied two rooms. The mother was weak and faint from want of food. The husband was a casual labourer, out of work, and " picked up a few odd pence where he could." There was no food in the house. The home was dirty and bare. It contained one bed, one small table, two broken chairs and one battered tin teapot, standing on an empty hearth. Weighing Centres.—There are three municipal weighing centres in the Borough, held in the afternoon at 2.30 p.m., at the following times and places. Tuesday: St. Luke's Institute, Radnor Street. Wednesday : The Branch Library, 47, Penton Street. Thursday : 268, St. John Street, Clerkenwell. The weighing centre at the Town Hall was transferred to 268, St. John Street in 1913. The Town Hall attendances are included in the statistics under St. John Street. 31 A summary of the meetings is appended :— Centre. No. of Meetings. Attendances Average Attendance. No. of Children. Penton Street 50 1,397 28 236 Radnor Street 51 1,580 31 273 St. John Street 50 1,907 38 296 Totals 151 4,884 32 805 The largest average attendance, and largest number of children both belong to the St. John Street Centre. The smaller attendance at the Penton Street Centre is probably due to the fact that some of the mothers prefer to attend the weighings held close by at the Dinner Centre at 26, Cumming Street, and in this way achieve a qualification for the purchase of cheap dinners at that centre for a payment which barely covers the cost of the food alone. Many of the children when first brought to the weighing centres were found to be fed chiefly on patent biscuits or boiled bread. The breast fed children were, however, in the majority, and were more than four times as many as the others who were not breast fed. In recent years the proportion of breast fed children to the others in the borough has shown a definite increase. On their first visits 75 per cent. of the babies were fat and plump, others, amounting to 20 per cent. were markedly thin. The residue, about 5 per cent. of the whole number, were already wasting. By far the larger number of babies are brought to the centres between the ages of one and three months : twenty-two were over 12 months of age. Most of the babies weighed between 7 and 8 lbs. at birth, 124 weighed between 8 and 9 lbs., 67 between 9 and 10 lbs., and 36 weighed 10 1bs. and over. Nine babies weighed under 4 lbs. at birth. Eight infants were premature ones. 32 Thirty per cent. of the children were first babies. Twenty per cent. of the mothers attended every week, eighteen per cent. came once only. The average gain in weight per week ranged from 3-9 ozs. to 4-5 ozs. The largest gains were 91 ozs. and 10 ozs.—both in children under three months. The weekly gain appeared to diminish as the child grew older— thus, at one centre the average gains were : up to three months of age, 6 ozs.; between 3 and 6 months, 4 ozs.; between 6 and 9 months, 4.3 ozs., and between 9 and 12 months, 3 0 ozs. This progressive diminution may possibly be associated with the return of the mother to work, with the consequent lessening of her care and supervision, and with the gradual change of the baby's food from breast milk to cow's milk, to be followed later by the child's weaning. The fathers were mainly of the working class, and chiefly general labourers, carmen, porters, packers, metal workers, street hawkers, warehousemen, horsekeepers and taxi-drivers. Thirty per cent. of the fathers were employed casually or were out of work. Mothercraft Competition.—This competition was held in April, 1913, and organised under the direction of the Mayor— Alderman Barton, J. P. and the Mayoress. It was limited to Finsbury mothers having, at the date appointed, living children under one year of age, and had for its object the public recognition of good mothers in the Borough, and their value and importance to the community and to the State. The competitors were received in the Town Hall by the Mayor and Mayoress, who provided refreshment and entertainment on the occasion. It was realized that, in the poorer districts of the Borough, there might be many mothers who, owing, perhaps, to domestic difficulties, were not so well placed as their more fortunate neighbours. The interests of such mothers were not allowed to suffer. Special allowance was made for the difficulties which, by their care, thrift and prudence, they had successfully overcome. In judging the infants, the following points were taken into consideration :— 33 1. Condition of skin. General cleanliness, and cleanliness of umbilicus, axillae, groins, nates and popliteal spaces. Absence of intertrigo and of vermin bites. 2. Muscles. Tone, activity, vigour, firmness and size. Firmness of the abdominal wall. Kick and muscular restlessness when undressed. 3. Straightness of limbs. 4. Eyes. Absence of discharge and of conjunctivitis. 5. Mouth and tongue. Cleanliness and freedom from thrush. 6. Clothing. Material, amount. Should be rational in design and application. The binder, if any, should be short and reasonably loose. 7. Inspection of milk bottle. 8. Inspection of weight chart and of weight progress of baby. 9. Apparent contentment of the baby and its ability to smile. The dummy or comforter was omitted from the list, because it was found that nearly every child used one. It was intended to give prizes not to the mothers of cherubs of the Rubens' type or for " fat stock," but to allot them to the mothers of strong, lusty, clean, muscular babies; to mothers with strong maternal instinct who had been consistently careful and attentive to the instruction given by the Lady Health Visitors. Prizes were awarded for the best infants between one and four months, between four and eight months, and between eight and twelve months, to the mothers of successfully reared twins and triplets, for well kept homes, and for regular attendance at the weighing centres. It is the irony of Fate that a few of the bonniest prize babies belonged to mothers who, from repute, were amongst the hardest drinkers in the borough. 34 Maternity Benefit.—The payment of maternity benefit has been of the greatest value to the mothers in Finsbury. It has been chiefly spent on nourishment for the mother and children, in buying clothes for the Gaby or redeeming them from pawn, in retaining the services of a neighbour, an amateur nurse to attend to the mother and her wants during the lying-in, and in getting necessaries and the "hundred and one little things that are wanted for a confinement at the last minute." It was sometimes spent before it was received. The amount was borrowed beforehand, and used to pay the doctor, to buy clothes for the mother or baby, or to pay off back rent. Usually, the money was spent on the mother and the children; it was only in a few cases of poverty and underfeeding that the husband participated in its distribution. Out of the large number of recipients, in only two cases was the maternity benefit known to have been diverted into improper channels and abused. In one instance, the mother and baby died, and the father, a street seller, received the maternity benefit and was "dead drunk" for two days. In the other, the family consisted of the parents, five underfed children, and occupied two rooms. The mother was extremely thin, and clad in a blouse and petticoat. She had no other clothing. She had been feeding for months on bread and tea, and had "forgotten what a dinner tasted like." The father was in work, and a drunkard. He was generally paid his wages on Friday, and on this day the family waited without food until his return at night. The father obtained the maternity benefit, spent it on drink, and had delirium tremens in the bedroom where his wife lay after her confinement. Two constables and a clergyman had to come in to hold the father down, while, in the words of a neighbour, "The was up and down like a cat in a fiddle.'' The following are a few actual examples of the ways in which the maternity benefit was spent by Finsbury mothers :— 1. Neighbour nurse, 12s. for two weeks' services. Baby's clothes, 6s. Redeeming mother's nightdress out of pawn, 2s. The rest, 10s., was spent on food for the mother and baby. The husband got nothing. 35 2. Neighbour nurse, 8s. Milk, 6d. a day. The rest went for the mother's washing, for chops and eggs for the mother, and to another neighbour for supervising and feeding the older children. 3. The family consisted of the parents and five children. They occupied two rooms. The mother worked up to the week before the birth of her baby. She received maternity benefit, 30s., and three weeks' sick pay at 7s. 6d. per week. She paid the neighbour nurse 10s., and spent the rest on nourishment for herself and clothes for the older children. In former years, following her confinement, she used to let the rent get behindhand for two or three weeks, and then when she got up and resumed work, paid it off at the rate of 1s. per week. In 1913, she worried no longer about the back rent—she was able to pay it as it accrued due for the first time in her life. Her lying-in was free from care—she had an even mind, because she knew "the finances was all right." 4. The whole of the maternity benefit was put into the savings bank in the baby's name. 5. The maternity benefit was all spent on food for the family. The mother, father, baby and grandmother were very thin and underfed. 6. The family consisted of the parents and seven children. They occupied two rooms. The mother saved 10s. out of the maternity benefit, and bought clothes and shoes for some of the older children so that they might go to school. 7. Sending children to the seaside, 5s. Neighbour nurse, 10s. Redeeming clothes from pawn, 2s. 6d. Back rent, household and general expenses, 12s. 6d. 8. Redeeming baby's long clothes out of pawn. Buying fresh clothes for baby. Shoes for five other children. 9. Perambulator, 30s, 36 10. Midwife, 12s. 6d. Neighbour nurse, 7s. 6d. Food for mother and redeeming baby's clothes, 10s. When the baby was born, all the mother had ready was two cotton shirts. The rest of the baby's clothes had been pawned for 2s. 11. Neighbour nurse, 10s. Back rent, 12s. 6d. The maternity benefit enabled many mothers, who used to get hospital students to attend to them, now to engage a qualified midwife. Dinner Centres.—There are two dinner centres in the Borough, both conducted by voluntary agencies. One is at 26, Cumming Street, and provides dinners for mothers of babies under nine months as long as they breast feed their infants. It was founded by the League of Service in 1910. In 1913, this centre gave dinners to 73 Finsbury mothers; of these, 11 paid twopence for each dinner, 24 paid a penny for each dinner, and 38 were fed free. The other centre is at 36, King Square, and is controlled by the League of Liberal Christianity. In 1913, the total number of Finsbury mothers who attended was 77; of these, 15 paid twopence for each dinner, 19' paid a penny for each dinner, and 33 were fed free. At King Square, 4,369 dinners were served during the year. Mothers ceased to attend on removal, on the weaning or death of the baby, or by reason of the difficulty of leaving young children at home without proper supervision. The expenditure incurred was £78. The payments made by the mothers amounted to £11. The influence of the dinner centres extends beyond the mere feeding. There is a marked improvement in the personal and domestic cleanliness of the mothers. They feel better, and begin to tidy up their rooms. The elation of good food induces them to scrub the floors, to wash the tables, and clean the sheets and bedding. They have more and better breast milk, and the baby puts on flesh and becomes contented. 37 PUERPERAL FEVER. This disease is compulsorily notifiable by Section 55 of the Public Health (London) Act, 1891. In 1913, there were 13 notifications and 5 deaths. The statistics for previous years are appended:— Puerperal Fever. Years. Totals. 1913. 1912. 1911. 1906-10 1901-5 Notifications 86 13 12 4 27 30 Deaths 47 5 4 3 17 18 This year, the number of notifications is the highest since the formation of the borough. The thirteen cases in the present year were attended, seven by medical students from St. Bartholomew's Hospital, two by a certified midwife, and four by private doctors. The associated causes and conditions were said to be : retained afterbirth (3), post partum hæmorrhage (2), miscarriage or abortion (2), decomposed foetus (1), and premature birth one case. In four instances no cause was ascertained; these were possibly cases where there had been want of care or cleanliness by the persons in attendance. At the present time, there is no definition of puerperal fever, so that the notification of the disease is in a very unsettled condition. It is very probable that all the cases, which occur in the Borough, are not notified. In Finsbury, every case is investigated by the Lady Sanitary Inspector. The premises are visited, the sanitary defects are ascertained, and made the subject of subsequent notice for amendment. The rooms are disinfected. 38 OPHTHALMIA NEONATORUM. This is the inflammation of the eyes that is apt to occur in the newly-born, and which is nearly always associated with the presence of venereal disease in the parent. Six cases were notified in 1913. In two there was a history of gonorrhoea in the mother. The babies apparently recovered with sight unimpaired, save in one case. The children were all visited from the Public Health Department, and the mothers were instructed how to carry out the treatment advised by the doctors. DEATHS AND DEATH RATES. The number of Finsbury residents who died in 1913 was 1,558, equivalent to a crude death rate for the whole Borough of 18.4 per 1,000 inhabitants living. The crude death rate for the whole of London was 14.2 per 1,000, and the corrected death rate 14.2 per 1,000. The Finsbury crude death rates for previous years are given in the attached table:— 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 I9.0 22.3 19.7 1904 21.4 20.6 22.8 24.0 1905 I9.3 l8.l 21.1 26.3 1906 21.4 21.1 21.5 26.1 1907 19.1 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 1912 18.5 18.0 19.1 28.3 1913 18.4 18.0 19.o 38.1 39 The death rates in St. Luke are generally higher, and in Clerkenwell generally lower than the rates for the whole of the Borough. With one or two slight exceptions the death rates in St. Luke tend to show a steady and progressive diminution, whereas the Clerkenwell death rates are rather uneven from year to year, This difference between the two districts 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. The factor for age correction derived from the recent census is .9887. This factor enables one district to be compared with another, and smooths down the irregularities which depend upon differences in the ages and sexes of the populations of the different areas. Multiplying this number by 18.4, the crude death rate, gives a corrected death rate of 18.2 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 population is 86,735, and the crude death rate becomes 17.9 per 1,000. This, multiplied by the factor .9887 gives a fully corrected death rate of 17.6 per 1,000. The comparison of Finsbury with the rest of the country may be seen below:— Corrected Death Rates for 1913. England and Wales 13.4 London 14.2 Finsbury 17.6 96 Great Towns 14.7 145 Smaller Towns 13.0 Rural Districts 12.1 The Finsbury deaths were apportioned as follows:— Clerkenwell, 993 ; St. Luke's, 540 ; St. Sepulchre 25 deaths. 40 The death rates of the Metropolitan Boroughs are subjoined. Death Rates, 1913. Battersea 14.1 Kensington 13.7 Bermondsey 17.9 Lewisham 10.6 Bethnal Green 15.7 City of London 14.5 Camberwell 13.7 Paddington 13.2 Chelsea 13.5 Poplar 16.7 Deptford 15.5 St. Marylebone 14.9 Finsbury 18.4 St. Pancras 15.0 Fulham 12.7 Shoreditch 18.6 Greenwich 14.3 Southwark 17.9 Hackney 13.6 Stepney 15.1 Hammersmith 14.2 Stoke Newington 18.1 Hampstead 10.8 Wandsworth 10.9 Holborn 14.4 Westminster 12.7 Lambeth 14.3 Woolwich 12.3 Islington 15.1 The deaths of residents in public institutions were :—In general hospitals, 239 (217); in special hospitals, 39 (36): in fever hospitals, 50 (54) ; in poor law institutions, 492 (486); in asylums, 55 (52) ; in various hospitals, homes of rest and homes for babies, 27 (28). The figures in brackets are the corresponding numbers for the previous year. It will be noted that 492—that is, 31 per cent.—of the whole number of deaths occurred in poor law workhouses and poor law infirmaries. The following table gives the numbers of deaths of Finsbury residents that have occurred in public institutions for the last 10 years:— » 41 Deaths in Public Institutions Year. Total Deaths. Deaths in Public Institutions of Finsbury Residents. Percentage. 1904 2,084 965 463 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 1912 1,599 873 54.6 1913 1.558 902 57.9 In Finsbury all deaths from phthisis and all the deaths of children under one year, received in the weekly returns of the Registrar-General, are carefully investigated. Yet, even with these limitations, many addresses of alleged Finsbury deaths are received every year which cannot be verified on enquiry. These faulty, misleading, or incomplete addresses, are nearly always derived from poor law institutions, occasionally from hospitals. Their investigation and the correspondence which follows their reception waste a considerable amount of the time of the staff. Much of this waste could be prevented if the addresses of the patients were verified when they were received into the poor law workhouses or infirmary. . However, owing to the establishment of a Metropolitan Common Poor Law Fund, the settlement of a patient which in former years used sometimes to be the subject of an acrid legal dispute, is now almost immaterial from a poor law standpoint. The poor law officers are now not so acutely concerned. The occasions on which these incorrect poor law addresses have been traced have been chiefly when the patients still lived, and had been notified to the Public Health Department as suffering from tuberculosis or from an infectious disease. To 42 take an actual example:—In 1913, a case of phthisis was notified to the Medical Officer, from a poor law institution, in a patient stated to be residing at an address in Noble Street, and who was apparently admitted to the institution as from that address. Enquiry showed that at the time of admission and at the time of notification the patient did not live in Noble Street, but had removed therefrom in 1911, and was now living in Gray's Inn Road, in St. Pancras. In the course of time, when this patient died, in the absence of this enquiry, this death would have been wrongly accredited to Finsbury. Notices of many poor law deaths are received each year in which the sole clue to the patient's finsbury residence consists of statements such as "of Clerkenwell,'' or "of St. Luke's." Sometimes the alleged Finsbury address of the deceased is a house that has been demolished 20 or 30 years ago. In many instances the deceased persons have never lived at the Finsbury addresses named on the death certificates, but have, perhaps, used them as accommodation addresses for the receipt oi letters, or they are the addresses of friends or relatives. Occasionally, the deceased persons have certainly never been within the confines of the Borough either during life or death, and yet they are received on the copies of death certificates sent by the Registrar-General as if they were Finsbury deaths. The genesis of these errors is sometimes easily explained. For example, a patient with phthisis lived in Islington, and was received into the Islington infirmary. His mother, who was his nearest friend, meantime moved into Finsbury. The patient was now transferred to the Holborn Infirmary, where he died. He was buried from the Islington address, where his brothers still lived. The Finsbury address on his death certificate was that of his mother. He had never lived at this Finsbury address. When these facts were brought to the notice of the RegistrarGeneral, his death was accredited to Islington. It is very probable that if poor law institutions and hospitals kept very careful and accurate records, and were to verify the addresses and statements of patients on their admission, that the corrections to the death returns arising from these two sources 43 alone would mean a fair diminution in the Finsbury death rate. If the addresses on death certificates give rise to difficulty, so, also, do the entries referring to the causes of death. To take two actual examples:— 1. A patient was notified to be suffering from phthisis by various poor law medical officers. He died, and his death was wrongly attributed on the death certificate to pneumonia by one of the doctors who had notified the patient. The matter was referred to the Registrar-General, who communicated with the doctor concerned. The cause of death was then altered to phthisis. 2. A Finsbury patient was notified to be suffering from phthisis on 11 occasions by seven different medical men, including one consultant, who was an assistant physician to a large London general hospital, and 5 poor law doctors. The patient was examined by the London representative of a large tuberculosis sanatorium and accepted for treatment as a suitable case. He was in a sanatorium for three months. He was under the supervision of the Public Health staff for live years, and had the usual signs and symptoms of phthisis. He died, and his death was entered on the death certificate as due to asthma by a poor law doctor, who had notified the patient as suffering from phthisis on three separate occasions. The facts were communicated to the Registrar-General, who wrote to the doctor who had signed the death certificate. He replied that, in his opinion," tubercle was not present." It will be seen, therefore, that death certification, at the present day, is still far from satisfactory. Other examples were given in the annual report for 1911. Inquests.—During the past year 183 inquests were held in the Borough, of which 10 were on the bodies of non-residents who died suddenly in the district. Sixty-four were on children under 5 years of age, 119 on adults and children over 5 years of age. Amongst the causes of death were the following :—Accidental falls, 17; Burns and Scalds, 10; run over by taxicabs and motor buses, 6; run over by cabs and horsed vans, 3; overlain in bed by parents, 17 deaths. None of these deaths, during the year, were certified to be accelerated by want of food, exposure or destitution. 44 INFANT MORTALITY. The infant mortality of any district for any stated year means the number of deaths of children under one year per 1,000 births. The corrected number of births of Finsbury children for 1913 is 2,494. In the same year 348 children died under one year of age and belonging to the Borough. The infant mortality is obtained by multiplying the number of deaths under one year, 348, by 1,000, and dividing the result by the number of births, 2,494, for that year. The infant mortality of the Borough for 1913 is 139; expressed in popular manner, this means that out of every 1,000 children born during the year 139 died before reaching their first birthday. The corresponding figures for previous years are annexed:— Infant Mortality, 1901-1913 Year. Corrected Births. Corrected Deaths. Infant 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 2,813 342 121 1911 2,676 411 154 1912 2.579 290 112 1913 2,494 348 139 45 The following table compares Finsbury with London and England and Wales generally:— Infant Mortality for 1913. England and Wales 109 Whole of London 105 Finsbury 139 96 Great Towns 117 145 Smaller Towns 112 Essentially Rural Districts 96 The infant mortality of Finsbury is 31 per cent. greater than the figure for the whole of London, and 19 per cent. more than the mortality prevailing in the 96 great towns The rates for the Metropolitan Boroughs are appended below:— Infant Mortality, 1913. Battersea 110 Lambeth 102 Bermondsey 132 Lewisham 75 Bethnal Green 117 City of London 96 Camberwell 106 Paddington 107 Chelsea 92 Poplar 113 Deptford 113 St. Marylebone 90 Finsbury 139 St. Pancras 93 Fulham 96 Shoreditch 155 Greenwich 103 Southwark 114 Hackney 99 Stepney 112 Hammersmith 103 Stoke Newington 82 Holborn 100 Wandsworth 88 Hampstead 68 Westminster 95 Islington 107 Woolwich 80 Kensington 112 46 The deaths of infants allocated to the various diseases are given in the following table, which contains the records for the last seven years:- Infant Deaths, 1907-13. 1913. 1912. 1907-11. Totals. Measles 7 29 79 115 Diphtheria 2 4 8 14 Scarlet Fever 1 1 1 3 Hooping Cough 11 16 66 93 Gastritis 3 — 4 7 Diarrhoea 39 8 257 304 Enteritis 40 26 84 150 Premature Birth 58 46 335 439 Congenital Defects 4 4 43 51 Marasmus 20 29 223 272 Tuberculous Meningitis 6 4 31 41 Other Tuberculous Diseases 9 6 29 44 Erysipelas — 1 4 5 Syphilis 7 10 36 53 Convulsions 3 15 50 68 Bronchitis 21 16 117 154 Pneumonia 59 39 247 345 Overlain in bed 17 11 103 131 Other Causes 41 25 170 236 Totals 348 290 1,887 2,525 During these yea1rs the births have numbered 19,239, and the average infant mortality has been 131 per 1,000 births. This result, allocated to the several diseases and disease groups, is as follows :— 47 Average Infant Mortality, 1907-13, due to specified causes. Measles 5.9 Diphtheria .7 Scarlet Fever .1 Hooping Cough 4.8 Gastritis, Diarrhæa, Enteritis 23.9 Premature Birth, Congenital Defects, Marasmus 39.5 Tuberculous Diseases 4.4 Erysipelas .2 Syphilis 2.7 Convulsions 3.5 Bronchitis and Pneumonia 26.0 Overlying 6.8 The largest number of deaths is attributable to premature birth and to its associated conditions. One out of every 25 children born in the borough is born prematurely, and dies from this cause. In previous reports, instances have been given which go to show that these premature births are the result of wilful and deliberate action on the part of the parents. Bronchitis and Pneumonia—diseases of exposure, and insufficient or improper clothing—are responsible for an infant mortality of 26 per 1,000 births, or one out of every 40 children born in the Borough dies before it is a year old from these diseases. Gastritis, Diarrhoea and Enteritis—diseases of dirty or improper conditions of feeding.—give an infant mortality of 24 per 1,000 births, or approximately one death in every 41 births. Overlying, in 7 years, has caused the deaths of 131 children— an infant mortality of 6.8 per 1,000 births. It will be noted that the mortalities due to the usual infectious diseases and to the various forms of tuberculosis are comparatively small. 48 The deaths in 1913 from bronchitis and pneumonia occurred chiefly in the following streets :—Affleck Street, Baker's Row, Dufferin Street, Easton Street, Farringdon Road, Galway Street, Gee Street, Lever Street, Great Bath Street, Hatfield Street, Northampton Buildings, Red Lion Street, St. John Street, St. Helena Street and Sidney Street. The deaths from premature birth were mostly in Affleck Street, Baron Street, Bowling Green Lane, Cow Cross Street, Farringdon Road, Galway Street, Lever Street, Meredith Street, Mitchell Street, Norman Street, Pentonville Road, Seward Street, and Upper Smith Street, that is, in what may be called the middle stratum of the Finsbury population, and not in the slums. The deaths from diarrhæal diseases occurred chiefly in the mean and squalid streets of the borough. In May of every year the following leaflet on Summer Diarrhoea is distributed to every tenement in those streets where deaths from this cause have mostly occurred in the preceding year, and to other special streets where the occupants are known to be domestically dirty and careless. During the summer the leaflet is distributed and re-distributed in these streets where these deaths occur, as soon as possible after the receipt of the Registrar-General's weekly death returns. It is believed that the people who live in these streets are much more likely to seriously consider the instruction imparted by the leaflet when they know that a death from this cause has occurred near to their own homes, and when the mean-street funeral, with its dingy plumes and dreary trappings, has advertised them of the occasion. SUMMER DIARRHŒA. Every summer during the warm weather, many hundreds of babies get sickness and diarrhoea, and very many die. This illness is nearly always caused by dirt getting into baby's mouth in some way—from dirty feeding bottles, teats, dummies, comforters, from dirty milk-jugs, from condensed milk tins left open to the air, from flies, or from the mother's hands or baby's hands if they have not been washed and kept thoroughly clean. 49 (a) What to do to keep sickness and diarrhœa away. 1.—Feed baby on the breast and keep the nipples very clean— wash them frequently with lukewarm water and borax. 2.-—Do not wean baby during July, August or September. 3.—If baby must be fed on the bottle, do not use a tube bottle. The tube bottle is a death trap. 4.—Only use a clean glass bottle with a teat over the neck and having no tube. 5.—Boil baby's milk as soon as it is taken in from the milkman. Be sure you put it in a clean milk jug and cover it with a muslin cover to keep the flies away. Remove the milk from the room, or put it in a closed cupboard, when you dust or sweep the room;. Always keep the milk covered. 6. If you are using condensed milk, clean the top of the tin carefully before opening it. Immediately after opening it, take a clean spoon and empty the whole of the condensed milk into a clean jar or glass vessel and keep it always covered. Do not buy cheap condensed milk. 7.—Wash your hands and fingernails very carefully before starting to prepare baby's food. Use a nail brush. Keep your nails short. 8.-—Keep all your spoons, knives, forks, cups and saucers clean. The best way of doing this is By putting them into boiling water for a few minutes and then rinsing them well under the water tap. 9.—Only make one feed at a time. 10.—Do not use old feeds. If baby does not use all the feed, throw out what is left in the bottle. 11.—Wash out the bottle and teat in hot water and washing soda directly after baby has been fed, and keep them in cold water until the next feeding time. 50 12.—Always have the bottle and teat quite clean, before putting in the feed. This is most important. 13.—Do not use a dummy teat. Do not put your fingers in baby's mouth. 14.—When baby is in his cot, protect his face and mouth from the flies. 15.-—Keep the baby's hands and face clean. 16.—Keep the house clean. The slops must be taken away early in the morning. Tea leaves, cabbage leaves, potato peelings, fish and bone refuse should be burnt—they should not be put in the ashbin. Keep the ashbin covered. 17.—Wash the baby's napkins in warm water only. Do not wash them with soap or with washing soda or they will make the baby sore. (b) What to do if baby catches the disease. 1.—If a baby or young child has diarrhœa, a doctor should be sent for at once. Until the doctor has seen the child give no breast milk, no cow's milk, or food of any kind, but only sips of pure water that has been boiled and allowed to become cool—two or three teaspoonfuls in the hour, from a clean teaspoon. 2.—Keep baby warm. Put on a flannel binder. Put a hotwater bottle or a warm brick wrapped in flannel to the child's feet, but not too near, or he may be burnt. 3.—Open all windows at the top. 4.—Remember that the illness is catching. Always wash your hands after changing baby and disinfect all clothing by boiling it in water. 5.—To prevent the buttocks getting sore, bathe them after every motion with warm water; clean them dry with a clean dry rag that has previously been boiled in water. Clean out the folds and creases very gently and when dry rub the best vaseline or olive oil very carefully between the 51 buttocks. Never use Fuller's earth. If a dusting powder is considered necessary, get some starch and zinc powder from the chemist. (c).—To remind you. 1.—Remember that diarrhœa in babies is a very serious illness, and not to be trifled with. If your baby has diarrhœa, get medical advice early and at once. 2.—Feed baby on the breast—diarrhœa chiefly attacks bottlefed babies. 3.—Remember to wash your hands and finger nails very carefully before starting to prepare baby's food. Use a nail brush. Keep your nails short. 4.—Keep the flies away from the food, from the milk, and from the baby's cot by using muslin or linen covers. Kill those flies. 5.—Extreme cleanliness in all things prevents diarrhoea. Do the best you can. 6.—A special teat, special milk bottle, special bristle brush for the milk bottle, a baby book and special fat food for babies may be obtained at cost price, or free of charge to those who are poor, by applying to the Lady Health Visitors at the centres named below, or from the Public Health Department, Town Hall, Rosebery Avenue. A special disinfecting soap for scrubbing out rooms may be obtained gratis from the Public Health Department. 7.—Bring your child to the weighing centres:—St. Luke's Institute, Radnor Street, Tuesday, 2,(30 to 4.30 p.m.; 47, Penton Street, Wednesday, 2.30 to 4.30 p.m.; 268, St. John Street, Thursday, 2.30 to 4.30 p.m. The Lady Health Visitors of the Borough will be very glad to see you and the baby. They will help and advise you as to your own health, as to baby's health, baby's food and baby's progress. A. E. Thomas, Medical Officer of Health. 52 Infant Mortality by districts in previous years.—The infant mortality rates for the period 1908-13 arranged according to districts are given in the annexed table Infant Mortality Rates, 1908-13. Year. The Borough Clerkenwell. St. Luke. St. Sepulchre. 1908 137 131 150 34 1909 128 135 130 300 1910 121 122 120 71 1911 154 145 169 181 1912 112 110 111 210 1913 139 135 146 200 In 1913 the deaths were—in Clerkenwell 217, in St. Luke 126, and in St. Sepulchre 5 deaths. General Observations.—The causes of infantile mortality in Finsbury are various, but may, in the main, be attributed to social and economic conditions. The problem is one that is intimately associated with questions of women's labour, rent, wages, expenditure and housing-—in short, with poverty and its usual concomitants. The reduction of infant mortality in Finsbury will not be accomplished save to a very slight degree by public health measures or by keener sanitary administration. The issue lies far deeper. In Finsbury, one-twelfth of the whole population lives four or more in one room. Nearly 6,000 families live and sleep in 6,000 rooms. Finsbury is the most crowded borough in London. The proportion of one-roomed tenements in Finsbury is 279 per 1,000—higher than, the corresponding figure for Stepney, Bermondsey, Shoreditch, Poplar or Bethnal Green. Out of every 1,000 inhabitants in Finsbury nearly 400 live more than 2 in one room. The deaths that occurred in 1913 and the families affected were specially investigated. Thirty per cent. of the parents lived and slept in one room per family, 46 per cent. 53 luxuriated in the possession of two rooms each. Twelve per cent. of the tenements were overcrowded. The kitchen was used for living and sleeping in 60 per cent. of the cases. In 45 per cent. of the families there was marked evidence of poverty verging in some instances on destitution. In 33 per cent. of the families the mother was the usual bread-winner and supported the husband and the rest of the family. Thirty per cent. had no separate cupboards to store their food. It had either to be kept with the wood and coke or on the table. Some of the tenements had no cupboards or storage accommodation for food, wood or coke. These deplorable conditions are usually found in the houses which were originally built of 8 or 10 rooms to accommodate one family—but which, with the degradation of the neighbourhood, have been eventually let in 8 or 10 tenements, consisting each of one room. So that possibly what was originally a bedroom or a lumber room may now be occupied by one family for living and sleeping. In some of these houses there may be a single entry to two or more one-roomed tenements lying side by side so as to destroy all opportunity of privacy or effective home isolation. The occupants have, from this standpoint, no real homes—they live in what may be almost termed "waiting rooms." With this limited accommodation and stinted cupboard room, with this crowding and overcrowding, go domestic dirt and squalid, unclean surroundings. With the poverty of the parents, with the employment of the mother, are associated the underfeeding of the mother, the malnutrition of the child, and the insufficient clothing of both. In this connection it may be stated here that the Poor Law Guardians and their officers have given most ready and valuable assistance to the cases which have been referred to them. By far the greater number of these families, however, refuse to accept poor law relief, and will not allow the use of their names for this purpose. These, then, are the actualities—the bedrock bottom 54 facts. Their gravity, their vicious influences, are not lightened by sterile discussions about the attributes of the civic conscience, or by academic disquisitions on the expediency of collective effort. It is not enough to have noble ideals and high aspirations. It is necessary to put these ideals to the test of practice, and to see the welcome results develop in consonance with reasonable expectations. The mother first wants food, suitable clothing, and relief from her task, not advice or excessive and officious inspection. When she has been clothed and fed, she will be fit and willing to learn and ready to take advice. As the nourishment of the mother improves, the baby gains health and strength. in a previous report it has been suggested that the establishment of creches and of dinner centres would help to this end. 'i his work might be well undertaken by voluntary societies in association with the municipal officers. CANCER. In 1913, death was accredited to Cancer in 93 persons, of whom 45 were males, and 48 females. The death rate was 1 098 per 1,000. The deaths in previous years from 1901 upward were 72, 72, 92, 79, 65, 84, 86, 87, 88, 79, 81 and 86 respectively. The following tables show the deaths distributed according to sex and age:- Cancer Deaths, 1901-1913. Ages. Under 10 years. 10- 20- 30- 40- 50- 60- 70- Totals. Males 7 9 11 25 65 146 160 102 525 Females 2 6 5 37 102 147 135 105 539 Totals 9 15 16 62 167 293 295 207 1064 55 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 more numerous. The parts affected are set out below: — Cancer Deaths, 1901-1913. Sites of the Disease. 1913. 1912. 1911. 1901-10. Totals. Face, Tongue and Jaw 6 6 6 75 93 Throat, Neck and Gullet 12 11 9 77 109 Stomach 12 14 5 107 138 Intestines 17 11 16 154 198 Liver 7 14 8 92 121 Pancreas 0 2 3 18 23 Breast 9 12 11 67 99 Womb 12 13 13 116 154 Various 18 3 10 98 129 Totals 93 86 81 804 1064 The sites of the disease differ in the two sexes. In man they are chiefly those parts concerned with feeding and the digestion of food, the mouth, tongue, stomach, liver and intestines; in woman they are chiefly those parts concerned with child-bearing and reproduction, the womb and the breast. ALCOHOLISM. Alcoholism and Cirrhosis of the Liver caused 27 deaths in 1913. 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 alcoholism 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. 56 The deaths in previous years are appended: — Deaths from Alcoholism, 1901-1913. Years. Alcoholism and Delirium Tremens. Cirrhosis of the Liver. Total. 1901-10 164 257 421 1911 11 18 29 1912 16 26 42 1913 9 18 27 Totals 1901-13 200 319 519 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 bronchitis, alleged "influenza," or to "paralysis," many street and night accidents, and possibly some of the cases of overlying are attributable directly or indirectly to alcohol. The ages at death are shown in the table :— Age. 20- 30- 40- 50- 60- 70- 80- Totals. Males 0 0 6 5 3 0 0 14 Females 0 3 4 2 3 1 0 13 Eight of the cases died in the workhouse and workhouse infirmary. 57 TUBERCULOSIS. Notification.—Finsbury was one of the very first boroughs to adopt the voluntary notification of phthisis and of "open" tuberculosis, that is, tuberculosis associated with discharges. This was in 1900, or 13 years ago. From the very first, the cases were visited by the public health staff, suitable enquiries were made into the origin of the disease, the home circumstances and the sanitary condition of the premises. Appropriate advice was given to the patient and to the contacts. A leaflet of instruction was left with the patient, and periodic disinfection of the premises was offered. In recent years events have moved more rapidly. 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 the 1st 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. By the Public Heal,th (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. Finally, by the Public Health (Tuberculosis) Regulations, 1912, all forms of tuberculosis are compulsorily notifiable from and after the 1st February, 1913. TUBERCULOSIS OF THE LUNGS. This disease is also known as pulmonary tuberculosis, phthisis, and, popularly, as consumption of the lungs. 58 The notifications and deaths of Finsbury cases of phthisis since 1901, are appended:— Phthisis Notifications and Deaths, 1901-1913. Total No. of Notifications. No. of Cases notified per 10,000 of inhabitants. Total No. of Deaths Death Rate per 1,000. 1901 70 69 216 2.13 1902 121 12.1 240 2.40 1903 219 22.2 223 2.26 1904 210 21.6 251 2.57 1905 178 18.5 215 2.24 1906 217 22.9 232 2.45 1907 217 23.2 243 2.6o 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 1912 438 49.6 160 1.85 1913 421 49.7 151 1.78 The actual number of notifications received in 1913 was 1,053, but of these many refer to the same patient. There were 421 primary notifications, of which 88 were from poor law sources, 149 from hospitals and dispensaries, 7 from schools, and 177 from private doctors. In reference to the 88 poor law cases, there were received 720 notifications, re-notifications, and notices of discharge. This means that each poor law case was notified on an average at least eight times, and is due to the fact that these pauper cases are restless in institutions, and frequently come out, especially at holiday time, and later seek re-admission. Two hundred and forty-eight cases gave a Clerkenwell address, 165 lived in St. Luke, 8 in St. Sepulchre. 59 Institutions.—The institutions and the number of notifications from each are appended:— Holborn Union Workhouse and Infirmary, 88; the Finsbury Dispensary, Brewer Street, North, 39; St. Bartholomew's Hospital, 34; Royal Chest Hospital, City Road, E.C., 29; Royal Free Hospital, 6; Cane Hill Asylum, 3; City of London Dispensary, 3; Long Grove Asylum, 3; Royal General Dispensary, Aldersgate, E.C., 3; Brompton Chest Hospital, 2; Hanwell Asylum, 2; Hospital for Sick Children, Great Ormond Street, W.C., 2; Kennington Tuberculin Dispensary, 2; Mount Vernon Hospital, Hampstead, N.W., 2; National Insurance Commissioners, 2; and one each from the following:—Banstead Asylum; Charing Cross Hospital; Claremont Mission, Pentonville, N.; Downs Sanatorium, Epsom; Eastern Hospital, Homerton, E.; General Post Office, St. Martin's-le-Grand; Italian Hospital, Queen's Square, W.C.; King's College Hospital; Park Hospital, Hither Green, S.E.; Royal National Hospital for Consumption, Ventnor, Isle of Wight; Royal Sea Bathing Hospital, Margate; St. Luke's House, Pembridge Square, W.; St. Luke's Hospital, Old Street, E.C.; St. Pancras Dispensary, and St. Peter's Home, Kilburn, N.W. Ninety-six Finsbury patients received institutional treatment in a sanatorium—other than in a poor law infirmary—and chiefly as insured patients under the National Insurance Act How many of the whole number are Finsbury cases. —A patient is said to belong to Finsbury by residence when he has resided in the Borough for at least five years, or, if not yet five years of age, since his birth. The period five 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 elicited by enquiry, is less than the length of the patient's residence in the Borough. 60 Adopting these definitions, the cases may be grouped as follows :— 1. Finsbury Cases by residence and infection 255 2. Finsbury Cases by infection 31 3. Finsbury Cases by residence 10 4. Not Finsbury Cases 125 421 The cases which may be definitely associated with the Borough are the first two groups, and amount to 286, that is, to 68 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, 15 in number. These patients are generally restless, wandering, and homeless. They move from lodging house to lodging house, infecting all, a danger to themselves and to the other occupants. They use common eating utensils and common towels. They spit broadcast on the walls and on the floors. They take no preventative measures. When, as sometimes happens, the keeper of the lodging house, or his deputy, has phthisis, the circumstances are even worse. Some 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 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. Such cases live in common 61 lodging houses, Rowton Houses, or in 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 1913, there were 125 cases notified, or over 29 per cent. of the whole number—which were considered to be dumped cases attributable to other districts. The never-ending immigration of these cases into the Borough is possibly the most serious difficulty of all in dealing with the phthisis problem in Finsbury. There is a continuous accession of patients who have developed the disease elsewhere, and worse still from the standpoint of a public health reputation, once they come into the Borough they show no disposition to move elsewhere. In course of time, when these patients die, their deaths are counted as Finsbury deaths, and tend to attach to the Borough a pubic health odium which it does not deserve. One hundred and thirty-one of the patients were bedridden at the time of notification.; some had been confined to bed for varying periods up to twelve months and more. Patients who. are not notified until they become bedridden are patients generally with longstanding 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:— Bastwick Street, 12; White Lion Street, 11; Baldwin Street, 9; Guinness Buildings, Lever Street, 9; Goswell Road, 8; Pentonville Road, 8; Risinghill Street, 8; Cumming Street, 7; Lever Street, 7; Old Street, 7; St. Bartholomew's Buildings, 7; Gee 62 Street, 6; Margaret Street, 6; Southampton Street, 6; Busaco Street, 5; Galway Street, 5; Northampton Square, 5; Rahere Street, 5; St. John Street, 5; Banner Street, 4; Central Street, 4; Cyrus Street, 4; Donegal Street, 4; Farringdon Road, 4; Northampton Buildings, 4; Penton Place, 4; Rodney Street, 4. The notifications from the Peabody Buildings were as follows:— Dufferin Street, 1; Errol Street, 1; Guest Street, 1; Farringdon Road, 3; Roscoe Street, 5. Sex and Age.—The notified cases, classified according to sex and age are given below: — Years 0 I 1-2 2-5 5-15 15-25 25-45 45-65 C5 + Totals. Males - - 6 27 39 89 63 9 233 Females - I 10 36 38 67 29 7 188 Totals - I 16 63 77 156 92 16 421 Length of residence.—The duration of residence in the Borough and of residence at the notified address were ascertained in many cases, with the following results :— Duration 0-1 week 1 week1 month 1-3 months 3-6 months 6-12 mouths 1-5 years 5 years and over Finsbury Residence 10 2 22 21 15 69 226 Present Address 20 18 37 44 51 125 78 Nearly 45 per cent. of the patients had lived less than one year at the addresses given when they were notified. These poor people, as their savings get exhausted, and their sick benefits get less, get in arrears with their rent, and are for ever moving from one house to another, often clandestinely, or 63 are being ejected. They thus continue infecting fresh tenements in their quests for cheaper accommodation, and in their struggles to stave off the ultimate resort to the poor law. Place of Birth.—This was ascertained in 335 cases as follows:—Finsbury, 133; other parts of London, 158; England and Wales, 30; Ireland, 2; foreign countries, 12 cases. Eightysix per cent. were Londoners by births; 39 per cent. were born in Finsbury. Presumed Source.—In most families where this fact was fairly well established, the father was marked out as the chief or only primary infecting agent. Next to the father in order of occurrence came the mother. In both instances the children were infected. Other presumed sources in order of frequency were the sister, the brother, the wife, the husband, the son, the daughter, or other relative. In many instances, especially in model buildings, the presumed source was a case in a tenement on the same landing as the case under investigation. In other examples the origin was a known case in the same block of buildings or in the same street, with whom the patient concerned used to work or play, or whom he used to visit and accompany. 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 341 patients. 0-1 month 1-3 months 3-6 months 6-12 months 1-5 years 5-10 years 10 years and over 21 34 48 44 134 38 32 Few cases are recognised in the early and curable stage—46 per cent. had been ill for periods over one year before notification This shows an improvement over 1912. when the corresponding figure was 68 per cent. It illustrates the expediency of a systematised search in the homes for slight, missed, and suspicious cases amongst the contacts in the households of notified and recognised cases. 64 OCCUPATIONS. The conditions in life, and occupations of the patients, were as follows:— Accountants' book ruler, 1; artificial flower maker, 4; art teacher, 1; barber, 2; barman, 4; bacon carrier, 1; baker, 1; blacksmith, 1; boot repairer, 1; book folder, 4; boxmaker, 8; bricklayer, 1; brushmaker, 1; buttonhole maker, 1; butcher, 1; caretaker, 1; capmaking, 2; cabinet making, 1; capsule making, 2; cardboard bust maker, 1; carman, 5; cellarman, 1; chemist, 1; chef, 1; churchworker, 1; checker and loader, 1; chaff cutter, 1; charwoman, 4; cloth shrinker, 1; clerk, 8; compositor, 2; commercial traveller, 1; cook, 2; distillery worker, 1; domestic servant, 4; dressmaker, 2; engraver (silver), 1; envelope maker, 1; errand boy, 1; feather worker, 3; fishmonger, 2; firewood dealer, 1; French polisher, 4; fur finisher, 1; gas fitter, 1; gilder, 1; glass blower, 1; goldbeater, 2; hawker (street), 11; hatblocker, 1; housework, 41; horsekeeper, 2; insurance agent, 2; infants, 9; jeweller's designer, 2; laundresses, 3; labourers, 12; litho stone grinder, 1; mason, 1; machinist, 2; metal polisher, 2; messenger, 2; milk carrier, 2; motor washer, 1; motor driver, 1; millinery, 2; mount finisher, 1; newsvendor, 2; nickel plater, 1; nurse, 1; optician, 2; ornamental smith, 1; paper hanger, 2; packing case dealer, 4; packing case maker, 3; pattern card mounter, 1; painter, 7; packer, 11; pipe maker, 1; porter, 12; postman, 2; printer, 12; railway shunter, 1; ragsorter, 1; restaurant manageress, 1; restaurant proprietor, 1: Royal Navy (Petty Officer), 1; road sweeper, 2; silk worker, 1; shoe black, 1; shutter maker, 1; showman (travelling), 1; stage hand, 1; stick mounter, 1; tailor, 2; tailoresses, 1; taxi-driver, 1; thermometer maker, 2; thermometer polisher, 1; tinman, 1; upholstering, 1; sawyer, 1; sausage skin washer, 1; sieve maker, 1; school children, 55; shop assistant, 3; silversmith, 2; surgical instrument maker, 1; warehouseman, 1; waiter, 1; waitress, 4; woodchopper, 4; wood carver, 2; wheelwright, 2; Christmas card tying, 1; no occupation, 19. Sixteen patients were homeworkers. 65 Unemployment and Insurance.—Enquiry was made as to the unemployment of the patients during the 52 weeks preceding notification. Thirty-three per cent. of the whole number had been in regular employment without losing a single day; 18 per cent. had been absent from work for periods ranging from a few days to one month; 11 per cent. had lost from one to three months work; 7 per cent. had been out of work from three to six months. The rest had been unemployed for six months or more. Twenty-three per cent. of the patients worked in the borough, 24 per cent. worked in other parts of London. One hundred and eighty-one were insured persons under the National Insurance Act, 106 were dependents. Sixty males and 18 females were sent to sanatoria by the London County Insurance Committee, and thereby obtained treatment and educational instruction of exceeding great value. Treatment.—Out of 421 patients, 113 had been treated at the Holborn Poor Law Infirmary or Workhouse. Eighteen patients received sanatorium treatment, in addition to the 78 paid lor by the Insurance Committee. Each patient, when visited, was asked whether he would like to have sanatorium treatment or not—199 stated that they would be very glad to have the opportunity of entering a sanatorium, 69 did not wish to accept. Home Circumstances and Social Conditions.—Fortyone were in great poverty, 18 others were destitute, that is to say, 59 households, or 14 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 povertv. 66 One hundred and forty-eight patients were total abstainers, 207 were said to be moderate drinkers, 21 drank to excess. Eighty-two families lived and slept, each family in one room. One hundred and forty-nine families lived each in two rooms. For these the prevention of infection would be a matter of great difficulty, if not almost impossible. Overcrowding was discovered in 24 households. In 406 homes, excluding common lodging houses, there were altogether 1,332 other members of the family besides the patient— these would be naturally in close contact with the disease, and very liable to be infected. In addition to these close contacts, there were 2,115 remote contacts living in these houses, so that there would be altogether 3,447 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. There are three types of home circumstanecs which are so common in Finsbury that they will have to be taken into serious consideration in any well-matured proposals for dealing with tuberculosis. In the first type—one or other parent has phthisis. There are many children, and the family lives in one or, at most, in two rooms. The father, it may be, is ill, and the mother is unable to go to work owing to the fact that she has to nurse her husband. Or, if she is able to go to work, her earnings are very small, and quite insufficient for the family. In the meantime the savings of the family are being exhausted or have been spent. During the mother's absence the children are supervised or fed by the father, sometimes they are in bed with him, and are consequently exposed to great risk of infection. The difficulty would be to a large extent solved if the father went into the poor law infirmary. This suggestion he refuses to entertain for a single instant, very often because "he wants to die at home." 67 In the second type—the parent with phthisis—the father, is in the infirmary, and is contemplating taking his discharge against medical advice, and to the consternation of the mother, who has obtained employment as a domestic servant, a charwoman or a bookfolder. The children are put by day in a crèche or in the care of a neighbour. The family live in one room. The mother's earnings are just enough for her and the children. If the father insists on leaving the infirmary, the mother's earnings are insufficient to maintain him, and the prospect is a very distressing one. In all probability it means that if the father is discharged at his own request, the whole family in a short time will have to go into the workhouse. In such straits, the mother generally writes to the Public Health Department, asking that the father shall be compelled to remain in the infirmary. Unfortunately, in London, there is no power which enables a local authority to accede to the mother's request. Compulsory removal and detention for phthisis are available by a private Act in the Borough of St. Helens, Lancashire, but in no other English town as far as is known. Many letters of this kind are received every year by the Finsbury Public Health Department. In the third type—a child generally of school age, is notified to have phthisis. The parents keep the child home to do most of the household work or send it hawking vegetables on the streets. They refuse to believe that the child is ill—or, at all events, make a statement to that effect. The child's condition gets worse. Arrangements are made to send the child to a sanatorium or to a country convalescent home. At the last minute the parents withdraw their consent—"Anybody can see there ain't nothing the matter with her, it's only a fancy illness." Repeated visits are paid to exhort the parents to realize the serious condition of the child and to rouse them to a sense of parental responsibility and effort. Fresh arrangements are made for the child to get into the country, and rendered fruitless by the discovery a day or two before the appointed time that the child "ain't got no boots." 68 The fact appears to be that the child, now relieved of school attendance, is so useful to the parents that they passively resist all plans which are conceived for her betterment. The three foregoing types are fairly common, and occur with unfailing regularity every year. There is one other type which is not quite so common, in which the whole family enter and leave the workhouse together. The father or mother has phthisis, and sometimes one or more children are affected. In one such family three children had phthisis. The mother is, possibly, a charwoman, the father does no work. They move from one address to another, either surreptitiously or are ejected for nonpayment of rent. The mother is pregnant, and towards the end of her term enters the workhouse for her confinement. The father, deprived of the mother's earnings, enters the workhouse too, and the children accompany him. Such families as these move from house to house, and from one borough to another, presumably leaving a wake of infection wherever they go. Illustrative Cases. - 1.—The father, mother, and five children, girls 12, 8, 6, 2 years, and a baby 10 weeks, occupied 2 rooms. The father had had phthisis for some considerable time. Latterly, the girl, 8 years, had been notified to have phthisis. The girl 6 years was suspected to have phthisis, but as yet showed no definite signs. The father had been out of work for 15 months, and refused to enter the poor law infirmary. He refused to allow the girl 8 years to go to an institution. The girl used to attend a hospital as an out-patient, but the mother was unable to take her regularly. The mother worked and earned a few shillings each week. The rooms, floors and bedding were clean. The windows were kept open. The prospects of the family would be considerably improved, and the chance of infection of the others lessened if the father and the girl 8 years were to enter the poor law infirmary. The father, however, refused his consent. Otherwise, this case might possibly be dealt with under Section 12 of the Children Act, 1908, which makes it an offence for any person having the custody of a child, to neglect, expose, or cause to be neglected or exposed, such child in a manner likely to cause the child injury to his health. 69 2.—The father, mother, 2 boys, 10 years, 3 years, and a baby 14 months, lived and slept in one room. The father was a casual labourer doing odd jobs. The mother had consumption when her last child was born, and was suckling it on insufficient food. She was using a meat extract bottle as a spittoon, was fouling its sides, and contaminating the chairs and table on which it was placed. The boy, 3 years, became infected, and died of tuberculous meningitis. The mother was an out-patient at a Chest Hospital. Later she was attended by a Poor Law District Medical Officer. Afterwards she entered the Poor Law Infirmary and died there. It is to be noted that these cases eventually become amenable to the Poor Law, and receive poor law relief. The pity of it is that they will not accept poor law institutional treatment while there is still time to prevent the infection attacking other members of the household. At first they go to a sixpenny doctor, and as often as not resent a thorough examination of their chests. They make the diagnoses themselves, and wish to be treated for an "influenza cold" or a "shocking bronchitis which never leaves off." Occasionally they don't trouble a doctor, but "fetch a bottle of medicine from the chemist." Later, when they fall out of work, they become out-patients at hospitals, and endeavour to mask their secession from private doctors and to retain the good opinion of their neighbours by alleging that the hospitals have more experience in chest complaints. But they aver that they still get their "own doctors for everything else." So they struggle on.. Finally, with savings exhausted, with little or no work, the furniture, bedding and personal clothing are in part sold, and now they are compelled to seek poor law relief, but too late to prevent the spread of the disease to the children. The mischief has been done. 70 3.—The father, mother and two girls, 19 and 16 years, occupied two rooms. The father had phthisis, and was bedridden. He was in an advanced stage of the disease, and reluctant to enter the poor law infirmary, but realised that "it must come to that in the end." He was being allowed one quart of milk and one egg daily by the Insurance Committee. The parents had had 10 children, but had lost five. Two children were married. One son, age 11 years, had phthisis, and was in a poor law institution. The mother was able to get casual work as a laundress, and occasionally earned five or six shillings in a week. Sometimes she earned much less. The family was supported almost entirely by the two girls who were at home. But even they had to husband their resources very carefully, and could not afford to keep the fire going all day. "As it was, all the coal they could buy only lasted until Thursday. They couldn't have a fire after that—they hadn't got the means. If the father went into the infirmary then they could give up one room and live in one room only." The tenement was clean, and rented at 7s. a week. The weekly expenditure of the family was:— Bread (2 loaves daily), butter (2 ounces daily), and tea, 4s. 6d; cocoa, 3d ; flour, 1½d.; sugar, 6d; coal, 2s. l½d.; wood, 3½d.; matches, ½d.; oil, 7d.; suppers, generally fried fish and chipped potatoes, 2s. 4d. Sunday was a special day set apart for a meat dinner, consisting of meat "pieces," 9d.; potatoes, 1d; pot-herbs, 1d., and suet, 1d. The mother's washing requisites cost: Soap, 3½d.; bleaching powder, l½d.; washing soda, ½d.; blue, ½d., and starch, 1d. This family of four adults lived in two rooms on a total of 19s. 4d. per week, including 7s. paid for rent. The father lived and slept in the kitchen. The girls slept in the other room. 4.—The family consisted of the parents, 5 girls, 14, 12, 7, 4, 2 years, and 2 boys, 10 and 9 years respectively. They lived in two rooms—very poorly furnished. There were two beds, and a "shake-down" on the floor. The bedding was very scanty and threadbare. There were only two chairs, and one of these was 71 broken. The mother was a homeworker, and made children's coats and costumes. She was thin, ill, and had chronic chest trouble. She was not notified to have phthisis. The husband was a casual labourer, and earned 9s. or 10s. per week. The second girl, aged 12 years, had phthisis. The eldest girl had left school. Her teacher offered to find the girl a situation as a domestic servant, and to provide a box of clothes for her outfit. The parents declined the teacher's offer. Three girls slept with their consumptive sister, and unless the parents were to consent to the removal of the ailing child to the poor law infirmary, the others ran a very serious risk of contracting the disease. 5.—The family consisted of the parents and 5 children, 8, 6, 3 and 2 years, and a baby 9 months. They lived in a Lambeth basement. A notice was served on them for its illegal occupation, and they moved into Finsbury. The mother and two children went to Hatfield Street. The father and three children came to Bastwick Street and stayed there a few nights. Then they went into the City Road Workhouse, whence they were transferred to the Infirmary. The father and the three children were notified as having phthisis. The father was out of work; he was said to be work-shy. He carried about with him an undated medical certificate purporting to be signed by a poor law medical officer to the effect that he was in good health and free from any signs of tuberculosis. The mother was an artificial flower maker, and always went into the workhouse for her confinements. She obtained work in Finsbury as a charwoman. 6.—The family consisted of the parents and 7 children, and occupied 3 rooms. A girl, 13 years, had phthisis. Arrangements were being made to send her away, but the mother took no trouble in the matter, and went to nurse a sick relative. She did "not think there was much wrong with the child, only a bit of a cough." A fresh arrangement was made, but again the girl did not go, this time because "she had no suitable clothes." 72 A complete outfit of clothes was obtained for her from a mission, and eventually, after much delay, and in spite of the protests of the father, she went away for a month. The father thought she "was all right, but a bit fanciful with her chest." The child, of course, should have been sent away to an institution and detained there for a prolonged period. There were no facilities for isolating her at home, and in course of time it was extremely probable that the other children would become infected. The above examples show the sad wastage of human life, which ought to be prevented in these lowly homes, a wastage which, it is submitted, might be much diminished by a wise administration, which deferred to some of the prejudices of the poor, by an administration which possessed sufficient elasticity to enable it to recognise and to propitiate the human factor and personal equation, both always present in these difficult cases. The Tenements.—Out of the whole number, excluding common lodging houses, 82 were one-roomed tenements, that is to say, in these tenements the patient and family lived and slept in one room only, 149 were two-roomed tenements—the rest had three to eight rooms. Twenty-four 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-nine tenements had only one cupboard each for food, clothes and coke. Twenty 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, when he uses the common towel and washing basin, the common knives, forks, spoons, cups, saucers and glasses, when the utensils of the household are all washed together indiscriminately, the spread of infection from the patient to his family is greatly 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. 73 Ninety-four tenements were on the list of houses-let-in-lodgings ; 47 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 twelve tenements. Of the houses occupied by the patients, 3 were milkshops, 4 were restaurants, 4 were public-houses, and 5 others were used for the sale or preparation of food products. It is very unfortunate and most undesirable that these consumptive patients should have to do with the handling or manufacture of articles for human consumption. There is not, however, at present, any practical method of preventing or otherwise satisfactorily dealing with their employment in such occupations. A sanitary survey was made of every tenement, and the nuisances found were made the subject of subsequent notice and amendment. The following defects were ascertained:—Insufficient head room, 62; dark kitchens, 37; dirty rooms, 26; damp rooms, 8; broken or dilapidated walls or roofs, 9; insufficient ventilation, 8, and verminous rooms, 8 tenements. 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. Persons and Beds in the Patient's Bedroom. One Bed. Two Beds. Three Beds Persons. Families. Persons Families. Persons. Families. 1 102 1 — — — 2 113 2 25 — — 3 29 3 40 3 2 4 4 4 31 4 I 5 - 5 12 5 2 6 — 6 I 6 .. 74 This list excludes 15 cases in common lodging houses. Only 102 patients out of 421 were able to have a bed and bedroom all to themselves. In the other households, where only one bed was available, 431 persons slept in the same bed with the consumptives, and were consequently exposed to infection. This number refers to those families which only possessed one bed. In addition to these there were 380 persons who occupied the same bedroom as a phthisical patient, and in some instances the same bed. Four bedrooms had no fireplace, so that ventilation in them was absent or impossible. Fifty-one bedrooms were dark, and had insufficient light. The ventilation was insufficient in 36 other bedrooms, making a total of 40 bedrooms, or 9 per cent, of the whole number. The defective ventilation and absence of ventilation greatly facilitate 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. Unfortunately, even when they have been provided, the occupants have been known to stuff the apertures with rags and thus render these gratings useless. The absence of fireplaces bespeaks very bad housing—in some instances these rooms without fireplaces were originally attached to the tenements as lumber rooms, or as odd rooms for storage purposes. They were not built for occupation as living or as sleeping-rooms. 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 frajne. Fifteen bedrooms had dirty walls and ceilings, 6 were damp. In 8 instances the walls and bedding were verminous. In 12 bedrooms the bedding was fouled with the patient's sputum:, in 9 the bedroom utensils were contaminated, in another 8 the patients had been spitting broadcast and had bes patted the floors and walls. In 6 homes the bedding was excessively filthy, grimy, and in parts almost caked with dirt and mucus. 75 The conditions thus found bespeak wanton carelessness, and show a callous indifference on the part of the patients concerned to the health and welfare of their families. The Kitchens.—In 248 instances, or 57 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 shows the difficulties of accommodation and the facilities for infection which accrue in these poor households. Sometimes the patient himself occupics the kitchen by day and night. Many of the kitchens were dirty, verminous, or damp. In 10 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 infection for the rest of the family. The Houses and Streets.— Sixteen houses in which cases occurred were being used for the purpose of sale or manufacture of food as follows:—Restaurants, 4; food preparation, 5; milkshops, 3, and 4 public-houses. Notifications of phthisis had been previously received from 140 houses, or from 33 per cent, of the whole number of houses affected. From two such houses, five and four previous notifications had been received; from each of 15 houses, 3 prior cases had already been notified. Deaths from phthisis had occurred in 62 houses, or in 15 per cent, of the houses concerned. It is possible that in both these groups the subsequent cases may have been due to family infection or to house infection. The demand for cheap tenement accommodation is often so urgent in the borough that very soon after a tenement is empty, it is sought by a prospective tenant, and occupied before the rooms have been disinfected or scoured out. Disinfection is offered in all eases, and a special soap provided free of cost by the Public Health Department. There is, however, no power to enforce compulsory cleansing or disinfection. 76 On the occurrence of a case of tuberculosis, the following letter is sent to the head of the household :— Dear Sik or Madam, I have received a certificate relating to a recent case of Consumption of the Lungs or of Tuberculosis in your house. Tuberculosis may affect many parts of the body, such as the lace, the nose, the bones, the joints, the lungs or the brain. When Tuberculosis affects the lungs, it is generally known as Consumption, so that Consumption is only another name for Tuberculosis of the Lungs. As you are aware, Consumption and Tuberculosis arc "catching," and it is most important, in the interests of the rest of the family, that the room occupied by the patient, the clothes lor wearing, week-day and Sunday clolhes, the curtains, the valances, the bedding, sheets, pilloiw-slips, night-shirts, towels, handkerchiefs, table cloths, dusters, dish rags, and feeding utensils, the knives, forks, spoons, cups, plates, drinking glasses, and saucers used by or for the patient should all be disinfected before they are used by anybody else. The room, the wearing apparel, the curtains, the valances, the bedding, the sheets, pillow-slips, towels, handkerchiefs, and linen will be disinfected by the Borough Officers free of charge. After disinfection, the room should be well scrubbed out with soap and water. The Borough Council supplies a disinfectant soap, which may be obtained gratis on request at the Public Health Department. All the feeding things used by the patient should be kept by themselves. They should be cleaned by themselves and not mixed with the things used by the rest of the family. They should be cleaned last of all, and not be used by other persons until they have first been disinfected. The feeding utensils should be placed in a vessel, such as a saucepan, containing cold water and a little washing soda. The whole should then be boiled and kept boiling for 10 minutes or longer by the clock. This will disinfect them. 77 The spit-cup, after it has been finished with, should be broken and burnt on the kitchcn fire—it should not be thrown into the ashbin or given to children to play with. Its contents, even when dried and old, are very infectious, and may give Consumption to those who handle it. Where a consumptive or tuberculous patient lives with others, disinfection should be done regularly and frequently as often as it can be conveniently managed. I am, Yours faithfully, A. E. Thomas, Medical Officer of Health. Occasionally, requests for disinfection are received "for the bed and pillows to be sanitarised as the patient has died with tubercollosis." These requests are very rarely made during the life of the patient. Whenever a case is visited the whole house is made the subject of a critical sanitary survey, and subsequent notices are issued for the defects found. In 1913, cases of phthisis and deaths from the disease occurred in 20 streets in which there had been no previous notifications or phthisis deaths. Disposal of Sputum.—Few of the patients used a special spit cup when they were first visited by the inspectors; some were said to spit into pieces of paper or rag, which were subsequently burnt. A few stated frankly that they spat into the fire or fireplace whenever this was convenient. Many were said to be very careless by the other members of the family. The others may be confidently assumed to have taken few or no precautions in disposing of their sputum. The result is very disheartening, especially when it is known that the Public Health Department supply special sputum flasks gratis. The Borough Council examines for medical men the sputa of all patients suspected to have phthisis, free of charge. In 1913, 252 specimens were examined. Of these, 48 were found to have the tubercle bacillus present. 78 Search for missed and unrecognised cases.—As the result of a special enquiry, in 22 affected families 25 suspicious cases of chronic cough and wasting were discovered and put in the way of obtaining treatment. The other families inhabiting the same houses as the consumptives were also investigated, and suspicious cases were referred to hospitals and dispensaries. This is one of the most important purposes of visitation, to enquire after missed and unrecognised cases in the homes of the patients and in the households of the other families inhabiting the houses affected. These overlooked cases, unless captured early, are possessed of infinite possibilities of spreading phthisic. Disinfection and Preventive Measures.—The rooms bedding, feeding utensils, to«els, handkerchiefs and iinen were disinfected in 162 instances, or in 38 per cent, of the households. In many of the affected homes the responsible head of the family refused any disinfection whatever, in some cases only the bedding was disinfected, in a few homes only the rooms were attended to. Some patients took no special precautions whatever to prevent the infection spreading to the rest of the family, and were apparently indifferent as to whether they caught the disease or not. A few patients thought that by using a spittoon they were doing all that could be reasonably expected of them—they were disinclined to put themselves to any further trouble. In every case it is urged that the patient should have a separate living room for his own exclusive use and a separate bedroom, or, failing these, a separate bed. The importance of separate feeding utensils, of separate towels, and handkerchiefs, of wet dusting and wet sweeping, of fresh air, open windows and sunshine, of the nutritive values of milk and eggs is strongly urged in every instance. In practice, it must, however, be confessed that in Finsbury the achievement of these ideal conditions is only too often impossible. In such straits the patient is instructed how to make the best of things as they are. 79 When they were first visited 222 patients did not know that they suffered from consumption, and in most of these cases the friends and relatives did not wish the patients to know. Some of these consumptives were in receipt of sick relief, and were being medically certified to have "bronchitis." One such consumptive congratulated himself that he had only got bronchitis and not consumption. It is quite obvious that very little progress will be made from a public health standpoint in face of this conspiracy of silence. The object of notification is in this way rendered almost ustless. If the patient, after he has been medically examined, after he has been notified, does not realise that he has phthisis, if his relatives persist in withholding the knowledge from him, then it will be of no avail to expect him to take those necessary preventive measures for the protection of the other members of the family. The consequences of this ignorance are disastrous. Many of these unwitting consumptives slept in the same bed with other members of the family. The other members were very loth to sleep elsewhere or to take any other means of safeguarding themselves lest they should arouse suspicion in the patient's mind. They, therefore, voluntarily exposed themselves to infection in order to keep the patient in a fool-happy condition of pernicious ignorance. Many of these patients slept with their parents, husbands, children, uncles, aunts or friends, sometimes three or more in a bed, in one case six in a bed. In 10 per cent, of the homes there were already other cases of phthisis previously notified and still living in addition to the special cases now under review. Thirty-five per cent, of the patients were said to be total abstainers, 49 per cent. moderate drinkers, while 5 per cent. drank to excess. The rest were school children and others about whom no information was obtained. In very few homes were wet dusting and wet sweeping adopted at the time of the first visit. Residence in Finsbury and in other Boroughs. Seventy-eight per cent, of the cases had lived in Finsbury from the time their illness was recognised by medical examination. Many of these, however, had lived elsewhere while they were still ill, but before the specific nature of their ailments was diagnosed. 80 Many had lived in other places even while they were definitely known to have phthisis. These places included other metropolitan boroughs, the suburbs of Greater London, Essex, Kent, Hertfordshire, Hampshire, Buckinghamshire, Yorkshire, the Midlands and Italy. The consideration of this distribution suggests that the successful treatment of tuberculosis in Finsbury is closely bound up with the treatment in the whole of London and in the rest of the country. Enquiry was made into the three last Finsbury addresses occupied by the patients while they were ill and before they had been notified. The results are embodied in the following table:- Previous Finsbury addresses during illness. No. of Patients. Previous phthisis cases at these addresses. Previous phthisis deaths at these addresses. 1 59 23 14 2 19 20 9 3 23 32 23 Some of the reasons given by the immigrants for their entry into the borough were "To be near the hospitals," "To get into the Holborn Infirmary," "To get rooms at a cheap rent," "To stay with relatives," "To stay with friends," "Finsbury is convenient for work" (these were chiefly labourers, carmen, porters, packers and charwomen employed in the borough or in the City of London), and "To stay with their compatriots" (these were Italian consumptives). Schools.-Forty-six of the patients notified were school children. The schools chiefly affected were Bath Street (7), Moreland Street (4), Risinghill Street (4), Compton Street (4), St. Peter's, Saffron Hill (3), Central Street (3), Hugh Myddelton School (3), The Holy Family (3), Ann Street (2),Chequer Street (2), Winchester Street (2), White Lion Street 2 cases. The others had one case each. 81 Milk Supply,—One hundred and fifty-two patients obtained their milk regularly from a milk shop or dairy; 179 consumed condensed milk and took no fresh milk. Forty-four bought from' casual street vendors. A list was made of the six wholesale dealers from whom the largest number of patients obtained their milk, and enquiries instituted as to the precautions adopted by these firms to keep their milks free from tubercle. The results are appended:—All the firms concerned make contracts with farmers, but none of them insist that the milk shall be from cows reported free from tuberculosis as the result of a tuberculin test. Company A deals with over 1,000 farmers, to all of whom it issues special printed regulations on the cleanly management of cows and cowhouses, on milking and the cooling of milk, on the washing and care of dairy utensils, and on the measures to be adopted in cases of illness occurring amongst the stock or farm hands. Frequent samples of milk are stated to be sent for bacteriological examination. The farms are periodically inspected by sanitary experts from London under a standing agreement. Cowmen, suffering with any illness are kept from the cows, and their wages are paid during this period by the Company. Company B buys from 300 farmers. It issues no regulations to farmers. It was stated that a few samples of milk had been bacteriologically examined for the company, but when this question was pressed no particulars could be given as to dates or the results of such examinations. The company reserved the right to have the farms and stock inspected by a veterinary surgeon appointed by themselves. In this connection, a few farms near their own chief establishment had been inspected in this way. Company C deals with 180 farmers. It sends no samples for bacteriological examination. It has a clause in the contract 82 agreement with farmers prohibiting any person on the farm affected with an infectious disease or tuberculosis, from taking any part in dairy operations. Company D deals with 100 farmers. It sends no samples for bacteriological examination. It never inspects the farms. It leaves these matters to local authorities. There is the usual clause in the contract agreement referring to the outbreaks of infectious disease amongst employees or their families, abstention from work, and notice to the company. Company E deals with a "arge number" of farmers. It has occasionally sent samples of milk for bacteriological examination and a veterinary surgeon to inspect the stock. The contract agreement has the infectious disease and prohibition clauses referred to above, and the company guarantees the farmers against any loss or damage arising by reason of any outbreak. Company F deals with 20 farmers, each of whom has to send to the company (1) a veterinary surgeon's certificate on the health of his cows every six months; (2) at the commencement of the contract term a certificate from the local sanitary authority as to the sanitary condition of the cowsheds and farm premises. The company sends no samples for bacteriological examination. As far as these results go, with an exception possibly in favour of the company first mentioned, the safeguarding arrangements indicated cannot be regarded as even verging on the satisfactory. Death Notification Interval.- Of all the 421 cases notified during 1913, 41 died before the end of the year. Six died within a week of the time when they were notified; 16 died within a month. One patient was notified five days after he had died. 83 These late notifications are of very little public health value. A good deal of the mischief has already been done before the cases came under the purview of the Public Health Department. Deaths.—In 1913, the number of Finsbury persons who died of phthisis or consumption of the lungs was 151, as against 160 in the previous year; in addition to these, 33 died from tuberculous meningitis, and 30 from other forms of tuberculosis. The deaths from all forms of tuberculosis were 214. The corresponding number for 1912 was 204. The deaths for previous years are given in the subjoined table :— Phthisis Deaths and Death Rates, 1901-1913. 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 2.13 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 1.150 1907 243 42 2.60 1.140 1908 221 39 2.40 1.115 1909 228 31 2.52 1.081 1910 166 31 1.86 1.015 1911 159 45 1.81 1.084 1912 160 44 1.81 1.039 1913 151 63 1.78 - It will be observed that the deaths and death rate this year are less than in 1912, and are both less than they have been since the Borough was formed. 84 It is very probable, however, that this list does not contain all the deaths from phthisis which occur in Finsbury. Many are doubtless concealed on the death certificates, and wrongly entered as due to pneumonia, bronchitis, pleurisy, asthma, or influenza. 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 151 draths, 103 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. Twenty-nine 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. Five were Finsbury cases by residence—that is, they had lived here for 5 years, although there was reason to believe that they had phthisis before coming to Finsbury. If wc include only the Finsbury cases by infection, and by residence and infection, these amount to 117, which may reasonably be associated with the Borough, and give a corresponding death rate from phthisis of 1.38 per thousand inhabitants. Allotted to districts, 107 belong to Clerkenwell, 42 to St. Luke, and 2 to St. Sepulchre. Of the whole number of deaths, 1,558, in Finsbury in 1913, 9.7 per cent, were due to phthisis, as against 10 and 9.3 per cent, in 1912 and 1911 respectively. Nearly four-fifths 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. Sixty died in the poor law institutions. 85 The death from phthisis in institutions for previous year are appended:- Phthisis Deaths in Institutions, 1901-1913. 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 1907 243 108 51 159 65 1908 221 81 50 131 59 1909 218 87 59 146 67 1910 166 63 25 88 53 1911 159 74 14 88 55 1912 160 71 32 103 64 1913 151 60 32 92 62 It is of 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 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 resided, for however, a short time immediately before admission makes the Finsbury death rate from phthisis higher than it otherwise would be. A patient who sleeps one night in Finsbury and is there admitted to the Holborn Infirmary to die there is counted as a Finsbury death. 86 The death rates in the metropolitan boroughs are sub-joined :— Phthisis Death Rates, London Boroughs, 1913. Borough. Phthisis Death Rate per 1,000. Borough. Phthisis Death Rate per 1,000. Battersea 1.14 Lambeth 1.3 Bermondsey 1.61 Lewisham 0.73 Bethnal Green 1.54 City of London 1.6 Camberwell 1.15 Paddington 1.07 Chelsea 1.17 Poplar 1.61 Deptford 1.33 St. Marylebone 1.37 Finsbury 1.78 St. Pancras 1 .76 Fulham 1.35 Shoreditch 1. 66 Greenwich 1.45 Southwark 1.92 Hackney 1 .12 Stepney 1. 6 Hammersmith 1.20 Stoke Newington 0.93 Hampstead 0.56 Wandsworth 0.88 Holborn 1.87 Westminster 1.24 Islington 1.26 Woolwich 1. 42 Kensington 1.08 County of London 1.30 Phthisis Death Rate 1912 England and Wales 1.039 The Finsbury death rate is seen to be the third in order, and is exceeded by the rates in Southwark and Holborn. Only 35 per cent. of the Finsbury phthisis patients who died in 1913 were born in the Borough: 48 per cent. were born in other metropolitan districts and had migrated into Finsbury. Twenty-five per cent. of the deceased patients lived and slept in one room with the other members of their families, 37 per cent. occupied two rooms in similar manner. During the illnesses which preceded their deaths, 21 per cent. had lived in other metropolitan boroughs, and had come into Finsbury so as to be near the hospitals. 87 The duration of the illness which preceded death was said to be less than one week in one instance, between one and three months in 9 patients, between 3 and 6 months in 19 cases, between 6 and 12 months in 17 persons, between 1 and 5 years in 66 patients, between 5 years and 10 years in 21 cases, and over 10 years in 9 persons. The streets where the largest numbers of deaths occurred were: Four deaths each in Galwav Street, Mitchell Street, Rahere Street and Warren Street. Three deaths each in Clerkenwell Road, Gastigny Place, Gee Street, Lloyds Row, Northampton Road, Pentonville Road, Smith Street, Union Place and White Conduit Street. Two deaths each in Bastwick Street, Busaco Street, Central Street, Gumming Street, Cyrus Street, Donegal Street, Duffenn Street, Farringdon Road Buildings, Godson Street, Guinness Buildings, Hatfield Street, Helmet Row, King Square, Lizard Street, Myddelton Square, Nelson Street, Northampton Buildings, Penton Place, Rodney Street, St. Helena Street, L'pper Ashby Street, Victoria Dwellings and Wilmington Place. Other forms of Tuberculosis.—The number of notifications received was 144; of these, 7 couid not be traced. The rest, 137, were derived from Clerkenwell, 77, and St. Luke's 60 cases. The parts affected were as follows:—Neck glands, 39; auxiliary glands, 1; mesenteric glands and peritoneum, 12; popliteal and femoral glands, 1; bronchial glands, 1; glands and muscles of leg, 1; ankle joint, 3; elbow joint, 4; knee joint, 10; hip joint, 26; wrist, 1; spine, 13; bones of leg and foot, 2; bones of arm, 1; shoulder blade, 2; sternum, 1; skin of face and neck (lupus), 9; skin of hands and forearm, 2; skin of buttocks, 1; chest wall and ribs, 2; bladder, 1; larynx, 2 ; and meninges of brain, 15 cases. Thirteen patients had more than one site affected with the disease. Forty-three patients were bedridden. Thirty-five were examples of "open tuberculosis," associated with discharges, and, therefore, presumably infectious to those brought into contact with the sufferers. 88 Sixty were school children. The schools chiefly affected were the following:—Hugh Myddelton (7), Bath Street (6), Moreland Street (6), Tavistock Place Special School (6), Compton Street (4), and St. Luke's Parochial School 3 cases. Of the whole number, 64 were considered to be Finsbury cases by residence and infection, 23 Finsbury cases by infection, 4 Finsbury cases by residence, and the rest, 46 in number, were not Finsbury cases. These last were persons who were affected with tuberculosis before coming into the Borough, and had chiefly moved into Finsbury so as to be near the hospitals to obtain free treatment. The patients came mostly from the following streets:—Bastwick Street (5), Northampton Buildings (5), Roscoe Street (4), Compton Buildings (4), Galway Street (4), Chadworth Buildings (4), St. Helena Street (3), Guinness Buildings (3), and Bartholomew's Buildings 3 cases. The number included 22 insured persons and 95 dependants. Special enquiry was made as to the existence of other suspected cases of tuberculosis in the family of the patient and in the other tenements in the house. As a result, 19 suspected cases were found and put in the way of obtaining medical advice and treatment. Fifteen of the patients lived and slept with their families in one room. Twelve of the tenements were overcrowded. The close contacts in the same families included 314 adults and children above school age, and 304 other children. The kitchen was used for living and sleeping in 73 instances. Twenty-one families were living under conditions of great poverty. In 34 cases the mother was the chief or only wage earner. The deaths included 33 from tuberculous meningitis— (Clerkenwell 23, and St. Luke's 10), and 30 from other forms of tuberculosis (Clerkenwell 16, and St. Luke's 14). The Finsbury death rate for all forms of tuberculosis in 1913 was 2.52 per 1,000—the corresponding rate for England and Wales in 1912 was 1.366. The death rate in Finsbury was nearly twice the death rate in the country taken as a whole. 89 GLANDERS AND ANTHRAX. Both these diseases are notifiable in London to the Medical Officer 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 amongit 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. No notices of cases or of outbreaks were received in 1913. A wholesale brush manufacturer, amongst whose staff several cases of anthrax have occurred in previous years, brought to the notice of the Public Health Department some Hungarian pig hair which he had received from abroad. It contained much manure, earth, stones, bones, pig toe cases, and pupa cases. It stank abominably and was maggoty. It is a pity that administrative power is not available to prevent the importation of this extremely offensive, and, from a manufacturer's standpoint, dangerous material. SMALL-POX. No case of small-pox was notified in Finsbury in 1913. The Medical Officer of Health was asked in consultation to see two cases suspected to be small-pox. Both proved to be cases of chicken-pox. In the one case, the medical practitioner became suspicious because the child had inflamed eyes. This is an unusual complication in chicken-pox, but fairly common in small-pox. In the other patient, the rash had invaded the hard and soft palate, and was vesicular in these parts. The tongue and teeth had become very thickly furred owing to the presence of these vesicles, which restrained the mobility of the tongue and prevented the usual cleansing processes which proceed in the mouth. Owing also, to the presence of the rash inside the mouth, chewing and 90 swallowing were very painful, and the child became very low and much wasted. The concurrence of all these signs alarmed the doctor and made him think that his original diagnosis of chickenpox might be wrong. Both children eventually recovered. CEREBRO-SPINAL FEVER. POLIO-MYELITIS AND POLIO-ENCEPHALITIS. These diseases were made notifiable by an order of the London County Council, dated March 9th, 1912, which came into operation from and on March 13th, 1912. For notification purposes, posterior basal meningitis is included in the term "cerebro-spinal fever." This term, however, is not to include cases of meningitis due to tuberculosis, syphil.s, middle oar disease or injury. Five notifications were received of cerebro-spinal meningitis and three of poliomyelitis. The cases and the results of the illnesses are appended. Cerebro-Spinal Meningitis, 1913. 1. May 3rd. Female, 4 years. Removed to St. Bartholomew's Hospital. Recovered. 2. May 27th. Female, 5 years. Removed to the Eastern Fever Hospital. Recovered. 3. June 10th. Male, 4 months. Treated at home. Recovered. 4. July 13th. Male, 17 months. Treated at home. Died. 5. December 22nd. Male, 4½ years. Removed to St. Bartholomew's Hospital. Died. This patient was notified after death. He had had pneumonia on November 29th, and diarrhoea from December 14th to December 16th. It is probable that this case was one of pneumococcal meningitis and not true cerebro-spinal fever. 91 Polio Myelitis, 1913. 1. March 11th. Male, 2 years. Removed to the Children's Hospital, Great Ormond Street. Died. The death was attributed to cerebro-spinal fever, not to polio myelitis. 2. May 17th. Male, 2 years. Removed to St. Bartholomew's Hospital. Recovered. 3. June 14th. Male, 9 years. Removed to St. Bartholomew's Hospital. Died. All the cases were investigated; one of the tenements was dirty and verminous, the others were clean. MEASLES AND HOOPING COUGH. Measles.—This disease is not notifiable. In 1913, notice of 276 cases was received from the London County Council Education Department, from head teachers of schools, from school visitors, from doctors, from the medical officers of 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 1913 are shown in the subjoined table:— Age Incidence of Cases of Measles, 1903-1913. Under 1 year of age in months. 1- 2- 3- 4- 5-10 10-15 Total 1903-1913. 0-3 3-6 6-9 9-12 4 43 129 179 726 683 850 1,228 2,388 78 6,308 92 The actual numbers notified year by year were:—577, 802, 561, 1,036, 478, 245, 436, 898, 384, 625 and 276 from 1903 to 1913 respectively. Ages at Death in Cases of Measles 1903-1913. Under 1 year of age in months 1— 2- 3- 4- 5-10 10-15 Total 1903-1913 0-3 3-6 6-9 9-12 3 15 56 96 352 116 73 21 19 8 759 The deaths year by year were 69, 60, 31, 115, 43, 38, 86, 73, 85, 129 and 30 from 1903 to 1913. The cases were most numerous in 1906, the deaths in 1912. In both these years the disease was very prevalent. The affected households 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. These leaflets are distributed and re-distributed to every tenement in those streets where measles is known to occur. The dirty tenements are disinfected at the end of the case. The rooms were disinfected in 185 tenements. Hooping Cough.—This is not a notifiable disease. Informa tion of cases is generally received from schools and from the other bodies and persons who send notices of measles. The deaths numbered 30; all were under five years of age. Disinfection is done on request: it is not done as a routine after recovery. The hospitals of the Metropolitan Asylums Board are now available for the reception of non-pauper cases as well as of pauper cases of hooping cough. The deaths from measles and hooping cough from 1909 to 1913, distributed according to streets and large blocks of buildings, are given in the annexed list:— 93 Street List of Deaths from Measles and Hooping Cough, 1909-1913. Street. M. H.C. Street. M. H.C. Affleck Street 4 - Corporation Row 4 Albert Street 6 — Costers' Dwellings 3 - Albion Place 1 — Crawford Passage 2 - Allen Street 1 1 Cumming Street 7 1 Amias Place 6 1 Cyrus Street 3 2 Ann Street — 3 Donegal Street 11 7 Arlington Street 1 — Donegal Street Buildings - 1 Attneave Street 1 — Aylesbury Street 1 1 Douglas Place 2 — Baker's Row 9 — Dufferin Street 3 — Baldwin Street 12 1 Dundee Buildings 2 1 Baltic Street 1 — Eagle Court 3 — Banner Street 1 — East Place 1 1 Baron Street 2 1 Easton Street 4 2 Bartholomew Square 4 — Farringdon Rd. Bldngs. 5 2 Bastwick Street 9 1 Faulkner's Alley — 1 Bath Buildings — 1 Fletcher's Row 2 — Bath Court 2 — Francis Court 1 — Benjamin Street — 1 Galway Street 4 2 Berkley Court 3 — Gastigny Place 2 1 Berkley Street 2 — Gee Street 5 — Brewer Street 3 1 Godson Street 1 — Brunswick Close 1 2 Goswell Place 1 — Busaco Street — 1 Goswell Road 1 — Buxton Street 2 1 Goswell Terrace 1 — Castle Street 1 — Gloucester Street — 1 Cavendish Buildings 1 2 Granville Square — 2 Central Street 4 2 Great Bath Street 3 1 Chadworth Buildiugs 1 0 Green Terrace 1 — Chapel Row 1 — Grimaldi Street 1 — Chapel Street 1 — Great Percy Street 2 — Charterhouse Square — 1 Guinness' Buildings 9 4 Church Row — 1 Hardwick Street — 1 City Road 1 — Hatfield Street 3 3 Claremont Square — 1 Helmet Row 3 — Clerkenwell Close 1 — Hermes Street 3 6 Coldbath Square and Buildings 6 3 Howard's Place 1 — Ironmonger Passage — 1 Coleman's Buildings — 1 Ironmonger Row 1 — Collier Street 2 3 Ironmonger Street 1 1 Compton Buildings — 1 James Gardens 1 — Compton Passage 3 1 Jay's Buildings 1 — Compton Street 1 — King's Cross Road 2 2 Corporation Buildings 2 - King Square 1 2 94 Street. M. H. C. Street. M. H. C. Leage Street 1 - Penton Place - 4 Leicester Place 1 - Penton Street — 3 Lever Street and courts opening to it 6 3 Pentonville Road 3 2 Percival Street — 1 Leverington Street — 1 Pickard Street — 1 Little Northampton St. 4 — Pine Street 2 1 Little Sutton Street 4 1 Powell Street — 1 Little Sutton St. Bdgs. 1 1 Pump Court 1 — Lizard Street 2 - Radnor Street 3 1 Lorenzo Street 1 — Rahere Street 3 2 Ludlow Street 2 — Rawstorne Buildings 1 1 Macclesfield Street 4 — Red Lion Street 3 - Macclesfield Place 1 — Richmond Street 2 1 Mallory Buildings — 1 Risinghill Street 6 5 Malta Street 1 1 Rodney Place 1 — Margaret Street 7 1 Rodney Residences 1 — Market Buildings 3 — Rodney Street 1 4 Mason's Place 6 - Roscoe Street 3 1 Medcalf Place 2 - Rosoman Street 3 — Merlin's Place 2 1 Sadler Street 1 - Mitchell Street 4 - Seklorde Street 2 2 Mitre Court 2 - Seward Street 1 - Moreland Street 1 1 Sidney Grove 1 - Murton Street 1 - Smith Street 3 1 Myddelton Street 2 - Southampton Street 4 3 Nelson Street 5 1 St. Bartholomew's Buildings 5 3 New Buildings 1 1 New Street 1 - St. Clement's Buildings 2 — Newcastle Place 1 - St. Helena Street 8 1 Noble Street 1 3 St. James' Street — 1 Norman Street — 1 St. James' Walk 1 2 Norway Street — 1 St. John Street 3 2 Norman's Buildings 2 1 Stewart's Place — 1 Northampton Buildings 5 3 Thomas Place 1 — Northampton Road 2 1 Tilney Court 3 — Northampton Street 4 — Tysoe Street — 1 Northampton Row — 1 Union Place 1 — Old Street 1 — Upper Smith Street — 1 Owens Row 1 — Valetta Street — 1 Paton Street 1 — Victoria Dwellings 5 1 Peabody Buildings, Farringdon Road 1 2 Vineyard Gardens 1 — Vineyard Walk 2 - Peabody Buildings, Guest Street 1 - Warden's Place 1 — Warner Street 1 - Peartree Street 2 1 Warren Street 9 2 Penny Bank Chambers 1 - Waterloo Street 2 1 Peerless Street 6 4 Weston Street 1 - 95 Street. M. H.C. Street. M. H. C. Wenlake Buildings - 1 Wilmington Square 1 - Whiskin Street 1 1 Winchester Street 1 1 White Cross Street 1 1 Winton Houses — 1 White Conduit Street — 3 Wynford Road 4 1 White Horse Alley 1 1 Wynyatt Street 1 - White Lion Street 5 3 Young's Buildings - 1 Wilmington Place 1 - Yardley Street — 3 Comparative Table. In 1913 Measles caused 30 deaths hooping cough, 30 deaths. These two diseases are very fatal to children under 5 years. The following table compares the deaths in children under five years from measles and hooping cough with the deaths from other infectious diseases : — Deaths in Children under 5 years, 1901-1913. Year. Measles. Hooping Cough. Small Pox. Scarlet Fever. Diphtheria. Enteric Fever. 1901-5 278 211 13 53 80 — 1906-10 347 202 — 39 80 1 1911 82 26 — 4 14 — 1912 124 30 — 4 12 — 1913 30 30 — 4 6 — Totals 861 499 13 104 192 1 From this table it appears that the deaths in 13 years due to scarlet fever, diphtheria, enteric fever, and small-pox, all taken together numbered 310, to hooping cough 499, to measles 861. 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 other four named infectious diseases. 96 DIPHTHERIA. The number of cases notified was 95. Of these, 4 were subsequently sent home as not suffering from diphtheria, leaving 91 true cases. This is the smallest number since the Borough was formed. There were 9 deaths, so that 9.8 per cent, of all the patients died. The number of cases is 68 less than last year, the number of deaths 5 less. The particulars of cases in previous years are appended:— Diphtheria, 1901-1913. 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 17.1 21.6 3.7 190 3 119 12 10.1 12.0 1.2 1904 123 14 11.4 12.6 1. 4 1905 126 11 8.7 13.1 1.1 1906 151 25 I6.5 15.9 2.6 1907 127 15 11.8 13.6 1.6 1908 130 16 12.3 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 10.7 18.1 1.9 1912 148 14 9.4 17.1 1.6 1913 91 9 9.8 10. 7 1. 06 All the cases were investigated, and the source, if possible, was ascertained. The premises were inspected and notices served for sanitary defects. The drains were carefully examined, and in nearly every case tested. In only 3 houses were they found to be defective. 97 Presumed Sources of Infection. In 9 instances the disease was contracted from known, missed, or unrecognised cases in the members of the patient's family. Two patients caught the disease in hospital after they had been admitted suffering from diseases other than diphtheria. These are called cross infections and occur when a patient is being treated in hospital for one disease, say, measles, or pneumonia, and contracts another disease, e.g., scarlet fever or diphtheria from some other hospital patient. Unfortunately, they occur in most fever hospitals, and point to flaws in their internal administration. Three caught diphtheria on visits to friends or relatives—seven on visits to places of entertainment. Eight were infected by school fellows or play fellows in the same blocks of model buildings. Five developed the disease after recent attacks of measles. The association between the two diseases, measles and diphtheria, is often a close one. There were no return cases. Cases discharged cured from Hospitals.—A few days after their arrival home from fever hospitals, all 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 tfound amongst these convalescent patients after their return home are shown below:— Neck Glands enlarged 13 Nasal Discharge 15 Sore Nostrils 2 Ear Discharge 1 Sores on face or ears 2 Anaemia 11 Sore Throat 1 Squint 1 Difficulty of swallowing 2 Vomiting 1 Weakness of limbs, probably slight paralysis following diphtheria 11 Shortness of breath 5 It is quite possible that some of the cases in the above list were discharged from hospital rather a little too soon. 98 Two of the cases were at first medically treated a few days for influenza and measles respectively before their true nature was recognised. Another case was of the hemorrhagic type, and characterised by profuse and recurrent bleedings from the nose and under the skin. The significance of these haemorrhages was not recognised for seven days. Two cases were originally notified as ones of scarlet fever. The mother of one patient stated that she thought her child was infected from a second-hand counterpane which had been bought in a market street. The counterpane was dirty and fouled, and had been used to cover the child concerned. It is very desirable that these second-hand clothes which are now sold in market streets should be disinfected and cleansed before being exposed for sale. It is curious that soiled and filthy garments are not allowed to enter South African ports save under a certificate from a Medical Officer of Health to the effect that such garments have been steam disinfected prior to export. They may, however, be sold in London streets freely and openly in their fouled, stinking and verminous condition. The wonder is that anybody will buy them. The removal of one case gave rise to some difficulty. The patient was a slum girl beyond the control of her parents. She had been notified to have diphtheria,, but evaded removal by going out veryearly every morning and returning after midnight. She was eventually captured at home at 5 o'clock in the morning and removed to hospital. The cases discharged from hospital with nasal discharge and sore throat were, after their return home, examined by the Medical Officer of Health, and swabs taken from the throats and noses. The diphtheria bacillus was not found present in any case. These swabs are examined bacteriologically free of charge for medical men by the Public Health Department. In 1913, 82 specimens were submitted with positive results in 12 instances. A supply of diphtheria antitoxin serum is kept at the public health office, and is available gratis for doctors on request. 99 SCARLET FEVER. The notifications numbered 251 and the deaths 5. The notifications were more in 1913 than they had been since 1908. The deaths were, with the exception of 1910, less than they had been in any previous year since the Borough was formed. The epidemic which prevailed in 1913 was an exceedingly mild one. The patients in some cases attended school throughout their illness until they peeled. Several cases were discovered peeling in school. Many of them had only complained of a slight sore throat about three weeks before, a sore throat sufficient to prevent them eating solids, but not sufficient to prevent them drinking. In these cases the rash had often been missed, and the temporary indisposition was attributed to "influenza," to "drinking cold water when the stomach was heated," to a "fright," to the "heat," to biliousness, in short, to anything but scarlet fever. One patient, who afterwards peeled, so deceived his medical attendant that the doctor frankly averred that he must be shamming. With such slight determining signs the investigation of these cases proved very difficult. One was medically treated at home as a case of "rheumatic fever " until the occurrence of a second case of scarlet fever in the family aroused the suspicions of the doctor, and drew his attention to the fact that the patient was now peeling. In some instances the children, when taken to a doctor, showed no physical signs, and the parents were told "to look out for peeling," and if it was observed "to bring the child again." This is one of the drawbacks of cheap medicine and dispensary practice. The onus of diagnosis is, in part, improperly cast on the untutored parent. With the exception of 21 cases, all the rest, 230 in number, were between one and fifteen years. The deaths were 1.93 per cent. of the total number of cases, or, roughly, one in every 50 children affected died. Seven cases were treated at home; suitable measures were taken to ensure the isolation of the patient. The rest, 244, were treated in hospital. The particulars with regard to previous years are appended. 100 Scarlet Fever, 1901-1913. 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 3.8 48.9 1.8 1902 381 15 3.9 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 4.6 47.5 2.1 1906 422 13 6.1 44.6 1.3 1907 471 16 3.4 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 1912 159 5 3.15 18.4 .58 1913 251 5 1.93 29.6 .59 Probable Source.—In 54 cases the infection was derived from previous cases in the same families, in another 2 the disease had been contracted from mild unrecognised cases in the affected households. Thirteen were examples of school infection, twenty-five were caught from playfellows in the street, eleven had been infected when visiting or being visited by friends or relatives. Five cases were not discovered until between 2 and 3 weeks after the rashes had appeared. The patients were then peeling. They were mild missed cases that had apparently only suffered from slight headaches and sore throat, which their parents attributed to the "heat" or some other cause. Ten developed scarlet" fever while detained in hospital for some other causes. 101 Their significance has already been referred to in the section under diphtheria. Seven were presumably infected by visiting places of entertainment. 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 clothing, were disinfected. There were three return cases. Cases discharged for 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. 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, and their faces. Twenty such cases were kept under the observation 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 40, general weakness of limbs 17, discharge from nose 16, sores on lips, face, ears, mouth, or nostrils, 14, conjunctivitis 2, peeling on hands or feet 5, sore throat 2, and shortness of breath 9, anaemia 2 cases. TYPHOID FEVER. In 1913, the number of cases notified was 15, with no deaths. The numbers in previous years are given in the accompanying table:— 102 Enteric Fever, 1901-1913. Year. No. of cases notified. No. of Deaths. Case Mortality. No. of Deaths per 100 casts 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 11.7 7.7 0.9 1903 47 11 23.4 4.7 1.1 1904 40 8 20.0 4.1 0.8 1905 42 9 21.4 4.3 0.9 1906 44 14 31.8 4.6 l.4 1907 22 2 21.0 2.3 0.2 1908 41 12 29.2 4.4 1.3 1909 15 3 20.0 1.6 0.3 1910 28 4 14.3 3.1 0.4 1911 74 9 12.2 8.4 10.2 1912 5 1 20.0 0.58 0.11 1913 15 0 0.0 1.7 0.0 All the cases were removed to hospital, and the diagnoses were confirmed in every instance. Sources of Infection. In two cases there was reason to believe that the infection was derived from carrier cases. In one such case, a woman had enteric fever in 1908, and moved into Finsbury in 1913, to live with her mother. Shortly after her arrival, her brother and sister were both notified to be suffering from typhoid fever. The urine and faeces of the presumed carrier were bacteriologically examined, and the faeces were reported still to contain the typhoid germs 5 years after the original attack. For the rest of the cases no definite source was found, though there was reason to believe that they probably had contracted typhoid by eating fouled mussels, watercress or ice cream. 103 The impugned mussels were bought from hawkers who sold them for immediate consumption in the street. They had not been cooked, and were still alive. It is a common belief among indifferent street vendors of shell fish that the addition of vinegar, especially if it contains "chillies," kills off the germs that are present. Samples of mussels were taken and sent to the Lister Institute lor bacteriological examination. The report was to the effect that the mussels contained an excessive number of sewage organisms. Further powers are needed to deal effectually with the sale of mussels to ensure that they are sold in a condition that may not work to the harm of the public. All cases of typhoid fever on their discharge from hospital are visited and examined. A leaflet of instruction is left with them and special attention is directed to its more important clauses, which are orally explained at some length. The fæces and urine are examined bacteriologically only in those patients discharged for home where there is some evidence or suspicion which points to their acting as typhoid carriers. Diagnosis.—Specimens of blood from, suspected cases of typhoid fever are examined free of charge for medical men by the Public Health Department. The examinations are conducted at the Bacteriological Laboratory of the Middlesex Hospital. In 1913, ten specimens of blood were received—four gave a positive Widal reaction, the rest were negative. INFECTIOUS DISEASES. General Considerations.—The notifiable diseases named in Section 55 of the Public Health (London) Act, 1891, are small pox, cholera, diphtheria, membranous croup, erysipelas, scarlet fever, typhus, enteric, relapsing, continued and puerperal fevers. Cerebro-spinal fever, posterior basal meningitis, polio-myelitis, polio-encephalitis, ophthalmia neonatorum, glanders, anthrax, and hydrophobia in man are likewise notifiable in London by an order of the London County Council, made under Sections 55 and 56 of the Public Health (London) Act. 104 Sections 60-65, 68-70, 72-74 of the same Act, referring to the cleansing and disinfection of premises and materials, and to contact with, or exposure of infected persons and things have been made applicable to measles. Measles and hooping cough are not notifiable. All cases of tuberculosis have been made notifiable by the Public Health (Tuberculosis) Regulations, 112, of the Local Government Board. 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. Cases of anthrax, or poisoning by mercury, arsenic, lead and phosphorus, must be notified to the Chief Inspector of Factories, Whitehall. Notifications.—The notifications of infectious disease received in 1913 were as follows :—Small-pox none (none), scarlet fever 251 (159), diphtheria 95 (133), cerebro spinal fever 5 (1), typhoid fever 15 (8), erysipelas 124 (143), puerperal fever 13 (12), ophthalmia neonatorum 6 (7), and polio myelitis 3 (7) cases. The figures in brackets refer to the year 1912. The numbers for previous years are appended :— Notifications of Infectious Disease, 1910 1913. Year. Number of Notifications Received. Notifications per 1,000 of the population. Percentage of Cases removed to Hospital. 1910 455 5.1 63 1911 640 7.3 61 1912 467 5.4 72 1913 511 6.03 74 The above table excludes notifications of Chicken-Pox—there were 181 in 1911. 105 The amount paid in fees for notifications of infectious disease was .£44 6s. The lowest was £41 12s. 6d. in 1912, and the highest was £176 16s. in 1902 at the time of the small-pox epidemic. The sums paid for notifications of tuberculosis were: to Poor Law Medical Officers, £3 9s.; to private doctors and members of hospitals staffs, £64 9s. 9d. The fees paid under the Diphtheria Anti-toxin (London) Order, 1910, amounted to 17s. 6d. Diagnosis.—In 15 cases out of a total number of 376, the patients after admission to a fever hospital were returned home as not suffering, at the time of admission, from any notifiableinfectious disease. Most of these mistakes were made by the house staffs of large general hospitals. The errors were chiefly in connection with scarlet fever—out of 261 cases removed, 10 were returned home as not having the disease. Deaths.—The number of deaths certified in 1913 as due to the infectious diseases named in the accompanying table, was 226. The corresponding death rate was 21 per 1,000 inhabitants. Deaths from Infectious Disease, 1910-1913. Small-Pox. Scarlet Fever. Diphtheria and Membranous Croup. Enteric Fever. Puerperal Fever Measles. Hooping Cough. Diarrhœa. Total. 1910 — 4 19 4 6 73 36 50 192 1911 — 6 17 9 3 85 27 152 299 1912 — 5 4 1 4 129 31 42 226 1913 — 5 9 — 5 30 30 107 186 The diminution this year is associated with the lessened number of deaths accredited to diphtheria and measles. 106 DISINFECTION. The Finsbury disinfecting station is at 49, Northampton Road, Clerkenwell. Here provision is made for the housing and accommodation of families during the disinfection of their premises after infectious disease, and for the reception of smallpox contacts during the incubation period. It was used in 1913 by two families from Finsbury (7 persons), and one family from Holborn (5 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 disinfector is a Washington Lyons high pressure steam apparatus. In 1913, 866 separate rooms were disinfected, of which 185 were for measles, 105 after notifications of phthisis, 56 after death from phthisis, 47 on account of vermin, and 15 on request. In addition, bedding and mattresses were steam disinfected for the following institutions:—The Claremont Hall Creche, St. Barnabas Home, St. Mark's Hospital, and the Remand Home. Altogether 6,945 articles were disinfected in connection with cases of infectious disease, and phthisis ; these were chiefly mattresses, pillows, bolsters, sheets, blankets, quilts, cushions, curtains, carpets, table cloths, and bedclothes. Besides these, 1,587 articles of wearing apparel were disinfected for City firms at a price agreed upon, prior to exportation to South Africa. PROTECTION OF FOOD SUPPLY. G0eneral Considerations.—Each of the five district inspectors is responsible in his own district for the inspection or foods, of bakehouses, 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. 107 Each inspector takes samples under the Sale of Food and Drugs Act in his district. These purchases are nearly always made by deputy. Meat and Food Inspection.-The Borough Council have appointed Mr. Hilling as a special meat inspector to inspect 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 total weight of diseased or unsound meat and offal and other foods confiscated in 1913, was over 123 tons. All the unsound, diseased, and decomposed meat is removed under agreement by Messrs. C. & H. Webb, fat melters, 155, Bow Road, London, E. Messrs. Webb have their factory in Bow Common Lane, and pay the Borough Council one penny per market stone of eight pounds for all the diseased and unsound butcher's meat removed by their men. It is to be noted that Messrs. Webb only pay for the diseased and unsound details comprised in the term "butchers' meat," It includes the following items : Sides, quarters and pieces of beef, carcases and pieces of mutton, lamb, veal, and pork, and pieces of bacon. It does not include diseased or decomposed offal (e.g., heads, tongues, plucks, livers, tripes, mesenteries, intestines, tails), sweetbreads, chitterlings, turkeys, pheasants, partridges, hares, ducks, rabbits or fish. Messrs Webb are allowed to have the diseased and unsound butcher's meat on the understanding that they also remove the very offensive offals and decomposed game and fish, which are of very little service for fat melting. The consignments are weighed under the supervision of the meat inspector, and before removal are thoroughly dowsed with crude disinfectant. 108 Messrs. Webb have entered into a bond with the Finsbury Borough Council (penalty for default £100) agreeing to destroy all the diseased and unsound offal in such a way as to prevent any portion or product arising therefrom being used for the food of man. Messrs. Webb sell the fat extracted from the meat to soap makers, and the residue to the makers of artificial manures. They do not sell to manufacturers of products for human consumption. From time to time surprise visits are paid by the Finsbury meat inspector to the premises of Messrs. Webb, to see that the terms of the agreement are strictly carried out. Prosecutions.—There were 2 prosecutions in respect of unsound meat in 1913. 1. Mr. Harry Eaton, 22 York Road, Forest Gate, was on April 30th, 1913, fined ^,30 and costs for selling to William Eaton, 1, Young's Buildings, meat which was unsound and unfit for human consumption. 2. Mr. William Eaton, 1, Young's Buildings, was fined £30 and costs for exposing and depositing for sale the unsound meat referred to above. 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 meat food products for export to the Argentine Confederation, to the United States of America, and to the Phillipine Islands. Twenty certificates were granted in 1913 to Messrs. Bovril, Ltd., 162 to 166, Old Street, Finsbury, E.C. Ox Tongues affected with Actinomycosis. Many thousands of ox tongues from La Plata, in the Argentine, were examined for actinomycosis. The percentage of these affected was 2.1 per cent. The tongues were generally of excellent quality, contained plenty of meat and submental fat, and had well developed papillae. To each tongue was attached the larynx, the salivary glands and in most cases the associated lymphatic glands. The oesophagus was absent. There was nothing unusual in the 109 appearance of the uncut tongues to attract attention. The blades had the ordinary appearance, there were no superficial erosions or swelling's either in the deep or superficial parts. The obviously diseased tongues had probably been rejected before export. The salivary glands were free from the signs of disease. The salivary lymphatic glands showed evidence of the presence of actinomycosis. The tongues were entire organs with large roots, and were such as are ordinarily sold in open market and known as full cut tongues. They had not been maimed or mutilated—none of the usual parts were missing. Some Argentine tongues received from another borough had been cut short at the roots, so as to remove the lymphatic glands and thus, presumably, prevent their examination. These maimed tongues were excluded from the market. There was no difference in consistency, colour, or size between the lymphatic glands affected and those unaffected. Many lymphatic glands had been cut open before exportation for purposes of examination, and were found to be healthy. In the diseased lymphatic glands there was no external indication of the presence of the disease within. This fact made these diseased tongues a real danger to the public-—they were very meaty and juicy, yet withal diseased and affected in such a way as only to be recognised by experts. The disease was confined to the lymphatic glands: it had not spread into the surrounding tissues. The local incidence of the affection suggests that it was in an early stage, and it is very possible that there might have been some point of entry such as a carious tooth, which had been overlooked in the Argentine. In previous years it was not uncommon to find the disease in the blades. Latterly, the tongues whose blades are diseased are rarely seen in Argentine consignments. The oversea sections and examinations of lymphatic glands in exported tongues are an innovation, and began towards the end of 1913. The appearance of the lymphatic glands on section varied —in some the nodules were very few, and ranged in size from a pin's head to a grain of barley. In others, the nodules were many, and were arranged in the form of a rosette. Some of the lymphatic glands were gritty. 110 On section the nodules stood out from the rest of the gland, and when many in number were paler than the gland tissue. When few, there appeared to be no difference to the naked eye between the colour of the diseased part and the rest of the lymphatic gland. On section and pressure the affected glands exuded a yellow, grey liquid, similar to pus in appearance. The appearance of the glands was similar to the condition found when the disease affected the blades. Unsound food submitted for examination. Food alleged to be unsound is occasionally brought to the Public Health Department for examination by dissatisfied purchasers and by salesmen who have lost the market. In the latter case, the salesmen fail to sell the food, keep it until it gets stale and offensive, bring it to the public health office, and allege it is in the condition: it was when first received by them. They wish to have the food condemned as unsound, and to receive a certificate to that effect to help them in recovering its value from the original vendor. In the former case, the action is usually based on spite or on some petty grievance. To take an actual example:—A woman bought a pound of sausages for 4d. She was served in mistake with pork sausages which were priced at 6d. a lb. She saw a sprig of thyme through the sausage casing, and, mistaking its character, asked that they should be changed. The salesman then realised that the woman had been served with the dearer pork sausages when she had only paid for beef sausages. This time he served the customer with beef sausages, much to her annoyance. She brought them to the Public Health Office, stating that they were putrid. They were quite good, and were eaten by the staff. In another instance, a customer bought some corned beef. He was dissatisfied with the portion cut—it contained too much fat. He sent the corned beef to the Public Health Department, alleging that it was diseased. The corned beef was of good quality. The shop was visited, and the meat on sale was also found to be of good quality. 111 In another case- there were two sheep heads on a stall. A customer bought one, and was handed the smaller one. He protested, and asked for the larger head, which had been already sold. Thereupon he brought the head which he had received to the Public Health Office, alleging that it was diseased, and that the small portion which he had eaten had made him ill. The head was carefully examined, and found to be quite good and wholesome. These complaints, which are actuated by spite or by dissatisfaction with the article purchased, take up an unnecessary amount of the time of the staff. Slaughter houses.-In Finsbury there are two slaughter houses; the owners' names and addresses are as follows:— Mr. Thos. Webb, 191, Goswell Road. Mr. J. A Mobbs, 14, Penton Street. The slaughter houses were inspected in 1913 on 104 occasions. No defects were ascertained, and consequently no notices were served. The average number of animals slaughtered is 24 per week— 2 heads of cattle and 22 sheep. The quality of the meat is distinctly good. There are no knacker's yards in the borough. 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 19a, Baldwin Street 7 17 Mrs. Nancy Evans Mr. Harry Eade 40. Rawstorne Street 15 15 Mr. J. H. Jenkins 230, St John Street 30 30 The premises were inspected by the district inspectors on 33 occasions. They are also periodically inspected by the London County Council staff and their veterinary inspector. No notices were served in 1913, 112 Dairies and Milkshops.—The number of persons registered during the year as purveyors of milk was 36, of which 11 were new registrations. During the same period 25 names were removed from the register for various reasons, chiefly on transfer of business. The total number left on the register was 253. Of these, 183 are milkshops, as distinguished from dairies, and sell milk in driblets, for a farthing or a halfpenny 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 205 occasions, and 43 notices served for various sanitary defects. In registering and regulating these small shops, it is the practice to enforce the appropriate provisions of the Dairies, Cowsheds and Milkshops Orders, the various Public Health Acts, and the General Powers Acts of the London County Council. It is a condition precedent to registration that no offensive material (such as, for example, paraffin oil) shall be sold from the same counter or from the same room as that from which the milk is sold, or sold from any place in or near that in which the milk is stored. The sale of paraffin oil or other material from the premises is not objected to provided the oil is stored and sold outside the shop. The floor of the chandlers' shop must be free from accumulations of litter, or of stored shop material, which would render it difficult or impossible to ensure the efficient cleansing and proper sweeping of the shop day by day. The shop milk must be kept in an approved vessel with an imperforate metal cover. It must be confessed, however, that in actual practice it is very difficult to secure satisfactory conditions of milk sale in these small general shops. Their occupants are too often dirty—personally and domestically. They are very undesirable persons to be entrusted with the handling and sale of milk. They do not realise that the care and cleanliness of milk is a problem in practical bacteriology. The shelves in the shop are dusty and overcrowded with 113 modifies for sale. As a result of the case Green v. Spiers & Pond, it would appear that there is at present no power to prevent the sale of milk in these shops. The occupier need not even be registered with the local authority. He may sell milk without being registered. The following table compares the milk vigilance of Finsbury with that of the other London boroughs:— MILK SAMPLES, 1912. Borough No. of Samples. No. Adulterated. Percentage. Battersea 635 57 8.9 Bermondsey 816 70 8.5 Bethnal Green 440 53 12.0 Camberwell 502 17 3.3 Chelsea 136 5 3.6 Deptford 341 30 8.8 Finsbury 372 28 7.5 Fulham 390 26 6.6 Greenwich 148 10 6.7 Hackney 557 47 8.4 Hammersmith 296 33 11.1 Hampstead 280 12 4.1 Holborn 229 13 5.6 Islington 606 33 5.4 Kensington 274 30 10.9 Lambeth 733 88 12.0 Lewisham 273 27 9.8 London (City of) 488 22 4.5 Paddington 320 56 17.5 Poplar 187 6 3.2 St. Marylebone 583 24 4.0 St. Pancras 388 39 10.0 Shoreditch 357 80 22.4 Southwark 780 40 5.1 Stepney 966 136 14.0 Stoke Newington 80 14 17.5 Wandsworth 785 107 13.6 Westminster(City of) 959 112 11.6 Woolwich 318 10 3.1 Whole of London 13,239 1,225 9.2 114 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 seventeenth on the list. The boroughs which precede it and their corresponding adulteration percentages are Shoreditch (22.4), Stoke Newington (17.5), Paddington (17.5), Stepney (14.0), Wandsworth (13.6), Bethnal Green (12.0), Lambeth (12.0), Westminster (11.6), Hammersmith (11.1); Kensington (10.9), St. Pancras (10.0), Lewisham (9.8), Battersea (8.9), Deptford (8.8), Bermondsey (8.5), Hackney (8.4). The percentage in Finsbury was 7.5. Milk Samples and Analyses—The total number of milk samples taken in 1913 was 360, of which 26 or 7.2 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 adulteration is the lowest yet recorded for the borough. No preservatives were found in any of the samples. No samples of cream were submitted to the Finsbury Public Analyst in 1913. The sale of cream has almost ceased in the borough save in a few restaurants, where it is supplied with fruit for consumption on the premises. On January 3rd, 1913, many samples of milk supplied by one of the largest firms in London were reported to smell very offensively, and some were brought to the Public Health Department by purchasers. They were sent to the Public Analyst, who reported that the offensive smell was due to the presence of Ammonium Sulphide. The milks contained 3.66 per cent, of fat and 9.28 per cent, of non-fatty solids, and were from this standpoint of excellent quality. The fouled milk was confined to the district supplied on the round of one milk carrier. Some was sent for bacteriological examination, and was found to contain Bacillus Coli in one thousandth of a cubic centimetre. Bacteriologically the milk was very unsatisfactory. The presence of the ammoium sulphide was surmised to be due to some malicious practical joker who had dropped the contents of a "stink bomb" into the churn when it was left unguarded during the time the milk carrier was on his round. These "stink bombs" contain ammonium sulphide, and may be purchased at most toy shops for a few pence. 115 The following table gives the statistics for the last 10 years:— ANALYSES OF MILK SAMPLES, 1904-1913. 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. 1904 346 48* 13.9 14 4 2 l 1 6.0 2 8 6 2 2 5.5 1905 349 38* 10.9 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 1912 370 28* 7.5 2 3 1 — — 1.6 8 5 7 — 1 5.6 1913 360 26 7.2 6 3 2 2 0 3.6 7 3 0 1 2 3.6 *These figures include samples of milk which were adulterated with preservatives. 116 Milk Prosecutions and the Warranty Defence.—In 1913 the question was raised as to the advisability of prosecuting milk vendors for faulty samples of milk sold by them, and in respect of which they either held, or alleged they held, warranties. On this matter the following observations are submitted:— During the ten years 1903-1912, the number of samples taken in Finsbury was 3,574. Of these, 407 were found to be adulterated by the addition of preservatives or not genuine on the standard adopted by the Board of Agriculture, that is a milk containing not less than 8.5 per cent, of non-fatty solids, and not less than 3.0 per cent, of fat. The practice of the Finsbury Borough Council has been to institute prosecutions where the milks, on analysis, show 8075 per ccnt. or less of non-fatty solids, or 2.85 per cent, or less of fat content. In this connection, however, it must be remembered that many magistrates show a disinclination to convict where the sole faults are in respect of small percentage diminutions of fat content. A letter of caution is sent to those dealers whose milks show results lying between the standards of the Board of Agriculture and of the Borough Council. From 1903-1912 there have been 180 milk prosecutions. In 27 of these the warranty defence was put forward. The warranty defence became available in October, 1875, but was not adduced in Finsbury until 31 years later, in 1906. 117 Milk Prosecutions, 1903 1912. Years. Prosecutions. Convictions. Warranty Defence. 1903 28 26 0 1904 20 20 0 1905 5 5 0 1906 18 14 4 1907 17 12 4 1908 15 10 1 1909 17 11 3 1910 22 15 6 1911 22 18 5 1912 16 13 4 Totals 180 144 27 In 1913, there were 14 milk prosecutions, with 8 convictions. The warranty defence was adduced in 6 cases, and upheld in five. From 1903 to 1913 then there have been 194 milk prosecutions, with 152 convictions, and 33 occasions on which the warranty defence was put in. Since 1903 there have been 3 prosecutions for giving false warranties, with convictions in each case. The circumstances under which the warranty defence becomes valid are briefly outined in the following paragraphs:— In any prosecution under the Sale of Food and Drugs Act, 1875, the defendant is to be discharged if he proves to the satisfaction of the justices or court: (a) That he had bought the articles in question as the same in nature, substance, and quality as that demanded by him by the prosecutor and with a written warranty to that effect. (b) That at the time of sale he had no reason to believe the article to be otherwise. (c) That he sold it in the same state as when he bought it. (Sale of Food and Drugs Act, 1875, Sec. 25.) 118 The warranty defence is not always available—there are limitations to its use. By Section 20 (Sale of Food and Drugs Act, 1899) a warranty or invoice shall not be available as a defence to any proceeding under the Sale of Food and Drugs Acts unless the defendant has, within seven days after the service of the summons, sent to the purchaser a copy of such warranty or invoice, with a written notice stating that he intends to rely on the warranty or invoice, and specifying the name and address of the person from whom he received it, and has also sent a like notice of his intention to such person. And the person by whom such warranty or invoice is alleged to have been given shall be entitled to appear at the hearing and to give evidence, and the court may, if it thinks fit, adjourn the hearing to enable him to do so. Since 1903, there have been in Finsbury 33 occasions on which the warranty defence was put forward. And in seven out of these 33 cases there were convictions, even although the warranty was put in evidence. The circumstances of these convictions were as follows:— 1. The defendant admitted on oath that he added annatto to the milk after receiving it from the warrantor—so that the warranty no longer held good. 2. The defendant's books showed that more milk had been sold than they had actually received. The warrantor proved to the satisfaction of the magistrate that he had not tampered with the milk. The magistrate stated he did not believe the evidence of the defendant. 3. Notice of the warranty defence was not given to the prosecutor within the statutory period of seven days after the service of the summons. (Two cases.) 4. The warranty was given after the purchase of the milk. 5. The warranty was inscribed to a dealer other than the defendant. The defendant was unable to produce a warranty personal to himself. 119 6. The magistrate was dissatisfied with the defendant's manner of giving evidence and with his attitude in the witnessbox, and stated he did not believe the defendant. In this connection it must be remembered that the burden of proof lies on the defendant. It will appear, therefore, that even though a warranty is produced in court it does not necessarily follow that it is genuine, good and valid. And it is very desirable that the warrantor and warrantee should both be in court to give on oath any explanation they desire to the magistrate and to be subject to cross eaxmination thereon. By this means evidence may be obtained which justifies a prosecution for giving a false warranty. It is undesirable that the Public Health Committee or its officers should undertake the work of determining whether a warranty defence is sufficient or not. Statements made to them are not on oath, and it is quite open for a disreputable dealer to produce a forged warranty, a false warranty, or a warranty wrongly dated and given after the date of purchase. The Public Health Committee have no means of compelling a dealer to produce his warranty, and he may state that he holds a warranty when, in point of fact, he has none. Further, it must be remembered that by the terms of the Sale of Food and Drugs Act, 1875, the defendant has to uphold the validity and genuineness of his warranty to the satisfaction of the justioes or of the Court, not to the satisfaction of the Borough Council or of its Public Health Committee. Again, whether a warranty is sufficient in law is sometimes very difficult to determine, so much so, that in the last edition of the standard text book on the Sale of Food and Drugs Acts the following passage occurs:— 120 "The question as to what constitutes a sufficient written warranty within the meaning of Sec. 25 (Sale of Food and Drugs Act, 1875), is by far the most difficult of any that have yet arisen under the Sale of Food and Drugs Acts. It has been discussed in a great many cases, and upon several points the mind of the courts has fluctuated so that it is impossible to state with accuracy what the law is at the present time." To sum up, then, it is desirable that a prosecution should issue whenever a Finsbury sample of milk is found to be faulty on the local standards, even though it may be ascertained and known that the vendor has a warranty in respect of such milk. The reasons why this course is urged are briefly:— 1. The warranty may involve difficult questions of law or fact for determination by a magistrate. 2. By Section 25 of the Sale of Food and Drugs Act, 1875, the sufficiency of the warranty has to be demonstrated to the satisfaction of the justices or Court. 3. In Court the defendant has to give evidence on oath in support of his warranty, and is subject to cross-examination. Such cross-examination may show that the warranty is faulty or may elicit grounds for a prosecution for giving a false warranty. 4. The warranty may fail through a technical error, e.g., it may not be pleaded in time. 5. The warranty defence generally means that the original warrantor gives evidence on oath, and is subjected to crossexamination, which may elicit material for a prosecution for giving a false warranty. 6. It is desirable that any explanation which a defendant may have to offer should be made on oath to a magistrate in open court. Statements made to' the Public Health Committee or to an officer of the Council are not on oath. The Public Health Committee have no means of compelling a milk vendor to state truthfully whether he has a warranty or not in respect of any consignment of milk. It is, however, still open for the Public Health Committee on the application of a milk vendor to interview him, to hear his explanation and to deal with the case on its merits. 121 False Warranties. These are dealt with in Section 20 (Sub-section 6) of the Sale of Food and Drugs Act, 1899, as follows:— Every person who in respect of an article of food or drug sold by him as principal or agent gives to the purchaser a false warranty in writing shall be liable on summary conviction to various penalties unless be proves to the satisfaction of the court that when he gave the warranty he had reason to believe that the statements or descriptions contained therein were true. There have been three prosecutions for a false warranty in Finsbury—there were convictions in all cases. The circumstances were these:- 1. The warrantor produced in evidence a churn ticket whose number had obviously been altered so as to make it appear that the warranty applied to a churn other than the actual one. The falsification was discovered by visiting the farmer who supplied the warrantor from Derbyshire. This farmer kept very accurate records of the movements and destinations of all his churns, which were daily checked and recorded. 2. The magistrate did not believe the evidence of the warrantor, and made a statement to that effect in court. 3. The milk vendor stated that the milk supplied was from a churn numbered (X), for which he held a warranty. Two visits were made to Horsmonden, Kent, and it was discovered that, on the date that the sample was taken, that churn (X) had been sent elsewhere, and not to the milk vendor implicated. It will be gathered that these prosecutions for giving false warranties are, as a rule, very difficult to sustain. The witnesses from whom the inculpating evidence is sought to be extracted, namely, the warrantor and warrantee, may be, and generally are, from the first hostile to the Borough Council, and, therefore, disinclined to open out. 122 A retailer, further, may produce a warranty from a small middleman, who himself produces a warranty from another small wholesale dealer, and so on until the chain of warranties becomes involved and intricate. And this is specially the case if the milk is derived from a large distributing agency having warranties from each one of its collectors. If the milk is derived from a farm, and if on each occasion of transfer it passes unmixed through the hands of each intermediary, then in such a case where the circumstances so warrant, a prosecution may be successfully launched against the false warrantor. This assumes that the farmer keeps accurate systematic dated records of milking, and of the daily movements of the churns, and is able and willing to give the Public Health Department the fullest information. It is not the custom in Finsbury to ask the milk vendor at the time of sale, or at any other time, whether he holds a warranty, unless the solicitor to the Council specially desires this information, and requests that it shall be obtained. It is believed that no useful purpose is generally served by getting this information. It is recommended that even should it be known that a milk vendor does possess a warranty a prosecution should nevertheless be instituted where the milk does not come up to the standards adopted by the Finsbury Borough Council. 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 1913, 601 samples were taken, of which 31, or 5.1 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:— 123 Substance. Samples taken. Adulterated. Substance. Samples taken. Adulterated. Milk. 360 26 Ground Ginger 20 Butter 133 5 Jam 6 0 Margarine 15 0 Dripping 1 0 Coffee 20 0 Lard 1 0 Cocoa 19 0 Cheese 1 0 Mustard 23 0 Pepper 20 o Total 601 31 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 610 524 86 14.10 10.8 1904 610 537 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 8.50 9.3 1912 601 567 34 5.65 8.8 1913 601 570 31 5.1 — Nine informal samples of butter were taken not under the Sale of Food and Drugs Acts. They were all genuine. 124 Public Analyst.— The Public Analyst is Mr. J. Kear Colwell, F.I.C. His chemical laboratory is in the Finsbury Town Hall. He is paid the following fees :— 1. For 500 samples taken each year under the Sale of Food and Drugs Acts—£250. 2. For an additional 100 samples of milk taken each year under the Sale of Food and Drugs Acts—7s. 6d. per sample. 3. For all samples taken outside the Sale of Food and Drugs Acts—15s. per sample. Examples of samples taken in recent years under (3) are given below :— Water for sewage contamination. Tinned salmon for poisonous metals. Rag Hock for chlorides. Ice Cream Shops. —These are all periodically inspected. At the end of 1913, there were on the register the names and addresses of the proprietors of 105 shops in the borough. They were inspected on 108 occasions, and as a result 20 notices were served for sanitary and other defects. There were no prosecutions. The methods of manufacture adopted by itinerant ice cream vendors are far from satisfactory. The difficulties of supervision are increased by the fact that the itinerant may sleep in one borough, manufacture his ice cream in another borough, sell it in many other boroughs, and may have a stale or inaccurate address on his barrow. It seems to be quite a usual practice for many of these barrow men to make the ice cream together in one house, and to give the address of this house, when challenged, or to have it on their barrows. Following any enquiry they adopt another place of manufacture, and are for the time being lost. Some appear to have a fairly well 125 defined daily round, chiefly in the streets of the City of Londonothers have irregular pitches. They move far afield, and may be in Hampstead one day and in Clapham the next. The use of the small conical glasses, which are lipped, tongued, licked ami gloated over by children, is most undesirable. For cleaning they are dipped momentarily into dirty water, which contains the accumulated mucus and mouth secretions of all previous buyers, and which is rarely renewed during the day. They are bathed in the dregs and sousings of prior users : they are swilled in diluted sputum. They are swabbed perfunctorily with a small, wet, offensive duster, and upended on a wet or soiled barrow top. The equipment of dusters is very scanty—one, or at most two, are used for the hundreds of occasions on which they are needed during the round. It seems to be almost impossible to make these itinerant ice cream and "hokey pokey" men adopt the most elementary rules which make for clean manufacture, clean conditions of sale, and clean conditions of presentation. Restaurants.—There are 228 restaurants in the borough. They are regularly inspected. In 1913 the number of notices served was 46, the number of inspections 228. 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 1913 the following names and addresses were on the register :— Wholesale Margarine Dealers.— W. Baker & Co., 1, Paul Street. De Graafe & Baker, 43 and 45, St. John Street. Harris Bros., 44 and 46, St. John Street. Harvey & Son, 29, Cowcross Street. Hermann Husburg, 28, Cowcross Street. Lidstone & Holme, 204 & 206, Old Street. 126 Lipton, Ltd., 3, High Street. Lipton, Ltd., Nelson Place Warehouse. Lovell & Christmas, 89 to 97, St. John Street. E. Mathews & Co., 126, Bunhill Row. Maypole Dairy Co., Ltd., 53, Chapel Street. Pearks, Ltd., 48, Ex mouth Street. J. Rose & Co., 3 & 4, Peter's Lane. Sloane, Wells & Taylor, Ltd., 24, St. John Street. Tetley & Co., 1, Paul Street. United Kingdom Tea Company, 1, Paul Street. Whitlock Bros., 33, Allen Street. Butter Manufacturers — Harris Bros., 44 and 46, St. John Street. Harris Bros., 94, St. John Street. Hunter's Dairies, Ltd., 47 to 51, Featherstone Street. Lipton, Ltd., 198 to 204, City Road. One hundred and forty-two samples of butter were taken for analysis, and five found to be adulterated ; 15 samples of margarine were obtained, all genuine. Bakehouses.—At the end of 1913, the total number of bakehouses in actual use in the borough was 57, of which 23 were above ground, and 54 below ground. The addresses were as follows:— Bakehouses above ground.— J. Baggazzi, 94, Goswell Road. W. Baker, 32, Exmouth Street. S. Buckland, 6, Clerkenwell Green. T. Cannon, 89, Central Street. T. Cannon, 162, Whitecross Street. W. R. Child, 64, Chiswell Street. J. H. Hughes & F. Phillips, 4, Cloudesley Road. F. Lernan, 13, Field Place. D. Liell, 65, Chapel Street, 127 J. Loibl, 164, Goswell Road. S. Longley, 97, Whitecross Street. R. Ponton, 2, Leverington Street. G. H. Purches, 202, Goswell Road. A. G. Restorick, 18, Penton Street. R. Saar, 207, Goswell Road. F. Schwalm, 2, Collier Street. W. Spooner, 50, Rosoman Street. F. H. Striebeg, 60, Compton Street. C. Taylor, 43, Liverpool Road. W. J. Todd, 22, Wynford Road. V. Wasem, 7, Liverpool Road. E. J. Woodcock, 2 and 3, Helmet Row. E. J. Woodcock, 161, Old Street. Underground Bakehouses.— A. H. Adams, 61, Whitecross Street. C. T. Brust, 53, Arnwell Street. T. Cannon, 58, Ironmonger Row. J. Dahms, 17, Exmouth Street. M. Dahms, 1, Wilmington Street. F. Decker, 422, St. John Street. E. Domm, 51, Rosoiman Street. W. H. Edwards, 5, Goswell Road. C. Epp, 16, Margaret Street. F. Gass, 272, Goswell Road. J. Kehrein, 2 and 4, Tysoe Street. W. Kling, 365, St. John Street. A. Kruger, 66, Bath Street. G. Lanz, 169, Whitecross Street. J. Lomas, 68, Compton Street. P. H. Moll, 6, Barnsbury Road. J. Peitz, 32, Northampton Street. W. Peters, 36, Corporation Row. E. Rapachi, 16, Donegal Street. E. Rutzler, 56, St. John Street. E. Rutzler, 40, Red Lion Street. 128 A. Schneider, 42, Southampton Street. E. Stilz, 72, White Lion Street. J. L. Stocker, 29, Central Street. W. Stone, 11, Bowling- Green Lane. O. S. Stumpf, 30, Penton Street. W.J. Todd, 92, King's Cross Road. H. Ullmar, 88, Farringdon Road. M. Volmar, 42, Bath Street. W. & H. Yooght, 3, Moreland Street. C. Wagner, 148, Whitecross Street. G. Werner, 124, Central Street. W. Werner, 2, Chapel Street. C. Wolf, 236, Goswell Road. All the bakehouses are periodically inspected; in 1913 the number of visits paid was 107. Notices for cleansing and dilapidations were issued in 25 instances. These were all complied with. HOUSING. In 1913, one house was represented by the Medical Officer of Health as being unfit for human habitation. The Council made a closing order on December 19th, 1913. The roof of the house was very much broken and leaking. The pantiles of the roof had parted, leaving intervals through which communication was established from the front top room with the outside air. In this room the laths were exposed and bereft of plaster over two large areas, and were wet and much bowed inwards so as to be dangerous to the occupants. The premises were otherwise internally dilapidated, broken, dirty, and in places damp. During wet weather the occupant of the ground floor caught in a galvanized iron receptacle the rain that percolated from the top floor. Registered Houses let in Lodgings.—No fresh houses were placed on the register in 1913. The register was, however, very carefully revised, and found to contain 1,188 houses. From 129 the outset, 1,321 houses had been registered. The difference between these two numbers is accounted for by houses demolished, houses transferred to other adjacent boroughs, and houses converted into workshops and restaurants. For the purpose of cleansing, 865 intimation notices and 318 statutory notices were served. For overcrowding, there were 56 notices. The number of visits paid was 6,611. There were no prosecutions. 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. Banner Street, 6 Rev. Preb. Carlile 140 105 Clerkenwell Green, 35 Mr. J. H. Claytor 73 34 Mary Curzon Hostel, King's Cross Road Duchess of Marlborough 56 45 Old Street, 97 Mr. W. H. Hatch 80 62 Pentonville Road, 19.23 Mrs. Shuttleworth 93 55 White Lion Street, 57 Mr. Shuttleworth 98 70 Totals 540 371 The Mary Curzon Hostel is for the reception, of women only, and was opened on October 6th, 1913. The common lodging houses in the metropolis 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 license 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:— 130 SYSTEMATIC HOUSE TO HOUSE INSPECTION, 1913. 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. Baker's Row 2 1 50·0 6 12 12 0 0 Baldwin Street 43 22 51·7 117 243 234 9 0 Baltic Street 8 5 62·5 30 48 41 7 0 Bartholomew Buildings 98 38 38·7 98 239 239 0 0 Buxton Street 8 5 62·5 25 62 62 0 0 Chapel Place 13 11 84·6 18 47 43 4 0 Claremont Mews 9 4 44·4 9 23 23 0 0 Clarence Place 4 1 25·0 4 12 12 0 0 Compton Street 51 7 13·7 83 278 239 39 0 Compton Passage 9 3 33·3 12 40 38 2 0 Crawford Passage 1 1 100·0 6 9 9 0 0 Donegal Street 10 1 10·0 23 65 52 13 0 Elizabeth Place 8 1 12·5 14 23 23 0 0 Hatfield Street 20 12 60·0 71 116 104 12 0 Helmet Row 32 15 46·8 120 207 206 1 0 Hewitt's Buildings 9 4 44·4 9 13 13 0 0 Holford Mews 3 1 33·3 3 6 6 0 0 Jay's Buildings 7 5 71·4 13 28 26 2 1 Lamb's Buildings 2 1 50·0 5 14 12 2 0 Little Sutton Street 33 28 84·.8 33 59 59 0 4 Little Sutton Street Bldgs. 41 19 46·3 41 75 75 0 0 Ludlow Street 10 5 50·0 15 26 26 0 0 Macclesfield Place 6 4 66·6 6 19 19 0 0 Market Buildings 12 2 16·6 12 12 12 0 0 Mitchell Street 14 6 42·8 54 93 89 4 0 Muriel Street 9 5 55·5 21 5i 51 0 3 Norman Street 9 3 33·3 20 48 47 1 0 Northampton Buildings 100 36 36·0 100 258 258 0 1 Northampton Road 55 32 58·1 173 375 375 0 0 Northampton Row 6 4 66·.6 13 37 35 2 0 Radnor Street 43 33 76·7 117 249 238 11 0 Richard Street 16 12 75·0 40 109 106 3 0 Risinghill Street 44 34 77·2 167 328 284 44 8 Rodney Place 11 6 54·5 19 42 39 3 2 Rodney Residences 21 11 52.3 21 62 62 0 0 Rodney Street 35 11 31·4 135 358 316 42 1 Roscoe Street 100 3 3·0 100 250 250 0 0 Sidney Place 8 8 1oo·o 11 28 28 0 0 Smithfield Buildings 10 1 1o·o 10 20 20 0 0 Warren Street 35 28 80.0 98 229 219 10 0 Withers Place 10 8 80·0 18 30 30 0 0 Young's Buildings 6 1 l6.6 6 19 19 0 0 Totals 971 438 45·1 1,896 4,462 4,051 211 20 131 The numbers of houses inspected similarly in preceding years were 1,746, 1,501, 1,447, 1,548, 2,250, 1,341, 806, 534, 789, 1.355, 888, and 1,336, from 1901 to 1912 respectively. The houses in the poorer districts are subject to more frequent systematic inspection than houses in the better parts. Some streets are inspected almost every year. In these cases this inspection is very necessary. In some streets, where the inhabitants are drunken, dissolute and reckless, where they are given to wilfully destroying- property, where they steal and sell the leads off the roof, where they break up the stair rods for firewood, and sell the rain-water pipes for old iron, in these streets fresh defects and dilapidations would be disclosed possibly every week or two, and it would appear to be impossible to inspect them too often. These people are unfit to be entrusted with decent houses. They come into Finsbury because they have been ejected elsewhere. Finsbury is one of the very few metropolitan boroughs where it is possible to rent a tenement without giving a reference to a previous landlord. In many London boroughs, the owner will not let to a new occupier unless and until he has visited and" seen the home'' of his prospective tenant and approved of its condition and of its cleanliness. A house agent or owner who has an undesirable tenant gives him notice to quit, and in case of default gets an ejectment order. This preliminary home inspection by the next landlord brings home to such a tenant, who maliciously damages property, the stern necessity of reform before he may hope to move elsewhere, with the alternative of ejectment into the street and a prolonged search for a new lodging. It is believed that comparatively few owners or house agents adopt this restrictive and drastically educative method in Finsbury. Crowding and Overcrowding—During the year 102 cases of overcrowding were dealt with and abated: 56 of these were in registered houses. Twenty were discovered as the result of systematic house-to-house inspection. The largest numbers of overcrowded tenements were in Risinghill Street (20), Cumming Street (5), Baltic Street (4), Bastwick Street (4), Donegal Street (4), Galway Street (4), Little 132 Sutton Street (4), Noble Street (4), Southampton Street (3), St. Helena Street (3), Warner Street (3), Baldwin Street (2), Mitchell Street (2), Muriel Street (21), Rodney Street (2), and Rodney Place (2). In the area covcred by systematic house to house inspection, 1,896 families occupied 4,051 rooms, or 213 rooms per family. Of the total number of rooms inspected 4.7 per cent, were empty; this shows that the crowding- is not due to lack of available accommodation. Examples of crowding and overcrowding' are appended:— Illustrative Examples.— 1. A family consisted of 7 persons, the father, mother, boys 4, 2, girls 11, 6 years, and a baby 6 weeks. They rented 2 rooms, but sublet the back room to a lodger. They were in arrears with their rent, and latterly paid no rent. Thus the family, although nominally occupying 2 rooms, really lived and slept in one room of 1,400 cubic feet, which contained one double and one single bed. They were said to have sub-let one room so as to obtain a little money to pay as a deposit when ejccted and about to negotiate elsewhere for a fresh letting. 2. A family consisting of the father, mother, a girl 21 years, and boys 16, 12, 9, 7 years occupied one room for living and sleeping. The room was incompletely divided into two parts by a wooden partition set up by the landlord. 3. A very small room, containing only 490 cubic feet of air space, was occupied for living and sleeping by the father, mother, and two girls, 7 and 3 years. It contained a single bed, 6 feet by 3 feet 6 inches. "There was hardly room for them to turn round." 4. The family consisted of the father, mother, and girls, 16, 5 and 4 years. They occupied one room, of 1,130 cubic feet, for living and sleeping. The room contained one double bed and a chair bed. The father was a plate polisher, and had been out of work for 2 months. The mother earned 5s. a week as a charwoman. The girl 16 years slept on a chair bed. 133 5. A room contained 678 cubic feet, and was occupied for living and sleeping by an old married couple. There was one bed. The tenement was slightly overcrowded. Their daughter and her four children, who had been in the workhouse for some considerable time, came out and went to live in the room which was already overcrowded. The four children slept with their grandparents. The mother was said to sleep elsewhere but she came and lived with her parents during the day time. 6. A complaint was received of an overcrowded room. The whole house was inspected, and 4 tenements were found to be overcrowded as follows :— Ground Floor Front.—837 cubic feet, occupied for living and sleeping by the father, mother, and boys 9 and 3 years., Overcrowded. Ground Floor Back.—564 cubic feet, occupied for living and sleeping by the father, mother and a boy 13 years. Overcrowded. First Floor Front.—1,153 cubic feet, occupied for living and sleeping by the father, mother, a boy 11 years, and 2 girls, 6 years and 8 months respectively. Overcrowded. First Floor Back.—586 cubic feet, occupied for living and sleeping by one female adult. The second floor was rented by one family, consisting of the father, mother, girls 13, 8, 3 years and a boy 16 years. The occupancies were :— Second Floor Front.—930 cubic feet, occupied for living and sleeping by the father, mother, and 3 girls. Overcrowded. Second Floor Back.—575 cubic feet, occupied for sleeping by the boy 16 years. Whilst the notices for the abatement of the overcrowding were still outstanding, the occupants of the second floor were, to the astonishment of the staff, increased by the addition of three lodgers, and the occupancies then became as follows:— 134 Second Floor Front.—930 cubic feet, occupied for living and sleeping by the mother, the 3 girls and 2 female lodgers, 25 and 16 years. The mother and the female adults slept in a double bed, the 3 girls slept on the floor. Second Floor Back.—575 cubic feet. There was one bed occupied by the father, the boy 16 years and a lodger 20 years. This family had a dog and 3 cats. 7. A married woman and a married man, not her husband, went to live together. They lx»th had families by their previous spouses. The united children numbered six, and consisted of 2 hoys, 10, 5 years, and 4 girls, 9, 8, 7 years and 13 months respectively. They occupied two rooms, and paid 7s. weekly rent. There were 2 beds, a double bed and a single one. The larger bed was occupied at the top by the parents ; the girl 7 years and the baby slept at the foot. '1 he single bed was occupied at the top by the girls 9, 8 years, and at the bottom by the girl 7 years and boy 10 years. The male adult earned 17s. 6d. per week and his food. The rooms were overcrowded. 8. A family, consisting of the father, mother, boys 11, 7, 2 years, and girls 9, 4 years, and 15 months respectively, rented 2 rooms, content 1,449 cubic feet, and 880 cubic feet. They sublet the smaller room to a woman and her daughter. The above examples taken from the records of the work of the Department will give some indication of the stress on room accommodation that is experienced in the poorer quarters of the borough and of the devices the poor have to adopt for sleeping purposes. Customs and Inland Revenue Acts, 1890 and 1903.— Applications were received for certificates in respect of one common lodging house, and 8 tenement houses. They were all carefully inspected, but no certificates were granted. In inspecting a common lodging house for such a certificate weight is attached to the following matters:— 135 1. The provision of two rooms for the occupation of the keeper or of his deputy. 2. A sufficient supply of lockers, or other receptacles, with suitable means of fastening, for clothes and for food storage. 3. A sufficient supply of kitchen utensils for cooking, for eating and for drinking. 4. The provision of lavatory basins, of facilities for washing clothes, shirts and socks, and for foot-washing. 5. A sufficient supply of hand towels and roller towels, their number, and their actual cleanliness and condition at the time of inspection. 6. 1 he provision on the premises of a bath available for use as such, and not kept as a storage receptacle for coal, boots, and odds and ends. 7. The provision of a room with some degree of privacy for repairing clothes. In the common lodging house under review two of the lodgers were found with bare legs in the common kitchen mending the trousers which they had taken off. They sat on forms near the table where others were feeding. 8. Hooks for coats and hats. 9. The height of the rooms. 10. A supply of hot water. The above details are in addition to the usual sanitary requirements, as, for example, the provision of sufficient water closet accommodation, of facilities for the disposal of house refuse, the lighting, the ventilation and the water supply. On the question of food storage, when the occupants were asked "Where do you keep your food?" they replied almost with one accord, "We don't keep it, we eat it as we get it, we can't keep it." The founding of Rowton Houses and of hostels in various parts of London has raised the standard of comfort which may now be reasonably expected in metropolitan common lodging houses. 136 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 and verminous. The parents are offered steam disinfection for the verminous bedding and clothing, and sulphur fumigation for the rooms. The number of children notified in 1913 was 1,265. The number of homes found clean on the first visit was 710, or 56 per cent. This confirms the view that, 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, 213 tenements were dirty or verminous. One hundred and fifty-four of the addresses were inaccurate. In 47 cases the tenements were disinfected by the Borough Council. Of the 218 dirty or verminous homes, the walls and ceilings of 184 were dirty and verminous. The bedding in 77 homes was very much fouled, the bedding in 71 was very verminous. In 47 instances the bugs had invaded the wall picture frames. The number of registered houses affected was 76 as against 137 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 eight instances underground rooms were found to be separately occupied in contravention of the provisions of the Public Health (London) Act, 1891, Section 96. Notices were served and the illegal occupations were discontinued. 137 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. 82, Bath Street 1 1 0 1 93A, Charterhouse Street 1 2 1 3 Claremont Mews 7 19 13 32 14, Clerkenwell Close 1 2 0 2 Davis' Yard 1 2 0 2 Garnault Mews 1 1 0 1 Holford Mews 3 7 2 9 Holford Yard 3 7 5 12 Jay's Buildings 12 40 31 71 119, Lever Street 1 4 2 6 1, New Court, Peter's Lane 1 2 4 6 FACTORIES AND WORKSHOPS. The number of workshops and workplaces on the Register at the end of 1918 was 1,984, compared with 1,950 at the end of 1912. During the year under review 119 entries were removed from the register owing to the closing of premises, the conversion of workshops into factories by the introduction of some form of mechanical power or to the removal of the occupiers to other places of business. The number of workshops and workplaces newly registered was 158. The factories on the register at the end of 1913 numbered 1,064, compared with 1,016 at the end of 1912. During the year 85 factories were removed from the register, and 183 were added. 138 There were still seven tenement factories on the register at the close of the year. The list included 7 tenement factories in which there were separate occupiers carrying on different trades or processes and supplied with mechanical power by the owners of the premises. The following paragraphs indicate the workshops, workplaces and factories on the registers, and show the large variety of manufacturing processes which are carried on in Finsbury. Workshops and Workplaces. -Clocks and watches, 125; jewellery, 108; cabinet and furniture making and polishing, 83; tailoring and clothing, 78; engraving, embossing and chasing, 63; provisions, bacon, grocery, and food preparation, 54; stabling, 53; leather, leather goods and trunks, 51; furriers and skin dressers, 48; forwarding goods, 45; building trades, 40; cycles and motors, 39; hats and caps, 38; boots and shoes, 38; gold and silver workers and refiners, 36; fancy goods and toys,, 35; drugs, chemicals, perfumery and sundries, 34; stationery and sundries, 31; underclothing, shirts, skirts, blouses and aprons, 29; farriers and smiths, 28; millinery, 27; picture-frames, mouldings and mounts, 26; mantles and costumes, 26; ironmongery and hardware, 25; feather work, 24; marine stores, rag and paper waste, 24; iron and metal work, 23; firewood and coal dealers, 22; boxmaking, 21; paper and cardboard, 21; glassware and glasswork, 20; ink, paint, oil, gum, colours, and dyes, 20; engineers and machinists, 20; laundries, 20; packing cases, 20; ties and neckware, 19; artificial flowers and plants, 19; barometers and thermometers, 19; optical goods, 19; stick making and mounting, 18; shop fitting and show cases, 18; basket, cane, bamboo, and wickerwork, 18; gilding and plating, 17; book and card edge gilding, 17; jewel and instrument cases, 15; rubber waterproof goods, 15; upholstery, 14; Christmas cards, postcards and art publishing, 14; brasswork, 13; children's underclothing, 13; woollen, linen, and cotton goods, 12; brushes, 12; timber, 11; wood, ivory, and bone carving and turning, 11; embroidery, lace and fancy needlework, 10; phonographs and automatic machines, 10; athletic and sports goods, 10; dressmaking, 10; pianos, organs and musical 139 instruments, 10; sign writing and ticket writing, 9; wirework, 9; harness and saddlery, 9; electrical goods, 9; surgical instruments and goods, 8; copper work, 8; tin plate work, 8; lapidary work, 8; marble and stone work, 8; trucks and barrows, 8; enamelling and japanning, 8; confectionery, 8; stamp and die cutting and sinking, 7; cloth trimmings sorting, 7; coach building and wheelwrights 6; lamps, lanterns, and stoves, 6; lithography and stereotyping, 6; umbrellas, 6; pipe making and mounting, 5; tailors' and drapers' dummies, 5; cork goods, 5; scales and and balances, 5; agricultural and horticultural goods, 5; scientific instruments, 5; linen collars and cuffs, 5; locksmiths, 4; china and earthenware, 4; gloves, 4; wines, spirits and cordials, 3; bedding and bedsteads, 3; glazier's diamonds, 3; machine ruling, 3; bottle washing and stoppering, 3; pattern cards, 3; saws, 3; wood carving and gilding, 2; photographic goods, 2; hair goods, 2; buttons, 2; knife cleaning goods, 2; books and book materials, 2, and others, making a total of 1,984. The summarised "other" workshops include the following manufactures, trades or occupations:—Clean towel supply, wax figures, sponges, tobacco, wigs, window cleaning, typewriters, teapot handles, carpet planning, disinfectant manufacture, mosaic work, naturalist, undertakers, domestic machinery, combs, and gold blocking. Factories.— Printing and stationery, 153; engineering and machinery, 102; shirts, skirts, blouses, ties and underclothing, 77; jewellery and gold and silver work, 50; gilding, plating and polishing, 50; bookbinding, 35; provisions, grocery, bacon and food preparation, 34; boxmaking and paper bag making, 29; foundries, 29; stick making and mounting, 28; iron and metal work, 19; glasswork, 18; brass and copper work, 15; pipe making and mounting, 15; ivory, wood and bone turning, 14; ink, paint, gum, soap, polish and varnish, 14; surgical goods, 14; engraving and die sinking, 13; cycles and motors, 13; paper and cardboard, 13; leather goods and bags, 12; brushes, 12; woodwork, 12; scientific and surgical instruments, 11; mantle making, 11; cabinet making, 10; clock, jewel and instrument cases, 10; shop fitting, 10; cigars, cigarettes and tobacco, 10; rubber goods, 10; art 140 publishing and Christmas cards, 9; picture frames and mouldings, 9: drugs and drysaltery, 9; optical goods, 9; beer and spirits, 9; packing cases, 9; clocks and watches, 8; vanwork and wheelwrights, 8; wirework, 7; art needlework and embroidery, 6; sports goods, 6; cold storage, 6; cutlery, 6; boots and shoes, 6; confectionery and cocoa, 5; laundries, 5; linen collars, 5; builders, 5; joinery and saw mills, 4; artificial flowers, 4; saw making, 4; book and card edge gilding, 4; buttons and studs, 4 horsehair, feathers and bedding, 4; mineral waters, 4; glazier's diamonds, 4; contractors (general), 4; trunks, 4; phonographs and records, 3; pianos and musical instruments, 3; upholstery, 3; barometers, 3; cornice poles, 2; pattern cards, 2; cork goods, 2; vulcanised fibre, 2; electro-typing, 2; marble work, 2; umbrellas, 2; lamps, 2; smiths and farriers, 2; clock cases, 2; furniture, 2; and 29 other trades, making a total of 1,064. The "other" trades in the above summary include the following:—Waste paper and rag sorting, hats, whips, electricity generating station, fur and skin dyeing, tar felting, bamboo work, murac, flooring, carpet planning, petrol purification, shipping agents, dyers, clean towel supply, fountain pen making, screen and panel painting, silica manufacture, pearl and tortoise-shell work, hydraulic pumping station and a bakery. The persons employed in the factories in Finsbury are approximately: males 20,500, females 17,500; in the workshops: males 12,000, and females 7,500. These numbers exclude the office hands and clerical staff. During the year 200 first visits and 299 revisits were made by the Council's inspector to factories, and 987 first visits and 1,113 revisits to workshops and workplaces. A summary of the defects found is appended:— 141 Summary of Defaults and Defects in Factories, Workshops and Workplaces for which Notices were served during 1913. Work. shops. Factories. Work. places. Totals. Dirty workshops and workplaces 71 2 1 74 Damp and dilapidated premises 14 3 ... 17 Dirty passages and staircases 15 1 1 17 Overcrowding of workshops 7 ... ... 7 Insufficient ventilation 14 ... ... 14 Want of drainage of floors 1 ... ... 1 Water supply lacking or inadequate 2 4 ... 6 Sanitary conveniences, dirty 97 27 7 131 Sanitary conveniences, defective 54 33 13 100 No sanitary convenience 1 ... 1 2 Insufficient sanitary convenience accommodation 17 17 2 36 Improper use of sanitary conveniences by both sexes 12 4 5 21 Yards dirty, or paving worn 11 4 1 16 Storage cisterns dirty or defective 11 1 ... 12 Accumulations of refuse 12 2 1 15 Dustbins, defective or absent 32 5 2 39 Drainage defective or choked 10 5 1 16 Rain-water pipes choked or broken 3 ... 1 4 Stables dirty .. ... 1 1 Stable paving defective ... ... 1 1 Nuisance from rats 1 1 ... 2 Absence of guttering 8 ... ... 8 Waste pipes defective 4 5 1 10 Ventilating pipe defective ... ... 1 1 Roofs leaky 17 1 ... 18 Nuisances from emission of black smoke ... 3 ... 3 Totals 414 118 40 572 In connection with these defects 280 intimation notices and 60 statutory notices were served, 142 Infectious Disease.—Notices were received of the occurrence of 3 cases of infectious disease (scarlet fever) in the homes of workers in Finsbury and resident in other districts. These cases were enquired into and suitable precautions adopted. The Home Office.—Sixty-eight notices of occupation of workshops were received from the Home Office during the year, and 23 notices of complaint relating to the following matters:— Sanitary conveniences, 10; dirty premises, 6; insufficient ventilation, 3; the discharging of fumes into workshop by gas stoves, 3; structural defects, one notice. The notices sent to the Home Office were as follows:—Abstract of the Factory and Workshop Act not affixed, 25; Abstract of the Factory and Workshop Act not affixed in a factory, or the Workshop Abstract exhibited in a factory, 11; d'rty walls, 3; insufficient ventilation, 4; lack of means of heating, 4; insufficient means of lighting, 1; dangerous machinery, 1; w.c. accommodation., one notice. Prosecutions.—There was one prosecution—for failing to alter and amend two w.c's. in a workshop. The defendant was fined £1 and £2s. 0d. costs. The Rag Flock Act, 1911.—Four samples of rag flock were taken during the year. Three were found to comply with the required standard of cleanliness, but the other was reported to contain 130 parts of chlorine per 100,000 parts of flock. The impugned sample, however, was declared to be a sample of cotton seed flock. No specimens of rag flock were found on the premises from which this last sample was taken. At one workshop, newly established, where the repairing of furniture was carried out, it was ascertained that old rag flock was being used for insertion into various articles of furniture. A letter of caution, a copy of the Rag Flock Act, and the regulations made thereunder, were sent to the occupier. 143 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.) 499 69 - Workshops (Including Workshop Laundries ) 1·525 229 1 Workplaces (Other than Outworkers' premises included in Part 3 of this Report) 603 42 — Total 2,627 340 1 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 92 87 .. .. Want of ventilation 14 13 .. .. Overcrowding 7 6 .. .. Want of drainage of floors 1 1 .. .. Other nuisances 168 163 .. .. Sanitary accommodation Insufficient Unsuitable or defective Not separate for sexes 38 37 .. .. 231 220 .. 1 21 21 .. .. Offences under the Factory and Workshop Act— Illegal occupation of underground bakehouse (S 101) .. .. .. .. Breach of special sanitary requirements for bakehouses (SS. 97 to 100) .. •• .. .. Other offences (excluding offences relating to outwork which are included in Part 3 of this Report) 48 .. 48 •• Total 620 548 48 1 144 145 HOME WORK. NATURE OF WORK. OUTWORKERS' LISTS, SECTION 107 OUTWORK IN SOME PREMISES, SECTION 108. OUTWORK IN FECTED PREMISES, SECTIONS 109, 110. Lists received from Employers. Notices served on Occupiers as to keeping or sending Lists. Prosecutions Instances. Notices served. cutions. Instances. Orders made (S.110). tions (Sections 109, 110). Sending twice in the year. Sending once in the year. Failing to keep or permit inspection of Lists. Falling to send Lists. Outwoikers. Contractors Workmen. Contractors Workmen. Wearing Apparel — Circular letters and forms are sent to all employers when the lists are nearly due. None. None. None. None. None. 2 None. None. (i) making, &c. 222 533 3431 26 65 318 2 (2) cleaning and washing .. .. .. .. .. .. .. Household linen .. .. .. .. .. .. .. Lace, lace curtains and nets .. .. .. .. .. .. .. Curtains & furniture hangings .. .. .. .. .. .. 2 Furniture and upholstery .. .. .. .. .. .. .. Electro-plate 8 2 23 .. .. .. .. File making .. .. .. .. .. .. .. Brass and brass articles .. .. .. .. .. .. .. Fur pulling .. .. .. .. .. .. .. Cables and chains .. .. .. .. .. .. .. Anchors and grapnels .. .. .. .. .. .. .. Cart gear .. .. .. .. .. .. .. Locks, latches and keys .. .. .. .. .. .. .. Umbrellas, &c 6 .. 42 .. .. .. .. Artificial flowers 12 .. 127 1 .. 2 .. Nets, other than wire nets .. .. .. .. .. .. .. Tents .. .. .. .. .. .. .. Sacks .. .. .. .. .. .. .. Racquet and tennis balls .. .. .. .. .. .. 4 Paper, etc., boxes, paper bags 28 .. 456 1 .. 4 .. Brush making 14 11 103 3 19 .. Pea picking .. .. .. .. .. .. .. Feather sorting.. .. .. .. .. .. .. .. Carding, &c., of buttons, &c .. .. .. .. .. .. .. Stuffed toys .. .. .. 2 .. 6 .. Basket making .. .. .. .. .. .. .. Chocolates and sweetmeats .. .. .. .. .. .. Cosaques, Christmas crackers, .. .. .. .. .. .. Christmas stockings, &c .. .. .. .. .. .. Textile weaving .. .. .. .. .. .. Total 290 546 4182 33 65 349 .. .. .. .. .. .. 10 .. .. 146 OTHER MATTERS. Matters notified to H. M. Inspector of Factories:— Failure to affix Abstract of the Factory and Workshop Acts (s. 133, 1901) 25 Action taken in matters referred by H. M. Inspector as remediable under the Public Health Acts, but not under the Factory and Workshop Acts (s. 5, 1901) Notified by H. M. Inspector 23 Reports (of action taken) sent to H. M. Inspector 23 Other 31 Underground Bakehouses (s. 101):— Certificates granted during the year None In use at the end of the year 34 Canal Boats Acts, 1877 to 1884.—During the year the total number of boats inspected was 118, of which 11 were carrying offensive cargoes. The Acts and Regulations were contravened in one instance, and for this a complaint note was seat to the owners requiring the abatement within a specified time. The details of the contraventions are as follows :— The boat was being worked without a registration certificate. This was remedied, and it was not found necessary to take legal proceeding's. 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. 1909 105 261 28 47 336 370 1910 1 12 299 29 36 364 413 1911 106 270 39 50 359 377 1912 100 249 28 41 318 363 1913 118 284 35 42 361 436 147 Of the 118 boats inspected, 84 were occupied by men only, 16 by men and women, and 18 by men, women and children. The children accompanying their parents on the boats appeared to be well cared for. 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 Norman. There is no separate remuneration for this work. Black Smoke.—During the year 72 black smoke observations were made by the district and workshop inspectors. Notices of 7 infringements were received from the London County Council, and 2 notices from the Coal Smoke Abatement Society. In 9 cases the black smoke was emitted for three 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 were no prosecutions. The Mortuary.—The municipal mortuary is at 47, Northampton Road, Clerkenwell. There are on the same premises a disinfecting station and a coroner's court. The returns for the year were:—Inquest cases, 138; bodies of persons removed after death from infectious diseases, 3 ; bodies deposited in the mortuary from one-roomed or two-roomed tenements owing to insufficient accommodation at home for the retention of the bodies, 4; bodies brought to the mortuary for the convenience of relatives, 190. The number of post-mortem examinations was 113. 148 The Shelter.—The Council's shelter is situated at 47, Northampton Road, Clerkenwell, in connection with the Disinfection Station. In 1913, 3 families, 12 persons in all, availed themselves of its accommodation while their rooms were being disinfected after the occurrence of infectious disease. Offensive Trades.—In Finsbury there is only one registered offensive trade—Mr. Joseph L. Henson, Tripe Dresser, 137. Whitecross Street. This was inspected on 5 occasions in 1913, It was not found necessary to serve any notice for sanitary defects. 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 a Keeper of the Mortuary and Coroner's Court. The Mortuary Keeper 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 1913 by the Sanitary Inspectors :— 149 WORK OF THE SANITARY INSPECTORS, 1913. Inspector Davis. Inspector Longden. Inspector Norman. Inspector Jackson. Inspector Rees. Totals. Houses damp, dirty or dilapidated remedied 319 203 103 67 119 811 Doors, windows, floors, walls, ceilings, sash cords repaired 133 74 42 15 45 309 Overcrowding cases abated in other than Registered Houses 22 12 3 4 5 46 Illegal occupation of underground rooms 4 3 0 0 1 8 Water closet defects remedied 221 188 175 96 132 812 Water closets erected 97 27 180 51 34 389 Urinal defects remedied 0 1 2 0 0 3 Urinals erected 11 2 9 7 1 30 Soil pipe and ventilating shaft defects remedied 1 3 0 0 1 5 Soil pipe and ventilating shafts erected 52 4 39 17 22 134 Yard defects remedied 119 107 50 25 75 376 Waste pipe defects remedied 44 18 15 10 0 87 Waste pipes erected 37 12 50 15 23 137 Water cistern defects remedied 20 20 15 10 16 81 Accumulations of rubbish or manure removed 30 15 10 12 27 94 Dung or Dust receptacles repaired or renewed 74 27 31 35 44 211 Drains relaid or amended 25 19 37 13 6 100 Drains cleared 88 38 87 62 41 316 Rain water pipes cleared, repaired, or renewed 12 15 19 12 7 65 Water supply to houses re-instated 2 2 2 1 3 10 Roofs and Gutters repaired 49 64 65 12 28 218 Area defects remedied 14 13 5 5 8 45 Washhouse defects remedied 118 68 21 17 63 287 Animal Nuisances abated 8 2 1 1 0 12 Floor space unventilated 2 1 0 0 5 8 Stables cleansed or repaired 1 1 0 0 3 5 Smoke observations 8 12 39 1 0 60 Water Supply laid on to upper storeys of house 2 11 0 2 3 18 Miscellaneous Nuisances abated 56 36 9 4 20 125 Bakehouses—inspections 32 22 22 19 12 107 Bakehouses cleansed or repaired. 9 6 3 3 4 25 Restaurants—No. of inspections 27 28 117 39 17 228 Restaurants cleansed or repaired 6 11 15 5 7 44 Milkshops—No. of inspections 43 31 60 35 36 205 Milkshops cleansed or repaired 7 15 12 7 2 43 Public Houses cleansed or repaired 2 6 6 2 0 16 Ice Cream Premises—No. of inspections 16 10 28 23 28 105 Ice Cream Manufactories cleansed or repaired 3 3 6 4 4 20 Butchers' shops cleansed or repaired 1 0 4 0 2 7 Fish Purveyors' Shops cleansed or repaired 1 0 1 0 0 2 Registered Houses—visits of inspection 1660 1483 1367 420 1681 6611 150 work of the sanitaty inspectors, 1913—continued. Inspector Davis. Inspector Longden. Inspector Norman. Inspector Jackson. Inspector Rees. total. Registered Houses — Overcrowding cases abated 26 10 9 5 6 56 Registered Houses—cleansed 219 129 119 165 202 834 Registered Houses — Intimation (Cleansing) Notices served 229 157 143 173 163 865 Registered Houses — Statutory (Cleansing) Notices served 86 33 59 59 81 318 First visits (complaints, casual visits) 1242 1386 1553 515 1891 6587 Re-visits 3431 2946 3124 910 2262 12673 Intimation Notices served 594 476 437 272 413 2192 Statutory Notices served 131 56 44 31 58 320 Infectious disease investigations 255 321 230 122 355 1283 House inspections 429 407 247 221 323 1627 House to house inspections 213 214 240 135 169 971 Canal Boats inspected 0 0 119 0 0 119 Cowsheds—No of inspections 0 0 4 2 7 13 Slaughterhouses—No. of inspections 4 0 0 0 5 9 Slaughterhouses—No. of notices served 0 0 0 0 0 0 Verminous tenements—No. of inspections 163 339 223 49 164 938 Verminous tenements cleansed by Borough Council - - - - - 47 Drains tested 72 79 65 31 83 330 Work of Mrs. Greenwood, Lady Sanitary Inspector, 1913. First Visits. Phthisis 48 Infant Deaths 278 Homeworkers 343 Factories & Workshops 49 Births 48 Complaints 48 Sundries 360 Re-visits. Phthisis 119 Infant Deaths 198 Homeworkers 101 Factories & Workshops 14 Complaints 52 Births 68 Number of Notices served 58 Dirty rooms and tenements 11 W.C's. dirty or defective 22 Insufficient W.C. accomodation 2 Yard paving defective or walls dirty 8 Wash-house walls dirty or paving defective 7 Rooms overcrowded 11 Dirty floors & bedding 12 Accumulations of refuse removed 4 Underground rooms illegally occupied 2 Workshops dirty, and insufficiently ventilated 4 Other nuisances 7 Nuisances referred to District Ispectors 13 Attendances at weighing centres 143 151 LEGAL PROCEEDINGS UNDER THE PUBLIC HEALTH (LONDON) ACT, 1891. Date, 1913. Name and Address of Defendant. Offence. Result. April 3rd Hawkey & Co., Ltd., 14, Worship Street, E.C. Failing to alter and amend a water closet at 14, Worship Street, E.C. Fined £1 and £2 2s. costs. June 20th Wm. Richardson, 9, Davenant Road, Holloway, N. Failing to unstop a choked drain at 79, Margaret Street. Fined £4 and 2s. costs. April 30th William Eaton, 1, Young's Bldgs., Old Street, E.C. For exposing and depositing for sale meat which was unfit for the food of man. Fined £30 and 2s. costs. April 30th Harry Eaton, 22, York Road, East Ham. For selling to the above William Eaton the unsound meat referred to above. Fined £30 and 2s. costs. LEGAL PROCEEDINGS UNDER THE NOTIFICATION OF BIRTHS ACT, 1907. Date, 1913. Name and Address of Defendant. Offence. Result. Feb. 11 Sarah Norman, 348, Upper Street, Islington, N. Failing to notify a birth at 35, Warren Street within 36 hours. Fined £1 and £1 2s. costs. 152 SALE OF FOOD AND DRUGS ACTS. Date, 1913. Name and Address of Defendant. Offence. Result. Jan. 2nd Thomas Jones, 32, President Street For selling milk containing 10 2 per cent. of added water Ordered to pay £1 1s. costs ,, 2nd The Cream Dairy Co., Ltd, 27-31, Caledonian Road For selling milk from which 5 per cent. of its fat had been abstracted Dismissed. Warranty proved ,, 2nd William Miller, 160, Whitecross Street For selling butter adulterated with water to the extent of 7 per cent, above the standard allowed by the Board of Agriculture Fined £1 and £1 3s. costs ,, 3rd Catherine Cimminola, 35, Warner Street For selling butter adulterated with 82 per cent. of foreign fat Fined 10s. 6d. and 2s costs ,, 9 th George Fredk. Wright, 189, Whitecross Street For exposing margarine for sale by retail without having it labelled Fined £2 and £1 3s. costs ,, 29th Thomas Sewe'l, 26, Clerkenwell Close For selling butter adulterated with 30 per cent. of foreign fat Fined £2 and 12s. 6d. costs Mar. 12th E. Rogers & Co., 50, Bath Street For selling milk from which 6 per cent. of its fat had been abstracted Summons dismissed. A notice was exhibited in the shop which the Magistrate held was a sufficient disclosure ,, 28 th William Hall, 66, Myddelton Street For selling milk containing 19.5 per cent of added water Fined £1 and 12s. 6d costs. May 29th William Hopkins, 31a, Glasshouse Yard For selling butter adulterated with 57 per cent. of foreign fat. Fined £1 and 12s. 6d. costs June 24th George Dinnis, 82, Chapel Street For selling butter adulterated with 34 per cent. of foreign fat. Fined £1 and 12s. 6d. costs „ 24th Frederick Robinson, 56, Collier Street For selling milk from which 8 6 per cent. of its fat had been abstracted Fined £1 and 12s. 6d. costs July 10th Liberto Savino, 125, Whitecross Street For selling milk from which 18.6 per cent. of its fat had been abstracted Fined £3 and £1 3s. costs „ 10th Horatio Jones, 67, Whitecross Street For selling milk from which 12 3 per cent. of its fat had been abstracted Fined 10s. and 12s. 6d. costs „ 11th Mary Ann Wilkins, 4, Albert Street For selling milk from which 366 per cent. of its fat had been abstracted Ordered to pay 12s. 6d. costs. „ 17th E. J. Butcher, 86, Bath Street For selling milk from which 6.6 per cent. of its fat had been abstracted Ordered to pay £1 3s. costs 153 Date, 1913. Name and Address of Defendant. Offence Result. July 17th H. D. Pugh, 124, Whitecross Street For selling milk from which 6.3 per cent. of its fat had been abstracted Dismissed. Warranty proved ,, 25 th David Williams, 69, Great Percy Street For selling milk from which 7.0 per cent. of its fat had been abstracted Dismissed. Warranty proved Aug. 28th George R. Denton, 3, Tabernacle Street For selling milk from which 16.6 per cent. of its fat had been abstracted Dismissed. Warranty proved ,, 29th J.P. Restaurants, Ltd., 55, Farringdon Road. Re 1, Clerkenwell Road For selling milk from which 30.6 per cent. of its fat had been abstracted Dismissed. A notice was displayed in the shop Oct. 24th Margaret Davies, 24, Collier Street For selling butter adulterated with 87 per cent. of foreign fat Fined £2 and 12s. 6d. costs Dec. 31st William James Hutt, 28, Rosoman Street For selling milk containing 9.1 per cent. of added water Fined £1 10s. and 12s. 6d. costs LOCAL GOVERNMENT BOARD AND OTHER TABLES. 156 TABLE I. Vital Statistics of Whole District during 1913 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. N umber Rate. 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 per 1,000 Nett Births. Number. Rate. 1 2 3 4 5 6 7 8 9 10 11 12 13 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 9 .6 67 935 411 154 1,697 19.4 1912 86,130 3,138 2,579 29.9 790 9 .1 69 878 290 112 1,599 18.5 1913 84,679 3,053 2,494 29.4 737 8.7 92 913 348 139 1,558 18.4 Area of District in acres (exclusive of area covered bv water). 5866 Total population at all aees 87,976 Number of occupancies, 21,278 Average number of persons per occupancy, 4.13. At Census of 1911. 157 TABLE II. Cases of Infectious Disease notified during the Year 1913. Notifiable Disease. Number of cases notified. Total cases noti6ed in each locality. (e.g., Parish or Ward of the District.) Total cases removed to Hospital. At all Ages. At Ages—Years. 1 2 3 Clerkenwell. St. Luke. St. Sepulchre. Under 1 1 and under 5 years 5 and under 15 years 15 and under 25 years 25 and under 45 years 45 and under 65 years 65 and upwards. Small Pox - - - - - - - - - - Cholera (C) Plague (P) — — — — — — — — — — — — Diphtheria (including Membranous croup) 95 6 38 33 9 7 2 — 51 42 2 95 Erysipelas 124 4 4 11 9 30 59 7 74 49 1 9 Scarlet Fever 251 1 71 158 13 7 1 — 151 99 1 244 Typhus Fever — — — — — — — — — — — Enteric Fever 15 — — 4 6 5 — — 11 3 1 15 Relapsing Fever (R) Continued Fever (C) — — — — — — — — Puerperal Fever 13 — — — 2 11 — — 8 5 9 Cerebro Spinal Meningitis 5 1 3 1 — — — — 4 1 — 2 Poliomyelitis 3 — 3 1 1 2 3 Pulmonary Tuberculosis 421 13 28 70 104 149 42 15 248 165 8 181 Other forms of Tuberculosis 144 5 27 76 25 8 3 — 76 67 1 78 Ophthalmia Neonatorum 6 5 1 — — — — — 5 1 — 2 Totals 1077 34 175 354 168 217 107 22 629 434 14 638 158 TABLE III. Causes of, and Ages at, Death during Year 1913. Causes of Death. All ages. Nett Deaths at the subjoined ages of "Residents" whether occurring in or without the District. 65 and upwards Total Deaths, whether of " Residents " or" Non-Residents" in Institutions in the District. Under 1 year. 1 and under 2 years. 2 and under 5 years. 5 and under 15 years. 15 and under 25 years. 25 and under 1 45 years. 45 and under 65 years. 1 2 3 4 5 6 7 8 9 10 11 Enteric Fever - - - - - - - - - - Small-pox - - - - - - - - - - Measles 30 7 21 2 - - - - - - Scarlet fever 5 1 2 1 1 - - - - - Whooping-cough 30 11 14 5 - - - - - - Diphtheria and Croup 9 2 2 2 3 - - - - - Influenza 12 1 1 — 2 — 2 3 3 — Erysipelas 2 — — — 1 — — 1 — — Phthisis (Pulmonary Tuberculosis) 151 1 2 4 14 73 45 12 - Tuberculous Meningitis 33 6 6 8 11 1 1 - — 1 Other tuberculous diseases 30 8 4 7 3 3 1 2 2 1 Cancer, malignant disease 93 — — — 1 2 7 51 32 14 Rheumatic Fever 4 — — — 2 2 — — — — Meningitis 10 2 2 4 1 — — — 1 — Organic Heart Disease 156 6 — — 9 7 26 50 58 6 Bronchitis 161 21 3 1 1 1 12 45 77 1 Pneumonia (all forms) 169 59 25 15 4 3 28 23 12 6 Other diseases of Respiratory organs 8 1 1 - - - 2 3 1 - Diarrhoea and Enteritis 107 79 19 3 2 2 1 1 — — Appendici is and Typhlitis 6 — — - 4 — — 2 — — Cirrhosis of liver 18 - - - - - 3 10 5 — Alcoholism 9 - - - - - 4 4 1 — Nephritis and Bright's Disease 122 - 1 2 - 1 10 52 56 1 Puerperal Fever 5 — — — — — 5 — — — Other accidents and diseases of Pregnancy and Parturition 5 - - - - 1 4 - - 5 Congenital Debility and Malformation, including Premature Birth 82 82 - - - - - - - 28 Violent Deaths, excluding Suicide 68 26 2 9 7 2 7 6 9 3 Suicide 8 — — — — — 3 3 2 — Other Defined Diseases 165 24 2 5 5 2 20 33 74 10 Diseases ill-defined or unknown 60 11 1 1 4 2 0 4 37 5 1558 348 106 67 65 43 209 338 382 81 159 TABLE IV. Infant Mortality, 1913. causes of death. Under 1 week. 1-2 weeks. 2-3 weeks. 3-4 weeks. Total under 4 weeks. 4 weeks and under 3 months. 3 months and under 6 months. 6 months and under 9 months. 9 months and under 12 mos. Total deaths under 1 year. All causes Certified .. .. .. .. .. .. .. .. .. .. Uncertified .. .. .. .. .. .. .. .. .. .. Small-pox .. .. .. .. .. .. .. .. .. .. Chicken-pox .. .. .. .. .. .. .. .. .. .. Measles .. .. .. .. .. .. 1 .. 6 7 Scarlet fever .. .. .. .. .. .. .. 1 .. 1 Whooping cough .. .. .. 1 1 .. 3 4 3 .. Diphtheria and Croup .. .. .. .. .. .. 1 .. 1 2 Erysipelas .. .. .. .. .. .. .. .. .. .. (Tuberculous Meningities .. .. .. .. .. .. 2 .. 4 0 Abdominal Tuberculosis .. .. .. .. .. .. 2 1 1 4 other Tuberculous Diseases .. .. .. .. .. 1 .. 2 2 5 Meningitis (not Tuberculous) .. .. .. .. .. .. 1 .. .. 2 Convulsions .. .. 1 1 2 .. .. 1 .. 3 Laryngitis .. .. .. .. .. .. .. .. 1 1 Bronchitis .. 1 2 1 4 8 2 4 3 21 Pneumonia (all forms) 1 .. .. 2 3 8 16 15 17 59 (Diarrhœa 2 1 .. .. 3 6 16 8 6 39 Enteritis 1 1 1 .. 3 9 15 9 4 40 Gastritis .. .. .. 1 1 2 .. .. .. 3 Syphilis .. 1 .. .. 1 4 2 .. .. 7 Rickets .. .. .. .. .. .. .. .. .. .. Suffocation, overlying 1 .. .. .. 1 10 4 2 .. 17 Injury at birth 3 .. .. .. 3 .. .. .. .. 3 Atelectasis 4 .. .. .. 4 .. .. .. .. 4 Congenital Malformations. .. .. 2 1 3 1 .. .. .. 4 Premature birth 37 7 9 2 55 3 .. .. .. 58 Atrophy, Debility and 1 .. 2 1 4 8 7 1 .. 20 Other causes 4 3 4 1 12 6 4 6 3 31 Totals 54 14 21 11 100 66 76 55 51 348 Nett Births in the year legitimate 2448 Nett Deaths in the year of legitimate infants 326 illegitimate 46 illegitimate infants 22