REPORT on the VITAL AND SANITARY STATISTICS of the BOROUGH OF LAMBETH DURING THE YEAR 1913. [With an account of the work done by (a) the Tuberculosis Medical Officers under the Lambeth Tuberculosis Dispentsaries Scheme, and (b) the Male and Female Sanitar\ Inspectors and the Health Visitor and also of the proceeding} taken under the Sale of Food and Drugs, the Factory and Workshops, and the Housing and other.4cts.] by Joseph Priestley, b.a., m.d., d.p.h., Medical Officer of Health and Chief Executive Tuberculosis Officer. London: Merser & Sons, Ltd., Printers, 268-270 Krnnington Road, S.E. 3 Public Health Department, Lambeth Town Hall, Brixton Hill, S.W. April, 1914. To the Mayor, Aldermen and Councillors of the Metropolitan Borough of Lambeth. Mr. Mayor and Gentlemen, In presenting the Annual Report for 1913, dealing with the Vital Statistics of the Borough of Lambeth, it is again my privilege to draw your attention to the favourable character of such Report, the lowness of the various deathrates (general, zymotic and infantile mortality) shewing the success of the preventive measures taken and the value of the sanitary work carried out for years past. .Standing out for particular attention, during 1913, is the inauguration of the Lambeth Municipal Tuberculosis Dispensaries Scheme, with the opening to the Public of the two Dispensaries—the Central at 73 Effra Road, Brixton, S.W., and the Branch in connection with St. Thomas’s Hospital (Out-Patients’ Departments). The special Report dealing with the work of the Tuberculosis Medical Officers at these two Dispensaries speaks for itself, and will be found, fully set out, as an addendum to this Report (vide Appendix pp. 75 to 103). Mention may also be made of an outbreak of milk-borne diphtheria (in Norwood and neighbouring districts), and the success of the preventive measures taken in connection therewith. A special Report on the outbreak will be found in the Appendix (vide pp. 35 to 74). To the Chief Officers of the Council, and to the Public Health Staff, my thanks are again due, as also to the Members of the Council, for assisting me in carrying out my important duties as Medical Officer of Health, and Chief Executive Tuberculosis Officer, for the Borough of Lambeth. I am, Mr. Mayor and Gentlemen, Your obedient Servant, Medical Officer of Health and Chief Executive Tuberculosis Officer. 4 I. VITAL STATISTICS. The Estimated Populations of the Borough to the middle 913 arc calculated from the Enumerated populations of the two decennial censuses 1901 and 1911, as follow:— Estimated Populations. (Estimated, Middle 1913.) I. Wards. Wards. Males. Females. Total. Marsh 11014 10083 21097 Bishop’s 15410 15655 31065 Wince's 20512 21240 41752 Vauxhall 15239 15187 30426 Stockwell 14862 17027 31889 Brixton 20482 23725 44207 Herne Hill 15548 17608 33156 Tulse Hili 14381 16830 31211 Norwood 14409 17867 32336 Borough ot l.ambeth 141917 155222 297139 11. Registration Sub-Districts. Sub-] )Districts. Males. Females. Total. Lambeth Church 23481 22760 46241 Bennington 23451 24219 47673 Stockwell 30102 32213 62315 Bixton 36030 41333 77363 Norwood 28850 34697 63547 Borough of Lambeth 141917 155222 297139 5 III. Parliamentary Divisions (Old). ###]Parliamentary Divisions. Males. Females. Total. North 26050 25450 51500 Kennington 35846 35994 71340 Brixton 35489 40609 70098 Norwood 43557 51457 95014 Parliamentary Area of Lambeth 140442 153510 293952 N.B.— The Parliamentary Divisions have not been altered by the London Government Act, 1899, nor by the proceedings that fixed the Boundaries of the Metropolitan Boroughs, so that the above figures dc not agree with those for the borough as a whole, but are comparable with those of the old Parish of Lambeth given in previous Reports. IV. Parliamentary Divisions (Adjusted). *Adjusted Parliamentary Divisions. New Wards. North Kennington Brixton Norwood *Adjusted Parliamentary Area of Lambeth Marsh Bishop's Prince's Vauxhall Stockwell Brixton Heme Hill Tulse Hill Norwood Total. 52162 721 78 76096 96708 297139 “N.B.—By the adjustment of the old Parliamentary Divisions- so as to be co-terminous with the Wards. TABLE A. Giving the number of Births and the Birth -Rates in each Registration Sub-District of the Borough of Lambeth during 1913 (arranged Quarterly). Registration Sub-Districts. 1st Quarter. No. of Births. 2nd Quarter. 3rd Quarter. 4th Quarter. Total for the Year 1913. Rate per 1000 Inhabitants. Lambeth Church* 606 572 578 610 2366 51.2 Kennington† 307 302 315 308 1232 25.8 Stockwell§ 548 493 489 483 2013 323 Brixton 386 383 412 370 1551 20.1 Norwood 336 305 269 269 1179 18.6 Borough of Lambeth 2183 2055 2063 2040 8341 28.1 *lncluding Lying-in Hospital (695 cases, of which 188 belong to London)—corrected rate (i.e., excluding all the Lying-in Hospital births) = 36.1. †ncluding Workhouse (223 cases, of which 206 belong to Lambeth)—corrected rate (i.e., excluding all the Workhouse births) = 21.2. §lncluding Maternity Hospital (594 cases, of which 138 belong to Lambeth)—corrected rate (i.e., excluding all the Maternity births) = 22.8. Inner Districts, 37.02; Outer Districts, 21.6 per 1,000—uncorrected (whole Borough = 28.1). Inner Districts, 27.3; Outer Districts, 19.9 per 1,000—corrected (i.e., excluding all Institutional births, whole Borough = 22.9). N.B.—The births in Stockwell new Sub-District are divided equally between the Inner and Outer SubDistricts of the Borough for the purpose of calculating th e comparative rates of such Sub-Districts. TABLE B. Showing the Populations (Estimated), Uncorrected Births, Corrected Deaths and Uncorrected Deaths in Public Institutions, in the Borough of Lambeth during 1913, and during the previous decennium 1901-10, together with the averages for the two decennia 1891-1900 (Parish) and 19011910 (Borough). Year. Estimated Population. Number of Births Registered. Corected Numbers of Deaths. Deaths in Public Institutions in Lambeth (uncorrected) Total Ages Under I Year. Under 5 Years. Deaths from 7 Chief Zymotic Diseases. 1913 297139 8341 4280 733 1094 369 2015 1901 30 2533 9093 5197 1267 1840 627 1590 1902 305102 9067 5387 1155 1722 561 1822 1903 307711 9069 4664 1138 1625 498 1619 1904 310359 9059 4880 1243 1778 603 1728 1905 313045 8835 4646 1014 1455 431 1807 1906 315774 8972 4709 1088 1561 522 1925 1907 318538 8650 4652 941 1458 379 1923 1908 321344 8906 4341 829 1-263 397 2011 1909 324188 8445 4540 830 1250 402 1994 1910 327074 8373 4080 691 1083 331 1749 average 1901-10 314566.8 8846.9 4709.6 1020.i 1503.5 475.1 1816.8 1891-1900 294049.7 9295.4 5405.3 1358.5 2070.2 700.4 1568.5 Note.—(a) Enumerated Population at Census 1901 was 301,895. (b) Enumerated Population at Census 1911 was 298,058. (c) Families or separate occupiers = 70887 (1901) and 70827 (1911). N.B.—The estimated population for 1913 is calculated from the 1901 and 1911 Censuses, and those for the decennium 1901-10 from the 1891 and 1901 Censuses. 8 TABLE C Shewing the Birth; and Death-Kates (corrected), and proportion of Deaths (uncorrected) Institutions, in the Borough of Lambeth for the Year 1913, and for the 10 years 1909-1910. the averages for the two decennia 1891-1900 (Parish) and 1901-10 (Borough The Year. Birth- Rate per 1000 Population. Corrected Death-Rate per 1000 Population. Corrected Deaths of Children under 1 year per 1000 total Births. Deaths of Children under 1 year per 1000 Deaths (corrected) Deaths of Children under 5 years, per 1000 Deaths (corrected) Corrected Zymotic DeathRate, per 1000 Population. Deaths in Public Institutions per 1000 total uncorrected Deaths. 1913 28.1 14.4 87.9 171.3 255.6 1.2 4 50.2 1901 30.1 17.2 139.3 243 8 354.1 2.7 395.4 1902 29.7 17.7 127.4 214.4 319.7 1.8 328.1 1903 29.5 15.2 125.8 243.9 348.4 1.6 333.6 1904 29.2 15.7 137.7 255.7 364.3 1.9 334.9 1905 28.2 14.8 114.8 218.3 313.2 1.4 369.1 1905 28.4 14.9 121.3 231.04 331.5 1.7 382.9 1907 27.2 14.6 108.8 202.3 313.4 1.2 309.4 1908 27.7 13.5 93.1 193.3 290.9 1.2 428.6 1909 26.4 14.0 98.3 182.8 275.3 1.2 408.9 1910 25.6 12.5 82.5 169.4 265.4 1.01 402.3 Average 1001-10 28.1 14.9 115.3 216.7 319.4 l.5 386.01 1891.1900 31.6 18.4 146.1 251.3 382.9 2.4 276.7 N B.—The rates for 1913 are calculated upon the population estimated from the 1901 and 1911 Censuses, and the decennia 1891-1900 and 1901-10 upon the populations estimated from the 18S1, 1891 and 1901 Censuses 9 THE BIRTH RATE. The total number of Births registered during the year 1913 is 8,341. Of the total 8,341 births, 4,184 are males, and 4,157 females, showing an excess of 27 males. Of the total 8,341 births registered, 695 took place in the Lying-in Hospital (York Road), and of these 188 belong to the Borough; 223 took place in the Workhouse (Brook Street), and of these 206 belong to the Borough; whilst 594 took place in the Maternity Hospital (Jeffrey’s Road), and of these 138 belong to the Borough. Thus, there are 980 births belonging to other districts. The Lying-in Hospital, the Workhouse and the Maternity Hospital tend to abnormally increase the birth-rates in Lambeth Church, Kennington and Stockwell Districts respectively, and the necessary corrections are, consequently, made in a footnote to Table A. The birth-rate for Lambeth is 28.1 per 1,000 inhabitants (29.5 for males and 26.8 for females); whilst in the various Registration Sub-Districts the birth-rates work out as shown in Table A, from which it will be seen that the uncorrected birth-rate in the Inner Districts is 37.02, and that in the Outer Districts 21.6 per 1,000—the corrected birthrates (i.e., excluding (a) Non-Lambethian births and (b) all Institutional births) being respectively (a) 24.8 and (b) 22.9 for the whole Borough, (a) 30.9 and (b) 27.3 for the Inner, and (a) 20.3 and (b) 19.9 for the Outer, Districts. Tables B and C show, for comparison, the number of births, and the birth-rates, for 10 years (1901-1910) in the Borough. The birth-rate for Lambeth (Parish and Borough) has been recently slowly, but steadily, declining. As has been previously noted, this decline is not peculiar to Lambeth, nor 10 even to England, but is to be found in nearly all civilised countries. Notification of Births Act. The Notification of Births Act, 1907, was adopted throughout the Borough, and came into operation on March 9th, 1908. Since the Act came into force, a total of 37,507 births have been notified up to the end of 1913, viz.: 3,473 in 1908 (10 months), 5,143 in 1909, 6,703 in 1910, 7,094 in 1911, 7,336 in 1912 and 7,158 in 1913. The notified cases are visited, or such other measures taken in connection therewith, in the way of distributing pamphlets, etc., as are found necessary. Methods of feeding are carefully inquired into and instruction given as required. Returns of all Births (with addresses of mothers), registered in Lambeth, have also been obtained from the District Registrars, and this information, in conjunction with that obtained from the Notification of Births Act, has again proved of great use statistically in connection with the Borough Council’s endeavours to lessen the mortality amongst infants (under 1 year of age). The maximum time allowed for birth registration is 42 days, but this delay is detrimental to satisfactory administrative procedure, and has been altered by the Notification of Births Act, 1907, which limits the time of notification to 36 hours from the time of birth, though, on the other hand, all births are not yet notified by those responsible under the Notification of Births Acts so that the supplementary information, obtained from the District Registrar, is of use. A list of all notified births is sent to the London County Council weekly in pursuance of sub-section 5, of section 2, 11 of the Act, and the Medical Officers of Health concerned are written to in connection with babies born in Lambeth Public Institutions, but belonging to Districts outside the Borough. The Registrar-General provides particulars of transferable births registered, and for 1913 his figures for the Borough of Lambeth are as follow:— Inward Outward Transfers. Transfers. Legitimate Males 19 472 Legitimate Females 12 405 Illegitimate Males 18 166 Illegitimate Females 17 126 Totals 66 1169 The Registrar-General’s corrected number of births for the year 1913 for the Borough is 7,233. THE DEATH-RATE. The total number of deaths registered during the year 1913 is 4,476 as compared with yearly averages of 5,669.5 and 4,971.5 respectively during the two decennia 1891-1900 and 1901-1910. Of the total 4,476 deaths registered during 1913, 2,307 are males and 2,169 females. The uncorrected death-rate for Lambeth is, therefore, 15.1 per 1,000 inhabitants (16.3 males and 13.9 females). These rates, are, however, uncorrected, and, on analysing the 4,476 deaths registered in the Borough, it is found that 883 represent deaths occurring within the Borough amongst persons not belonging thereto. These deaths are to be deducted, but, on the other hand, there are 687 deaths registered outside the Borough of persons belonging thereto, and these must be added, giving a corrected number of deaths for Lambeth during 1913 of 4,280, and a corrected death-rate of 14.4 per 1,000 inhabitants. 12 The yearly averages of corrected deaths within the Parish and Borough of Lambeth during the two decennia, 18911900 (Parish), and 1901-1910 (Borough), are, respectively, 540.1.3 and 4,709.6. Deaths in Out-Lying Institutions. The Outside Institutions, etc., where the 687 Lambethians died during 1913 may be grouped as follows:— I. General Hospitals. Charing Cross 28 St. Bartholomew’s 9 Guy’s 26 St. George’s 13 King’s College 5 University 3 London 9 Westminster 66 Middlesex 16 II. Special Hospitals. Bethlem Royal 1 French 2 Bolingbroke 3 German 1 Bow Institution 21 Gt. Ormond Street 11 Brompton 11 Grove 20 Brook Hospital 2 Heart, Soho 1 Cancer 8 Homœpathic 3 Catholic Nursing Home for Sick stitute 1 ren, Sydenham 3 Central London Hostel of God 9 Throat and Ear 2 Infants’, Vincent Sq. 33 Chelsea Hospital for Italian Hospital 1 Women 3 Mount Vernon 2 Chest, Bethnal Green 1 Metropolitan 1 City of London 1 National 4 Downs Sanatorium, New Hospital for Sutton 5 Women 1 East London 2 Northern Fever Hospital Evelina 22 2 Freidenheim 2 Park 14 Queen Alexandra— St. Mary’s 5 Military 2 Seamen’ Hospital 1 13 II. Special Hospitals—continued Queen Mary’s 4 South-Eastern 12 Royal Eye 1 Southern Hospital 1 Royal Free 3 Union Infants 1 Seaman’s Hospital 1 University College 1 St. Joseph’s, Hackney 4 Victoria 1 St. Peter’s 3 Western 7 St. Luke’s House, West London 1 Kensington 8 III. Infirmaries and Workhouses. Belmont Workhouse 1 St. James’ Infirmary City of Westminster 1 (Battersea) 4 Camberwell Infirmary 4 St. Giles’ Work- Hampstead Workhouse 1 house 1 Kensington Infirmary 1 Southwark Infirmary 5 Marylebone Infirmary 2 Wandsworth Infirmary 2 St. George’s Work- Westminster Infirmary 2 house (Southwark) 1 IV. Asylums. Ban stead 10 Fountain (temporary) 3 Camberwell House 1 Hanwell 6 Cane Hill 19 Horton 28 Caterham 23 Leavesden 2 Claybury 3 Long Grove, Epsom 26 Colnev Hatch 5 Manor 6 Darenth 2 Peckham House 5 Dartford 8 Tooting Bee 41 V. Unclassified. Places. Adelphi Theatre 1 River Thames 11 Battersea Park Road Streets 5 Station 1 Surrey Commercial Coliseum Music Hall 1 Docks 1 Holloway Prison 2 Sewer, Kensington 1 Olympia, Addison In Train, Victoria Road 1 Station 1 Railway Arch,Wands H.M. Prison, Wandsworth Road 1 worth 1 Private Houses 24 14 Summary. I. General Hospitals 1/5 II. Special Hospitals 249 III. Infirmaries and Workhouses 24 IV. Asylums 188 V. Elsewhere (unclassifiable) 51 Total 687 Whether the corrected or uncorrected death-rates for the Borough (as a whole) be taken, they are satisfactory for the year 1913 (the thirteenth year of the existence of the Borough). Sub-dividing the death-rates according to Registration Sub-Districts, it is again shewn that the Inner Districts (Lambeth Church, Kennington, and inner part of Stockwell) have, collectively and individually, suffered more than the Outer Districts, e.g., outer part of Stockwell, Brixton and Norwood. So, too, if the deathrates be sub-divided amongst the Wards, it will be noted also that the Inner Wards, e.g., Marsh, Bishop’s, Prince’s and Vauxhall, have, collectively and individually, suffered more than the Outer Wards, e.g., Stockwell, Brixton, Herne Hill, Tulse Hill and Norwood. The reason for this difference is again to be noted in the fact that the Inner Districts are more congested than the Outer. The status of the inhabitants and the general conditions (sanitary and otherwise), under which they live, are also matters to bear in mind, when dealing with this subject. Taking the Registration Sub-Districts (Table D (1)), and the Wards (Table D (2)), into which the Borough is subdivided, the corrected death-rates for 1913 will be found to vary between the Inner and the Outer Districts as follows: 15 1913 Registration Sub-Districts and Wards. Inner. Outer. General Death-rate (corrected) 18.1 11.8 Zymotic Death-rate (corrected) 2.1 0.7 Of the Registration Sub-Districts, Lambeth Church has the highest general and zymotic death-rates, and Norwood the lowest general and zymotic death-rates; whilst, in the Wards, Prince’s has the highest general, and Marsh and Bishop’s the highest zymotic death-rates, and Tulse Hill the lowest general and zymotic death-rates. Tables E, F, and G show the uncorrected returns (male and female), registered during 1913, arranged as to Registration Sub-Districts, age-periods, and quarters respectively, and are given for comparison with similar tables in former Lambeth Reports, though uncorrected returns are not of much value. Age Periods of Corrected Deaths. The 4280 corrected deaths during 1913 may be further analysed, and tabulated as follows:— 733, i.e., 17.1 per cent. of the total corrected deaths took place under 1 year of age. 361, i.e., 8.4 per cent. between 1 and 5 years. 1094, i.e., 25.5 per cent. under 5 years. 184, i.e., 4.3 per cent. between 5 and 20 years. 486, i.e., 11.4 per cent. 20 to 40 years. 868, i.e., 20.3 per cent. 60 and over. 1648, i.e., 38.5 per cent. over 5 years. 16 TABLE. D (i). BOROUGH OF LAMBETH STATISTICS FOR 1913. Registration Sub-Districts. Total number of Deaths (corrected). Death-Rates (corrected) per 1000 population. Total number of Deaths (uncorrected) Infantile Mortality (uncorrected) General Zymotic. General. Zymotic. Under 1 year. per 1000 births. Lambeth Church 878 122 18.9 2.6 289 122.1 Kennington 865 81 18.1 1.7 130 105.5 Stockwell (Inner 503 54 14.1 1.2 123 61.1 Outer 377 22 Brixton 953 52 12.3 0.7 213 137.3 Norwood 704 38 108 0.6 76 64.5 Borough of Lambeth 4280 369 14.4 1.2 831 99.6 Inner Districts 2246 257 18.1 2.1 481 104.4 Outer Districts 2034 112 11.8 0.7 350 93.8 N.B.—In calculating the infantile mortality rates, the uncorrected deaths and births registered in Stockwell Registration Sub-District are divided equally between the Inner Stockwell Sub-District (= Vauxhall Ward) and the Outer Stockwell Sub-District (== Stockwell Ward). 17 Table d (2). BOROUGH OF LAMBETH. STATISTICS FOR 1913. Wards. Total Number of Deaths (corrected). Death-Rates (corrected) per 1000 population. Total Notified Cases. Zymotic Incidence per 1000 population. General. Zymotic. General. Zymotic. Marsh 874 49 17.7 2.3 205 9.7 Bishop’s 504 73 16.2 2.3 412 13.3 Prince’s 865 81 20.7 1.9 602 14 .4 Vauxhail 503 54 16.5 1.9 430 14.1 Stockwell 377 22 11.8 0.7 355 11.1 Brixton 562 28 12.7 0.6 543 12.3 Heme Hill 391 24 11.8 0.7 432 13.03 Tulse Hill 335 17 10.7 0.5 222 7.1 Norwood 369 21 11.4 06 330 6.3 Borough of Lambeth 4280 369 14.4 1.2 3531 11.9 Inner Districts 2247 257 181 2.1 1642 13.3 Outer Districts 2034 112 11.8 0.7 1882 10.9 18 TABLE E. Shewing the uncorrected Mortality (Male and Female) in the different Registration Sub-Districts of the Borough of Lambeth (arranged Quarterly) during the year 1913. Sub-District. 1st Quarter. 2nd Quarter. 3rd Quarter. 4th Quarter. Total 1912. M. F. Total M. F. Total. M. F. Total. M. F. Total. Lambeth Church 173 135 308 160 110 270 195 125 320 214 159 373 1271 Kennington 193 176 369 160 143 303 118 122 240 158 171 329 1241 Stockwell 84 103 187 74 70 144 75 70 145 79 82 161 637 Brixton 104 111 215 101 80 181 76 87 163 110 124 234 793 Norwood 75 103 178 50 80 130 59 52 111 49 66 115 534 Totals 629 628 1257 545 483 1028 523 456 979 610 602 1212 4476 19 TABLE F. Shewing the uncorrected Mortality (Male and Female) at various age-periods in the different Registration Sub-Districts of the Borough of Lambeth during the year 1913. Sub-District. Under 1 year. 1 to 5 years. 5 to 60 years. 60 years and upwards Total. 1913. M. F. Total M. F. Total. M. F. Total. M. F. Total. Lambeth Church 160 129 289 96 53 149 365 250 615 121 97 218 1271 Kennington 66 64 130 42 26 68 256 196 452 265 326 591 1241 Stockwell 66 57 123 52 48 100 104 103 207 90 117 207 637 Brixton 124 89 213 31 26 57 116 118 234 120 169 289 793 Norwood 41 35 76 15 11 26 80 80 160 97 175 272 534 Totals 457 374 831 236 164 400 923 746 1669 691 885 1576 4476 TABLE . G. Shewing the uncorrected Deaths (Male and Female) at various age periods in the Borough of Lambeth (arranged quarterly) during the year 1913. Age-periods. 1st Quarter. 2nd Quarter. 3rd Quarter. 4th Quarter. Totals. M. F. Total. M. F. Total. M. F. Total. M. F- Total. Under 1 year 111 100 211 101 82 183 140 85 225 105 107 212 831 Between 1 and 5 yrs. 68 45 118 66 42 108 39 37 76 63 40 103 400 Between 5 and 60 yrs. 247 211 458 197 556 353 211 170 381 268 209 477 1669 60 yrs. and upwards 203 272 475 187 203 384 133 164 297 174 246 420 1576 Totals 628 629 1257 545 483 1028 523 456 979 610 602 1212 4476 20 2 1 Changes in Registration ok Deaths. The Registrar-General decided to publish from January 1st, 1911, in his annual reports, an analysis of deaths according to administrative areas instead of registration areas as hitherto, and this decision necessitates a complete distribution of the deaths of persons dying away from their homes to the administrative areas in which they had previously resided. Reports were received quarterly during 191.1 from the Registrar-General—a total of 91 deaths—on slips, giving particulars of outside deaths assigned to the Borough of Lambeth, in addition to those occurring in the Metropolis or in the Metropolitan Institutions (outside Lambeth), which are still reported as hitherto. The tables at the end of the Report (Appendix), known as the Local Government Board Tables, have been revised and modified, in consequence, and will give accurate corrected statistics of deaths within the Borough of Lambeth (differing slightly from the statistics in the body of the Report), the figures required for the necessary corrections being I hose specially supplied by the Registrar-General. These Registrar-General's figures for 1911 are as follows:— Age Periods. Males. Females. Totals all ages. 0—1 3 1 4 1— 2 .... 1 1 2— 5 4 ... 4 5—15 .... .... .... 15—25 3 2 5 25—45 6 15 21 45—65 23 14 37 65 and upwards 10 11 21 Total all ages 49 44 93 22 23 TABLE H I TABLE H I Shewing the estimated populations and the number Districts of the Borough during 1913. The Deaths are from of Deaths, with Death-rates in each of the Registration Subcorrected by adding Lambethians who die outside the all causes, and from the chief zymotic diseases, and are and by re-distributing persons (who die in Public Institutions) Borough, by omitting strangers who die within the Borough, illness. into the Districts from which they have been removed during A. Registration _ Sub-Districts. REGISTRATION SUB-DISTRICTS. Estimated Population (middle 1913) Total Deaths (corrected). General corrected Deathrate per 1000 of the Population. Small Pox. Measles. Scarlet Fever. Total Deaths (corrected) from Total Zymotic Deaths. Zymotic Death-rate per 1000 of the Population (corrected). Zymotic Death-rate per 1000 of the Total Deaths (corrected). Diarrhoea Death-rate per 10000 of the Population. Diphtheria and Membranous Croup. Whooping Cough. Typhus. Typhoid or Enteric. Continued Fever. Cholera. Diarrhœa. Lambeth Church 46241 878 18.9 ... 39 2 9 10 ... ... ... ... 62 122 2.6 138.9 13.4 Kenningtont† 47672 865 18.1 ... 24 2 7 11 ... ... ... ... 37 81 1.7 93.6 7.8 Stockwell§ 62316 880 14.1 ... 22 4 12 10 ... 2 ... ... 26 76 1.2 86.4 4.2 Brixton 77363 953 12.3 ... 9 5 1 11 ... 4 ... ... 22 52 0.7 54.4 2.8 Norwood 63547 704 10.8 ... 4 1 8 5 ... 1 ... ••• 19 38 0.6 53.9 2.9 Borough of Lambeth 297I39 4280 14.4 ... 98 14 37 47 ... 7 166 369 1.2 86.2 5.6 Of the 880 deaths in Stockwell Registration Sub-District, Inner Registration Sub-Districts—death rates Outer Registration Sub-Districts—death rates N.B.—Of the total deaths (corrected), 42 shew no addresses, and the Workhouse Infirmary (26), or in the 503 belong to the Inner and 377 to the Outer Stockwell Sub-District, (general 181, zymotic 21). (general 118, zymotic 0.7). have been included in Kennington Sub-District—having occurred in Workhouse (16) respectively. 24 TABLE H (2). TABLE H (2). Shewing the estimated populations and the number of Deaths, with Death-rates, in each of the Wards of the Borough during 1913. The Deaths are from all causes, and from the chief zymotic diseases, and are corrected by adding Lambethians who die outside the Borough, by omitting strangers who die within the Borough, and by re-distributing persons (who die in Public Institutions) into the Districts from which they have been removed during illness. B. Wards. B. Wards. WARDS. Estimated Population (middle 1913). Total Deaths (corrected). General corrected Deathrate per 1000 of the Population. Small Pox. L . Total Deaths (corrected) from Total Zymotic Deaths. Zymotic Death-rate per 1000 of the Population (corrected). Zymotic Death-rate per 1000 of the Total Deaths (corrected). Diarrhoea Death-rate per 10000 of the Population. Measles. Scarlet Fever. Diphtheria and -Membranous Croup Whooping Cough. Typhus. Typhoid or Enteric. Continued Fever. Cholera. Diarrhœa. Marsh 21079 374 17.7 .. 19 ... 3 4 ... ... ... ... 23 49 2.3 131.0 10.9 Bishop’s 31065 504 16.2 ... 20 2 6 6 ... ... ... ... 39 73 23 144.8 12.6 Prince’s 41752 865 20.7 ... 24 2 7 11 ... ... ... ... 37 81 1.9 93.6 8'8 Vauxhall 30426 503 16.5 ... 19 1 7 8 ... 2 ... ... 19 54 1.9 107.4 6.2 Stocksvell 31889 377 11.8 ... 3 3 5 2 ... ... ... ... 7 22 07 58.4 2.2 Brixton 44207 562 12.7 ... 8 1 1 5 ... 3 ... ... 10 28 0.6 49.8 2.3 Heme Hill 33156 391 11.8 ... 1 4 ... 6 ... 1 ... ... 12 24 0.7 61.4 3.6 Tulse Hill 31211 335 10.7 ... 2 ... 2 2 ... ... ... ... 10 17 0.5 50.7 3.2 Norwood 32336 369 11.4 ... 2 1 6 3 ... 1 ... ... 9 21 0.6 56 .9 2.8 Borough of Lambeth 297139 4280 14.4 ... 98 14 37 47 ... 7 ... ... 166 369 1.2 86.2 5.6 25 Inner Wards—death rates (general, 18.l; zymotic, 2.1). N.B.— Of the total deaths (corrected), 42 show no addresses and occurred in the Workhouse Infirmary (26) or in the Workhouse Outer Wards—death rates (general, 11-8 ; zymotic, 07). have been included in Bishop’s and Prince’s Wards, having (16) respectively. 26 Causes of the 93 Outside Deaths. Causes of Death. Male. Female. Diphtheria 1 .. Influenza ... 2 Typhoid 1 ... Measles ... 1 Phthisis (Pulmonary Tubeiculosis) 6 8 Other Tubercular diseases 1 ... Cancer, malignant disease 5 ... Heart disease 3 7 Bronchitis 3 1 Pneumonia 1 3 Broncho-Pneumonia ... 1 Other Lung diseases 1 2 Nephritis and Bright’s disease 3 1 Violent deaths 4 3 Suicide 1 1 Appendicitis 1 ... Nervous diseases 5 6 Strangulated Hernia ... 1 Diabetes Mellitus 1 ... Diseases of Digestive ... System 1 Prepura hemorrhagica ... 1 Rheumatic Fever 1 2 Not classified above 11 3 49 44 INFANTILE MORTALITY, 1913 Of one 4,280 corrected deaths, 733 are infants under one year of age. The total number of registered births is 3,341, and, of these, 507 occurred at the Lying-in Hospital, and belong to districts outside Lambeth Borough, 17 occurred 27 at the Workhouse, and belong to districts outside Lambeth Borough, and 436 occurred at the Maternity Hospital and belong to districts outside Lambeth Borough. In this way, the corrected number of births for the Borough is 7,361* The corrected infantile mortality (i.e., rate of corrected deaths under one year per 1,000 corrected births) is therefore, 99.6. The annual average for the decennium 1901-10 (Borough), is 122.7. In calculating this corrected infantile mortality, it must be remembered that, whilst we subtract the births that belong to outside districts, we do not add the births of infants of Lambethian mothers who may happen to be residing outside the Borough at the times of such births. Taking the uncorrected births and the corrected deaths under 1 year, the infantile mortality rate is 87.9. The annual average for the decennium 1901-10 (Borough), is 114.8. Taking the uncorrected number of births (8,341) and the uncorrected number of deaths under 1 year of age (831), the uncorrected infantile mortality is 99.6. The annual average for the decennium 1901-10 (Borough) is 123.8, and that for the decennium 1891-1900 (Parish) is 150.5. The chief causes of the deaths were debility, atrophy, and inanition, congenital malformations, measles, whooping-cough, bronchitis, and other diseases of the respiratory organs, diarrhoea, and premature births. In the Registration Sub-Districts, the uncorrected infantile mortality varied from 137.3 per 1,000 births in Brixton to 61.1 in Stockwell (the low rates of 122.1 in Lambeth Church, 105.5 in Kennington, and 61.1 in Stockwell, being due to the fact that these Sub-Districts contain the General Lying-in Hospital, the Workhouse and the Clapham Road Maternity Hospital respectively), thus— *The Registrar-General returns the corrected number of births for the Borough during 1913 as 7233. 28 Total No. of Births (uncorrected). 1913. Total Deaths under 1 year (uncorrected). 1913. Infantile Mortality per 1,000 births (uncorrected). 1913. Lambeth Church* 2366 289 122.1 Kenningtont† 1282 130 105.5 Stockvell‡ 2013 123 61.1 Rrixton 1551 213 137.3 Norwood 1179 76 64.5 Lambeth 8341 831 99 6 Inner Districts—104.4, Outer Districts—93.8 Excluding all the Lying-in Hospital births, the rate is 172.9. †Excluding all the Workhouse births, the rate is 128 8. ‡Excluding all the Maternity births, the rate is 86.7. N.B. —The births and deaths in Stockwell Registration Sub-Districts aredivided equally between the Inner and Outer Districts for the purpose of ealculating infantile mortality rates for such Districts in this Table. The Infantile Mortality is regarded as a sensitive index of the sanitary state of a District, and, judged by this index, Lambeth Borough again takes a good position amongst Sanitary Districts, a satisfactory fact to be able to slate and one that is due to the precautionary measures that are taken. Systematic visiting and giving advice as to the feeding and management of infants and children, together with the free distribution. of official pamphlets dealing with the same and kindred subjects, account in part for the decline in the infantile mortality-rate throughout the Borough, whilst the influence of the Milk Deoot must not be forgotten. The Notification of Births Act 1907, is valuable in connection with precautionary measures taken to prevent infantile mortality. Meteorological conditions were favourable during 1913 to a low infantile mortality-rate (vide Diarrhoea). A leaflet was distributed freely throughout the crowded Inner Districts of the Borough during 1913, dealing with preventive measures to be taken against Summer Diarrhœa. 29 CLASS I. -ZYMOTIC DISEASES. Principal Zymotic Diseases. The principal zymotic diseases are seven in number, viz., smallpox, measles, scarlet fever, diphtheria (including membranous croup), whooping cough, “fever” (including typhus, typhoid or enteric, and simple, or relapsing, or continued), and diarrhcea; and the zymotic death-rate is made up from the total deaths from these diseases. In the Borough, during 1913, there were registered 400 deaths from the seven zymotic diseases, and of these 110 are strangers belonging to other districts, and 290 parishioners who died within the Borough. 79 parishioners, however, died from the seven principal zymotic diseases outside the Borough. Subtracting the strangers, and adding on the parishioners who died without the Borough, there is a corrected total of 369, giving a zymotic corrected death-rate of 1.2 per 1,000 inhabitants. The yearly averages of the numbers of deaths (corrected) from the 7 principal zymotic diseases for the two decennia 1891-1900 (Parish), and 19011910 (Borough), are respectively 679.6 and 475.1. As a test of the sanitary condition of a community, the zymotic death-rate is of approximate value, and in this respect Lambeth Borough stands well. The zymotic death-rates (corrected) for the different Registration Sub-Districts vary as shown in Tables D (1) and H (1) which, in addition, give the general death-rates. Lambeth Church shows the highest, and Norwood the lowest zymotic death-rates respectively. The corrected zymotic death-rate for the Inner Districts is 2.1, and for the Outer 0.7—a difference explainable, as before, by the crowding and absence of proper means of home isolation and nursing in the former, as compared with the latter districts. Crowded districts naturally suffer more in this respect than those more sparsely populated. b 30 Similar conclusions are obtainable by comparing the zymotic death-rates (corrected) for the different new Wards, as shewn in Tables D(2) and H(2), from which it is seen that, of the 9 Wards into which the Borough is divided, Marsh and Bishop’s show the highest and Tulse Hill and Norwood the lowest, zymotic death-rates. During the year 1913, under the Notification Clauses of the Public Health (London) Act, 1891, 3,531 cases of Infectious Diseases were reported, including the newly-notifiable cerebro-spinal meningitis 7, polio-myelitis acuta 6, ophthalmia neonatorum 57 and whooping cough 1,428. The yearly averages of notification certifiates received during the two decennia 1891-1900 (Parish) and 1901-1910 (Borough) are respectively 2,658.4 and 1,912.5. Of the total 3,531 cases notified during 1913, 1753, i.e., 49.6 per cent., were removed to the Hospitals of the Asylums Board or to other Hospitals, and 1,778, i.e., 50.4 per cent., remained under treatment at their homes. If the newly-notifiable diseases, cerebro-spinal meningitis, polio-myelitis acuta, ophthalmia neonatorum and whooping cough be excluded, the percentage of cases removed to Hospital for isolation and treatment durng 1913 was 81.6 —a good average when compared with the following last 4 quinquennial averages (also exclusive of the special diseases mentioned above), i.e., since the compulsory notification of infectious diseases came into force under the Public Health (London) Act, 1891 1891-5, 31.5; 18961900, 54.7; 1901-1905, 67.9; and 1906-10, 82.8. Taking the total number of notified cases 1(3,531) of infectious diseases, the zymotic incidence* throughout the Borough for 1913 is 9.7 per 1,000 population (13.3 Inner and J Hb' Whooping Cough, Ophthalmia Neonatorum, Polio-myelitis Acuta, Cerebro spinal Meningitis are included in the 1913 figures. Excluding them, the incidence rate for 1913, is 68 for the Borough. 31 10.9 Outer Districts) as compared with two decennial averages 1901-1910 (Borough) and 1891-1900 (Parish) of 6.1 and 9.04 respectively. During 1913, the highest incidence rate is 14.4 (Prince’s), and the lowest 6.3 (Norwood). Further, excluding the ophthalmia neonatorum and whooping cough cases, in connection with which no systematic sanitary examination was made, the number of infected houses, in which the remaining 2,046 notified cases occurred, was 1,879, and in each of these houses a systematic sanitary examination was made of the drains and the traps, fittings and appliances with the following results:— (a) 110 (i.e., 5.9 per cent.) were found to have defective drains, i.e., gave results with the tests employed. (b) 857 (i.e., 45.6 per cent.) were found to have defective traps, fittings and appliances. (c) 912 (i.e., 48.5 per cent.) showed no defects. These figures are comparable with the quinquennial averages for the Parish during 1891-95 and 1896-1900, and for the Borough during 1901-5 and 1906-1910, given in Table 1. Sub-divided according to the different notifiable diseases the results for 1913 show as follow:— B 2 32 Disease. No. of Infected Houses. Number shewing Defects as to Percentage shewing Total Defects. Percentage shewing no Defects. Drains. Traps, Fittings and Appliances. Total. Smallpox — - - - - - Cholera — - - - - - Diphtheria 365 25 183 208 56.9 43.1 Membranous Croup 7 — 4 4 57.1 42.9 Erysipelas 206 8 95 103 50.0 50.0 Scarlet Fever 1227 73 554 627 511 48.9 Typhus — — — - - - Typhoid 34 1 11 12 35.3 64.7 Continued 2 — 2 2 100.0 0.0 Puerperal 25 1 4 5 20.0 80.0 Cerebro-spinal Meningitis 7 — 3 3 42.9 57.1 Anterior poliomyelitis 6 2 1 3 50.0 50.0 Totals 1879 110 857 967 51.5 48.5 N.B.—56 ophthalmia neonatorum and 1037 whooping cough infected houses are omitted, no systematic sanitary examinations being made in those cases. Table I. Giving number of Infected Houses, with percentages of (1) General Defects, and (2) Defective Drains, during 1913, together with the averages during the quinquennia 1891-1895 (Parish), 18961900 (Parish), 1901-1905 (Borough) and 1906-1910 (Borough). 1891-1895 (Average). 1896-1900 (Average). 1901-1905 (Average). 1906-1910 (Average). 1913 (Totals). Number of Infected Houses 2229.8 2262.4 1682.6 1719.2 1879 Number of Houses with defects found 1220.0 1096.0 911.2 1033.6 967 Number of Houses with defective drains found 5100 366.6 214.6 166.6 110 Number of Houses with no defects found 1009.8 1166.4 771.4 685.6 912 N.B.—56 infected houses (wherein 57 cases of Ophthalmia Neonatorum occurred and 1037 infected houses, wherein 1428 cases of whooping cough occurred) are omitted from the 1913 figures, so that the results may be strictly comparable with those of previous years, i.e., before Ophthalmia Neonatorum and Whooping Cough were made notifiable diseases. 34 35 The Health Department has also heard of, and dealt with, Chicken-pox, 679; Measles, 1085; Cancer, 71; other diseases tuberculosis (1571 pulmonary and 456 non-pulmonary), notified with during 1913. Plague was made compulsorily notifiable on September 19th, 12th, 1907; Poliomyelitis acuta on September 1st, 1911; on January 1st. 1913. N.B.—In addition to the above, Chicken-pox was compulsorily (Jan. 1st to 6th), 1904 (April 8th to Nov. 8th), and 1911 (March tively 1560, 40, 556 and 238. TABLE J. TABLE J. compulsorily Notifiable Zymotic Diseases under the Shewing the number of Certificates for the Act, 1891, received in the Borough of Lambeth during notification clauses of the Public Health (London) with the averages of the two decennia 1891—1900 1913, and during the decennium 1901-1910, together (Parish) and 1901-1910 (Borough). Disease of Lambeth. Borough Annual Average, 1901-1910. (Borough.) Annual Average 1891-1900 (Parish). Total, 1913. 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 - - - - - 0.2 11.5 — Cholera 1 1 - - - - - - - - 49.9 22.0 — Smallpox 54 350 72 23 1025 1268 1481 1428 1164 910 11051 1331.3 1370 Scarlet Fever 1041 1330 744 660 439 415 317 320 373 318 379.8 715.1 385 Diphtheria 511 459 329 317 11 11 13 12 3 6 10.4 26.2 7 Membranous Croup 13 15 9 11 - — 1 - - — 0.1 1.1 - Typhus — — — — 77 89 56 63 49 77 100.5 189.6 38 Typhoid or Enteric 147 213 133 101 2 1 6 3 1 1 4.1 25.7 2 Continued or Relapsing 6 10 7 4 287 263 231 206 189 192 241.4 347.0 206 Erysipelas 236 317 236 257 12 27 22 10 16 18 17.0 18.9 25 Puerperal 16 17 17 15 - - - - - - - - *Plague - - - - - - 13 14 14 5 11.5 - 7 *Cerebro-Spinal Meningitis — — — — - - - - - - - - 6 *Poliomyelitis acuta — — — — - - - - - - - - 57 *Ophthalmia Neonatorum — — - - - - - - - - - - 1428 *Whooping Cough — — — — - - - - - - - - - Totals 3035 2712 1547 1382 1853 2074 2140 2056 1809 1527 19125 2658.4 3531 Average per 1000 of population 6.7 8.9 5.03 4.5 5.9 6.6 6.6 6.4 5.6 4.7 6.1 9.04 9.7 the following non-notifiable infectious diseases during 1913:— (e.g., Mumps, Influenza, Scabies,etc. 76, 2027 primary notifications of under the Tuberculosis Regulations, live also been received and dealt 1900; Cerebro-Spinal Meningitis (“Spotted Fever”) on March Ophthalmia Neonatorum on March 13th, 1911 and Whooping Cough notifiable as follows:—1902 (Feb. 7th to Dec. 31st), 1903 .22nd to June 22nd), the numbers of cases notified being respec- 36 TABLE K. Shewing corrected zymotic seasonal (quarterly) variations in the number of deaths from the 7 principal zymotic diseases in the Borough of Lambeth in the different Registration SubDistricts during 1913. Registration Sub-District. 1st Quarter 2nd Quarter. 3rd Quarter. 4th Quarter. Year 1913. Zymotic Death-rate per 1000 inhabitants. Lambeth Church 27 35 38 22 122 2.6 Kennington 19 17 26 19 81 1.7 Stockwell 16 19 29 12 76 1.2 Brixton 14 9 14 15 52 07 Norwood 10 9 8 11 38 06 Borough of Lambeth 86 89 115 79 369 1.2 Inner Districts 2.1; Outer Districts 0.7 per 1000 inhabitants. 37 TABLE L (I). Shewing the total cases notified compulsorily under the Compulsory Notification Clauses of the Public Health (London) Act, 1891, in the Borough of Lambeth, during 1913 (arranged Quarterly). 1st Quarter. 2nd Quarter. 3rd Quarter. 4th Quarter. Total for 1913. Cholera - — — — - Smallpox - — — - - Scarlet Fever 204 287 287 592 1370 Diphtheria 83 71 72 159 385 Membranous Croup 1 2 — 4 7 Typhus — — — — — Typhoid or Enteric Continued or Relapsing 12 4 11 11 38 Fever 1 - — 1 2 Erysipelas 39 52 39 76 206 Puerperal 9 5 6 5 25 *Plague — — — — — *Cerebro-Spinal Meningitis — 4 2 1 7 *Poliomyelitis acuta — 2 1 3 6 *Ophthalmia Neonatorum 12 17 18 10 57 *Whooping Cough 417 555 318 138 1428 Totals 778 999 754 1000 3531 Plague was made compulsorily notifiable on Sept. 19th, 1900 Cerebro-Spinal Meningitis on March 12th, 1907, Poliomyelitis acuta on September 1st, 1911, Ophthalmia Neonatorum on March 13th, 1911 and Whooping Cough on 1st January, 1913. Chicken-pox was compulsorily notifiable as follows: 1902 (Feb. 7th to Dec. 31st), 1903 (Jan. 1st to 6th), 1904 (April 8th to Nov. 8th), and 1911 (March 22nd to June 22nd), the numbers of cases notified being respectively 1660, 40, 656 and 238 38 TABLE L (2). Shewing the total cases notified voluntarily in the Borough of Lambeth during 1913 (arranged quarterly), together with the yearly averages for the decennium 1901-10 (Borough). - 1st Qr. 2nd Qr. 3rd Qr. 4th Qr. Total, 1913. Yearly average 10 years (1901-1910). Measles 651 310 61 63 1085 1376.4 Whooping Cough 132 303 131 46 612 429.6 Chicken-pox* 306 231 62 80 679 599.5 Consumption† 619 477 632 589 2317 668.6 Cancer 14 22 18 17 71 26.5 Total 1722 1343 904 795 4764 3100.6 *Chicken-pox compulsorily notifiable as follows:—1902 (Feb. 7th to Dec. 31st), 1903 (Jan. 1st to 6th), 1904 (April 8th to Nov. 8th), and 1911 (March 22nd to June 22nd), the numbers of cases notified being respectively 1560, 40, 556 and 238. †Consumption voluntarily notifiable throughout the Borough since June 1st, 1902, and compulsorily (Poor Law cases) under the Public Health (Tuberculosis) Regulations, 1908, since January 1st, 1909, and compulsorily (Hospitals) under the Public Health (Tuberculosis in Hospitals) Regulations, 1911, since May 1st, 1911. N.B.—76 other diseases (not classified) i.e., Scabies, Influenza, Ringworm, etc., and Vermin infections (649 Houses and 477 persons' clothing) were also dealt with during 1913. 39 TABLE M. Showing corrected Zymotic seasonal (monthly) variations in the number of deaths from the principal Zymotic diseases, and from Erysipelas, Puerperal Fever, Cerebro-spinal Meningitis Poliomyelitis acuta, and Ophthalmia Neonatorum in the Borough of Lambeth, during 1913. For the 4 weeks ending January. February. March. April. May. June. July. August. September. October. November. December. Total 1913 Smallpox - - - - - - - - - - - - - Scarlet Fever - 4 1 3 — — 2 1 — 1 — 2 14 Diphtheria 3 3 5 3 5 3 1 1 1 4 4 4 37 Membranous Croup — — — — — — — — — - — — — Typhus - - - - - - - - - - - - - Typhoid or Enteric 2 — — 2 — — 2 1 - — — 7 Continued or Relapsing Fever — — — — — — — — — - — — — Diarrhoea (including Cholera) 6 3 7 6 6 6 12 20 53 23 15 9 166 Measles 7 11 28 22 10 6 7 4 2 — — 1 98 Whooping Cough 3 5 5 3 11 4 5 4 1 2 — 4 47 Total of Seven Chief Zymotic Diseases 21 26 46 39 32 19 27 32 58 30 19 20 369 Erysipelas 1 — — 2 1 — — - — — 1 3 8 Puerperal Fever — 2 1 — I 1 — 1 2 — 1 — 9 Cerebro-spinal Meningitis — — — — 1 — 1 1 — - 1 — 4 Poliomyelitis acuta - - - - - - - - - - - - - Opthalmia Neonatorum - - - - - 1 - - - - - - 1 40 TABLE N. I TABLE N. Shewing the number of Deaths (corrected) from the 7 prin cipal zymotic diseases in the Borough of Lambeth during 1913 and during the decennium 1901-1910, together with the yearly averages for the two decennia 1891-1900 (Parish) and 1901- 1910 (Borough). Disease. 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 Annual average of ten years 1901 — 1910 (Borough). Annual Average of ten years 189]—1900 (Parish). Total (corrected) Deaths in 1913. Smallpox 4 60 4 - — — — — — — 6.8 1.1 — Scarlet Fever 39 48 23 16 31 28 38 42 27 22 31.4 48.8 14 Diphtheria 47 49 28 33 37 49 47 44 57 25 41.6 124.5 36 Membranous Croup 3 4 1 1 — 2 _ 2 1 1 1.5 6.8 1 Fever Typhus - - - — — - - — — - 0.0 0.3 — Typhoid or Enteric 23 38 24 11 10 22 5 8 9 17 16.7 34.7 7 Continued or Relapsing 3 I 1 — - 1 — — 1 —: 0.7 1.7 — Diarrhoea 272 159 160 265 176 268 71 150 118 90 172.9 196.5 166 Cholera 2 — 1 4 2 4 - - - - 1.3 8.8 — Measles 119 84 130 164 96 77 107 101 104 122 110.4 145.6 98 Whooping Cough 115 118 126 109 79 71 111 50 85 54 91.8 143.7 47 Borough of Lambeth 627 561 498 603 431 522 379 397 402 331 475.1 706.1 369 41 42 The quarterly seasonal mortality (corrected) from the whole of the different important zymotic diseases (i.e., principal and others) during 1913 is as follows:— 1913. Smallpox. Scarlet Fever. Diphtheria. Membranous Croup. FEVER. Diarrhoea. Cholera. Measles. Whooping Cough. Erysipelas. Puerperal Fever. Influenza. Total. Typhus. Typhoid or Enteric. Continued or Relapsing. 1stQr. - 5 8 — — 2 — 13 — 45 13 1 4 32 123 2nd Qr. — 3 13 — — 2 — 15 — 39 17 3 2 18 112 3rd Qr. — 3 4 - — 3 — 81 — 12 12 — 2 4 121 4th Qr. - 3 11 1 — — — 57 — 2 5 4 2 13 98 Totals - 14 36 1 — 7 — 166 — 98 47 8 10 67 454 Taking the zymotic diseases collectively, it is noticed that the 1st quarter showed the highest mortality, and the 4th the lowest. Scarlet fever, measles, puerperal fever and influenza, reached their maxima in the 1st quarter; diphtheria and whooping cough in the 2nd; diarrhoea and typhoid (or enteric) in the 3rd; and erysipelas and membranous croup in the 4th. Table K shews the zymotic seasonal variations in the different Registration Sub-Districts, while Table M gives the monthly mortalities from the zymotic diseases. Table N gives the deaths registered in the Borough of Lambeth from the seven principal zymotic diseases during 1911, and for the two decennia 1891-1900 (Parish) and 19011910 (Borough). 43 SMALLPOX During 1913, no single case of genuine small-pox was notified, nor was a single death from smallpox registered, within the Borough. Two doubtful cases (1 adult male and I boy) were reported at houses in Brailsford and Kennington Roads, respectively, but both proved not to be smallpox. The annual averages for smallpox for the decennium 1901-1910 are (1) notified cases 49.9, and (2) deaths 6.8, though no genuine case has been notified nor death registered within the Borough during the past 8 years. 6 “contacts”* were watched for 16 days each within the Borough during 1913, in connection with (a) persons arriving by vessels from abroad, such vessels coming from smallpox-infected places, or being themselves (?) smallpoxinfected by cases on board, e.g., S.S. “Victoria” (1) and S.S. “Manova” (5). Vaccination. The Vaccination Returns of the Local Government Board for the Borough are to be found in Tables O and P, dealing with the whole year 1912, and the first half of 1913 respectively.† These Returns are obtained from the Vaccination Officers. The total number of conscientious objectors who obtained certificates during 1913, irrespective of the dates of births of the children to which they relate, is 1,802, whilst the total number of certificates of successful primary vaccinations at all ages received during 1912 and 1913 are 5,677 and 4,440 respectively. *1 of the “contacts” could not be traced, a wrong address having been given to the Port Sanitary Authorities. †The yearly returns are not made up by the Local Government Board until August of the following year, so that only the Returns for the first half of the year 1913 can be given in this Report. 44 TABLE VACCINATION RETURNS (LAMBETH BOROUGH) FOR THE FIRST HALF-YEAR, 1913. Registration Sub-Districts. No. of Births (corrected). Successfully Vaccinated. Insusceptible to Vaccination. Dead Unvaccinated. Conscientious Objectors. Removed to other Parishes (known or unknown). Postponed by Doctors. Lambeth Church 1161 562 ... 70 137 348 5 Kennington 624 316 ... 37 99 125 23 Stockwell 1027 496 ... 56 229 214 23 Brixton 764 329 ... 49 196 128 52 Norwood 622 291 2 39 221 46 11 Lambeth 4198 1994 251 251 882 861 114 The Yearly Returns are not made up for the Local Government Board until the August in the following year. 45 TABLE O. VACCINATION RETURNS (LAMBETH BOROUGH), 1912. Registration Sub-Districts. No. of Births, (uncorrected). Successfully Vaccinated. Insusceptible to Vaccination. Dead Unvaccinated. Conscientious Objectors. Removed to other Parishes (known or unknown). Postponed by Doctors. Waterloo 1418 625 ... 89 134 569 1 Lambeth Church 1041 560 ... 64 113 283 13 Kennington 1318 701 1 107 183 285 18 Stockwell 1936 991 5 104 394 438 3 Brixton 1486 740 7 81 347 257 50 Norwood 1060 555 4 49 364 64 19 Lambeth 8259 4172 17 494 1535 1896 104 46 CEREBRO-SPINAL FEVER (EPIDEMIC CEREBRO- SPINAL MENINGITIS) OR “SPOTTED FEVER.”* During 1913, 7 cases of cerebro-spinal fever were notified in the Borough, 2 in Lambeth Church, 3 in Kennington and 2 in Brixton Registration Sub-Districts, and, of the 7 cases notified, 4 died ( = 57.1 per cent.). The necessary precautionary measures were taken in each case, 2 of the patients being removed to Hospital (1 from Lambeth Church and 1 from Kennington Sub-Districts). Particulars are set out in L.G.B New Table V (vide Appendix). ACUTE POLIO MYELITIS (ACUTE POLIO-ENCEPHALITIS).* During 1913, 6 cases of acute polio-myelitis were notified1 in the Borough, 1 in Lambeth Church, 1 in Kennington, 1 in Stockwell (Inner), 1 in Brixton and 2 in Norwood Registration Sub-Districts, and, of the 6 cases notified, none died. The necessary precautionary measures were taken in each case, 3 of the patients being removed to Hospital (1 from Lambeth Church, 1 from Brixton, and 1 from Norwood Sub-Districts). Particulars are set out in L.G.B. New Table V. (vide Appendix). CHICKEN-POX Chickenpox was not compulsorily notifiable during 1913 in the Borough, but through the head teachers of schools and voluntarily from other sources, 679 cases were reported to the Council and, in connection with these, disinfection and other necessary precautionary measures were taken. SCARLET FEVER During 1913, in the Borough, 1,370 cases of scarlet fever were notified, and 14 deaths registered, giving a case mortality of 1.02 per cent. The annual averages for *Made notifiable by Orders of the London County Council from and including March, 13th, 1912, throughout the administrative County of London, such Orders having been duly approved by the Local Government Board. 47 the two decennia 1891-1900 (Parish) and 1901-1910 (Borough) are respectively (1) notified cases 1,331.3 and 1,105.1, and (2) deaths 48.8 and 31.4. Of the 1,370 persons notified in the Borough during 1913, 1,212* (i.e., 88.5 per cent.), were removed to Hospital, and of these 14 died (i.e., 1.2 per cent.) whereas 158 (i.e., 11.5 per cent.) were treated at home, and of these none died. It will be noted that, of the total 1,370 persons reported as suffering from scarlet fever during 1913, within the .Of the 1212 cases of Scarlet Fever removed to Hospital, 82 proved at Hospital not to be suffering from that disease. The age and sex incidence and mortality for the 1,370 scarlet fever cases notified in Lambeth Borough during 1913 are as follow:— Age. Number of Cases notified. Deaths. Death Rate per 100 Notified. M. F. Total M. F. Total Total. Under 1 year 3 4 7 - - - 0.0 1 to 2 20 19 39 2 - 2 5.1 2 to 3 36 24 60 1 1 2 3.3 3 to 4 47 56 103 2 2 4 3.9 4 to 5 34 67 101 1 1 2 1.9 5 to 6 76 64 140 2 - 2 1.4 6 to 7 61 84 145 1 - 1 0.7 7 to 8 67 60 127 - - - 0.0 8 to 9 48 56 104 - - - 0.0 9 to 10 36 59 95 - - - 0.0 Over 10 years 184 265 449 1 - 1 0.2 Total 612 758 1370 10 4 14 1.02 48 Borough of Lambeth, 310 (i.e., 22.6 per cent.) were under five years of age, and 921 (i.e., 67.2 per cent.) under 10 years of age: whilst the case mortality was greatest amongst those between 1 and 2 years of age. Of the 449 persons over 10 years of age, 1 died (i.e., 0.2 per cent.). During 1913, outbreaks of scarlet fever were investigated in connection with 17 schools (infants' departments) and 42 absentees were visited and enquiries made in regard to the illnesses for which the scholars were being kept away from school. Doubtful cases of "sore-throat" (14 in number) and suspicious "peeling" cases (24 in number) were excluded, and the children not allowed to return until furnished with medical certificates. Several class-rooms and a whole school (infants' department) were closed in connection with three schools, owing to outbreaks of scarlet fever (and other infectious diseases*) amongst the scholars. The distribution of the cases of, and the mortality from, scarlet fever amongst the different Registration SubDistricts of the Borough during 1913, is as follow:— Registration Sub-Districts. Total No. of Cases Notified. Cases treated at Home. Cases removed to Hospital. No. of Deaths. Case Mortality per 100. At Home. In Hospital. Total. Lambeth Church 200 3 197 - 2 2 1.0 Kennington 217 11 206 - 2 2 0.9 Stockwell 320 36 284 - 4 4 1.25 Brixton 456 86 370 - 5 5 1.1 Norwood 177 22 155 - 1 1 0.6 Borough of Lambeth 1370 158 1212 — 14 14 1.02 * Measles, Diphtheria, Mumps and Chicken-pox. 49 14 schools were disinfected during 1913 in connectionwith scarlet fever cases notified amongst the scholars. MEASLES AND WHOOPING COUGH. In the Borough, during 1913, 98 and 47 corrected deaths were registered from measles and whooping cough, giving corrected death-rates per 10,000 of the populations of 3.3 and 1.6 respectively. The Inner Districts suffered (deaths per 10,000 of the population) more than the Outer Districts, thus:— Inner. Outer. Whooping Cough 2.33 1.04 Measles 6.6 0.9 Of the Lambeth Registration Sub-Districts, Lambeth Church suffered most, and Norwood least, from measles, and Kennington most, and Norwood least, from whooping cough. The annual average numbers of deaths from measles and whooping cough respectively during the two decennia 1891-1900 (Parish) and 1901-1910 (Borough), are 145.6 and 110.4 (measles) and 143.7 and 91.8 (whooping cough). Measles. Of the 98 deaths from measles in the Borough during 1913, 94 (i.e., 95.9 per cent.) occurred amongst children under 5 years of age, showing that measles is a disease of young children, and especially fatal to such. 23 of the deaths (i.e., 23.5 per cent.) occurred amongst infants under 1 year of age. With regard to measles, extra precautions are taken in connection with disinfection of measles-infected houses, exclusion of children (both infected children and also children from infected houses) from schools, the closing of classes or 50 whole schools on account of outbreak of measles, the distributing- of leaflets and posters, and the educating of parents to regard measles as a serious and dangerous infectious disease, and not as a trivial complaint of childhood. Measles is not compulsorily notifiable, but 1,085 cases (during 1913) were reported voluntarily (chiefly through schools) to the Borough Council. Measles being chiefly a "School Disease," this voluntary system of notification is valuable. Of the 1,085 notified cases, 222 (i.e., 20.5 per cent.) were removed to hospital from the Borough, non-pauper as well as pauper cases being now received for treatment and isolation in hospital, under the new Metropolitan Asylums (Measles) Order (August 9th).* Measles is spread chiefly through Schools, especially Infants' Departments, and during 1913 precautions were taken in respect thereto in the way of exclusion of all known cases of measles, and all "unprotected" children, i.e., those who have not previously had an attack of the disease, therebv securing the minimum interference with school attendance. 124 schools (Infants' Departments) were dealt with, representing 150 different class-rooms or grades, and a total of 1,743 children, excluded for periods varying from a few days to a few weeks on account of outbreaks of measles in connection therewith (a total of 354 cases of measles); whilst, in addition, three class-rooms in connection with 2 schools (infants' departments), were closed entirely. 7 schools were disinfected in connection with outbreaks of measles. W hooping Cough.† Whooping cough became compulsorily notifiable on, January 1st, 1913, and, during 1913, 1,428 cases were • Of the 222 cases of Measles removed to Hospital, 4 proved at Hospital not to be suffering from that disease. †Thc Council, by Order on Oct. 3rd, 1912, made Whooping Cough compulsorily notifiable by medical men and parent or relatives from trial period of 5 years, commencing June 1st, 1913. The Order was approved by the Local Government Board on Oct. 31st, 1912. 51 notified and, of these, 90 were removed to Hospital. 47 of the total 1,428 cases notified died (i.e., 3.3 per cent.). Whooping cough is a serious disease, especially to young children. Of the 47 deaths registered in the Borough during 1913 from this disease, 45 (i.e., 95.7 per cent.) occurred in children under 5 years of age, and 21 of the deaths (i.e., 44.7 per cent.) occurred amongst infants under 1 year of age. It is, therefore, a disease of childhood, and its prevention is being systematically attempted, chiefly in the way of compulsory notification of the cases, disinfection of whooping cough-infected houses, exclusion from school of children (both infected and from infected houses), and the educating of parents up to the dangerous nature of the disease and the importance of careful nursing of the patients when suffering from this complaint. Unfortunately, whooping cough, like measles, is, at present, regarded as a harmless complaint of childhood, and the ignorance displayed and the apathy shown, is well known to all who visit amongst the poorer classes. It is hoped that, by making the disease compulsorily notifiable, attention will be drawn to its serious nature, and the need that exists for taking precautionary measures in regard thereto. Of the 1,428 cases of whooping cough notified during 1913, 90 (i.e., 6.3 per cent.) were removed to hospital, non-pauper as well as pauper cases being received for treatment and isolation in hospital, under the new Metropolitan Asylums (Whooping Cough) Order, 1912 (August 9th*). 612 cases of the disease, in addition, were voluntarily notified through schools. Leaflets (dealing with the dangers and treatment ot the disease) were left at all notified whooping cough-infected houses. During 1913, 7 schools (15 class-rooms) were dealt with on account of outbreaks of whooping cough—a total of 33 cases with 436 exclusions of "unprotected" scholars (i.e., *Of the 90 eases of Whooping Cough removed to hospital, 4 proved at hospital not to be suffering from that disease. 52 children who had not previously had attacks of the disease) for varying periods. In no instance were the classrooms closed. No school nor classroom was required to be disinfected during 1913 in connection with an outbreak of whooping cough. CHOLERA AND PLAGUE. In the Borough, during 1913, no case of plague, suspected or otherwise, was notified, and no death from plague was registered. No case of cholera was notified, and no death from cholera was registered during 1913. A suspected cholera case in Stockwell District was investigated, 'but the bacteriological examinaton proved negative, no cholera vibrio being isolated. During the decennium 1901-10, no case of plague was notified and no death from plague was registered, within Details of the incidences of measles and whooping cough in the different Registration Sub-Districts of Lambeth Borough during 1913 are as follow:— Registration Sub-Districts. Number of Deaths from Whooping Cough. No. of Deaths from Measles. Whooping Cough Deaths per 10000 Inhabitants. • Measles Deaths per 10000 Inhabitants. Lambeth Church 10 39 2.2 8.4 Kennington 11 24 2.3 5.03 Stockwell 10 22 1.6 3.5 Brixton 11 9 1.4 1.2 Norwood 5 4 0.8 0.6 Borough of Lambeth 47 98 1.6 3.3 53 the Borough, but, during the same period, 2 cases of cholera were notified and 14 deaths from cholera registered—all cases probably of epidemic diarrhoea and cholera nostras or English cholera. 1 plague “contact” arrived from abroad (from Sydney) per S.S. “Mongolia” and was watched on arrival, but, in connection therewith, no case of plague developed. DIPHTHERIA. During 1913, 36 deaths were registered in the Borough from diphtheria, and a total of 385 cases were notified, giving a case-mortality of 9.3 per cent. The annual averages for two decennia 1891-1900 (Parish), and 1901-10 (Borough) are respectively (1) notified cases, 685.2 and 379.8, (2) deaths 124.7 and 41.6. Of the 385 cases notified during 1913, 334* (i.e., 86.8 per cent.) were removed to hospital, and 32 died, giving a case-mortality of 9.6 per cent. amongst the cases treated in hospital; whilst 51 (i.e., 13.2 per cent.) were treated at home, and 4 died (i.e., 7.8 per cent.) The case-mortality rate for the whole of the Borough during 1913 is again low, pointing to (1) the mildness of the majority of the cases notified, and (2) the value of antitoxin in the treatment of diphtheria, especially in the very early stages of the disease, † The slight increase in the numbers of notified cases of diphtheria is due to the outbreak of milk-borne diphtheria in Upper Norwood at the end of the year (see Appendix pp. 35 to 74). Allowing for this slight increase, the 385 notifications received during 1913 in the Borough shew that the decrease of the past ten years has been maintained, the figures for the 4 quinquennia 1891-1895, 1896-1900, 1901-1905, and 1906-1910, being 551.6, 818.6, 513.7 and 348.6 respectively. * Of the 334 cases of Diphtheria removed to Hospital, 44 proved at Hospital not to be suffering from that disease. t 50 Bottles of Antitoxin were distributed during 1913 under the new Antitoxin Order. 54 The decrease in the number of diphtheria deaths throughout the Borough during recent years is again noteworthy, viz.: during the four quinquennia 1891-1895, 1896-1900, 1901-1905, and 1906-1910, yearly averages of 123.2, 125.8, 38.8 and 44.4 respectively. Even allowing for the slight fallacy that may arise from comparing statistics of the old Parish with those of the new Borough, this decrease in the mortality from diphtheria is again noteworthy, and, when taken in conjunction with the decrease in the number of notifications of the same disease received, allowing for the slight increase due to the outbreak in Upper Norwood, during 1913, points to a marked general decline in the prevalence of diphtheria during the past years, thus:— Quinquennial Period. Population (estimated). Number of Deaths. Death-rate per million living. Old Parish of Lambeth. 1863—1867 902119 148 164 1868—1872 1021165 96 94 1873—1877 1132106 184 163 1878—1882 1245913 255 205 1883-1887 1313211 365 278 1888—1892 1367734 537 393 1893—1897 1443857 683 483 1898-1900 924333 362 392 Borough 1901—1905 1538750 194 126 1906—1910 1606918 222 138 1911 297957 43 144 1912 297550 29 97 1913 297139 36 121 The statistics for London, as a whole, are no less noteworthy. 55 During 1913, no school was closed on account of diphtheria, but exclusion of “sore throats”. was resorted to in the case of 4 schools (4 classrooms), wherein 4 cases of diphtheria occurred, a total of 12 children who were not allowed to resume attendance until certificates (based on bacteriological examination) had been furnished stating that they were free from infection. One school was disinfected during 1913 in connection with an outbreak of diphtheria. The age and sex incidence and mortality from diphtheria cases notified in the Borough of Lambeth during 1913 areas follow:— Diphtheria. Ages. No. of Cases Notified. Deaths. Death Rate per 100. M. F. Total. M. F. Total. Under 1 year 13 5 18 3 1 4 22.2 1 to 5 74 49 123 15 7 22 17.9 5 to 10 63 72 135 5 4 9 6.7 10 to 20 26 44 70 — — — 0.0 20 to 40 8 23 31 — — — 0.0 40 to 60 2 4 6 — — — 00 60 and over — 2 2 — 1 1 50.0 Total 186 199 385 23 13 36 94 The distribution of the disease in the different Registration Sub-Districts of the Borough of Lambeth, together with the numbers of deaths amongst both hospital- and home-treated patients, etc., during 1913, are as follows:— 56 Registration Sub-Districts. Total No. of Cases Notified. Cases treated at Home. Cases removed to Hospital. No. of Deaths. Case Mortality per 100. At Home. In Hospital. Total. Lambeth Church 64 - 64 - 9 9 14.1 Kennington 55 2 53 - 7 7 12.7 Stockwell 94 16 78 3 8 11 11.7 Brixton 71 7 64 — 1 1 1.4 Norwood 101 26 75 1 7 8 7.9 Borough of Lambeth 385 51 334 4 32 36 9.4 997 swabs from suspected diphtheria throats or noses were examined at the Bacteriological Laboratory during 1913, and, of these, 130 (i.e., 13.04 per cent.) showed the presence of the true Klebs-Loeffler (diphtheria) bacilli. In this connection, the point cannot be too well emphasisea that a positive bacteriological result proves much, but that a negative result proves practically nothing. Several negative results must be obtained in succession before any trustworthy conclusions are to be drawn from the absence of the bacillus. MEMBRANOUS CROUP During 1913, in the Borough, 7 cases of membranous croup* were notified, and 1 death was registered from the disease, giving a case mortality of 14.3 per cent. 4 cases were removed to hospital. The annual averages for the decennium 1901-10 are (1) notified cases 10.4, and (2) deaths 1.5.† *Membranous Croup Notification Certificates received since the formation of the new Borough:- 1901, 13; 1902, 15; 1903, 9; 1904, 11; 1905, 11; 1906, 11; 1907, 13; 1908, 12; 1909,3; 1910, 6; 1911, 4; 1912, 5; and 1913, 7. † In London Statistics Diphtheria and Membranous Croup are now grouped together by the Registrar-General. 57 TYPHOID FEVER. During 1913, 7 deaths were registered in the Borough from typhoid (enteric) fever, and a total of 38 cases notified, giving a case-mortality of 18.4 per cent. The annual averages for the two decennia 1891-1900 (Parish) and 19011910 (Borough) are respectively, (1) notified cases 189.7 and 100.5, and (2) deaths 34.7 and 16.7. Of the 38 cases notified in the Borough during 1913, 33* (i.e., 86.8 per cent.) were removed to hospital, and 5 died, giving a case-mortality of 15.2 per cent, amongst the patients treated in hospital; whilst 5 (i.e., 13.2 per cent.) were treated at home, and 2 died, giving a case-mortality of 40 per cent. amongst the patients treated at home. The age and sex incidence and mortality for typhoid cases notified in Lambeth Borough during 1913 are as follow:— Ages. Number of Cases Notified. Deaths. Deathrate per 100. M. F. Total. M. F. Total. Under 1 year - - - - — - - 1 to 5 — - - — — — 5 to 10 3 — 3 - — — 0.0 10 to 20 1 9 10 - 2 2 20.0 20 to 40 12 8 20 1 2 3 15.0 40 to 60 1 4 5 1 1 2 40.0 60 and over — - - - - - - Total 17 21 38 2 5 7 18.4 It will be noted that there was no case notified, and no death registered, amongst children under 5 years of age. * Of the 33 cases of Typhoid Fever removed to hospital, 7 proved at hospital not to be suffering from that disease. 58 whilst the greatest number of both cases and de iths occurred1 amongst persons between 20 and 40 years of age. Details as to incidence of the disease during 1913 upon the Registration of Sub-Districts of the Borough are as follow:— Registration Sub-Districts. Total No. of Cases Notified. Cases treated at Home. Cases removed to Hospital. No. of Deaths. Case Mortalitv per 100. At Home. In Hospital. Total. Lambeth Church 9 1 8 - - - 0.0 Kennington 5 — 5 — — — 0.0 Stockwell 8 1 7 — 2 2 25.0 Brixton 6 - 6 1 3 4 66.7 Norwood 10 3 7 1 - 1 10.0 Borough of Lambeth 38 5 33 2 5 7 18.4 14 out of the 38 cases notified were traced to sources outside the Borough, 7 were found not to be suffering from the disease and 8 were secondary cases, i.e., derived from previous cases (notified or unrecognised) as far as could be discovered. No case could be traced definitely and conclusively to infected ice-creams, water, milk, fried or shell fish or watercress, though in 3 cases there was a history of shell fish (mussels) having been consumed by patients 2 to 3 weeks prior to their attacks. Of the 34 typhoid-infected houses, 12 (i.e., 35.3 per cent.) showed, on inspection, defective drains, traps, fittings, or appliances, whilst in 1 (i.e., 2.9 per cent.), the drains themselves were found to be defective (i.e., gave a result with the test). 59 47 samples of blood were examined at the Bacteriological Laboratory during 1913 for the Widal reaction of typhoid, and, of these, 12 (i.e., 25.1 per cent.) gave the reaction (slightly marked in 7 cases). In so far as typhoid fever is regarded as a sanitary index of a district, the statistics for the Borough during 1913 are of a satisfactory character. SIMPLE, CONTINUED, RELAPSING AND TYPHUS FEVERS. During 1913, 2 cases of continued fever were notified, but no death from this disease was registered, in the Borough. One case was removed to hospital. The annual averages for continued fever for the decennia 1901-10 are (1) notified cases 4.3, and (2) deaths 0.7. No case of typhus was notified, and no death from the disease was registered, during 1913, in the Borough. One case of typhus was notified in the Borough during the decennium 1901-10, i.e., annual average of 0.1. PUERPERAL FEVER During 1913, in the Borough, 10 deaths were registered from puerperal fever (a disease of child-bed), and 25 cases notified, giving a case-mortality of 40 per cent. 15 of the cases were removed to hospital, non-pauper as well as pauper patients being received for treatment and isolation at the Metropolitan Asylums Board Hospitals under the new Metropolitan Asylums (Puerperal Fever) Order, 1912 (August 20th). The annual averages for the two decennia 1891-1900 60 (Parish) and 1901-1910 (Borough) are respectively (1) notified cases, 18.9 and 17.0, and (2) deaths 11.5 and 7.8. Puerperal fever is a preventable disease, and is caused through want of care on the part of the nurse, or the medical practitioner, attending upon a lying-in woman. 8,173 births were registered in the Borough during 1913, and in only 25 cases was puerperal fever notified—a satisfactory fact to be able to report. In each case enquiries were made, and the Midwives (when in attendance) were visited at their homes, their rooms (or houses) and clothes disinfected, and their other patients (being attended at the time) followed up and watched as required. ERYSIPELAS. During 1913, in the Borough of Lambeth, 206 cases of erysipelas were notified and 8 deaths registered, giving a case-mortality of 3.9 per cent. Of the 206 cases notified, 59 (i.e., 28.6 per cent.) were removed to hospital. The annual averages for the two decennia 1891-1900 (Parish) and 1901-1910 (Borough) are respectively (1) notified cases 347.0 and 140.8, and (2) deaths 17.7 and 12.3. The advantages from the notification of erysipelas are few, as the majority of cases notified as “erysipelas” are not such as were contemplated by the framers of the Notification Act. DIARRHŒA. During the year 1913 there were registered in the Borough, 166 deaths from diarrhœa, as compared with yearly averages of 196.7 and 173.0 respectively for the two decennia 1891-1900 (Parish) and 1901-10 (Borough). 61 Taking the statistics of the Parish and the Borough for the 4 quinquennia 1891-1895, 1896-1900, 1901-1905, and 1906-1910 respectively, when the yearly averages for diarrhœa (and cholera) were 191.6, 219.4, 208.6 and 140.2, a comparison may be made of the variations in the incidence of these diseases. Of the 166 deaths registered, during 1913, in the Borough, 162 (i.e., 97.6 per cent.) were in children under 5 years, and 131 (i.e., 78.9 per cent.) in infants under 1 year of age. July, August, September and October were the most fatal months, and, during this period of 4 months, the incidence of diarrhœa (deaths per 10,000 of the population) upon the Inner Districts was proportionately greater than that upon the Outer Districts. In this connection, it is interesting to note that the 4ft. earth thermometer first registered 56 deg. F. on June 18th, rising to a maximum 60.3 deg. F. on September 4th, and sinking to 56 deg. F. again on October 19th. 56 deg. F. is the so-called “critical” earth temperature for diarrha, ie., the temperature at which the germs of this disease begin to multiply, and prove themselves dangerous.* Hence its importance, statistically, in connection with diarrhœa, a disease which, though it kills chiefly young children, attacks at times persons of all ages—a fact not generally recognised. Age mortalities (corrected deaths) from diarrhœa were as follows:— M. F. Total. Percentage of total deaths. Under 1 year 77 54 131 78.9 1 to 5 15 16 31 18.7 5 to 20 0.0 20 to 40 1 1 0.6 40 to 60 0.0 Over 60 3 3 18.1 Total 92 74 166 100.0 *The 4-ft. earth temperatures were taken in Regent's Park, and thanks are due to the Secretary of the Royal Botanic Society for the information in connection therewith. 62 The details as to the diarrhœa incidence (mortality) during 1913, upon the different Registration Sub-Districts and the Wards of Lambeth Borough are as follow:— Borough of Lambeth. Registration Sub-Districts. Number of Deaths Diarrhœa Death-rate per 10000 Population. Lambeth Church 62 13.4 Kennington 37 7.8 Stockwell 26 4.2 Brixton 22 2.8 Norwood 19 2.9 Borough of Lambeth 166 5.6 BorouGh of Lambeth. Wards. Number of Deaths. Diarrhœa Death Rate per 10,000 Population. Marsh 23 10.9 Bishop's 39 12.6 Prince's 37 8.8 Vauxhall 19 6.2 Stockwell 7 2.2 Brixton 10 2.3 Herne Hill 12 8 .6 Tulse Hill 10 3.2 Norwood 9 2.8 Borough of Lambeth 166 5.6 63 Taking the whole of the cases registered, during 1913, the diarrhœa death-rate per 10,000 population in the Inner Registration Sub-Districts and Inner Wards is 9.5, as compared with 2.8 for the Outer Registration Sub-Districts and Outer Wards—a difference which is generally found to obtain, and which is understood when the crowded state of the Inner Registration Sub-Districts and Inner Wards is remembered. 24 deaths (10 in infants under 1 year of age) were registered during 1913 from "enteritis." During recent years there has been a marked improvement in the diagnosis of deaths from diarrhoeal diseases, so that, to obtain comparable figures, attention should be paid not only to diarrhœa deaths certified, but also to all deaths arising from diseases of an enteritic nature, i.e., those in which the intestines are affected. Practical measures were again taken to prevent epidemic diarrhœa and other infectious diseases in infants and to promote hygienic conditions in the feeding of infants, systematic visiting of houses wherein births were notified under the Notification of Births Act, 1907, and wherein deaths were registered as having occurred from epidemic diarrhoea, the teaching of proper feeding and care of infants by the Council's female staff, the work of the Milk Depot and the Infants' consultations in connection therewith, etc., may be tabulated as some of the measures taken during 1913 with success. In addition, a special leaflet was again issued during the year, dealing with precautions against summer diarrhœa in connection with irregular and improper feeding of infants and the value of the milk depot in relation thereto, the danger of contamination of food by flies, the importance of removing at once all accumulations 64 of refuse and other offensive matters, uncleanliness generally as a cause of diarrhœa, etc. GLANDERS, ANTHRAX, ETC. During 1913, 9 notifications of animal glanders in the Borough were received under the London (Notification of Glanders) Order, 1907,* but no case of human glanders, anthrax or hydrophobia was notified. EPIDEMIC INFLUENZA. During 1913, 67 deaths were registered from influenza in the Borough. Of the 67 deaths, 32 were registered during the first, 18 during the second, 4 during the third, and 13 during the fourth quarter of the year. The annual averages for the two decennia 1891-1900 (Parish) and 1901-10 (Borough) are respectively 107.5 and 53.2. OPHTHALMIA NEONATORUM (CONTAGIOUS OPHTHALMIA OF NEWLYBORN INFANTS). Ophthalmia neonatorum was made compulsorily notifiable in the Administrative County of London as from, and including, March 13th, 1911, by Order made by the London County Council and duly approved by the Local Government Board. *The Order includes also Anthrax and Hydrophobia occurring in human beings. 65 During 1913, within the Borough, 57 infants were notified as suffering from the disease. Each case was visited officially and the necessary precautionary measures were taken. No case was removed to hospital.* All the infants recovered except one, whose left eye was destroyed. The London County Council Medical Inspectors under the Midwives Act report all cases of inflammation of the eyes of newly-born babies to the Medical Officers of Health of the various Metropolitan Districts, i.e., in addition to notifying cases of diagnosed ophthalmia neonatorum as required by the Order. TUBERCULOSIS Full details of the Lambeth Municipal Tuberculosis Dispensaries Scheme are to be found in the Appendix pp. 75 to 103. During 1913, 370 deaths (corrected) were registered in the Borough as due to phthisis (tuberculosis of the lungs), 11 as due to tabes mesenterica, 49 as due to tubercular meningitis and hydrocephalus, and 55 as due to other forms of tuberculosis, making a total of 485 deaths from tuberculosis (all forms)—i.e., 11.3 per cent, of the total deaths (corrected) registered from all causes. During the four quinquennia, 1891-5 (Parish), 1896-1900 (Parish), 1901-5 (Borough) and 1906-10 (Borough), the yearly averages of deaths from tuberculosis (all forms), were respectively 675.0, 690.0, 647.4 and 567.4, whilst, during the same quinquennia, the yearly averages of deaths from phthisis, or pulmonary tuberculosis, alone were respectively 478.8, 496.8. 462.8 and 421.6. Sub-dividinc the total tuberculosis (all forms) deaths during 1913 amongst the different Registration Sub-Districts it is found that the numbers of deaths vary as follow:— *.\o special hospital accommodation tor eases of ophthalmia neonatorum has been provided in London, the general and special hospitals dealing with the cases in their out-patient and in-patient departments as required. 66 Registration Sub-Districts. Deaths from Total Deaths. Tuberculosis (all forms). Phthisis. Tabes. Mes. and Tub. Men. Other forms Tuberculosis. Lambeth Church 91 19 11 121 Kennington 68 14 15 97 Stock well 74 10 11 95 Brixton 84 12 12 108 Norwood 48 5 6 59 No Address 5 - - 5 Borough of Lambeth 370 6o 55 485 1,484 samples of sputum were examined at the Council's Bacteriological Laboratory during 1913, and of these, 614 (i.e., 41.4 per cent.) showed the presence of the tubercle bacillus. The distribution of tuberculosis, as a disease, can be gauged from the official notifications that have been received, viz.: under (a) the voluntary Lambeth Notification (Consumption) Scheme, 1902,* which came into force on June 1st, 1902, (b) the compulsory I'oor Law, Hospitals and Private Pulmonary Tuberculosis Schemes, known as the following Regulations, viz.: the Public Health (Tuberculosis) 1908, the Public Health (Tuberculosis in Hospitals) 1911, and the Public Health (Tuberculosis), 1911, and (c) the new Regulations dealing with all forms of Tuberculosis, and *No notifications were received during 1913 under the Lambeth Notification (Consumption) Scheme 1902. 67 known as the Public Health (Tuberculosis) Regulations, 1912, which came into force on February 1st, 1913, all previous Regulations being then revoked. All the sources of notifications received during 1913 are set out in Tables Q (I.), Q (II.), Q (III), and Q (IV.), dealing with (a) Wards, and (b) Registration Sub-Districts, those notifications received under the old Regulations, 1908 and 1911, during January, 1913, being set out as in previous Annual Reports (for comparison), and those received under the new Regulation, 1912, during the remaining 11 months of 1913, being set out in the new forms required by the Local Government Board. In each case notified, from whatever source, a visit is paid, unless the notifying medical man is of opinion that such an official visit is unnecessary, leaflets are distributed and disinfection is carried out as required, but with due regard to privacy, instructions being given to the officers to avoid doing anything likely to cause pain or annoyance to patients or their friends. The usual precautionary measures are taken (distribution of pamphlets, disinfection, isolation, etc.). Taking all the primary notifications of pulmonary tuberculosis (consumption) received during 1913—a total of 1,571 the disease appears to have had a greater incidence upon the Inner than the Outer Districts (Registration SubDistricts and Wards), viz. : 827 to 744, i.e., 6.7 to 4.3 per 1,000 population due to (a) the more crowded conditions, persons in houses, and houses over area, and (b) the different (poorer) status of the inhabitants, in the former as compared with the latter. Taking the primary notifications of 'tuberculosis (all forms) received under (a) the Regulations 1908 and 1911 (Pulmonary), and (b) the Regulations 1912 (Pulmonary and Non-Pulmonary), the incidence rates of the disease per 1,000 of the populations in the Registration Sub-Districts and Wards during 1913, are as follow:— 68 (a) Tuberculosis (Pulmonary). 1. Wards— Inner—6.7, viz.: Marsh, 6.1; Bishop's, 8.9; Prince's, 6.8; Vauxhall, 4.5. Outer—4.3, viz.: Stockwell, 316; Brixton, 5.2; Heme Hill, 4.7 ; Tulse Hill, 3.8; Norwood, 3.8. 2. Registration Sub-Districts— Inner—6.7, viz. : Lambeth Church, 7.7; Kennington, 7.0; Inner Stockwell, 4.5. Outer—4.3, viz.: Outer Stockwell, 3.6; Brixton, 5.0; Norwood, 3.8. Borough of Lambeth = 5.3. (b) Tuberculosis (all forms). 1. Wards— Inner—8.6, viz.: Marsh, 8.2; Bishop's, 11.7; Prince's, 8.8; Vauxhall, 6.2. Outer—5.7, viz.: Stockwell, 4.9; Brixton, 6.7; Heme Hill, 6.5; Tulse Hill, 4.9; Norwood, 5.4. 2. Registration Sub-Districts— Inner—8.6, viz.: Lambeth Church, 10.1; Kenning ton, 8.8; Inner Stockwell, 6.2. 69 Outer—r.7, viz.: Outer Stockwell, 4.9; Brixton, 6.5; Norwood, 5.2. Borough of Lambeth = 6.9. The corresponding death-rates from (a) tuberculosis (pulmonary), and (b) tuberculosis (all forms) per 1,000 of the population living are for the Registration Sub-Districts as follow :— (a) Tuberculosis (Pulmonary)— Inner—1.6*, viz.: Lambeth Church, 1.9; Kennington, 1.4; Inner Stockwell, 1.2. Outer—0.9,* viz.: Outer Stockwell, 1.2; Brixton, 1.1; Norwood, 0.8. Borough of Lambeth = 1.2. • (b) Tuberculosis (all forms)— Inner—2.2*, viz.: Lambeth Church, 2.6; Kennington, 2.1 ; Inner Stockwell, 1.6. Outer—1.3*, viz.: Outer Stockwell, 1.5; Brixton, 1.4; Norwood, 0.9. Borough of Lambeth = 1.6. *ln calculating these death-rates for the Registration Sub-Districts (Inner and Outer), the deaths registered in Stockwell Sub-District arc divided equally between Inner and Outer Stockwell. TABLE Q, (I.)— Notification Certificates received during January, 1913, 1908 (Forms A, B, C and D) (2) the Public Health Public Health (Tuberculosis Regulations), 1911 (Forms A under the new Public Health (Tuberculosis) TUBERCULOSIS NOTIFICATIONS. under (1) the Public Health (Tuberculosis) Regulations, (Tuberculosis in Hospitals) Regulations, 1911, and (3) the and B), and during February to December (inclusive), 1913, Regulations, 1912, (Forms A, B, C, D). Wards. 1. PUBLIC HEALTH WARDS. TUBERCULOSIS REGULATIONS. Tuberculosis (Pulmonary.) Tuukrculosis (All Forms.) 1913. Poor Law (1908). Hospii als 1911. Private 1911. Pulmonary. NEW, 1912. 1 Non-Pulmonary. A. B. C. D. A. B. C. D. Forms. A. B. c D. Total. Total. A. B. Total. Primary. Total. Primary. Total. Poor Law Sanatorium. Poor Law. Sanatorium. Primary. Total. Primary. Total. Poor Law. Sanatorium. Poor Law. Sanatorium. Marsh 2 2 11 2 2 Bishop's IS 1 o 18 3 19 1 20 114 122 1 1 20 21 23 13 38 42 1 2 6 1 1 Prince's 7 6 1 14 12 14 14 224 250 14 15 39 29 27 29 55 63 7 8 3 2 4 2 7 ? 11 233 255 12 13 40 21 20 19 72 77 6 9 8 2 7 107 118 6 7 23 14 13 18 41 47 9 9 1 7 — 5 Total Inner Wards 26 14 5 45 32 42 2 44 678 745 33 36 122 85 83 79 206 229 23 28 1 24 5 17 Stockwell 3 3 5 5 5 Brixton 4 2 1 7 13 12 1 13 101 115 2 4 12 12 3 11 32 33 4 4 — — — Heme Hill 2 2 - 4 9 - - 5 192 224 6 7 15 19 13 13 52 61 5 4 3 — 3 Tulse Hill 3 2 5 4 8 1 9 137 160 2 3 14 21 16 13 4 7 63 6 V — — 1 N or wood 1 — — 1 5 7 2 9 101 110 1 2 7 9 4 7 28 32 5 6 — — 1 106 115 2 4 7 20 7 20 44 49 4 6 - 4 - 2 Total Outer Wards 13 4 3 20 36 37 4 41 637 742 13 20 55 81 43 64 203 228 24 27 - 7 7 Borough of Lambeth 39 18 8 — 65 68 79 6 85 13151469 46 56 177 166 126 143 409 457 47 55 1 31 5 24 70,71 72 73 TABLE Q (II.) TUBERCULOSIS NOTIFICATIONS. Notification Certificates received during January, 1913, under (1) the Public Health (Tuberculosis) Regulations, 1908 (Forms A, B, C, and D), (2) the Public Health (Tuberculosis in Hospitals) Regulations, 1911, and (3) the Public Health (Tuberculosis) Regulations, 1911 (Forms A and B), and during February to December (inclusive), 1913, under the new Public Health (Tuberculosis) Regulations, 1912 (Forms A, B, C, and D). 2. REGISTRATION SUB-DISTRICTS. Registration Sub-Districts. 1913. PUBLIC HEALTH (TUBERCULOSIS) REGULATIONS. Tuberculosis (Pulmonary). Tuberculosis, (All Forms). Pulmonary. New 1912. j Non-Pulmonary. Poor Law (1908). Hospitals 1911. Private 1911. B. c. D. A. B. c. D. Forms. A. B. c. D. Totals. Total. A. B. Total. & Primary. Total. Primary. Total. Poor Law. Sanatorium. Poor Law. Sanatorium. Primary. Total. Primary. Total. Poor Law. Sanatorium. Poor Law. Sanatorium. Waterloo 2 _ 9 11 2 2 114 122 1 1 20 21 23 13 38 42 1 2 - 6 1 1 Lambeth Church 15 1 2 18 3 17 1 18 176 202 11 12 34 24 23 25 51 59 6 7 — 3 1 3 Kennington 7 6 1 14 12 16 16 281 303 15 16 45 26 24 23 76 81 7 10 — 8 3 8 Stockwell (Inner) 2 7 2 11 6 7 1 8 107 118 6 7 23 14 13 18 41 47 9 9 1 7 5 Total Inner Districts 26 14 5 — 45 32 42 2 44 678 745 33 36 122 85 83 79 206 229 23 28 1 24 5 17 Stockwell (Outer) 3 3 5 5 5 . 101 115 2 4 12 12 3 11 32 33 4 4 Brixton 6 4 1 — 11 22 17 1 18 329 384 8 10 29 40 29 26 99 114 11 11 — 3 — 4 Norwood 4 2 6 9 15 3 18 207 225 3 6 14 29 11 27 72 81 9 12 4 3 Total Outer Districts 13 4 3 20 36 37 4 41 637 724 13 20 55 81 43 64 203 228 24 27 — 7 — 7 Borough of Lambeth 39 18! 8 — 65 68 79 6 85 1315 1469 46 56 177 166 126 143 409 457 47 55 1 31 5 24 75 74 METROPOLITAN BOROUCH OF LAMBETH. Q, (III.). TABLE Regulations), 1908 and 1911. Public Health (Tuberculosis) 1st to 31st January, 1913 (inclusive), the new Public Health summary of Notifications received during the period from ing into force on February 1st, 1913. (Tuberculosis) Regulations, 1912, com Number of Notifications on Forms A and B (1908) and Form A (1911). Number of Notifications on Form B (1911). N umber of Notifications on Form C (1908). Number of Notifications oil Form D 1908). Age-Periods. Primary Notifications. (Medical). ♦Total Notifications (i.e., including cases previously notified by other doctors). (Medical) Primary Notifications. (Medical.) tTotal Notifications (i.e., including eases previouslynotificd by other Doctors). (Medical.) Poor Law Institutions. (Non-Medical) Poor Law Institutions. (Non-Medical.) 0 to 1. 1 to 5. 5 to 10. 10 to 15. 15 to 20. 20 to 25 25 to 35. 35 to 45. 45 to 55. 55 to 65. 65 and upwards. Total. Under 5. 5 to 10. 10 to 15. Total. Pulmonary— Males 3 2 1 6 6 29 40 23 7 1 118 118 — 1 2 3 3 7 Females — — 5 7 5 14 24 12 8 10 1 86 86 - - 3 3 3 1 Non- Pulmonary— Males - -- - - - - - - - -- - - - - - - - - - Females - - - - - - - - - - - - - - - - - - - - *No Re-notifications under Form A. 57 Poor Law and 6 schools = 210 total primary notifications (Forms N.B.—Pulmonary—75 private, 68 hospitals, 4 dispensaries, A and B). 76 . 77 METROPOLITAN BOROUCH OF LAMBETH. TABLE ' Q (IV.). Public Health (Tuberculosis) Regulations, 1912. Summary of Notifications received during the period from ] st February, 1913, when the Public Health (Tuberculosis) Regulations, 1912, came into force, to the end of the week ending on the 3rd January, 1914. Agc-Pcriods. Number of Notifications on Form A. Number of Notifications on Form B. Number of Notifications on Form C. Number of Notifications on Foi m D. Primary Notifications. (Medical.) |4 Total Notificat ons {i.e., including cases previously notified by other Doctors). ( Medical.) Primary Notifications (Medical.) fTotal Notifications (i.e., including casespreviouslynotified by other Doctors). (Medical.) Cases admitted to Cases discharged from 0 to 1. | 1 to 5. 5 to 10. 10 to 15. 15 to 20. 20 to 25. 25 to 35. 35 to 45. 45 to 55. 55 to 65. 65 and upwards. Total. Under 5. 5 to 10. 10 to 15. Total. Poor Law Institutions. (Medical.) Sanatoria. Poor Law Institutions. (Medical.) Sanatoria. Pulmonary— - Males 1 7 19 42 36 88 176 179 108 46 13 715 812 11 12 23 25 126 88 86 81 Females — 8 18 28 54 87 172 140 55 28 10 600 657 12 11 23 31 51 78 40 62 Non-Pulmonary— Males 2 38 55 39 IS ( 9 14 7 10 2 4 198 226 14 17 31 36 — 17 2 12 Females 3 43 41 31 ! 27 | 19 22 10 8 1 6 211 231 — 6 10 16 19 1 14 3 12 * Re-notifications (Form A) = 154 (males 97, females 57), pul- monary and 48 (males 28, females 20), non-pulmonary, tRe-notifications (Form B) = 10(males 2, females 8), pulmonary and 8 males 5, females 3\ non-pulmonary. N.B.—Pulmonary—672 private, 291 hospitals, 255 dispensaries, 97 Poor Law Officers and 46 schools= 1361 total primary notifications (Forms A and B). Non-Pulmonary—86 private, 308 hospitals, 10 dispensaries, 5 Poor Law Officers and 47 schools = 456 total primary notifications (Forms A and B). 78 I he 24 deaths from venereal affections (syphilis, etc.), are the only other point calling for note in the class of zymotic diseases. A Royal Commission has been appointed during 1913 to investigate the question of venereal diseases and the means to be taken to prevent their ravages. Classes II. iuid III.—Parasitic and Dietetic Diseases. 23 deaths were registered from chronic Alcoholism, and 1 was registered from Delirium Tremens. Class IV.—Constitutional Diseases. Of the total 936 deaths under this class, 36'J were due to Cancer, 370 to Phthisis, and 115 to Tubercular Meningitis and other forms of Tuberculosis. Class V.—Developmental Diseases. The total number of deaths in this class was 350, consisting of 130 from Premature Birth, 174 from Old Age, and 12 from Atalectasis and 34 from Congenital Malformations. Class VI.—Local Diseases. 1. Diseases of the Nervous System caused 333 deaths, including 25 from Convulsions, 184 from Apoplexy,, and 20 from Epilepsy. 2. 555 deaths were due to diseases of the Circulatory Svstem. 3. The diseases of the Respiratory Organs caused 806 deaths (373 from Bronchitis and 125 from Pneumonia, 165 from Broncho-Pneumonia, and 7& from Pleuro-Pneumonia). 79 4. Diseases of the Digestive Organs caused 240 deaths, of which 24 were due to Enteritis, 6 to Peritonitis, 65 to diseases of the Liver, 14 to Dentition, and 24 to Appendicitis. 5. Diseases of the Urinary System caused 191 deaths. 6. Diseases of the Reproductive System, Integumentary System, Locomotive System, Lymphatics, Organs of Special Senses, and Gland-like Organs of uncertain use, caused together 70 deaths. ■Class VII.-—Deaths from I'iolence. 181 deaths in all, including 142 from Accidents or Negligence, 15 from Burns and Scalds, 16 from Drowning, 11 from Suffocation in Bed (10 being infants under 1 year of age), 37 from Suicide and 2 from Homicide 1 manslaughter and 1 murder). •Class VIII.—Other Causes. 99 deaths were registered in this class, consisting of deaths from Dropsy, Tumours, Hajmorrhages, Debility, Atrophy and Inanition, or other ill-defined or non-specified causes. Different rates of mortality from different diseases and groups of diseases are given in terms of the total deaths (corrected or uncorrected) in Tables R and S ; whilst Table R gives also the deaths from the chief Infanti'a Diseases, expressed in terms of the Infantile population (or Number of Births). Allowing for the slight differences between the corrected and uncorrected death returns, it will T)e noted that in regard to both infantile and other diseases Lambeth again compares favourably with London. 80 TABLE R. Shewing Classification of Causes of Deaths (corrected) in the Borough of Lambeth during 1912 and 1913. A.—Total Deaths from all causes and at all ages with percentages of such deaths to total deaths (corrected). Class of Disease. Borough Borough. 1912. 1913. No. of Deaths (corrected). Percentage of Total Deaths (corrected). No. of Deaths (correct- Percentage of Total Deaths (corrected). I.—Zymotic Diseases 384 9.8 494 11.5 Seven Principal 287 7.3 369 8.6 Influenza 40 1 .02 67 1.6 II.—Parasitic 1 0.02 ... III.—Dietetic 32 0.8 25 o-6 IV.—Constitutional 930 23.7 936 21.9 Cancer 371 9.4 369 8.6 Phthisis 381 9'.7 370 8.6 Tubercular Diseases, excluding Phthisis 99 2.5 115 2.7 Rheumatism (Acute and Chronic) and Gout 19 0.5 22 0.5 V.—Developmental 346 8.8 350 8.2 Old Age 176 4.5 174 4.I VI.—Local Diseases 1994 50.8 2 195 51.3 Circulatory System 453 11.5 555 12.9 Bronchitis ... 36' 9.2 373 8.7 Pneumonia and BronchoPneumonia 261 6-6 290 6.8 Pleurisy and Pleuro-Pneumonia 84 2. 1 89 2.1 Respiratory System, excluding Phthisis 763 19.4 806 18.8 VII.—Violence 151 3.8 181 4.2 Suicide 34 0.9 37 0.9 VIII.—Other Causes 87 2.2 99 2.3 81 TABLE R—continued. B.—Deaths (corrected) of Infants under One Year of age from the chief infantile diseases, and from all cause"!, expressed in terms of 1000 births (corrected). Borough 1912. Borough 1913. Total Deaths under One Year (Corrected). Proportion to 1000 Births (Corrected).* Total Deaths under One Year (Corrected). Proportion to 1000 Births (Corrected).* From all causes 598 86.02 733 101.3 Diarrhoea 64 9.2 131 18.1 Convulsions 11 1.6 20 2.8 Respiratory Diseases 111 15.9 149 20.6 Premature Births 124 17.8 130 17.9 Tubercular Diseases (including Phthisis) 24 3.4 22 3.04 Measles 19 2.7 23 3.2 Whooping Cough 24 3.4 21 2.9 Suffocation in Bed 9 13 10 1.4 Enteritis 8 1 I 10 1.4 Dentition 8 11 10 1.4 *N.B.—The Registrar-General gives the corrected Lambeth births for 1912 and 1913 as 6952 and 7233 respectively, 82 . 83 . «3 TABLE S. TABLE S [Local Government Hoard Old Table A] _ , , Table of DEATHS during the year 1913 in the Borough of Lambeth Mortality prom all causes at subjoined Ages. Mortality from subjoined causes, distinguishing Deaths of Children under Five Years of Age. Names of Localities adopted for the purpose of these Statistics, public institutions being shewn as separate localities. At all ages Under 1 year. 1 and under 2 2 and under 5. 5 and under 15 15 and under 2o 25 and under 45 45 and under 05. 65 and upwards 1 2 3 4 5 1 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Scarlatina. Diphtheria, j Membranous Croup. Puerperal. Enteric or Typhoid. g . Typhus. Erysipelas. Meas'es. Whooping Cough. Diarrhoea and Dysentery. Rheumatic Fever. Phthisis. Bronchitis, Pneumonia and Pleurisy. Heart Disease. Influenza. Injuries. Cerebrospinal Fever. Appendicitis. All other Diseases. Total. (a) (1) (c) (d) (e) (f) (g) (h) (i) j k ... ... ... ... ... 1 ... 26 ... ... 30 ... ... ... 2 ... 47 107 Royal Infirmary (Women 139 65 23 19 11 2 12 6 1 Under 5 ... 1 ... 1 ... ... ... ... ... ... ... 2 1 5 ... ... ... 1 22 32 and Children) 5 upwds. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... General Lying-in-Hos- Under 5 ... ... ... ... ...... ... ... ... ... ... ... ... ... ... ... ... ... 20 20 pital, York Road 27 20 ... ... ... ... 7 ... ... 5 upwds. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 7 l ... ... ... 1 2 17 2 27 1 12 2 1 75 144 St Thomas's Hosoital 687 87 23 34 73 61 154 198 57 Urider 5 4 5 1 ... 2 2 16 19 44 38 1 36 379 543 at. nomas nospiui... 5 upwds. ...... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 22 6 24 47 ... 5 63 167 Remainder of Lambeth 418 117 33 17 8 12 57 79 95 Under 5 2 1 34 57 35 4 35 83 251 Church i 5 upwds. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... 8 9 cLambeth Workhouse ... 38 9 ... ... ... ... 3 4 22 Under 5 ... ... ... ... ... ... ... ... ... ...... ... ... 12 12 ... 1 ... 4 29 5 upwds. ... ... ... ... ... ... ... ... ...... ...... ... ... ... ... ... ... . ... 25 1 1 24 58 Lamoeth Infirmary 779 39 14 5 1 14 157 236 313 Under 5 ... ... ... ... 2 ... 5 ... ... ... 5 115 107 145 1 20 3 316 721 5 upwds. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... < ... St. Peter's House 35 .. ... ... ... 1 2 32 Under 5 ... ... ... ... ... ... ... ... ... ... 13 4 1 17 35 5 upwds. ... ... ... ... ... ... 18 9 16 1 31 ... ... 3 53 131 Remainder of Kenning- 389 82 25 24 12 8 27 98 113 Under 5 ... ... ... ... ... ... 1 1 ... ... 33 58 47 1 13 104 258 ' ton 5 upwds. ... ... ... ...... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 24 ... ... ... ... 2 ... ... 2 1 ... 4 69 / South-Western Hospital 117 10 22 37 20 4 18 5 1 Under 5 12 24 ... 5 15 ... ... 3 ... ... ... 1 2 ... ... 2 7 48 5 upwds. 2 11 10 10 Clapham Maternity 11 10 ... ... ... 1 ... ... ... Under 5 ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... ...... ... ... 1 5 upwds. ... ... ... ... ... ...... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... 14 '/ 8 ... 1 33 2 1 10 65 144 Remainder of Stockwell 509 103 25 16 16 16 60 102 171 Under 5 ... ... ... 1 ... ... ... ... 1 3 36 76 50 14 13 ... ... 171 365 5 upwds. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 84 85 TABLE S.—continued. TABLE S.—continued. [Local Government Board Old Table A—continued.] classified according to Diseases, Ages, and Localities. Table of DEATHS during the year 1913 in the Borough of Lambeth Mortality from all causes at subjoined Ages. Mortality from subjoined causes, distinguishing Deaths of Children under Five Years of Age. Name's of Localities adopted tor the purpose of these Statistics, Public institutions being shewn as separate localities. At all ages. Under 1 year. 1 and under 2. 2 and under 5. 5 and under 15. 15 and under 25 25 and under 45. 45 and under 65. 65 and upwards. 1 2 3 4 | 5 6 1 7 8 9 to 11 12 13 14 15 ! 16 17 18 19 20 Scarlatina. Diphtheria. Membranous Croup. Puerperal. bnteric or Typhoid. Typhus. Erysipelas. Measles. Whooping Cough. Diarrhoea and Dysentery. Rheumatic Fever. Phthisis, Broncnuis. Pneumonia and Pleurisy. Heart Disease. Influenza. Injuries. Cerebrospinal Fever. Appendicitis. All other , Diseases, Totals. (a) (b) (c) (d) (e) (f) (g) (h) (i) (j) k King's College Hospital. ... ... ... ... ... ... ... ... ... 3 ... 7 10 35 6 3 1 7 3 7 3 Under 5 ... ... ... ... ... ... ... ...... ... ... ... ... 4 3 ... 6 ... 2 10 25 5 upwds. ... ... ... ... ... ... ... ... 1 42 ... ... 17 1 ... 4 ... 1 65 132 Belgrave Hospital 140 104 14 14 8 ... ... ... ... Under 5 1 ... ... ... 1 ... ... ... ... ... ... 2 ... 1 ... ... 3 8 5 upwds. ... 1 ... ... ... ... 8 7 10 ... ... 34 ... 1 3 ... ... 65 128 Remainder of Brixton 618 103 13 12 11 19 68 139 253 Under 5 ... ... ... 1 1 ... 2 ... ... 1 1 57 105 89 16 10 1 206 190 5 upwds. ... ... ... ... Lambeth Workhouse Schools 1 ... ... ... ... 1 ... ... ... Under 5 ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... 1 ... 5 upwds. ... ... British Home of Incurables 6 ... ... ... ... ... 2 4 Under 5 ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... 6 5 upwds. ... ... ... ... ... ... ... 3 5 13 ... ... 19 1 1 3 ... ... 57 102 Remainder of Norwood 527 76 15 11 8 20 43 120 231 Under 5 ... ... ... 1 1 ... ... ... ... 1 ... 34 52 72 22 13 ... 2 226 425 upwds. ... 1 17 ... ...— 1 92 36 182 ... 4 250 5 3 43 5 2 563 1231 Totals 4476 831 210 190 175 161 612 998 1299 Under 5 12 32 ... ... 20 ... 10 6 1 3 12 329 506 508 59 153 2 44 1560 3245 I 5 upwds. 2 13 The subjoined numbers have also to be taken into account in judging of the above records of mortality. Deaths occurring outside ... ... ... ... ... 20 11 30 ... 1 26 ... ... ... ... 77 174 657 107 39 28 29 28 146 174 136 Under 5 2 7 ... 3 1 ... .... 1 1 1 1 61 45 90 6 37 ... 6 255 513 sons belonging thereto 5 upwds. 3 2 ... ... ... ... 1 18 2 50 ... 1 49 1 ... 10 3 2 157 311 883 205 44 62 83 54 166 182 87 Under 5 4 13 ... 10 14 ... 2 3 ... ... 2 24 26 47 1 42 1 26 368 572 not belonging thereto 5 upwds. 1 5 TABLE T. TABLE T. Table of Population, Births and of New Cases of Infectious Sickness, coming to the knowledge of the Medical Officer of Health (by notification), during the year 1913> in the B°rough of Lambeth, classified according to Diseases an(^ Localities. [Local Government Board Old Table B.] Population at all Ages. £ Registered Births 1913. New Cases of Sickness in each the knowledge of the Medical during Locality, coming Officer of Health 1913. to Number of such Cases removed from their Homes in the several Localities for Treatment in Isolation Hospital during 1913. Registration Sub - Districts. (a) Census 19)1. lb) Estimated to middle of 1913. (c) 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 1 3 9 10 11 12 Scarlatina. Diphtheria. Membranous Croup. Fevers. Ccrebro-spinal Meningitis. Poliomyelitis Acuta. Ophthalmia. Whooping Cough. Scarlatina. Diphtheria. Membranous Croup. Fevei s. Cerebro-spinal Meningitis. Poliomyelitis Acuta. Ophthalmia. Whooping Cough. Typhoid or Enteric. Continued. Puerperal. Cholera. Erysipelas. Typhoid or Enteric. Continued. Puerperal. Cholera. Erysipelas. Waterloo 47910 46241 2366 74 31 2 6 2 ... 15 1 1 2 71 73 31 2 5 ... 2 ... 6 ... 1 ... ... Lambeth Church 126 33 ... 3 ... 2 ... 23 1 ... 7 1/8 124 33 ... 3 ... ... ... 9 1 ... ... 6 Kennington 48609 47673 1232 217 55 3 5 1 5 ... 46 3 1 14 291 206 53 ... 5 ... 4 ... 14 1 29 Stockwkll 82608 62315 2013 320 94 1 8 5 ... 39 1 16 301 284 78 1 7 ... ... ... 8 ... ... ... 27 Brixton 76650 77363 1551 456 71 1 6 1 6 ... 64 2 1 16 351 370 64 1 6 1 4 17 ... 1 ... 16 Norwood 62281 63547 1179 177 101 ... 10 5 ... 19 ... 2 2 236 155 75 7 3 5 1 12 Totals 298058 297139 8341 137C 385 7 38 2 25 .... 206 7 6 57 1428.1212 334 4 33 1 15 59 2 3 90 88 TABLE U. Shewing Classification of Certain Causes of Deaths (uncorrected) in the Borough of Lambeth, during 1912 and 1913, given in percentages of the total uncorrecteed deaths. A.—Deaths at all Ages. Lambeth. Percentage of total Deaths (uncorrected) 1912. 1913. I. Principal Zymotics 8.2 8.6 Influenza 0.9 1.3 Measles 2. I 2.1 Whooping Cough 1.1 0.8 Diarrhoea and Dysentery (including Cholera) 2 .03 3.9 II. Rheumatic Fever and Heart Rheumatism 0.3 0.3 III. Diseases of Circulatory System 10.4 10.9 IV. Bronchitis, Pneumonia and Pleurisy 16.9 16.2 Phthisis 8 6 7.1 V. Injuries ... 4.2 4.2 B—Deaths under i Year of Age (per iooc uncorrected). Births All Causes 87.5 99.6 89 BOROUGH OF LAMBETH. SUMMARY OF VITAL AND MORTAL STATISTICS, etc., FOR 1913. Area of Borough—4,080.4 statute acres (inclusive of land and inland water, but exclusive of tidal water 82.1 and foreshore 31.1 statute acres respectively), divided into 5 Registration Sub-Districts, 4 Parliamentary Divisions, and 9 Wards. The Parliamentary Divisions and Wards are not co-extensive but the Registration Sub-Districts and the Wards are. Population—estimated middle ef 1913—297,139 (males 141,917, females 155,222). 'Density—72.8 persons per statute acre (including land and inland water, but exclusive of tidal water and foreshore). Rateable Value—1,878,118 for the year ending March 31st, 1913 (as settled at Quinquennial Valuation, and including Government property and alterations made by Provisional Valuation Lists). Births—8,341, being 28.1 per 1,000. Deaths (corrected)—4,280 being 14.4 per 1,000. Infantile Mortality—733 deaths (corrected) under 1 year, being 87.9 per 1,000 total (uncorrected) births. Zymotic—Death-rate, 1.2 per 1,000 (total corrected zymotic deaths, 369). •The densities vary in the different Registration Sub-Districts as follows—Lambeth Church (354"3 acres) 130'5, Kennington (398'3 acres) 119'7, Stockwcll (583 acres) 106'9, Brixton (1026'6 acres) 75'3, and Norwood (1718"2 acres) 36'9 per statute acre respectively. 90 II. —SANITARY WORK (Dealing with the sanitary circumstances and administration of the Borough of Lambeth.) Return shewing' the Number of Notices served in the Borough of I.ambeth, from the 1st January to the 31st December, 1 ft] 3. Number of Notices served 14,397. A. COMPULSORIL Y NOTIFIABLE INFECTIOUS DISEASES. (Pubic Health (London) Act.) No. of Notices served 3531 No. of Infected Houses 2972 Smallpox — Scarlet Fever 1227 Typhoid 34 Typhus — Continued Fever 2 Diphtheria 365 Membranous Croup 7 Puerperal Fever ... . 25 Erysipelas ... 206 English Cholera — Cerebro-Spinal Meningitis 7 Acute Polio-Myelitis 6 Ophthalmia Neonatorum 56 Whooping Cough ... 1037 91 B. GENERAL NUISANCES AND DRAINAGE EFFECTS. (Public Health (London) Act, and Metropolis Local Management Act.) No. of Notices served 10866 Works, Structural— Drainage Defective 987 Intercepting Traps with Fresh Inlets required 102 Ventilating I'ipes required '206 Indoor Sinks connected with Drain 197 Rain Water Stacks connected with the Drain 531 Bath Waste connected with the Drain 73 Traps defective, or of Obsolete Pattern 601 Closet Pan and Connections Defective 807 Water Supply to Closet Defective 909 Closet Dilapidated 651 Draw-off Main for Drinking Purposes required 195 Dust Bins Defective 798 Premises Dilapidated 804 Ventilation under Floors required 302 Roofs Dilapidated 501 Soil Pipes Defective 51 Paving Defective 1103 Damp and Unwholesome Houses 296 Dung Receptacles required 9 Defective Water Pipes . 37 No W.C. Accommodation 7 9167 92 Works, Not Structural:— Cisterns Dirty 305 Manure Accumulations 31 Underground Rooms occupied 16 Animals Improperly Kept 27 Stopped Drains 179 Overcrowding- 19 Foul Urinals 21 Refuse Accumulations 116 No Water Supply or Defective Water Supply 3G9 Dirty Premises . 4071 5154 93 PARTICULARS OF SANITARY WORK CARRIED OUT IN LaMBETH BOROUGH DURING 1913, TOGETHER WITH YEARLY AVERAGES FOR (a) THE DECENNIUM 1903-1912 (borough) and (b) THE 24 YEARS 1877-1900 (parish): Year. Total Number of Notices (excluding those served under the Housing of the Working Classes Act). Sanitary Works, Structural and Permanent. Sanitary Works, not Structural. 1913 14397 9167 5154 1912 12506 8679 4044 1911 12440 8008 3103 1910 12110 7341 3042 1909 12764 8219 3323 1908 14258 9561 3645 1907 14883 9902 3252 1906 14768 9650 2941 1905 13053 9447 2838 1904 11778 8433 2975 1903 13043 10448 3043 Yearly Average for 10 Years 19031912 (Borough) 13160.3 8968.8 3220.6 Yearly Average for 24 Years 18771900 (Parish) 5944.6 4756 .9 2135.9 94 SUMMARY OF WORK DONE BY THE MALE SANITARY INSPECTORS DURING 1913. Inspections 8309 Re-inspections 65316 Complaints attended to 5081 Cases of Infectious Disease notified 3531 Cases of Non-Notifiable Diseases Dealt with 4741 Rooms disinfected . 8098 Bedding, etc., disinfected 5975 Bedding, etc., destroyed 80 Drains tested (with chemical, water or both) 8461 Sanitary Works compleled 5397 Plans of drainage reconstructions received and approved 302 Premises the Drains of which have been totally or partly reconstructed 384 Samples of Food and Drugs submitted to Analyst 1855 Notices— Sanitary Work (Preliminary or Intimation 7121 and Statutory 3705) 10826 Infectious Diseases (Public Health Act, 1891). 3531 Metropolis Local Management Acts . 40 Sanitary Nuisances abated— (a) Structural 9167 (b) Non-Structural 5154 Summonses issued— Public Health Act 6 Food and Drugs Acts 54 Convictions obtained— Public Health Act 3 Food and Drugs Acts 43 Vide also Section of Report dealing with the Housing, Town Planning &c., Act, 1909. 95 MALE SANITARY INSPECTORS * During 1913, there has been no change in the personnel of the Male Sanitary Staff. Work of Male Sanitary Inspectors. During 1913, the following routine work was carried out:— (1) 8309 inspections and 65316 re-inspections; (2) 384 houses re-drained throughout or in part (the drains being in every case water-tested); (3) 8461 tests (hydraulic, smoke or chemical) made; (4) 91 Water Certificates (representing 96 houses, separate or in block, and 102 tenements), issued, in accordance with section ¥8 of the Public Health (London) Act, 1891 ; (5) 5081 complaints attended to; (6) 14397 notices served—14357 under the Public Health (London) Act, 1891 (7121 Preliminary, 3705 Statutory and 3531 Infectious Diseases) and 40 under the Metropolis Local Management Acts, dealing with 9167 structural and 5154 nonstructural defects. The Male Public Conveniences situated within the Borough are under the supervision of the Male Inspectors. Drainage Cases. Several cautionary letters were sent to builders, who had carried out drainage work (a) without giving previous notice, or (b) contrary to the requirements of the L.C.C. By-laws. In the latter case, the work was altered so as to comply with the requirements. Unsound Food. During 1913, several consignments of unsound food, discovered within the Borough were inspected, condemned and destroyed, under the supervision of the Sanitary Inspectors and the details reported to the Council at the time. * There are 12 District Inspectors, viz., F. E. Baxter, J. M. Jones, J. S. Smith, J. Barfcot, G. J. Gavin, T. H. Hooper. T. H. Jackson, W. Wallis, W. W. Howes, J. M. Scorrer, J. S. Clements and A. Farran.and one special Inspector for Food and Drugs (W.J. Perrin). 96 Inspection of Market Thoroughfares. During 1913, the market thoroughfares were under biweekly special inspections by the Sanitary Inspectors, 2 Inspectors being on duty at a time—Saturday nights (9 to 12) and Sunday mornings (9 to 12). The market thoroughfares are Atlantic Road, Wandsworth Road, New Cut, Lower Marsh and Lambeth Walk. These systematic inspections are of value in securing wholesome food being exposed, on stalls and in shops for sale. No official seizures were necessary. Outside Urinals of Public Houses. During 1913, the outside urinals connected with public houses were under inspection, and notices were served as required. House-to-House Inspections. House-to-house inspections, during 1913, are dealt with under the Housing, Town Planning, etc., Act, 1909. Other Inspections. The work in connection with disinfection, smoke abatement, inspection of factories and workshops, bake-houses, restaurants, and dining (coffee rooms), births, the milk depot, tuberculosis icases, etc., and the carrying out of Food and Drugs and Housing Acts, is dealt 'with under separate headings in this report. Legal Proceedings. It is again satisfactory to note that, during 1913, in but very few cases was it found necessary to resort to legal proceedings before the Court in connection with Sanitary work carried out under the Public Health and Metropolis Management Acts—6 summonses, which resulted in £\ 19s. Od. costs, as follow: convictions, 3; withdrawn (payment of costs), 1 ; and adjourned sine die, 2. These legal proceedings had reference to (a) defective drains, (b) dirty premises, (c) dilapidated premises, (d) defective soil and vent, pipes, (e) anima's improperly kept, so as to be a nuisance. 97 FEMALE SANITARY INSPECTORS. During 1913, there has been no change in the personnel of the Female Sanitary Staff. Work of Female Inspectors. The two Female Sanitary Inspectors carried out, during 1913, duties in connection with the inspection of (a) Factories, Workshops (Work-places), Shops, Out-Workers' Homes, Laundries, Restaurants, etc., wherein women and girls are employed; (b) the Underground Conveniences (belonging to the Council), and other Ladies' Sanitary Conveniences (Railway Stations, Hospitals, etc.); (c) Houses wherein births occurred or deaths amongst infants under 1 year of age, or deaths from infantile diarrhoea; (d) Schools wherein there were infectious disease outbreaks; (e) Houses wherein cases of tuberculosis or ophthalmia neonatorum were notified, etc. The year's work, 1913, may be tabulated as follows:— Work carried out by the Two Female Sanitary Inspectors during the Year, 1913. * Workshops visited and inspected— (a) Dressmakers 30 (b) Milliners 6 (c) Laundries 10 (d) Tailors 12 (e) Upholsterers — (f) Dyers — (g) Blouses 14 (h) Ties 1 (i.) Others (e.g., embroidery, shirts, bandeaux, underclothing, etc.) 21 Workrooms inspected 99 Workshops* re-inspected 2 * Workshops include Work-places. 98 Work rooms re-inspected 4 Workshops*: workrooms therein measured 276 Workshops* newly discovered and registered 14 t Premises visited, but not inspected, owing to the persons or patients concerned being- out or, if employees being no longer employed 1427 Workshops* removed from Register 2 Workshops* reported to H.M. Inspector 5 Workshops* reported by H.M. Inspector 6 Female Conveniences visited and inspected— Public (visits paid) 230 Private . — Schools visited— Public (visits paid) 126 Private . — Special places visited and inspected— (a) Private Houses‡ 2610 (b) Outworkers . 192 Outworkers and Private Houses|| re-inspected 516 Written Intimations and Statutory Notices served 238 No. of Workshops*, etc. in which defects were round 246 No. of Workshops*, etc., in which no defects were found 2778 Nuisances referred to M.O.H. for attention by male inspectors 19 * Workshops include Work-places. † Births (561), Workshops (5), Out-workers (246), Diarrhoea cases (52), Schools (43), special complaints (28), and Tuberculosis cases (492). ‡Births (1417), Diarrhoea cases (121), Tuberculosis cases (1016), Ophthalmia cases (20), and special complaints (36). || Births (92), Diarrhoea cases (7), Tuberculosis cases (319), Ophthalmia cases (51), and special complaints (11). 99 Particulars of Defects Found. 'Workshops,*etc.— Workrooms— Overcrowded Damp Dirty Ill-ventilated Badly-lighted Insufficiently warmed Otherwise Defective or dirty— Yards Floors Roofs Windows Ceilings Rain Water Pipes Sink Wastes Water supply Premises generaly Sanitary Appliances : Water Closets— Dirty Ill-lighted Unventilated Choked Defective Defective Flushing Tanks and Water Supply Sanitary Appliances : Drainage— Choked Defective Unventilated * Workshops include Work-places. 11 24 51 5 - 1 1 23 16 14 7 3 7 7 73 39 4 13 17 2 7 IOO Sanitary Appliances : Dustbins— Wanting- 12 Defective 35 Sanitary Appliances : Lavatories— Dirty Defective *No separate suitable sufficient W.C. accommodation for the sexes . 1 Miscellaneous defects, e.g., accumulations, animals, improperly kept, personal uncleanliness, etc. 11 The Female Inspectors, during- 1913, were engaged in visiting 121 houses wherein deaths from infantile (summer) diarrhoea were reported as having occurred, with a view to helping to further elucidate the predisposing causes of this disease; in inspecting schools (126) in connection with outbreaks of disease (more especially measles); and in visiting (a) 1417 private houses, wherein births had been notified or registered, with a view to educating the mothers and others concerned how best to feed their infants, and (b) 1016 private houses, wherein tuberculosis patients had been notified, with a view to educating the patients and their relatives or friends in the nature of the disease, and the simple precautionary measures to be taken to prevent its spread to others, and (c) 20 private houses, wherein infants suffering from ophthalmia neonatorum had been notified, with a view to educating the parents and others concerned in the proper treatment for that disease. Revisits were paid to, and re-inspections made of, houses in connection with 92 births and 7 diarrhoea, 319 tuberculosis and 51 ophthalmia cases, etc. * The Sanitary Accommodation Order 1903 does not apply to the Metropolis. 101 FACTORIES AND WORKSHOPS Factories During 1913, ,2 new factories were added )to the Register, consisting of (a) bedsteads, 1; (b) Laundry, 1. The Inspection of Factories by the Sanitary Inspectors is limited to that of the sanitary accommodation provided for the workers (such accommodation to be separate, sufficient, and suitable) and sanitary defects, when found, are reported by the Factory Inspectors. Workshops During 1913, 57 new 'workshops were added to the Register, consisting of the following:— Name of Trade or Business. Dressmakers Laundries Milliners Tailors Blouses Scenic Artists Mantles Underclothing Ties and Belts Boots and Shoes Babies' Linen Not classified No. of Workshops. 13 2 3 10 5 1 4 1 4 3 3 8 Total 57 102 Full particulars concerning these 57 workshops were entered up in the Register shewing that, at the time of inspection, there were 87 workrooms, in which were working 316 persons—62 males and 254 females, as follow : 5 Notices as to "protected persons" (i.e., children, young persons, and women) employed were sent on, during 1913, to the Factory Inspectors, from time to time as required, (i.e., where no Abstract under the Act was found to have been posted up in a work-place). 48 Notices of occupation (representing 46 workshops) were received during 1913 by the Borough Council from the Factory Inspector. 6 written Notices were received during 1913 ;by the Borough Council from the Factory Inspectors with reference to contraventions of the Public Health Acts in connection with Factories and Workshops, and all such nuisances were abated, as found necessary, and due notices sent to the Factory Inspectors as to action taken in each case. In connection with the 57 new workshops, inspected during 1913, the insanitary conditions found at the time of inspection are set out in the Table subjoined. The cubic capacities of the different workrooms were, naturally, found to vary considerably, and in 5 workrooms (i.e., 5.7 per cent.), overcrowding was found to exist. M. F. Total. Children Young Persons Adults 7 37 44 55 217 272 103 WORKSHOPS REGISTERED DURING 1913. Numbers of Rooms and Persons Employed. Wards. No. of Workshops. No. of Workrooms. Children. Young Persons. Adults. TOTALS. M.. F. M. F. M. F. M. F. Total. Marsh 8 10 ... ... 3 4 10 45 13 49 62 Bishop's 1 I ... ... ... 10 19 29 29 Prince's 3 4 ... ... 1 6 1 9 2 1 5 17 Vauxhall 5 7 ... ... 2 2 6 9 8 11 19 Stockwell 11 15 ... ... ... 6 8 32 8 38 46 Brixton 21 27 ... ... 1 7 28 41 29 48 77 Heme Hill 4 5 ... ... ... ... ... 12 ... 12 12 Tulse Hill 6 10 ... ... ... 1 1 22 1 23 24 Norwood 3 8 ... ... ... 1 1 28 1 29 30 Total 57 87 ... ... 7 37 55 217 62 254 316 104 IO5 WORKSHOPS:—Details as to Sanitary , Conditions and Defects found in 1918. Details as to Sanitary Conditions and Defects found. Marsh. Bishop's. Prince's. Vauxhall Stockwell. Brixton. Heme Hill. Tulse Hill. Norwood. Totals. . f satisfactory 3 1 3 5 11 20 3 6 3 55 Ventilation not ... ... ... 1 1 ... ... 2 satisfactory . 3 1 3 5 11 19 4 5 3 54 Cleanliness not ... ... ... 2 1 3 damp ... ... ... ... ... ... ... ... ... ... Workrooms not 3 1 3 5 11 21 4 6 3 57 ( warm... 3 1 3 5 11 21 3 6 2 55 Workrooms no t ... ... ... ... ...• 1 ... 1 2 State of Sanitary good 3 1 3 5 11 21 4 6 3 37 fittings, &c. bad ... ... ... ... ... ... ... ... ... ... ventilated 2 1 3 5 11 21 4 6 3 56 Soil pipe not ventilated 1 ... ... ... ... ... ... ... ... 1 no soil pipe ... ... ... ... ... ... ... ... ... outside 1 ... 1 2 2 7 1 1 15 Position of J inside ... 1 2 1 1 7 2 1 ... 15 W.C. i outside and inside 2 ... ... 2 8 7 1 4 3 27 I.no W.C ... ... ... ... ... ... ... ... ... Separate W.C. accom- Yes 2 1 2 2 9 10 1 4 3 34 modation (sufficient and suitable) (.No 1 ... 1 3 2 11 3 2 23 Communication (direct) C Yes ... ... ... ... ... ... ... ... ... ... between W.C s and rooms (.No 3 1 3 5 11 21 4 6 3 57 •In only 1 of these 23 cases was separate W.C. accommodation required—persons of one sex only being employed in the other 22 cases. 1o6 OUT-WORKERS The work, commenced by the Female Inspectors in 1903, and continued since, connected with the visiting and inspecting of out-workers' premises and homes (situated within the Borough), was further continued during 1913. Lists of out-workers require to be sent in to the Council by employers, engaged in the special trades scheduled in the Home Work Order, 1911, twice yearly, viz. : on or before February 1st and August 1st respectively. During 1913, 20 February and 22 August lists were received, dealing with 207 and 217 out-workers respectively. Of the 424 outworkers, 181 belonged to Lambeth and 243 elsewhere. Particulars of the latter were sent to the Authorities concerned, whilst, in return, 157 lists were received from various authorities dealing with 953 workers, of whom 920 belonged to Lambeth and 33 to districts outside Lambeth. Of the total 1101 Lambeth out-workers reported, 154 were new out-workers, i.e., not previously notified, as follows:— Mantles 9 Blouses and skirts 13 Ties, belts, and braces 16 Children's underclothing and costumes 4 Women's clothing 11 Tailors 28 Embroidery . 6 Waistcoats 2 Shirts 4 Printers 1 Corsets 3 Boots and shoes 12 Millinery . 3 Dresses 5 Collars . 2 Bag stringing 11 Boxes and boxmaking 4 Pattern bookmakers 2 Brushes I Artificial flowers 7 Paper Bag6 9 Tennis Ball Covering 1 154 107 The Wards, in which the houses (wherein the 154 new out-workers were found to be working during 1913) are situated, are as follows :— Wards. No. Marsh 16 Bishop's 20 Prince's . 34 Vauxhall 9 Stockwell . 20 Brixton 26 Wards. No. Heme Hill 19 Tulse Hill 9 Norwood 1 Borough of Lambeth 154 FEMALE HEALTH VISITOR Work of Female Health Visitor. The Council's Health Visitor has been engaged, during 1913, in the systematic visiting and re-visiting of houses wherein births had been notified, in looking after the milk depot children (at the depot and at their own homes), in inspecting the infants notified as suffering from ophthalmia neonatorum, and in assisting in making enquiries in connection with tuberculosis cases—-this lastmentioned work being carried cut on a separate day or days from those devoted to infant visiting, etc. The work may be summarised as follows :— Visits and Revisits made 1st Q. 2nd Q 3rd Q 4thQ Total in connection with— Births 359 216 525 360 1490 Ophthalmia cases 26 26 58 21 131 Depot children 51 10 10 8 79 Milk Depots— York Koad 12 10 16 15 53 Moffat Institute 77 85 74 74 310 Special cases .20 7 7 5 39 Tuberculosis cases 109 87 83 118 397 Piemises, but no one . found at home 132 88 222 160 602 'Used as a branch (distributing centre) in connection with the Council's York Road Milk Depot. 108 DISINFECTING DEPARTMENT* Details of work done during 1913, in connection with the Disinfecting Department, are subjoined. A total of 3,531 infectious diseases, notifiable compulsorily under the clauses of the Public Health (London) Act, 1891, were reported and dealt with, including cases of cerebro-spinal meningitis (7), acute polio-myelitis (6), ophthalmia neonatorum (57), and whooping-cough (1,428), whilst the following diseases were voluntarily notified by school teachers and others: measles (1,085), chicken-pox (679), cancer (71), verminous houses (649), and bedding or clothing (1,386). and other diseases! (176), 1,753 cases were removed to hospital. In addition, 1,571 cases of pulmonary tuberculosis (consumption), were notified and dealt with—210 ulnder the old Public Health (Tuberculosis) Regulations, 1908 (Poor Law), 1911 (Hospitals), and 1911 (Private), and 1,361 under the new Public Health (Tuberculosis) Regulations, 1912. The houses were visited and pamphlets left, dealing with consumption and its prevention, and disinfection was carried out, as required, in the event of death or removal of a patient. 456 cases of non-pulmonary tuberculosis were notified and dealt with in the same way under the new Public Health (Tuberculosis) Regulations, 1912. 23 schools were disinfected in connection with outbreaks of infectious disease, viz. : measles, 7, scarlet fever, 14, diphtheria, 1, and mumps, 1. A total of 8,098 infected rooms and 29,881 infected articles (bedding, etc.) were disinfected officially. *The Staff consists of 1 Superintendent (W. Lockyear), 4 Disinfectors, 4 Drivers, 1 Boiler Attendant, and 1 Yard and Stable Attendant. †Mumps, scabies, ringworm, influenza, &c. 109 The yearly averages are given in the Table of Disinfection Work carried out during the past 30 years. Summary of work carried out by the Disinfecting Department in the Borough of Lambeth during 1913. Total No. of rooms disinfected by Council 8098 Cases in which bedding was disinfected at home 2420 Do. do. do. at Chamber 3555 Do. do. do. destroyed 80 Premises disinfected and disinfectants supplied 19375 No. of Cleansing Notices served in connection 'with infected houses 1783 Certificates of Medical Practitioners received in lieu of disinfection by the Council 15 Schools disinfectedf (156 class-rooms) 23 Certificates of disinfection left with occupiers of disinfected premises 6097 Library books disinfected‡ 343 Mattresses re-tabbed by Council 913 Cabs disinfected 4 Railway carriage disinfected 1 Articles of bedding, etc., disinfected. Beds 2178 Bolsters 1773 Pillows 4852 Mattresses . 1757 Palliasses 85 Chair Cushions 517 Clothing . 6078 Sheets 2431 Blankets . . 4099 * The number is increased, compared with previous years, owing to bedding no longer being removed to the disinfecting station in the cases of Measles, Chicken-pox and Whooping Cough, t Scarlet Fever 14, Diphtheria 1, Measles 7, Mumps 1. t 158 Public Library and 190 Private Library Books. 1 10 Rugs and Mats 62 Counterpanes and Eiderdown Quilts 2043 Carpets ... ... ... ... 16 Extras (i.e., articles not included above) 3930 Total 29831 Articles of bedding, etc., destroyed. Beds 47 Bolsters 13 Blankets 9 Pillows SO Quilts and Counterpanes 6 Mattresses 38 Palliasses 59 Sheets . 5 Chair Cushions 18 Clothing . ;6 Carpets 3 Extras (i.e., articles not included above) 272 Total 556 Practically all the disinfection was carried out by the Council's staff—only 15 certifictes being received from Medical Practitioners during 1913, as follows :— Medical Practitioners Certificates accepted in lieu oj Disinfection being carried out by the Borough Council. Nature of Certificate. 1st Q. 2nd Q. 3rd Q. 4th Q. Total. For Rooms onlv ... ... ... ... ... For Bedding onlv ... ... ... ... ... For Rooms and Bedding 7 6 1 1 1 5 Total 7 6 1 1 15 Refuges. There is one refuge in the Borough, at Wanless Road but it has not been called into use during 1913. 111 DISINFECTION STATISTICS. For eight years prior, and twenty-two years subsequent, to the passing of the Notification of Infectious Diseases Act; and for the year 1913. Yearly average for 8 years preceding the Notification Act, 1882-1889 (Parish). Yearly average for 11 jears succeeding the Notification Act, 1890-1900 (Parish). Yearly average for 12 years succeeding the Notification Act, 1901-10 & 1906-12 (Borough) 1913. 1901-5. 1906-12. No. of Cases in which At Home 142.8 240.8 16.6 1403.3 2420 Bedding, etc., has ) been disinfected At Chamber 452 8 2333.3 2337 0 2875.1 3555 No. of Cases in which Bedding, etc., has been destroyed 45 7 121.6 74.2 107.4 80 No. of Articles of Bedding, tc, disinfected 2253 2 15600.4 34032 4 22510.1 29881 No. of Articles of Bedding, etc.. destroyed 113 0 489.4 7100 329. 0 556 Premises disinfected and disinfectants supplied 916.8 6191.7 11738.4 13151.0 19375 Infectious diseases Notifiable ... 2408.5 2835.2 1821.4 3529t dealt with Non.notifiable ... 299.3 2260 8 4076.3 4741 * This number is increased for 1906, 1907, 1908, 1909, 1910 and J911, on account ot bedding no longer being removed to the Disinfect on Station as a routine in connection with Mettles, Whooping Cough and Chicken-pox. † Whooping: Cough became compulsorily notifiable on January 1st, 1913, so that the figures for notifiable infectious diseases for 1913 are increased. N.B.—The Statistics for 1901-1913 r-fer to the pres;nt Borough Council ; those for all previous years to the late Vestry, 1 12 Cleansing of Verminous Persons. No proper local arrangements have yet been made l v the London County Council for tRe cleansing of verminous school children and occupiers of common lodging houses within the Borough—statutory obligations imposed upon the County Council by Parliament. The London County Council, as the Educational Authority, have simply suggested that the Borough Council should provide cleansing stations under the Cleansing of Persons Act, 1897 (a permissive Act), and that the County Council should have the use of the same by agreement at stipulated charges, for the cleansing of verminous (a) school children, and (b) adults, e.g., inmates of common lodging houses, the stations to be planned with separate entrances for children and adults. The stipulated charge offered by the County Council is 52/t) a child, such payment to cover any number of attendances by the child at the station for cleansing within a period of one calendar month from the date of the first cleansing. No stipulated charge is offered for adults. This suggestion of the County Council has not yet been accepted by the Borough Council, who are of opinion that the provision of cleansing stations for verminous (a) school children, and (b) inmates of common lodging houses, is' a statutory obligation devolving upon the County Council, under whose jurisdiction schools and common lodging houses are. Meanwhile, Lambeth Borough remains unprovided with the required cleansing stations. Verminous premises are disinfected as required, but such disinfection is not satisfactory without the school children and inmates of the common lodging houses, who are themselves verminous, being cleansed also at the same time. "3 The numbers of verminous houses and rooms disinfected and cleansed during 1913, and the four previous years are:— Year. Houses. Rooms. 1909 148 387 1910 207 646 1911 268 535 1912 580 11091 1913 649 927* SMOKE ABATEMENT During 1913, observations and enquiries were made >n connection with smoke abatement throughout the Borough and smoke notices were served as required. In no cass was it found necessary to proceed to a summons. The L.C.C. and the Coal ^Smoke Abatement Society reported, during 1913, nuisances as follows:— 1. London County Council—6 letters dealing with alleged smoke nuisances connected with: Doulton & Co., Ltd. (High Street), Frederick Hygienic Laundry, Ltd. (Langton Road), Sir Joseph Causton & Sons, Ltd. (Clapham Road), Hammerton & Co., Ltd. (Stockwell Green), A. Beattie & Co. (39 Lower Kennington Lane), and J. & A. Sharwood & Co., Ltd. (Offley Road). • Bedding 1245 and Clothing 141, in addition. 114 2. Coal Smoke Abatement Society 11 letters dealing with alleged smoke nuisances connected with :— Lion Brewery Co, (Belvedere Road), Walker, Parker & Co. (Belvedere Road), Meredith Bros. (Belvedere Road), Holloway Bros. (Belvedere Road), St. Thomas's Hospital (Westminster Bridge), McGaw & Co. (York Road), J. C. & J. Field (Upper Marsh), London & South Western Railway (Waterloo Station). Special observations were made, during 1913, with reference to St. Thomas's Hospital (Westminster Bridge), Rogers & Cook (South Lambeth Road), Lion Brewery (Belvedere Road), Sir Joseph Causton & Sons, Ltd. (Clapham Road), Arlington Laundry (Cambria Road), and Meredith Bros. (Belvedere Road). A new furnace was provided to the boiler in connection with the Arlington Laundry (Cambria Road), whilst a new boiler plant was installed in connection with Rogers & Cook (South Lambeth Road), consisting of two Lancashire boilers (30ft. bv 8ft. 3in. each), two Fergusson's superheaters and one of Green's patent economisers—all installed in new settings and in a new boiler house. The flues are connected to a newly erected chimney 100ft. Oin. high. In connection with Sir Joseph Causton & Sons, Ltd. (Clapham Road), a combustion indicator was placed in the boiler house, so as to enable the stokers to have a constant knowledge of the condition of the smoke issuing at any time from the top of the chimney stack. The St. Thomas's Hospital authorities are considering a scheme for enlarging the boiler plant, so as permanently to abate the nuisance from black srroke from time to time as complained of, as also the nuisance from fine particles of unburnt or partially burnt coal, which, at times, issue from the chimney shaft, and are deposited upon the St. St. Thomas's Hospital premises and other neighbouring premises. 115 UNDERGROUND CONVENIENCES* The conveniences were kept 'under regular inspection and supervision during 1913—'the male conveniences by the male inspectors and the female conveniences by the female inspectors. During 1913, '.there has been no alteration in the personnel of the attendants. ANALYSIS OF FOOD AND DRUGS, WATER, etc. 1.—Food and Drugs. During the year 1913, 800 formal samples were purchased within the Borough, and submitted to the Public Analyst for analysis. Of the 800 samples, 80 (i.e., 10 per cent.) were reported by the Analyst to be adulterated, and 54 summonses were issued, with the result that 43 convictions were obtained, together with £T6 5s. 5d. in penalties and ^38 13s. 6d. in costs. The annual averages of the two decennia 1891-1900 (Parish) and 1901-1910 (Borough), are respectively: (1) number of samples aken 501.9 and 1352.4, of which 74.6 and 89.1 (i.e., 14.9 and 6.6 per cent.) were found on analysis to be adulterated; (2) number of summonses taken out 53.1 and 63.8 with 52.3 and 48.5 convictions, and ^104 5s. 5d. and ^74 0s. 4d. in penalties and ^35 0s. 3d. and ;£38 16s. 6d. in costs. * The Staff consists of 19 male and 17 female attendants. There are 8 male and 7 female conveniences. 116 During 1913, 1,055 informal samples (139 adulterated) were taken by the Inspector, in addition to the 800 formal samples (80 adulterated), making a total of 1855 samples, of which 219 (t.e, 11.8 per cent.) were reported by the analyst to be adulterated, varying quarterly as follows :— 1st quarter, 13.4 per cent., 2nd, 11.6 per cent., 3rd, 10.9 percent, and 4th, 11.5 percent. Particulars of the 1,855 articles submitted by the Food and Drugs Inspector during 1913 are as follow:— (a) Mjlk. 1. Formal Samples. 477 samples were taken, and of these 50 (i.e., 10.5 per cent.) were declared by the Analyst to be adulterated. Of the 477 samples, 2 were separated milk (none adulterated), 1 was skim milk (not adulterated), and 474 were ordinary milks (50 adulterated). These 50 adulterations were as follows:— (1) Extraneous water 24, varying from a minimum 1 to a maximum 45 per cent., viz., 1, 2, 2, 2 3, 3, 5, 5, 6, 6, 7, 7, 8, 8, 9, 9, 10, 12, 13, 1,3, 14, 21, 37 and 45 respectively. (2) Deficiency in milk-fat 23 varying from a minimum 2 to a maximum 37 per cent., viz. : 2, 3, 3, 4, 4, 4, 4, 6, 6, 6, 7, 7, 9, 9, 10, 10, 10, 10, 11, 12, 19, 30 and 37 respectively. (3) Extraneous water and deficiency in milk-fat (3), viz., 5 and 3, 6 and 17, 15 and 6 per cent., respectively. In 23 cases, no summonses were taken out for the following reasons:— , , (1) Amounts of adulteration being too small (21), viz. : (a) extraneous water, 1, 2, 2, 3, 3, 3, 4, 117 5 and 5 per cent, respectively; (b) fat deficiencies, 2, 3, 3, 4, 4, 4, 4, 6, 6, 6, 7 and 10 per cent, respectively. (2) Sample being used for evidence only (1), viz. : 19 per cent, fat deficient. (3) Bottle burst (1), viz. : 37 per cent, fat deficient. Out of the 27 samples, there were 20 convictions, 6 summonses were dismissed, the Magistrate being satisfied with the evidence for the defence, and 1 summons was adjourned sine die. The total fines amounted to £20 10s. 0d., with £22 Is. Od. costs. 2. Informal Samples. 18 samples were taken, but none were declared by the Analyst to be adulterated. (b) Butter. 1. Formal Samples. 218 samples of butter were taken, and of these 28 (i.e., 12.8 per cent.) were declared by the Analyst to be adulterated the adulterations consisting of (1) added margarine (21), varying from a minimum 75 per cent, to' a maximum 100 per cent. viz. : 75, 90, 90, 90, 95, 96, 98, 98, 98, 99, 100, 100, 100, 100, 100, 100, 100, 100, 100, 100 and 100 respectively; (2) preservatives present (4), varying from a minimum 0.12 per cent, to a maximum 0.28 per cent, crystallised boric acid, viz. : 0.12, 0.28, 0.18 and 0.28 respectively; (3) added margarine and preservatives present (3), viz. : 93 and 0.12, 94 and 0.12, and 100 and 0.22 respectively. In 3 cases, no summonses were taken out for the following reasons : (1) amount of adulteration being too small (1), viz. : 0.28 per cent, boric preservative. 118 (2) Vendor absconded before summons could be served (1) viz.: 75 per cent. margarine; (3) Insufficient evidence obtainable (1), viz.: 98 per cent. margarine respectively. Out of the 25 summonses taken out, there were 22 convictions, 3 summonses were withdrawn for the following reasons: (a) Magistrate satisfied with the evidence for the defence (1), and (b) wrong persons summoned (2). The total fines amounted to 10s. 0d., with ;£l6 costs. 2. lnjormal Samples. 809 samples were taken, and, of these, 124 (i.e., 15.8 per cent.) were declared by the Analyst to be adulterated, viz.: (1) added margarine (118), (2) preservatives present (4), and (3) added margarine and preservatives present (2). (c) Margarine. 17 samples of margarine were taken formally, but none were declared by the Analyst to be adulterated. (d) Cream. 6 samples were taken informally, and of these 5 were declared by the Analyst to be adulterated, the adulterations consisting of the presence of preservatives, viz.: (a) ordinary cream 0.06, 0.25, 0.31, and 0.43 per cent. of crystallised boric acid respectively; (b) preserved cream 0.33 per cent. of crystallised boric acid in excess of that declared on the label. (e) Coffee. 4 samples of coffee were taken formally (none adulterated) and 15 samples informally (none adulterated). (f) Mustard. 8 samples of mustard were taken formally (1 adulterated with 25 per cent. of wheaten flour), and 30 samples informally (1 adulterated with 25 per cent. of wheaten flour). 119 In the case of the adulterated formal sample, the defendant was fined 5s. with 12s. 6d. costs. (g) Pepper. 8 samples of pepper were taken formally (none adulterated) and 30 samples informally (none adulterated). (h) Other Groceries. 7 samples of arrowroot, 6 of cocoa, 6 of ground rice, and 8 of rice, were taken informally, but none were declared by the Analyst to be adulterated. 6 samples of sago were taken informally, and, of these, 1 was declared by the Analyst to be adulterated, viz.: with 4.5 per cent. of cane sugar. (i.) Drugs. 3 samples were taken formally (1 adulterated, viz.: saffron with 16.3 extraneous mineral matter), and 62 samples informally (4 adulterated, viz.: (a) saffron with 17.6 per cent. extraneous mineral matter, (b) cream of tartar with 10 per cent. deficiency in potassium tartrate, (c) tincture of iodine with 16 per cent. excess of iodine, (d) gregory powder, made with carbonate and not with oxide of magnesia). In the case of the adulterated formal sample, the summons was withdrawn, by direction of the Public Health Committee, owing to a difficulty re Warranty. (j) Lard. 48 samples of lard were taken formally (none adulterated) and 6 samples informally (none adulterated). (k) Vinegar. 3 samples of vinegar were taken informally, and of these 1 (i.e., 33.3 per cent.) was declared by the Analyst to be adulterated, viz.: deficient in acetic acid to the extent of 26 per cent. 120 (l) Bacon. 6 samples were taken informally, and, of these, 3 were declared by the Analyst to be adulterated, the adulterations consisting of .0.08, 0.16 and 0.21 per cent. of crystallised boric acid respectively. (m) Other Articles. 3 samples of sultanas, 3 of currants, 3 of raisins, 9 of bottle fruit, 6 of cheese, 3 of bread, 4 of oatmeal, and 6 of wheaten flour, were taken informally, but none were declared by the Analyst to be adulterated. 17 samples of dripping were taken formally, but none were declared by the Analyst to be adulterated. Summary of Legal Proceedings taken under the Sale of Food and Drugs Acts. Of the total 54 summonses taken out, viz: 27 milks, 25 butters, 1 mustard and 1 saffron (drug), there were convictions in 43 cases, in 20 milks, 22 butters (6 under the Margarine Act), and 1 mustard, whilst in the remaining 11, the results were as follows:— (a) 7 summonses dismissed:— (1) Contrary proved, 7 (all milks). (b) 3 summonses withdrawn:— (1) Wrong persons summoned, 2 (butters). (2) By order of Public Health Committee, 1 (saffron). (c) 1 summons adjourned sine die (milk). Registration of Margarine Factories. During 1913, two margarine manufactories were registered, viz.: 22 Wilcox Road, and 58 Patmos Road. 121 Since the Margarine Act, 1887, came into force within the Borough, the following premises have been registered in addition to the above: 233 Wandsworth Road, 417 Brixton Road, 413 Norwood Road, 71 Robsart Street, 75 Atlantic Road, 114 Camberwell New Road, 32 Commercial Road, 14 Vassall Road, 92 Lambeth Walk, 266 Brixton Road, 64 Stamford Street, 21 Lower Marsh, *11-13 Gray Street, 7 Juxon Street, 15 New Cut, 448 and 450 Brixton Road, and Wessex House (Oakley Street). Expenses ok carrying out the Food and Drugs Acts. The total expenses connected with the carrying out of the Food and Drugs Acts in the Borough during 1913 amounted to £98 7s. 3d., and are made up as follow:— £32 1s. 8d. for samples, £34 16s. 0d. for assistants, £8 0s. 0d. for witnesses, £17 16s. 6d. for travelling expenses (including £8 18s. 0d. for cabs) and £5 13s. 1d. for sundries. The salary of the Food and Drugs Inspector (£120, rising by £10 annual increases to £200), and the cost of the summonses (£7 2s. 0d.), are not included. The annual averages for the last 10 years (1903-12) are (1) total expenses, £81 10s. 1d., (2) number of formal samples, 1,571. 2. Water. No sample of water was submitted for analysis during 1913. Public Health (Milk and Cream) Regulations, 1912. All samples of milk are examined by the Public Analyst, as a routine, for the presence of preservatives, and, of the total samples of milk taken during 1913 (477 formal and 18 "Registration was withdrawn on May 29th, 1913. 122 informal), in no single instance were preservatives found. Six samples of cream (one a preserved cream) were taken during 1913, and 5 (including the preserved cream) were found to be adulterated, the adulterations consisting of (a) the presence of preservatives in fresh cream, and (b) an excess of declared preservative in preserved cream, thus:— 1. Milk; and cream not sold as preserved cream:— (a) (b) No. of samples No. in which a examined for the preservative presence of was reported preservative to be found Milk 495 0 Cream 5 4 2. Cream sold as preserved cream:— (a) Correct statement made on label — (b) Statement incorrect (viz. : slight excess beyond quantity declared) 1 No action was taken owing to the difficulty in proving guilty knowledge. Informal v. Formal Sampling. During 1913, a total of 1,055 informal samples have been taken, as compared with 800 formal samples. The Local Government Board drew the attention of Sanitary Authorities to the advisability of taking informal samples instead of formal samples with all the formalities required by the Acts, i.e., samples of foods and drugs for analysis without disclosing to the vendors the purpose for which the samples are required, as the Board is of opinion that, ;by that means, habitual offenders could be more readily detected, and especially those guilty of the fraud of substituting margarine for butter. Informal sampling is particularly useful to the Inspectors, who desire to detect tradesmen in a small way of business, who may practice 123 adulteration systematically, and, indeed, speaking generally, such informal sampling, when judiciously carried out, is shown, by evidence that is accumulating, to be by far the best method for the detection of offenders under the Food and Drugs Acts. A deputy calls again and again, day by day or week by week, or longer, at a certain shop or shops where it is thought adulteration is being systematically carried out, and in that way, is regarded, after a longer or shorter period by the tradesman as a regular customer, who can with safety, they think, be imposed upon ! A formal sample or samples are taken after an interval, and the vendors are caught. The suspicions of trades are not raised by informal sampling, and much time is saved. Informal sampling (where the samples are reported against) must be followed up by formal sampling. Of the 108,174 samples submitted for analysis during 1912-13 in England and Wales, nearly 24,000, taken in 184 districts, were purchased informally, 1,886 being condemned. The results obtained in the case of samples of butter purchased within the Borough of Lambeth, during 1912, when practically there was no informal sampling, and during 1913, when there was systematic informal sampling, are as follow:— Year. Formal. Informal. Samples taken. Samples adulterated. Samples taken. Samples adulterated. 1912 581 31=6.4% 5 2 1913 318 28 = 12.8% 809 124 Informal sampling is of little use in the case of milk (except, perhaps, "station" milk), but is of value in the case of butter. 124 SALE OF FOOD AND DRUGS ACTS. Samples procured, together with the results of the analyses, during the year 1913:— Samples. Formal. Informal. Number Analysed Number Adulterated. Number Analysed Number Adulterated. Milk* 477 50 18 ... Butter 218 28 809 124 Lard 48 ... 6 ... Coffee 4 ... 15 ... Margarine 17 ... ... Mustard 8 ... 30 1 Pepper 8 ... 30 ... Arrowroot ... ... 7 ... Vinegar ... ... 3 1 Sago ... ... 6 l Oatmeal ... ... 4 ... Ground Rice ... ... 6 ... Flour (Wheaten) ... ... 6 ... Cocoa ... ... 6 ... Dripping 17 ... 62 ... Drugs 3 ... 4 Rice ... ... 8 ... Cream ... ... 6 5 Sultanas ... ... 3 ... Currants ... ... 3 ... Raisins ... ... 3 ... Bottle Fruit ... ... 9 ... Cheese ... ... 6 ... Bacon ... ... 6 3 Bread ... ... 3 ... Totals 800 80 1,055 139 Total Samples taken 1,855 Samples Adulterated 219 * 2 separated and 1 skim milk. I25 Particulars as to samples analysed, and proceedings taken, under the Sale of Food and Drugs Acts, during 1913 (Borough), together with the yearly averages for the two decennia, 1891-1900 (Parish) and 1901-10 (Borough). Year. No. of Samples analysed. No. of Samples adulterated. Percentage of Samples adulterated. No. of Summonses issued. No. of Convictions. Penalties. Costs. £ s. d. £ s. d. 1913 800 80 10.0 54 43 76 5 5 38 13 6 1910 1800 70 3.9 49 33 66 12 0 30 2 6 1909 1800 88 4.9 76 59 86 10 0 48 9 8 1908 1800 153 8.5 109 76 88 4 6 72 11 7 1907 1800 154 8.6 110 79 118 10 0 61 16 0 1906 1500 69 4.6 38 35 52 0 0 27 3 7 1905 1200 57 4.7 41 30 47 0 0 19 8 0 1904 1200 79 6.6 66 43 80 19 6 39 17 6 1903 1010 97 9.6 66 60 71 7 6 38 17 0 1902 704 51 7.2 21 19 14 5 0 16 5 6 1901 710 73 10.3 62 51 114 15 0 33 14 0 Average of 10 years, 1901-1910 (Borough) 1352.4 89.1 6.6 63.8 48.5 74 0 4 38 16 6 Average of 10 years, 1891-1900 (Parish) 1501.7 746 151 531 52.5 104 5 5 35 0 3 Inspector Perrin commenced his duties on February 21st, 1898, vice Inspector Wiggs, whodid the work from August, 1892 to November, 1897. N.B.—During 1913, in addition to the 800 formal, 1,055 informal samples were taken, and, of the informal samples, 139 (i.e., 13.2 per cent.) were declared by the Analyst to be adulterated. K 126 COMMON LODGING HOUSES The 6 Common Lodging Houses (for men) within the Borough were inspected during 1913, but no defects were found to exist. The 6 common lodging houses were again licensed by the London County Council at the Annual Licensing Meeting held June 26th, 1913, in accordance with the requirements of Section 46 of Part ix. of the London County Council (General Powers) Act, 1902:— Author- Dates when registered Situation, of premise,. ised originally Lodgers. 27th January, 1905 10a Belvedere crescent 99 18th July, 1900 108 Lambeth walk (c.h.) 39 (house in rear) 30th October, 1890 55 Belvedere road 49 21st December, 1883 90-92 Westminster bridge 197 road 24th October, 1885 89&91 Wandsworth road 188 12th February, 1887 106 Wandsworth road 133 HOUSES LET IN LODGINGS. The 372 registered houses were under inspection during 1913, but no new houses were registered under the by-laws. Experience in Lambeth goes to show that the by-laws do not work out in practice as well as was anticipated when the by-laws were framed—the powers under the other Sections of the Public Health (London) Act, 1891, being more 127 easily used in connection with keeping of houses let in lodgings in proper order and condition. The Council has drafted, during 1913, for approval by the Local Government Board, new by-laws, made under Section 16 of the Housing, Town Planning, etc., Act, 1909. REVENUE ACT. 1903 (And Section 35 of the Housing, Town Planning, etc., Act, 1909). During 1913, 84 certificates under the Revenue Act, 1903, in connection with tenements (or dwellings) so constructed as to afford suitable, separate accommodation for each of the families inhabiting the same, were applied for, and, of these, 38 were granted unconditionally, 36 were granted conditionally, i.e., subject to certain alterations and improvements being carried out, and 10 were refused. (1) Certificates granted unconditionally. Blocks or Houses. Tenements 21 Alexandra Road 1 2 110a, 110b, and 110c Brixton Hill 3 9 63 Mervan Road 1 2 117 Oakley Street 1 5 65, 67, 69, 71, 73, 75, 77, 79, 130 132 Stamford Street 5 20 11 38 E 2 128 (2) Certificates granted conditionally. blocks or Houses. Tenements. 7 Alexandra Road 1 2 67 Angell Road 1 3 29 Guildford Road 1 3 15 Kepler Road 1 2 56, 58, 60, 62 Lambert Road 2 4 30, 32 Morval Road 2 4 29, 31, 33 Rosendale Road (Southwell and Delcourt Mansions) 3 12 52, 52a South Island Place 1 2 125, 127, 129, 131 Strathleven Road 2 4 14 36 (3) Certificates refused. 50, 52 Branksome Road 2 6 41, 43 Margate Road 2 4 4 10 HOUSING OF THE WORKING CLASSES HOUSING, TOWN PLANNING, &c., ACT, 1909. House-to-House Inspections. These inspections are necessary under Section 17 of the Housing, Town Planning, &c., Act, 1909, and under Regulations issued, as an Order, on September 2nd, 1910, with respect to the method in which such house-to-house inspections of the district are to be made and records kept During 1913, the Medical Officer of Health, as required by Article 1 of the Regulations or Order, prepared the following lists of dwelling houses, the early inspection of which was, in his opinion, desirable:— 129 Marsh Ward.—Ethelm Street, Gilbert's Court, James Place, Linnett Street, Starling Place and Tanswell Street. Bishop's Ward.—China Walk, Karl Place, and St. Alban's Buildings. Prince's Ward.—Bloomfield Place, Bonnington Square, Durham Street, Farnham Royal, Glasshouse Street Heyford Terrace, Kennington Grove, Montford Place, The Grove (South Lambeth Road), Trigon Grove, Tyers Street, Vauxhall Street, and Wickham Street. Vauxhall Ward.-—Albert Square Mews, Meadow Place and Old South Lambeth Road. Stockwell Ward.—Bedford Court, Burgoyne Road, Clarence Cottages, Nealdon Street, and Tandridge Place. Brixton Ward.—Ann's Place (Robsart Street), Cancell Road, Clark's Row (Robsart Street), Chryssell Road, Frederick Crescent, Halstead Street, Ingleborough Street, Ingleton Street, Peckford Place and Russell Grove. Heme Hill Ward.—Lewis Road and Lewis Road East. Tulse Hill Ward.—Archbishop's Terrace, Birkbeck Place, Birkbeck Road and Somers Road. Norwood Ward.—Berridge Road and Rommany Road. A total number of 775 houses have been systematically inspected during 1913, and in 48, i.e., 6.2 per cent., a result has been obtained from the test applied to the drains. A total of 1,987 other nuisances were found to exist in 661 houses (i.e., 85.3 per cent. of the total houses inspected) but many were of a trifling nature and not in any sense dangerous to the health of the inmates of the houses concerned. In 114, i.e., 14.7 per cent., no nuisances were found on inspection. 130 Summary. Number of houses inspected 775 Number of houses in which a result was obtained from test (chemical) applied to drains 48 Number of houses in which other nuisances were found to exist 661 Number of houses in which no nuisances were found to exist 114 Nature of all Nuisances found and dealt with under the Housing, Town Planning, etc., Act, 1909, or the Public Health (London) Act, 1891. Dirty premises (walls, ceilings, etc.) 93 Defective roofs, gutters, and rain-water pipes, etc. 250 Defective yard pavings 263 Defective flushing apparatus in w.c.s. 38 W.C. pans foul 5 Drinking water taps defective 7 Drains stopped 7 Floors, windows, doors, and sash-cords defective 226 No dust bins (or dust bins defective or dilapidated) 73 Damp premises 243 Overcrowding 7 Defective w.c.s. 18 Defective drains 48 Defective or deficient vent. or soil pipes 5 Defective sink wastes (or not under-trapped) 115 Defective manhole covers 3 Animals improperly kept 1 Cisterns uncovered or improperly covered 3 Improper water supplies (not from main direct, etc.) 50 Forecourts insufficiently paved, or unpaved 33 W.C.s insufficiently lighted and ventilated 1 Want of Ventilation under floors 115 131 Want of proper dung receptacles — Underground rooms illegally occupied 11 Accumulations of manure 3 Defective traps and stopped gullies 1 Sinks connected direct to drains 1 Mica valves defective 25 Light and air spaces limited 125 Dilapidated Premises 47 Sundry minor defects, viz.: Defective fire-places (18) coppers (14), and chimneys (7) 39 Total 1987 Under the House-to-House Inspections Regulations, or Order, of 2nd September, 1910, certain classifications are adopted, so as to secure uniformity of statistics throughout the various sanitary districts, and, adopting this classification, the results in connection with the 775 houses inspected during 1913 may be tabulated as follows:— i. Arrangements for preventing contamination of Water Supplies. (a) Drinking water from the main 616 (b) Drinking water from cisterns 30 (c) Cisterns uncovered, or improperly covered 3 (d) Defective water taps 7 ii. Water Closet Accommodation. (a) Defective water closets 18 (b) Foul water closets 5 (c) Water closets insufficiently lighted and ventilated 1 (d) Defective water closet flushing apparatus 37 (e) Defective, or deficient, ventilating or soil pipes 5 132 iii. Drainage (with Results of Tests). (a) Results from chemical tests 48 (b) No results from chemical tests 727 (c) Drainage stopped 7 (d) Defective manhole covers 3 (e) Defective mica valves 25 iv. Condition as to Light, Circulation of Air, Dampness and Cleanliness. (a) Light and circulation of air limited 125 (b) Damp premises 243 (c) Dirty premises 293 (d) Over-crowded premises 7 v. Paving, Drainage and Sanitary Condition of Yard or Out-Houses belonging to or connected with the Dwelling Houses. (a) Defective yard paving 263 (b) Insufficiently paved forecourts 33 vi. Arrangements for House Refuse. (a) No dust bins, for dust bins defective or dilapidated 73 (b) Want of proper dung receptacles (c) Accumulations of manure 3 vii. Any Underground Rooms so dangerous or injurious to health as to be unfit for human habitation. (a) Underground rooms occupied in contravention of Section 17, Sub-section 7 11 viii. Defects or other matters tending to render houses dangerous or injurious to the other inmates. (a) Dilapidated premises 47 '33 (b) Defective roofs, gutters, rain water pipes, etc. 250 (c) Defective floors, windows, doors, sash boards, fireplaces, coppers and chimneys 265 (d) Sink waste pipes connected direct to drain or defective or not under-trapped 116 (e) Want of air, or insufficient ventilation under floors 115 (f) Defective traps (gullies, etc.) and stopped gullies 1 (g) Animals improperly kept 1 ix. Action taken. Under the Housing, Town Planning, etc., Act, 1909, and the Public Health (London) Act, 1891, whilst in 16 cases, the dwelling-houses were closed by the Borough Council as the Local Authority under the Housing, Town Planning, etc., Act, 1909, as being unfit for human habitation, and have since been closed and demolished, closed, or put (or are being put) into proper order and condition so as to render them fit for human occupation. Representations and Closing Orders under Section 17. During 1913, the Medical Officer of Health made the following representations to the Council as the Local Authority under the Act, and Closing Orders were made by the Council in each case. 134 PREMISES. STATE. Date of Orders made by the Council. 1, 2, 8, 4, 5, 6, 7, 8, Wigton Place (late Cumberland Mews), Milverton Street, Kennington, S.E. Dwelling-housesbeing unfit for human habitation (a) by virtue of their positions (above stables), allowing the effiuvia from such stables to permeate the dwelling-rooms, and (b) on account of the water closets being placed beneath the staircases in positions which are dark, unventilated, and difficult and dangerous of access. May 29th 1913 19, Albert Square Mews, Albert Sq., Clapham Road, S.W. The dwelling-house being unfit for human habitation (a) by virtue of its position (above stable), allowing effluvium from stable to permeate the dwelling-room, and (b) on account of the watercloset being placed beneath the staircase in a position which is dark, unventilated and difficult and dangerous of access. July 10th 1913 1, 3, 5, 7, 14, 16, 63 67, 69, 118, 115 117, 119, 121, 123 Wickham Street The dwelling-houses being unfit for human habitation, being, generally speaking, dirty, damp and dilapidated and worn out. Nov. 27th 1913 135 During 1913, 24 houses were dealt with by Closing Orders, and of these, 13 have since been demolished, and 11 have been or are being rendered fit for human habitation. In connection with the closing of houses under the Housing, Town Planning, &c., Act, 1909, a total of 1)4 dwelling houses within the Borough have been represented by the Medical Officer of Health as being unfit for human habitation from the time the Act came into force (December 3rd, 1909) until the end of 1913, and Closing Orders have been made by the Borough Council, as the Local Authority, in connection therewith under Section 17 of the Act, with the result that:— (a) 69 houses have been closed and since demolished; (b) 25 houses have been, or are in process of being, rendered fit for human habitation (22 houses completed). In addition to the houses mentioned above, 27 houses have been dealt with under Section 15 of the Act, and voluntarily closed and since demolished by the owners. Comparison may be made with similar work (closure of dwelling houses) carried out under the Housing of the Working Classes Act, 1890, Section 32, from the date upon which it came into force (viz.: August 18th, 1890) up to the introduction of the Housing, Town Planning, &c, Act, 1909,—a period of 19 years—during which a total of 3.5 houses were dealt with by notices served by the late Vestry and the present Borough Council, under Section 32 of the Housing of the Working Classes Act, 1890, on the representation of the Medical Officer of Health that such dwelling houses were unfit for human habitation, viz.:— (a) 1891 to 1900 (10 years)—old Vestry 337 (b) 1901 to 1909 (9 years)—Borough Council 48 Total 385 136 It must be remembered that the powers under the Housing, Town Planning, &c., Act, 1909, are wider than those under the Housing of the Working Classes Act, 1890, and deal with empty houses as well as with occupied houses; whilst Closing Orders under the former Act are made by the Borough Council, whereas under the latter Act such Closing Orders could only be made by a Magistrate, after taking evidence, in the usual way, in the Court. The important point has been raised again as to whether or not a condemned dwelling house can be converted to other uses after condemnation, e.g., for a store. The general interpretation placed upon Section 18 (2) of the Housing, Town Planning, &c., Act, 1909, is that demolition must follow condemnation of a dwelling house, unless such dwelling house be put into proper order and condition, i.e., rendered habitable as a dwelling house. The Scottish Law Officers of the Crown hold the following opinion (vide Local Government Board for Scotland Annual Report, 1912), and this may be quoted for reference:— "We are of opinion if the owner of a building which has been occupied as a dwelling house undertakes that it shall no longer be so occupied, but shall be put to a different use, e.g., a store, then a demolition order under Section 18 (2) of the Housing, Town Planning, &c., Act, 1909, ought not to be pronounced. If, however, the building, although not occupied as a dwelling house, is in such a condition as to be a nuisance, or dangerous to the health of the public or of the neighbours, then a demolition order must be pronounced, even although there is no intention to use it as a dwelling house. This appears to us to be the correct interpretation of the Act, which in Section 18 (1), and in the former of the two alternatives to which Section 18 137 (2) relates, speaks exclusively of dwelling houses. It would, in our judgment, be absurd to compel the owner of, say, a store, to render it 'fit for human habitation' on pain of having it demolished. This would be the effect of so interpreting the Act as to force an owner whose property had once been used as a dwelling house to continue so to use it, or have it demolished by order of a public authority." MUNICIPAL MILK DEPOT* The statistics for 1913 are subjoined. 246 new infants and children were entered upon the Register and fed, their ages being at the time of commencing the milk:— Under 3 months 135 9—12 months 8 3—6 months 73 Over 12 months 7 6—9 months 23 246 Of the 135 infants under 3 months, 18 were aged 14 days or under, viz.:—1, 1, 1, 2, 2, 3, 4, 5, 6, 10, 10, 10, 10, 11, 11, 12, 12 and 13 days respectively. These 246 infants and children may be classified, as to their states of health at the time of being put upon the milk, as follows:—Healthy, i.e., showing no sign of wasting or disease, though below par constitutionally 129, weakly 15, wasting 47, diseased 55, total 246. The diseases from which the 55 infants and children were actually suffering at the time of being put upon the milk were: Diarrhoea 12, sickness 6, bronchitis 15, pneumonia 2, eczema 1, tabes * The Staff consists of a Manageress (Miss Paterson), one permanent Assistant (Miss Violet Berkeley) and one temporary Assistant. Miss Paterson succeeded Mrs. Burke (resigned) on April 24th, 1913. 138 mesenterica, 1, indigestion 1, convulsions 1, rickets 3, hernia 1, sickness and diarrhoea 5, measles 1, harelip 1 anæmia 1, nœvus 1, teething 2, and operation 1. In 2 cases the infants were in a "moribund" condition. The periods during which the 246 infants and children continued to use the milk were:— 26 weeks and over 31 Under 4 weeks— 13—26 weeks 47 2—4 weeks 26 6—13 weeks 52 Under 2 weeks 58 4—6 weeks 29 246 54.1 per cent. used the milk for periods extending from 6 to 26 weeks and over, whilst 34.1 per cent. used the milk for short varying periods under 4 weeks. The reasons assigned for discounting the milk after varying intervals were:—(1) leaving the neighbourhood; (2) unable, or too far, to send; (3) by order of medical attendant; (4) unable to pay; (5) taken off by Relieving Officer; (6) unsuitable. In regard to (6), it is noteworthy that, of the 246 infants and children fed, in only 2 cases (i.e., 0.8 per cent.), was the milk stated to be unsuitable. An average of 98.9 infants and children were fed per week at the Depot, necessitating the distribution for the year of 253,176 bottles of milk mixture, whilst, in addition, milk was also supplied as follows:— 1. Lambeth Infirmary—a total of 1,140 (estimated) infants and children, using 12,708 pint bottles of milk mixture; 2. Lambeth Workhouse—a total of 69 (estimated) infants and children", using 780 pint bottles of milk mixture; 139 3. Invalids—a total of 14 persons, using 4,005 pint bottles of milk mixture. i. Relieving Officers' cases—a total of 20 children over 2 years of age, using 404 pint bottles of milk mixture. Weekly medical consultations with mothers were held at the Depot, the babies being weighed, the weights and other details tabulated in the Milk Register, whilst the babies were visited also at their homes by the Health Visitor as required. Milk was distributed not only from the Depot, but also from the Moffatt Institute (Upper Kennington Lane), the latter branch depot (distributing centre) being used for the convenience of the mothers living in the Vauxhall District. Of the 246 new infants and children fed, 10 died, and the periods (in days), during which they had been fed upon the milk prior to death, varied as follow:—3, 4, 9, 14, 26, 31, 39, 40, 126, and 142 respectively. In other words:— Infants and children fed for 13 weeks and over 81 (2 deaths) Infants and children fed for 4 to 13 weeks 81 (3 deaths) Infants and children fed for periods under 4 weeks 84 (5 deaths) N.B.—Of the 10 deaths, all were in infants under 12 months, viz.:—11 days, 3 weeks, 1 month, 1 month, 2 months, 2 months, 2 months, 2 months, 7 months, and 3 months respectively. The stated causes of death were measles 1, bronchitis 2, pneumonia 1, marasmus 1, convulsions 1, and diarrhoea 4. 140 The mortality rates amongst the Depot-fed infants and children are lower than those registered in the Borough generally. As has been pointed out in previous reports in connection with these mortality rates, allowance must be made for the difficulties of strictly comparing the rates amongst infants and children fed upon the milk and under observation for varying periods, with the rates for the whole, or portions, of the Borough, for a year or period of years. To be statistically correct, only those infants or children who have been fed upon the Depot milk for continuous lengthened periods should be tabulated, whilst the numbers of deaths that occur during any given period less than a year should be increased pro rata, when dealing with rates for a year or period of years. It is assumed that the rates that are found to exist for short periods would be maintained during longer periods—an assumption that, in practice, is found to be warranted. It must be remembered that, as already stated, the infants who are placed upon the Depot milk are, as a rule, unhealthy and below par constitutionally, it not actually diseased, at the time of commencing the milk, and the longer they use the milk, the better their chances of life. If some children died during the first month during which they were taking the milk, it would be misleading to assume that all children would die at the same rate during the succeeding period of eleven months. The most conclusive proof of the value of a Milk Depot, in so far as the infants and children fed are concerned, is to be found in the medical histories of individual cases, which show again and again, in the case of the Depot that those infants and children who appear to be seriously ill and wasting, if not moribund, as the result of improper or irregular feeding, at the time of commencing the milk, actually recover and become strong and healthy. The educational value, too, of a Milk Depot must not be lost sight of. 141 The net expenditure upon the maintenance of the Milk Depot, during the year ending December 31st, 1913, is stated by the Borough Accountant to have been £306 0s. 2d. (a) Expenditure £891 0 8 (b) Income 585 0 6 i.e., Expenditure in excess of Income £306 0 2 The net yearly expenditures since the Depot was opened are: 1906, £233 12s. 6d.; 1907, £206 0s. 0d.; 1908, £233 16s. 7d.; 1909, £315 8s. 8d.; 1910, £294 5s. 3d.; 1911, £214 18s. 10d.; 1912, £256 13s. 11d.; 1913, £306 0s. 2d. The financial statistics must be considered with the good derived by the infants and children fed. BAKEHOUSES There are, within the Borough, 214* Bakehouses (135 above ground and 79 underground), and these were inspected officially during 1913, and the necessary annual whitewashing and cleaning carried out, as required. *72 were certified during 1903-4 as "suitable" for occupation as underground bakehouses under section 101 Factory and Workshop Act, 1901. 142 DAIRIES, MILKSHOPS AND MILK STORES. During 1913, 64 applications For registration were received and dealt with by the Council as follow:— 1.—Applicants not registered, the premises being "un suitable" (i.e., not in accordance with the Council's requrements)—7. Wards and Addresses of Premises. Names of Applicants. Dates of Refusal by Council. MARSH. 56 Ethelm Street Swilt, James C. Feb. 13th 127 Oakley Street Potter, Fred. Chas. Feb, 27th BISHOP'S Nil PRINCE'S 119 Tyers Street Stow, William Jan. 30th 119 Tyers Street * Steggall, Frank April 24th VAUXHALL. Nil STOCKWELL. 31 Bedford Road Masters, George Feb. 27th * Change of occupier. 143 1.—Applicants not registered, the premises being "unsuitable" (i.e., not in accordance with the Council's requirements)—continued. Wards and Addresses of Premises. Names of Applicants. Dates of Refusal by Council. BRIXTON. Nil HERNE HILL. Nil TULSE HILL. 3 Probert Rood Roberts, Thomas Sept. 9th NORWOOD. '25 Camden Hill Road. White, John June26th 2.—Applicants registered the premises being "suitable" (i.e., in accordance with the Council's requirements) —57. Wards and Addresses of Premises. Names of Applicants. Dates of Registration by Council. MARSH. 64 Broad wall * Selby, Charles Jan. 16th 48 Coral Street Bennett, Wm. James Jan. 16th 14 Duke Street Deerman, Arthur J. Sept. 18th 17 Duke street Rees, John Sept. 18th * Change of occupier. 144 Applicants registered, etc.—continued. Wards and Addresses of Premises. Names of Applicants. Dates of Registration by Council. 9 Eaton Street Field, Elizabeth Feb. 13th 1 Howley Place Rogers, Edward June 12th 6 Lanfranc Street Woolley, Harry April 10th 2 Oakley Street Hughes, Edward June 26th 127 Oakley Street Potter, Fredk. Charles April 10th 6 Tower Street Stott, Ernest Mar. 10th BISHOP'S. 9 China Walk Manwaring, George Nov. 13th 4 Crozier Street* Maier, Eugen Jan. 16th 11 Lambeth Walk Nicholls, Henry June 26th 26 Lambeth Walk Dickman, Harry Oct. 2nd 17 Little Paris Street Gillson, Charles F. Nov. 13th 137 Lollard Street Goode, Joseph May 29th 141 Lollard Street Jones, Susannah June 26th 11 Oakden Street Parker, George James April 10th 1 Old Paradise Street Taynton, Samuel Bailey Feb. 27th 5 Upper Marsh Gibbons, William Hy Nov. 13th 25 Upper Marsh Evans, Rees Nov. 13th 36 Upper Marsh Ingram, Ellen C. Oct. 30th 89 Walcot Square Penneck, Jane July 10th 52 Walnut Tree Walk Baker, David Sept. 18th PRINCE'S. 2 Kennington Grove Lovegrove, John Mar. 13th 70 Tyers Street Smith, Thos. James Oct. 30th 119 Tyers Street Steggall, Frank May 8th 3 Windmill Row Burrows, Mary Ann May 29th * Change of occupier. 145 Applicants registered, etc.—continued. Wards and Addresses of Premises. Names of Applicants. Dates of Registration by Council. VAUXHALL. 29 Paradise Road Black, James A. Oct. 16th 6 Portland Place, S. Osborne, James Oct. 2nd STOCKWELL. 20 Garden Row* Belton, Alfred Edmond Feb. 27th 56 Stockwell Road Goodwin, Charles Marshall Feb. 27th 12 Stockwell Green Collett, Albert and Squires, Samuel June 26th 49 Willington Road Pickard, Thomas H. J. April 10 th BRIXTON. 40 Atlantic Road Oettle, Charles Oct. 30th 56 Brixton Road Geddes, John Percy May 8th 433 Brixton Road Williamsons, Ltd. Sept. 18th 54 Elliott Road Berkshire, William April 10th 9 Gordon Grove Tyler, Henry Wm. Oct. 30th 50 Holland Road Gander, Thomas Jan. 30th 54 Holland Road James, Mary May 8th 53 Langton Road Hills, George Ernest April 10th 86 Patmos Road Smith, John W. Oct. 30th 15 Robsart street Moylett, Patrick May 29th 56 South Island Place* Bone, Frances Mary May 29th 23 Warham Street † King, Robert John Feb. 13th 23 Warham Street † Beal, Mary Ann June 12th * Change of Occupier. † Since withdrawn. 146 Applicants registered, etc.—continued. Wards and Addresses of Premises. Names of Applicants. Dates of Registration by Council. HERNE HILL. 229 Coldhatbour lane Knight, Robert Oct. 30th 319 Coldharbour Lane Mozzocchi, Joseph Oct. 30th 331 Coldharbour Lane Warman, Annie Oct. 30th 2 Vaughm Road Wood, George July 10th 2 Vaughan Road Hill, Wm. Horace July 24th TULSE HILL. 9 Croxted Road Welfords Surrey Dairies, Ltd. April 24th NORWOOD. 38 Gipsy Hill White, John July 24th Knight's Hill Wraight, Dumbrill & Co., Ltd. Oct. 30th 232 Rommany Road Leg, Nicholas June 12th 20 St. Got harts Road Ashley, Sidney July 10th COWHOUSES. There were, within the Borough, at the end of 1912, 43 registered Cowhouses, and, at the Annual Licensing of the London County Council, held on October 27th and December 11th, 1913, the licenses were renewed with the following exceptions:— 30 Upper Kennington Lane (premises unoccupied). 67 Rosendale Road (no application made). I 17 LIST OF THE 11 COWHOUSES LICENSED IN THE BOROUGH OF LAMBETH DURING 1913. Wards. Situation of Premises. No. of Sheds. Names of Licensees. Marsh 6 Coral Street, Lower Marsh 1 Owen, William. Bishop's 24 Distin Street 2 Vaughan, David. „ 36 Tracey Street 1 Evans, Anne. Vauxhall 9 Dawlish Street 1 Adams, John. „ 38 Hartington Road 1 Williams, John Morgan and Lewis, Davis Brixfon 34 Ingleton Street 1 Baker, Sarah Amelia & Frederick. Norwood 93 Clive Road, W. Norwood 1 Wraight, Dumbrill & Co. Ltd. „ 15 Croxted Road, W. Dulwich 1 Wraight, Dumbrill & Co. Ltd. „ E der Road Dairy, W. Norwood 9 Bacon, Charles. „ 156 Hamilton Road, W. Norwood 3 Grant, George Ephraim. „ 76 & 78 Gipsy Hill 3 French, James Thomas. 148 The Borough Council is now responsible for the periodical inspection of the Cowhouses, and the due enforcement of all By-laws and Regulations, made in connection therewith under the Dairies, Cowsheds and Milkshops Orders, 1885), 1886, and 1899. Such duties were carried out by the London County Council previous to the passing of the Local Government Act, 1899. During 1913, no action was required to be taken before the Magistrate in regard to infringements of By-laws, but a cautionary letter was addressed to the occupier of the cowshed at 6 Coral Street, drawing attention to the unsatisfactory manner in which the manure was being dealt with on several occasions when the Inspector called. SLAUGHTER-HOUSES There were within the Borough, at the end of 1912, 19 registered Slaughter-houses, and at the Annual Licensing of the London County Council, held on October 27th and December 11th, 1913, the licenses were renewed with the following exceptions:— 18 Paradise Road (no application made). 10 Foxley Road (no application made). List of the 17 Slaughter-Houses licensed in the Borough of Lambeth during 1913. Wards. Situations of Premises. Names of Licensees. Marsh 99 Lower Marsh* Bacchus, James „ 106 „ „ Thomas, Robert Edwin * Small cattle only to be killed. 149 Wards. Situations of Premises. Names of Licensees. Bishop's 151 Lambeth Walk Milton, Robart William Prince's 60 Kennington Park Road Grellier, Frederick „ 406 Kennington Road Parsons, Bernard William Vauxhall 152 Clapham Road Lawrence Bros Stockwell 27 Bedford Road, Clapham Road Pooley, John Peed Brixton Near Railway Hotel Brewery, Electric Lane, Brixton Ford, Henry, & Co , Ltd. „ Industry Terrace (yard leading to), Canterbury Road Warren, Emma Sanders Heme Hill 207 Coldharbour Lane Clark, Albert John „ 309 Coldharbour Lane Ford, Henry, & Co., Ltd, „ 77 Dulwich Road Atkin, Jim Cook Tulse Hill 12 Lower Tulse Hill Rooksby, Walter „ 45 New Park Road Beaumont, Edith Mary Norwood 125 Hamilton Road Forss, Thomas Lionel „ 120 High Street*† Griffiths, Frederic „ 121 „ „ Hindle, Richard John * Small cattle only to be killed. † Special conditions laid down. 150 The Borough Council is now responsible for the periodical inspection of the Slaughter-houses and the due enforcement of all By-laws and Regulations, &c., made in connecnection therewith, under the Slaughter-houses, &c., Metropolis Act, 1874, and the Local Government Act, 1888. Such duties were carried out by the London County Council previous to the passing of the Local Government Act, 1899. During 1913, no action was required to be taken before the Magistrate in regard to infringement of By-laws, but a cautionary letter was sent to the occupier of the Slaughterhouse at 120 High Street, West Norwood, drawing attention to what the Inspector found at one of his usual inspections. viz.: (1) garbage from previous slaughtering left in uncovered receptacles, (2) the floor of the slaughter-house left uncleansed on completion of the slaughtering, and (3) 13 sheep accommodated in the pound, which is 45½ square feet in area. OFFENSIVE TRADES During 1913, no nuisance was reported in connection with the three offensive trades, which are registered as established within the Borough, and which are under the supervision of the Borough Council:— 1. Fat Melters—Upper Marsh (Messrs. J. C. & J. Field). 2. Soap Boilers—Upper Marsh (Messrs. J. C. & J. Field). 3. Tripe Boilers—103 Lambeth Walk (Messrs. Bennett, Son & Co.). 151 REFUSE AND MANURE DEPOTS. The 13 Public Depots, situated in the Borough, were under constant (daily, during the summer months) supervision during 1913, and, in connection with the Destructors and Dust Yards situated in Tinworth Street (Prince's Ward) and Commercial Road (Marsh Ward), a large number of visits were paid, but in no instance was a nuisance discovered with which the Council could deal under the By-laws, having regard to the provision in the By-laws, which permits of the depositing of refuse and offensive matters for a reasonable period of 12 hours during the process of removal. Cautionary letters were sent, as required, in one or two instances, but no action was taken before the Magistrate. EFFLUVIUM NUISANCES. (a) Arlington Laundry, Cambria Road, Herne Hill. A petition was received on the 1st July, 1913, signed by 31 inhabitants of the neighbourhood, drawing attention to an alleged nuisance arising from the choking fumes issuing from the chimney connected with the Arlington Laundry, Cambria Road, Herne Hill. Enquires in the neighbourhood elicited the fact that in addition to smoke and choking fumes, small particles of unburnt or partly burnt coal, were deposited from time to time in the gardens in the neighbourhood. A letter was sent to the proprietors of the laundry, and a new furnace was in consequence fitted, being provided with smoke preventing appliances. The chimney connected with the furnace is not very high and it was pointed out to the proprietors that the nuisance would not be satisfactorily abated, unless this chimney were heightened, in addition to the provision of the new furnace with its smokepreventing appliances. 152 It was decided to allow the matter to stand over for the purpose of seeing if the nuisance was satisfactorily abated without the chimney being heightened, and, consequently, the Borough Council decided to take no further action for the time being under Section 21 of the Public Health (London) Act, 1891 but gave instructions for a further report to be presented to them in due course (during 1914). (b) Lilford Road Railway Arches. A Petition was received on 1st August, 1913, signed by 14 inhabitants of the neighbourhood, drawing attention to an alleged nuisance arising from the making of dog biscuits, etc., in connection with certain arches situated in the Lilford Road. A letter was sent to the occupiers of the railway arches, with the result that the nuisance was abated, by the moving into the country of that portion of the business which appeared to cause the nuisance, and the prevention of the preliminary sorting at the arches of the refuse fat used as one of the ingredients in connection with the making of dog buiscuits. No action was, consequently, taken by the Borough Council under Section 21 of the Public Health (London) Act, 1891, the nuisance being satisfactorily abated between the time the petition was received and the first meeting of the Council afterwards. BACTERIOLOGICAL LABORATORY At the Bacteriological Laboratory, during 1913, 2,565 examinations were carried out as compared with a yearly average for the decennium 1903-12 (Borough) of 1,053.1. The local and central position of the Laboratory at Wanless Road is advantageous, enabling the results of examinations to be quickly obtained at a minimum cost. 15 3 The Laboratory was originally fitted up by the late Vestry in 1899, and since then (up to the end of 191'}) *13,252 examinations have been made, viz.:—Tuberculosis 4391, typhoid fever 945, diphtheria 7,698, and others 218. The total 2,565 bacteriological examinations carried out during 1913 deal with 1,484 sputa (suspected consumption), 47 bloods (suspected typhoid fever), 997 throat and nose membranes and discharges (suspected diphtheria) and 37 other materials, e.g., hairs (2), urine (4), fceces (1) and smearings of pus (30). Details are as follow:— Tuberculosis— 1,484 samples of sputa from doubtful tuberculosis cases were examined, and in 614 (i.e., 41.4 per cent.) tubercle bacilli were found. Pneumococci were isolated in one sample. Pulmonary consumption (with tuberculous expectorations) was made voluntarily notifiable throughout the Borough of Lambeth on (and after) June 1st, 1902, and pulmonary consumption compulsorily notifiable under the Public Health (Tuberculosis) Poor Law Regulations, 1908, on and after January 1st, 1909, under the Public Health (Tuberculosis) in Hospitals) Regulations, 1911, on and after May 1st, 1911, under the Public Health (Tuberculosis) Regulations, 1911, on and after January 1st, 1912, and tuberculosis (both pulmonary and other forms) under the new Public Health (Tuberculosis) Regulations, 1911, on and after February 1st, 1913. By means of bacteriological examinations, greater exactitude in diagnosis of tuberculosis (pulmonary) is secured. The large increase in the numbers of samples of sputum examined during 1913 is due to the introduction * 1889, 389; 1900, 703; 1901, 479; 1902 466; 1903, 525; 1904, 447; 1905,1874; 1906, 761; 1907, 786; 1908, 718; 1909, 781; 1910, 605; 1911, 976; 1912, 1177; 1913, 2565; total, 13,252. 154 of the new Public Health (Tuberculosis) Regulations, 1912, and the carrying out of the "sanatorium benefit" under the National Insurance Act, together with the opening to the public of the Council's Tuberculosis Dispensary (Central). Typhoid Fever. 47 samples of blood from suspected typhoid cases were examined, and in 12 (i.e., 25.1 per cent.) the characteristic Widal reaction was obtained, although in 7 cases the reactions were but slightly marked. A high dilution oi blood-serum was used (1-60 to 1-100). Diphtheria. 997 samples of throat and nose membranes and secretions from doubtful diphtheria cases were examined, and in 130 (i.e., 13.04 per cent.), the true Klebs-Loeffler bacilli were isolated. 40 swabs (all negative as far as Klebs-Loeffler bacilli were concerned) were connected with an outbreak of sore throats at the Norwood Schools; Pseudo Hoffmann bacilli found in 6. In 867 (i.e., 86.96 per cent.) of the total number of throat and nose samples examined, the Klebs-Loeffler bacilli were not isolated, but other bacilli were, e.g., staphylococci, streptococci, toruloe, micrococci, diplocccci, sarcince and pseudo (Hoffmann) bacilli. The last-named, viz.: pseurlo (Hoffmann) bacilli, were isolated in 41 cases—8 in pure cultivation, 30 mixed with staphylococci and streptococci, and 3 mixed with true Klebs-Loeffler bacilli. 37 samples of other materials were examined, viz.: hairs (for tinea tonsurans), 2 (0 positive), pus smearings (for gonococci) 28 (15 positive), urine (for phosphates and urates) 2 (1 positive), urine (for gonococci) 1 (negative), urine (for 155 albumen) 1 (positive), urethal discharge (for tubercle bacilli) 1 (negative), uterine smear (for staphylococci) 1 positive), and fœces (for blood) 1 (negative). The pus smearings were from the eyes (1), urethra (17), and vagina (10). 1913. Sputa— Tub. Bac. found. Bloods— Typhoid reaction obtained. Throat and Nose Membranes and Discharges— Klebs. I.ceffler Diphtheria Bac. found. Yes. No. Total. Yes. No. Tota l. Yes. No. Tota l. January 63 43 106 1 4 5 2 25 27 February 56 68 12 4 3 5 8 7 31 38 March 48 92 140 3 4 7 13 56 69 April 56 108 164 — 2 2 7 38 45 May 42 65 107 - 1 1 12 65 77 June 35 49 84 1 4 5 7 45 52 July 31 57 88 1 5 6 2 44 46 August 54 52 166 1 3 4 1 31 32 September 55 77 132 — 2 2 6 103 109 October 63 76 139 — 1 1 10 120 130 November 58 84 142 1 1 2 10 105 115 December 53 99 152 1 3 4 53 204 257 TOTALS 614 370 1484 12 35 47 130 867 997 N.B.—37 other samples were also examined during 1913, viz.: Hairs (2), Fœces (1), Pus Smearings (30), Urine (4). Antitoxin. The Borough Council distributed during 1913, free of cost to medical practitioners practising in the Borough, 50 vials of antitoxin under the Antitoxin Order, 1910. 156 MORTUARIES AND CORONERS' COURTS* The 2 Coroners' Courts are under the jurisdiction of the London County Council—the Wanless Road one being the freehold of the County Council, and the High Street one being rented at a rent of £100 per annum by the London County Council from the Borough Council, the freeholders The 2 Mortuaries (Wanless Road and High Street) are the freeholds of the Borough Council. The following are the details of work done during 1913 at the two mortuaries and coroners' courts:— (a) Total number of bodies received, 383—280 at High Street and 103 at Wanless Road. (b) Post-mortem examinations conducted 208—144 st High Street and 64 at Wanless Road. (c) Coroners' court sat 177 times—137 at High Street and 40 Wanless Road. (d) Number of bodies brought in by the Police, 56—44 to High Street and 12 to Wanless Road. (e) Number of bodies brought in by undertakers or private persons 327—236 to High Street and 91 »o Wanless Road. * The Council's Mortuary Keepers are:—Joshua Fazey (Wanless Road and Robert William Harriss (High Street). There is alto a Deputy Mortuary Keeper. 157 (f) No infectious bodies received either at High Street or at Wanless Road. There were 49 suicides investigated (18 drowning, 4 poisoning, 5 hanging, 11 throat cutting, 5 shooting, 3 coal gas, and 3 on railway track); and 122 accidental deaths—falls 41, run over 38, crushing 8, poison 2, strangulation 2, overlying 10, burns and scalds 17, and drowning 4. Of the total 383 bodies received, 238 were males and 145 females. The yearly averages for the two decennia 18911900 (Parish) and 1901-10 (Borough) are respectively (a) bodies received 355.8 and 399.8, (b) post-mortems conducted 210.8 and 218.4, (c) sittings of coroners' court 194.0 and 175.7. The mortuary for Norwood has not yet been provided, but it has been provisionally arranged on the plan for such a mortuary in connection with a small part of the freehold site (south-eastern corner) in Rommany Road, which is being developed by the Council for a Dust Depot at Norwood. The old Watch House (the residence of the High Street Mortuary Keeper) was condemned during 1912 on the ground of its dampness due to its unfavourable site and the absence of damp courses and concrete, etc., and a temporary residence was provided for the Mortuary Keeper at 206 Lambeth Road. 158 INQUESTS. During the year 1913, within the Borough of Lambeth, 316 Lambeth cases were submitted to the Coroner (who, in 19 instances, decided that no further inquiries were necessary, the deaths being due to natural causes). In the remaining 297 cases, inquests were held with the following result:— I. Natural Causes 141 II. Accidental Causes 115 Burns and Scalds 13 Drowning 6 Run over 15 Falls, etc. 26 Suffocation 11 Fracture 19 Misadventure 14 Crushed 4 Blood Poisoning 7 III. Homicidal Causes 37 Suicide 34 Murder 2 Manslaughter 1 IV. Open Verdicts 4 Found Drowned 4 Total 297 159 CLERICAL STAFF. The clerical staff consists of 1 Chief Clerk Class 1 (W. R. Lawrence); 1 Special Clerk to the Medical Officer of Health, to have the status of a Chief Clerk in Class 1 (A. L. Baxter); 2 Assistant Clerks, Class 2 (W. J. Lawrence and A. E. Ruel) and two Boy Clerks, Class 3 (W. E. Croley and T. N. Charlton. During 1913, there were 14,831 letters, &c., received (entered in letter book), 25,157 letters, etc., sent out (entered in postal book), 14,397 Notices issued, 7,390 letters typed, and 5,081 complaints entered in the complaint book. APPENDIX. F Local Government Board New Tables. Table i. VITAL STATISTICS OF THE BOROUGH OF LAMBETH DURING 1913 AND PREVIOUS FIVE YEARS (1908-12). Year. Population estimated to Middle of each Year. Births. Total Deaths Registered in District. Transferable Deaths. ‡ Nett Deaths belonging to the District. Uncorrected Number. Nett. of Nonresidents registered in the District. † of Residents not registered in the District. † Under 1 Year of Age. At all Ages. Number. * Rate. † Number. Rate per 1,000 Nett Births. * Number. * Rate. Number. † Rate. 1 2 3 4 5 6 7 8 9 10 11 12 13 1908 321344 8906 8035 25.0 4692 14.6 863 512 829 103.1 4341 13.5 1909 324188 8445 7578 23.4 4876 15.0 826 490 830 109.5 4540 14.0 1910 327074 8373 7344 22.5 4348 13.3 795 527 691 94.1 4080 12.5 1911 297957 8405 7292 24.5 4584 15.4 852 712 905 124.0 4444 14.9 1912 297550 8168 6953 23.3 4189 14.1 823 634 600 86.3 4000 13.4 1913 297139 8341 7238 24.4 4476 15.1 883 780 537 74.2 4373 14.7 Notes.—This Table is arranged to show the gross births and deaths in the Borough, and the births and deaths properly belonging to it with the corresponding rates. For years before 1911 the corrected rates are slightlv different. The rates are calculated per 1000 of the estimated gross population, and no deductions have been made from the population for large Public Institutions for the sick or infirm. * In Column 6 are included the whole of the deaths registered during the year as having actually occurred within the Borough. In Column 12 is entered the number in Column 6, corrected by subtraction of the number in Column 8 and by addition of the number in Column 9 Deaths in Column 10 are similarly corrected by subtraction of the deaths under 1, included in the number given in Column 8, and by addition of the deaths under 1 included in the number given in Column 9. †Column 8 is prepared from the returns made by the local Registrars of Deaths in accordance with the rule in the next paragraph below; the Registrar-General supplied the particulars of deaths (93) entered in Column 9; and all such deaths are included in this Column, unless an error has been detected, and its correction has been accepted by the Registrar-General. For Column 4 the Registrar-General has furnished a Statement of the number of births needing to be added to or subtracted from the total supplied by the local Registrar (1169 outward and 66 inward transfers). "Transferable Deaths" are deaths of persons who, having a fixed or usual residence in England or Wales, die in a district other than that in which they resided. The deaths of persons without fixed or usual residence, e.g., casuals, are not included in Columns 8 or 9, except in certain instances under 3 (b) below. In Column 8 the number of transferable deaths of "non-residents" which are deducted and in Column Column 9 the number of deaths of "residents" registered outside the district which are added are stated in calculating the nett death-rate of the Borough. Census 1911. Area of Borough in acres (exclusive of area covered bv water), 4079.6. Average number of persons per house (estimated) 6. 7. Number of inhabited houses 44123. 'Total population at all ages, 298058. 3 Local Government Board New Tables. Table ii. F 2 CASES OF INFECTIOUS DISEASE NOTIFIED WITHIN THE BOROUGH OF LAMBETH DURING THE YEAR 1913. NOTIFIABLE DISEASE. number of cases notified. total cases notified in each locality. (e.g. Parish or Ward) of the District. total cases removed to hospital. At all Ages. At Ages—Years. Lambeth Church. Kenning ton. Stockwell. Brixton. Norwood. Under 1. 1 to 5. 5 to 15. 15 to 25. 25 to 45. 45 to 65. 65 and upwds. Small-pox — — - - - - - - - — — — — — Cholera - - - - - - - - - - - - - - Diphtheria (including Membranous Croup) 392 18 126 180 38 24 5 1 66 58 95 72 101 338 Erysipelas 206 4 10 15 21 71 62 23 38 46 39 64 19 59 Scarlet Fever 1370 7 303 897 113 43 6 1 200 217 320 456 177 1212 Typhus Fever — — - - - - - - - - - — — — Enteric Fever 38 - - 9 12 13 4 - 9 5 8 6 10 33 Relapsing Fever — - - - — - - - - — — — — — Continued Fever 2 - - - - 2 - - - 1 — 1 — 1 Puerperal Fever 25 — — — 6 19 — — 4 5 5 6 5 15 Plague — — — — — — - — — — — — — — Pulmonary Tuberculosis* 1571 1 18 174 296 772 285 25 354 337 252 387 241 — Other Forms of Tuberculosis † 456 5 81 213 73 53 21 10 96 83 86 110 81 — Cerebro-spinal Meningitis 7 2 4 1 — — — — 2 3 — 2 — 2 Polio myelitis acuta 6 - 5 — 1 - — — 1 1 1 1 2 3 Opthalmia Neonatorum 57 57 - - - - - - 9 14 16 16 2 — Whooping Cough ‡ 1428 178 812 430 1 6 1 — 249 291 301 351 236 90 5558 272 1359 1919 561 1003 384 60 1028 1061 1123 1472 874 1753 Isolation Hospitals, Name and Situation—Hospitals of the Metropolitan Asylums Board (one situated in the Brixton Sub-District and Stockwell Ward of the Borough of Lambeth). Total available beds provided by the Board—8555. Number of Diseases that can be concurrently treated— All notifiable infectious diseases and (partly) Measles and Whooping Cough. * Excluding all renotifications (164) of pulmonary tuberculosis, and notifications under Form C (8) of the 1908 Regulations, and under Form C (343) and Form D (269) of the 1912 Regulations. † Excluding all renotifications (56) of non-pulmonary tuberculosis, and notifications under Form C (32) and Form D (29). ‡ Whooping Cough became compulsorily notifiable within the Borough of Lambeth on January 1st, 1913. 4 Local Government Board New Tables. Table iii. CAUSES OF, AND AGES AT, DEATH (CORRECTED) DURING THE YEAR 1913. BOROUGH OF LAMBETH. CAUSES OF DEATH. NETT DEATHS AT THE SUBJOINED AGES OF "RESIDENTS " WHETHER OCCURRING WITHIN OR WITHOUT THE DISTRICT (a). TOTAL DEATHS WHETHER OF "RESIDENTS" OR "NONRESIDENTS" IN INSTITUTIONS IN THE DISTRICT (b). All ages. 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 45 years. 45 and under 65 years. 65 and upwards 1 2 3 4 5 6 7 8 9 10 11 All causes Certified (c) 4280 4017 705 145 151 115 131 801 851 1118 2015 Uncertified 263 28 15 10 20 13 51 67 59 Typhus Fever ... ... ... ... ... ... ... ... ... ... Enteric Fever 7 ... ... ... 1 1 4 1 ... 18 Continued Fever ... ... ... ... ... ... ... ... ... ... Small-pox ... ... ... ... ... ... ... ... ... ... Measles 98 23 43 28 4 ... ... ... ... 30 Scarlet Fever 14 ... 2 8 3 1 ... ... ... 14 Whooping Cough 47 21 16 8 2 ... ... ... ... 2 Diphtheria and Croup (See note (d)) 37 4 7 16 9 ... ... ... 1 42 Influenza 67 2 ... 1 3 3 7 19 32 2 Erysipelas 8 ... ... ... ... ... 1 4 3 9 Cerebro-Spinal Fever 3 l 1 ... 1 ... ... ... ... 6 Polio-myelitis acuta ... ... ... ... ... ... ... ... ... ... Venereal Diseases 24 10 2 ... ... ... 2 7 3 ... Phthisis (Pulmonary Tuberculosis) 370 1 1 2 7 52 183 103 21 137 Tuberculous Meningitis (See note (e)) 49 12 11 16 7 1 2 ... ... ... Other Tuberculous Diseases 66 9 6 6 10 7 18 6 3 ... Rheumatic Fever 11 ... ... ... 3 1 4 3 ... 7 Cancer, malignant disease (See note (f)) 369 ... ... ... 1 2 42 165 159 ... Bronchitis 373 48 12 5 2 1 20 64 221 244 Broncho-Pneumonia 165 76 35 14 2 ... 12 10 16 Pneumonia (all other forms) 201 20 7 6 5 8 39 54 62 Other diseases of Respiratory organs 67 5 1 4 2 3 7 20 25 ... Diseases of Circulatory System 555 3 ... 1 12 14 60 166 299 217 Diseases of Nervous System 333 30 6 9 9 6 39 100 134 ... Diarrhœa and Enteritis (See note (g)) 190 141 28 10 2 ... 4 3 2 111 Appendicitis and Typhlitis 24 ... ... ... 8 4 5 4 3 44 Alcoholism (See note (h)) 24 ... ... ... ... ... 9 13 2 ... Cirrhosis of Liver 45 ... ... ... ... ... 7 30 8 ... Nephritis and Bright's Diseases 165 3 ... 2 ... 4 29 74 53 ... Puerperal Fever (See note (i)) 10 ... ... ... ... 1 9 ... ... 14 Other accidents and diseases of Pregnancy and Parturition 10 ... ... ... ... 1 9 ... ... ... Congenital Debility and Malformation, cluding Premature Birth (See note (j)) 165 158 3 1 1 1 ... ... ... ... Violent Deaths, excluding Suicide 144 18 6 9 16 11 22 25 37 88 Suicides 37 ... ... ... ... ... 14 21 2 Other Defined Diseases 503 65 12 8 10 12 42 94 261 1030 Diseases ill-defined or unknown 99 83 6 2 1 1 2 4 ... ... 4280 733 160 161 135 144 852 918 1177 2015 Notes ro Table iii. (a) All "Transferable Deaths" of residents, i.e., of persons resident in the District who have died outside it, are included with the other deaths in columns 2-10. Transferable deaths of non-residents, i.e.. of persons resident elsewhere in England and Wales who have died in the District, are in like manner excluded from these columns. For the precise meaning of the term "transferable deaths" see footnote to Table I. The total deaths in column 2 of Table III. equal the figures for the year in column 12 of Table 1. (b) All deaths occurring in institutions for the sick and infirm situated within the district, whether of residents or non-residents, are entered in the last column of Table III. (c) All deaths certified by registered Medical Practitioners and all Inquest cases are classed as "Certified": all other deaths are to be regarded as "Uncertified." (d) This heading includes all deaths from croup except those certified as due to 'spasmodic.' 'stridulous,' 'catarrhal,' or 'false' croup. (e) Under "Tuberculous Meningitis" are included deaths from Acute Hydrocephalus. (f) Under "Cancer" are included deaths under such headings as Carcinoma. Scirrhus, Epithelioma, Rodent ulcer. Sarcoma, Cancer, and Malignant Disease. (g) Under this heading are included deaths registered as due to Epidemic diarrhoea. Epidemic enteritis. Infective enteritis. Zymotic enteritis, Summer diarrhoea. Choleraic diarrhoea. Cholera (other than Asiatic), Gastro-enteritis, Gastro-intestinal catarrh. Muco-enteritis. Colitis, etc Deaths from Diarrhoea secondary to some other well-defined disease are included under the latter. For "Dysentery" see note at foot of Table III. (h) Under this heading are included deaths from Delirium tremens, acuta and chronic alcoholism, etc.. but not those certified as due to organic disease attributed to alcoholism. The number of the latter rnay with advantage be stated separately, though this statement cannot be included in Table III. (!) Under "Puerperal Fever" are included deaths under such headings as Pyaemia. Septicaemia. Sapraemia, Pelvic peritonitis. Peri- and Endo-metritis occuring in the Puerperium. (j) Under this heading are included also deaths from Atrophy and Marasmus of Infants, and want of Breast-milk, but not from Atelectasis. 6 7 Local Government Board New Tables. Table iv. BOROUGH OF LAMBETH—INFANTILE MORTALITY, 1913. Nett Deaths from stated causes at various Ages under 1 Year of Age. Under 1week 1-2 weeks. 2-3 weeks. 3-4 weeks. Total under 1 month. 1-3 months. 3-6 months. 6-9 months. 9-12 months. Total Deaths under 1 year. All Causes Certified 139 31 22 30 222 130 154 104 95 705 Uncertified 5 3 - 1 9 9 5 2 3 28 Chicken Pox - - - - - - - - 1 1 Measles - - - - - 1 2 6 14 23 Diphtheria and Croup - - - - - - - 3 1 4 Whooping Cough — — 1 — 1 3 3 9 5 21 Diarrhœa — — - 1 1 30 50 25 25 131 Enteritis (Epidemic) — 1 2 — 3 — 4 2 1 10 Influenza — — — — — — — 2 — 2 Cerebro Spinal Meningitis - - - - - - 1 - - 1 Ophthalmia Neonatorum — 1 — — 1 — — — — 1 Tuberculous Meningitis 1 - — — 1 3 4 2 2 12 Abdominal Tuberculosis — — — — — 1 1 1 1 4 Other Tuberculous Diseases — — — — — 2 3 1 — 6 Congenital Malformations 11 2 2 2 17 6 4 - - 27 Premature Birth 86 10 6 8 110 18 2 - - 130 Atrophy, Debility and Marasmus 14 7 5 3 29 18 24 3 5 79 Atelectasis 10 2 - - 12 - - - - 12 Erysipelas — - - - - - - - - - Syphilis 1 - 1 1 3 5 1 1 - 10 Rickets - - - - - - 1 2 1 4 Meningitis (not Tuberculous) — - 1 2 3 - 1 - - 4 Convulsions 7 1 1 2 11 5 4 - - 20 Gastritis 1 — — 1 2 5 1 - - 8 Dentition - — - - - - 3 5 2 10 Laryngitis — — - - - - - - - - Bronchitis - 2 2 3 7 15 9 9 8 48 Pneumonia 1 - - - 1 3 2 l 6 13 Broncho Pneumonia - 3 1 5 9 15 16 20 16 76 Pleuro - — - - - 3 2 1 1 7 Suffocation, overlying - — — - - 1 7 1 1 10 Accident, other than Suffocation 4 — — - 4 - 2 - - 6 Other causes not classified above 8 5 — 3 16 5 12 12 8 53 144 34 22 31 231 139 159 106 98 733 8 9 Local Government Board New Tables.] Table v. BOROUGH OF LAMBETH—Particulars of cases of acute polio-myelitis, and polio-encephalitis and epidemic cerebro-spinal meningitis, notified within the Borough of Lambeth, during 1913. Total number of Cases notified. NUMBER OF CASES. 0-1 year. 1-5 years. 5-10 years. 10-15 years. 15-20 years. 20-30 years. Over 30 years. M. F. M. F. M. F. M. F. M. F. M. F. M. F. Cases. Deaths. Permanent Paralysis* Cases. Deaths. Permanent Paralysis.* Cases. Deaths. Permanent Paralysis.*| Cases. Deaths. Permanent Paralysis.* Cases. Deaths. Permanent Paralysis.* Cases. Deaths. Permanent Paralysis.* Cases. Deaths. Permanent Paralysis * Cases, Deaths. Permanent Paralysis.* Cases. Deaths. Permanent Paralysis.* Cases. Deaths. Permanent Paralysis.* Cases. Deaths. Permanent Paralysis.* Cases. Deaths. Permanent Paralysis.* Cases. Deaths. Permanent Paralysis.* Cases. Deaths. Permanent Paralysis.* Acute Polio-myelitis 6 - - - - - - 1 - - 4 - 4 - - - - - - - - - - - - - - - - - - - - - 1 - 1 - - - - - - Cerebro-Spinal Fever 7 1 1 - 1 - - 1 1 - 3 1 1 - - - - - - - - - 1 1- - - - - - - - - - - - - - - - - - - - Number of cases removed to Isolation Hospital. *i.e., Recovered with permanent Paralysis of one or more groups of muscles. Acute Polio-myelitis — - 2 - — — — — — — 1 — - Cerebro-Spinal Fever — — 1 1 - - - - - - - - - - Observations In 2 of the polio myelitis, and 2 of the cerebrospinal meningitis cases, there was some evidence of animals (cats and dogs) being connected, in some way or other, with the illnesses. N.B.—The usual preventive measures, that are taken in connection with other infectious diseases, were taken, together with the routine stripping of papers off the walls of infected rooms. 10 Home Office Tables. BOROUGH OF LAMBETH, 1913. FACTORIES, WORKSHOPS, LAUNDRIES, WORKPLACES AND HOMEWORK. 1.—Inspection of Factories, Workshops and Workplaces including inspections made by sanitary inspectors. Premises. Number of Inspections. Written Notices. Prosecutions. Factories (Including Factory Laundries). 2 Workshops (Including Workshop Laundries). 94 238 - Workplaces (Other than Outworkers' Premises included in part 3 of this Report). - Total 96 238 - 11 2.—Defects found in Factories, Workshops and Workplaces. Particulars. Number of defects. No. of Prosecutions. Found. Remedied. Referred to H.M. Inspector. Nuisances under the Public Health Acts*:— Want of Cleanliness 51 51 - - Want of Ventilation 5 5 — — Overcrowding 11 11 — — Want of drainage of floors - — — — Other nuisances 243 243 — — Sanitary accommodations. insufficient - - — — unsuitable or defective 73 73 - - (not separate for sexes 1 1 — Offences under the Factory and Workshops Act:— Illegal occupation of underground bakehouse (S. 101) - - - - Breach of special sanitary requirements for bakehouses (SS. 97 to 100) - - - - Other offences (Excluding offenccs relating to outwork which are included in Part 3 of this Report) - - - - Totals 384 384 — — * Including those specified in Sections 2, 8, 7 and 8 of the Factory and Workshop Act, as remediable under the Public Health Acts. 1 2 13 3.-HOME WORK NATURE OF WORK OUTWORKERS' LISTS, SECTION 107. OUTWORK in UNWHOLESOME PREMISES Sections 108. OUTWORK in INFECTED PREMISES Sections 109, 110, Lists received from Employers. Notices served on Occupiers as to keeping or sending lists. Prosecutions Sending Twice in the year. Sending Once in the year. Failing to keep or permit inspection of Lists. Failing to send Lists. Instanced. Notices served. Prosecutions Instances Orders made (S. 110). Prosecutions (Section 109,110). Lists. Outworkers.+ Lists. Outworkers. Contractors, Workmen. Contractors Workmen, (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) Wearing Apparel — nil. nil. nil. nil. nil. nil. nil. (1) making, &c. 27 10 255 6 ... 19 32 (2) cleaning and washing ... ... ... ... ... ... ... 6 Household linen ... ... ... ... ... ... ... ... L.ace, lace curtains and nets ... ... ... ... ... ... ... ... Curtains and furniture hangings ... ... ... ... ... ... ... ... Furniture and upholstery 1 ... ... ... ... ... 2 ... Electro-plate ... ... ... ... ... ... ... ... File making ... ... ... ... ... ... ... ... Brass and brass articles ... ... ... ... ... ... ... ... Fur pulling ... ... ... ... ... ... ... ... Cables and chains ... ... ... ... ... ... ... ... Anchors and grapnels ... ... ... ... ... ... ... ... Cart gear ... ... ... ... ... ... ... ... Locks, latches and keys ... ... ... ... ... ... ... ... Umbrellas, &c. ... ... ... ... ... ... ... ... Artificial flowers ... ... ... ... ... ... ... ... Nets, other than wire nets ... ... ... ... ... ... ... ... Tents ... ... ... ... ... ... ... ... Sacks and bag stringing 2 ... 68 ... ... ... ... ... Racquet and tennis balls ... ... ... ... ... ... ... ... Paper bags and boxes 2 ... 44 ... ... ... ... ... Brush making ... ... ... ... ... ... ... ... Pea picking ... ... ... ... ... ... ... ... Feather sorting ... ... ... ... ... ... ... ... Carding, &c., of buttons, &c. ... ... ... ... ... ... ... ... Stuffed toys ... ... ... ... ... ... ... ... Basket making ... ... ... ... ... ... ... ... Printing 2 ... 31 ... ... ... ... ... Cigarette making 2 ... 7 ... ... ... 2 ... Total 36 10 405 6 405 19 36 ... ... ... ... ... ... 6 ... ... *If an occupier gives out work of more than one of the classes specifed in column 1, and subdivides his list in such a way as to show the number of workers in each class of work, the list should be included among those in column 2 (or 5 as the case may be) against the principal class only but the outworkers should be assigned in columns 3 and 4 (or 6 and 7) into their respective classes. A footnote should be added to show that this has been done. †The figures required in columns 2, 3 and 4 are the total number of the lists received from those employers who comply strictly with the statutory duty of sending two lists each year and of the entries of names of out-workers in those lists. The entries in column 2 must necessarily be even numbers, as there will be two lists for each employer—in some previous returns odd numbers have been inserted. The figures in columns 3 and 4 will usually be (approximately) double of the number of individual out-workers whose names are given, since in the February and August lists of the same employer the same outworker's name will often be repeated. 14 4.—Registered Workshops. Workshops on the Register (s. 131) at the end of the year 1913. Number. (1) (2) Bakehouses 214 Restaurants 296 Laundries 203 Dressmakers 320 Tailors 137 Milliners and Mantle Makers 82 Blouse Makers 75 Other Businesses 378 Total number of workshops on Register 1705 5.—Other Matters. Class. (1) Number. (2) Matters notified to H.M. Inspector of Factories:- 5 Failure to affix Abstract of the Factory and Workshop Act (s. 133) — Action taken in matters referred by H.M. Inspector as remediable under the Public Health Acts, but not under the Factory and Workshop Act (s. 5) Notified by H.M. Inspector 6 Reports (of action taken) sent to H.M. Inspector 6 Other - Underground Bakehouses (s. 101):— Certificates granted during 1913 — In use at the end of 1913 7 2 Note.—The Factory and Workshop Act, 1901 (s. 132) requires the Medical Officer of Health in his Annual Report to the District Council to report specifically on the administration of that Act in workshops and workplaces, and to send a copy of his Annual Report, or so much of it as deals with this subject, to the Secretary of State (Home Office). If the Annual Report is presented otherwise than in print, it is unnecessary to include in the copy sent to the Home Office the portions which do not relate to factories, workshops, workplaces or homework. The duties of Local Authorises and the Medical Officer of Health under the Acts are detailed in the Home Office Memoranda, issued to all Districts, Councils and Medical Officers of Health. 15 London County Council Table. SANITARY PROCEEDINGS DURING 1913. (Return prepared for the London County Council.) Premises. Number of Places. Number of inspections, 1913. Number of notices, 1913. Number of prosecutions, 1913. On register at end of 1912. Added in 1913. Removed in 1913. On register at end of 1913. Milk premises* 143 57 2 198 594 48 - Cowsheds 13 — 2 11 22 3 - Slaughter houses 19 — 2 17 64 6 - Other offensive trade premises 3 — — 3 6 - - Registered houses let in lodgings 372 — — 372 744 - Bakehouses 214 - — 214 428 — - Restaurant Kitchens 248 — — 248 - — — *During 1913, a total of 57 applications were received and approved, but 2 were withdrawn by the applicants after registration, and 5 were simply changes of occupiers. 16 Total number of Intimation or Preliminary Notices served for all purposes 7121 Overcrowding— Dwelling rooms overcrowded 19 Remedied 19 Prosecutions — Underground Rooms— Illegal occupation 16 Closed — Insanitary houses— Closed (under the Public Health (London) Act, 1891) — Closed (under the Housing of the Working Classes Acts, including the Housing, Town Planning, etc., Act) 24 Verminous rooms cleansed 927 Shelters provided under Sec. 60 (4) of the Public Health (London) Act, 1891— Number provided 1 Persons accommodated — 17 Revenue Act, 1903 — Houses for which applications were received 29 Tenements comprised therein 84 Tenements for which Certificates were (a) granted 38 ,, ,, ,, (b) refused 10 ,, ,, ,, (c) deferred* 36 Common Lodging Houses— Certificates granted 6 Number of prosecutions under By-laws, under Public Health Act, 1891— Mortuaries— Number of bodies 383 (infectious cases 0). 18 19 LAMBETH BOROUGH.-Deaths Registered from all Causes during the year, 1913. Note.-The Deaths of Non-Residents occurring in Public Institutions situated in the District are excluded, and the Deaths of Residents occurring in Public Institutions situated beyond the limits of the District are included. Sub-Districts. Sub-Districts. Total. Lambeth Church. Kenning ton. well. Brixton. wood. No dress. All Ages. M. F. M. F. M. F. M. F. M. F. M. F. M. F. I. Specific Febrile, or Zymotic Diseases 82 58 55 41 53 48 45 43 35 33 ... 1 270 224 494 II. Parasitic Diseases ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... III. Dietetic Diseases 3 1 3 4 3 2 2 2 2 3 ... ... 13 12 25 IV. Constitutional Diseases 98 84 80 88 107 96 114 109 77 76 3 4 479 457 936 V. Developmental Diseases 25 37 32 42 17 43 38 55 20 41 ... ... 132 218 350 VI. Local Diseases 225 197 206 221 254 195 230 266 176 194 17 14 1108 1087 2195 VII. Deaths from Violence 34 13 14 19 24 14 23 11 19 8 1 1 115 66 181 VIII. Deaths from Ill-defined and not specified Causes 10 11 14 4 14 10 9 6 13 7 1 ... 61 38 99 Totals 477 401 404 119 472 408 461 492 342 362 22 20 2178 2102 4280 1—Specific Febrile or Zymotic Diseases. 1.—Miasmatic Diseases. Small-pox vaccinated ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Unvaccinated ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... No Statement ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Measles 27 12 13 11 14 8 4 5 2 2 ... ... 60 38 98 Whooping Cough 7 3 5 6 2 8 4 7 2 3 ... ... 20 27 47 Scarlet Fever 1 1 1 1 4 ... 3 2 1 ... ... ... 10 4 14 Typhus ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Simple Continued and Ill-defined Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Enteric or Typhoid Fever ... ... ... ... 1 1 1 3 ... 1 ... ... 2 5 7 Diphtheria 6 3 4 3 6 5 1 ... 6 2 ... ... 23 13 36 Membranous Croup ... ... ... ... ... 1 ... ... ... ... ... ... ... 1 1 Influenza 4 ... 2 2 8 8 8 11 10 14 ... ... 32 35 67 Other Miasmatic Diseases 1 ... ... 1 1 ... 1 1 ... ... ... ... 3 2 5 Cerebro Spinal Fever ... 1 ... ... ... ... 1 1 ... ... ... ... 1 2 3 2.—Diarrhœal Diseases. Cholera Nostras ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cholera Asiatica ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diarrhœa Dysentry 31 31 26 11 13 13 13 9 9 10 ... ... 92 74 166 3.—Malarial Diseases. Remittent or Relapsing Fever . ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Ague ... ... ... ... ... ... ... ... ... ... ... ... ... ... 4.—Zoogenous Diseases. Cowpox and effects of Vaccination ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Diseases (e.g., Hydrophobia, Glanders, Splenic Fever) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 5.—Venereal Diseases. Syphilis 4 3 2 3 2 1 4 ... 1 ... ... 1 13 8 21 Gonorrhœa, Stricture of Urethra ... ... 1 ... ... ... 1 ... 1 ... ... ... 3 ... 3 6. Septic Diseases Erysipelas 1 ... ... ... 1 2 2 1 1 ... ... ... 5 3 8 Pyæmia, Septicæmia ... 2 1 ... 1 ... 2 ... 2 ... ... ... 6 2 8 Puerperal Fever ... 2 ... 3 ... 1 ... 3 ... 1 ... ... ... 10 10 20 21 LAMBETH BOROUGH —Deaths Registered from all Causes during the year 1913—continued. Note—The Deaths of Non-Residents occurring in Public Institutions situated in the District are excluded, and the Deaths of Residents occurring in Public Institutions situated beyond the limits of the District are included. Sub-Districts. Sub-Districts. Total. Lambeth Church Kennington. Stockwell. Brixton. Norwood. No Address. All Ages. II.—Parasitic Diseases. M. F. M. F. M. F. M. F. M. F. M. F. M. F. Thrush, and other Vegetable Parasitic Diseases ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Worms, Hydatids, and other Animal Parasitic Diseases ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... III.—Dietetic Diseases. Want of Breast Milk, Starvation ... ... 1 ... ... ... ... ... ... ... ... ... 1 ... 1 Scurvy ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Chronic Alcoholism 3 1 2 4 2 2 2 2 2 3 ... ... 11 12 23 Delirium Tremens ... ... ... ... 1 ... ... ... ... ... ... ... 1 ... 1 IV —Constitutional Diseases. Rheumatic Fever ... 2 1 2 1 2 2 1 ... ... ... ... 4 7 11 Rheumatism of the Heart ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Rheumatism 1 ... 1 1 ... ... ... 2 ... ... ... ... 2 ... 5 Gout ... ... 2 1 2 ... 1 ... ... ... ... ... 5 1 6 Rickets ... 2 2 ... 1 ... 1 ... ... ... ... ... 4 2 6 Cancer, Malignant Disease 22 31 20 36 42 48 35 53 36 44 1 1 156 213 369 Cancum Oris (Noma) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Tabes Mesenterica 1 ... 4 1 1 ... 2 1 1 ... ... ... 9 2 11 Tubercular Meningitis, Hydrocephalus 10 8 5 4 6 3 5 4 3 1 ... ... 29 20 49 Phthisis 55 36 35 33 41 33 52 32 28 20 2 3 213 157 370 Scrofula ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other forms of Tuberculosis 7 4 8 7 7 4 6 6 4 2 ... ... 32 23 55 Purpura, Hæmorrhagic Diathesis ... ... ... ... ... 1 ... 1 ... ... ... ... ... 2 2 Anæmia, Chlorosis, Leucocythæmia ... ... 1 ... ... 1 2 2 1 1 ... ... 4 4 8 Glycosuria, Diabetes Mellitus 2 ... ... 1 5 3 6 4 4 3 ... ... 17 11 28 Other Constitutional Diseases ... 1 1 2 1 1 2 3 ... 5 ... ... 4 12 16 V.—Developmental Diseases. Premature Birth 17 18 12 8 11 8 20 16 7 13 ... ... 67 63 130 Atelectasis ... ... 1 1 1 2 4 1 1 1 ... ... 7 5 12 Congenital Malformations 3 9 2 2 1 5 2 6 2 2 ... ... 10 24 34 Old Age 5 10 17 31 4 28 12 32 10 25 ... ... 48 126 174 VI.— Local Diseases. 1.—Diseases of Nervous System. Inflammation of Brain or Membranes 2 2 1 3 3 3 ... 2 3 ... ... ... 9 10 19 Apoplexy, Softening of Brain, Hemiplegia, Brain Paralysis 15 11 11 17 17 21 23 21 17 29 1 1 84 100 184 Insanity, General Paralysis of the Insane 6 1 6 2 3 4 5 2 4 2 ... ... 24 11 35 Epilepsy 1 1 3 4 2 1 1 4 ... 3 ... ... 7 13 20 Convulsions 3 3 6 2 2 2 1 1 3 2 ... ... 15 10 25 Laryngismus Stridulus (Spasm of Glottis) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Disease of Spinal Cord, Paraplegia, Paralysis Agitans 1 ... 4 4 2 1 2 2 4 2 ... ... 13 9 22 Other Diseases of Nervous System 2 7 2 2 4 1 1 4 2 3 ... ... 11 17 28 2. Diseases of Organs of Special Sense. (e.g., of Ear,Eye, Nose) 4 1 ... ... 1 1 4 1 ... ... ... ... 9 3 12 22 23 LAMBETH BOROUGH.-Deaths Registered from all Causes during the year, 1913-continued. Note.-The Deaths of Non-Residents occurring in Public Institutions situated in the District are excluded, and the Deaths of Residents occurring in Public Institutions situated beyond the limits of the District are included. Sub Districts. Sub Districts. Total. Lami beth i Church. Kennington. well. Brixton. wood. No dress All Ages 3.—Diseases of Circulatory System. M. F. M. F. M. F. M. F. M. F. M. F. M. F. Pericarditis ... ... ... ... 2 1 ... ... ... ... ... ... 2 1 3 Acute Endocarditis 2 4 ... ... ... 1 3 1 2 ... ... ... 7 6 13 Valvular Diseases of Heart 13 13 14 23 21 15 15 22 12 18 ... ... 75 91 166 Other Diseases of Heart 13 11 12 18 15 14 24 28 17 15 2 2 83 88 171 Aneurism 4 ... 2 2 3 ... 1 ... 9 1 2 ... 21 3 24 Embolism, Thrombosis ... ... ... 4 1 2 3 3 1 3 ... 1 5 13 18 Other Diseases of Blood Vessels 18 8 14 22 24 8 12 21 12 15 ... 6 80 80 160 4.—Diseases of Respiratory System. Laryngitis 1 ... 1 ... ... 1 ... ... 1 1 ... ... 3 2 5 Croup ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Emphysema, Asthma 1 ... 1 5 2 1 5 1 4 2 ... ... 13 9 22 Bronchitis 34 48 31 37 42 40 41 56 11 30 1 2 160 213 373 Pneumonia 11 10 17 11 27 6 16 14 6 7 ... ... 77 48 125 Pleurisy 1 ... 1 2 1 1 3 2 1 1 ... ... 7 6 13 Bronchopneumonia 26 26 22 18 11 17 12 11 8 14 ... ... 79 86 165 Pleuropneumonia 11 4 12 7 9 6 6 8 4 4 5 ... 47 29 76 Other Diseases of Respiratory System 5 1 3 2 4 2 2 2 1 4 1 ... 16 11 27 5.—Diseases of Digestive System. Appendicitis 1 1 3 1 1 3 4 2 7 1 ... ... 16 8 24 Dentition 2 2 1 2 2 1 1 1 2 ... ... ... 8 6 14 Sore Throat, Quinsy ... ... ... ... 1 ... 1 1 ... ... ... ... 2 1 3 Diseases of Stomach 2 4 7 2 3 5 5 4 2 5 ... ... 19 20 39 Enteritis 6 3 2 1 2 2 1 2 3 2 ... ... 14 10 24 Obstructive Diseases of Intestine 2 1 2 2 7 1 4 4 2 4 ... ... 17 12 29 Peritonitis ... ... ... 2 2 2 ... ... ... ... ... ... 2 4 6 Ascites ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cirrhosis of Liver 10 4 5 4 6 2 4 5 5 ... ... ... 30 15 45 Jaundice and other Diseases of Liver 1 5 1 1 1 3 2 2 2 2 ... ... 7 13 20 Diseases of the Pancreas ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Diseases of Digestive System 5 2 5 7 3 4 1 2 3 4 ... ... 17 19 36 6.—Diseases of Lymphatic System. (e.g., of Lymphatics and of Spleen) 2 ... ... ... 1 ... ... ... 1 ... ... ... 4 ... 4 7.—Diseases of Gland-like Organs of Uncertain Use. (e.g., Bronchocele, Addison's Disease) 1 ... ... ... ... ... ... 3 ... ... ... ... 1 3 4 8.—Diseases of Urinary System. Nephritis 3 2 1 1 3 1 1 3 1 ... ... ... 9 7 16 Bright's Disease, Albuminuria 13 12 11 8 16 16 19 18 17 14 4 1 80 69 149 Disease of Bladder or of Prostate 1 1 4 ... 4 ... 4 1 3 ... ... 1 16 3 19 Calculus (Stone) ... ... ... ... 1 ... ... 1 ... 2 ... ... 1 3 4 Other Diseases of the Urinary System ... 1 ... ... 1 ... ... ... ... ... 1 ... 2 1 3 9.—Diseases of Reproductive System. a. Of Organs of Generation. Male Organs ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Female Organs ... 2 ... 1 ... ... ... 7 ... 3 ... ... ... 13 13 24 25 LAMBETH BOROUGH.-Deaths Registered from all Causes during the year, 1913-continued. Note.-The Deaths of Non-Residents occurring in Public Institutions situated in the District are excluded, and the Deaths of Residents occurring in Public Institutions situated beyond the limits of the District are included. Sub-Districts. Sub-Districts. Total. Lambeth Church ningon well Brixton. Norwood. Address. All Ages. M. F. M. F. M. F. M. F. M. F. M. F. M. F. b. Of Parturition. Abortion, Miscarriage ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Puerperal Convulsions ... 1 ... ... ... 1 ... ... ... ... ... ... ... 2 2 Placenta prævia, Flooding ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Accidents of Child Birth ... 2 ... 1 ... 2 ... 2 ... 1 ... ... ... 8 8 10.—Diseases of Bones and Joints. Caries, Necrosis ... ... ... ... ... ... 1 ... ... ... ... ... 1 ... 1 Arthritis. Ostitis, Periostitis ... 2 1 ... 1 1 ... ... ... ... ... ... 2 3 5 Other Diseases of Bones and Joints 1 ... ... 1 ... 1 ... ... ... ... ... ... 1 2 3 11.—Diseases of Integumentary System. Carbuncle, Phlegmon ... 1 ... 2 1 1 1 1 4 ... ... ... 6 5 11 Other Diseases of Integumentary System 1 ... ... ... 2 ... 1 1 2 ... ... ... 6 1 7 VII.—Deaths from Violence. 1.—Accident or Negligence. Fractures and Contusions 9 4 3 6 7 3 7 5 3 1 ... 1 29 20 49 Gunshot Wounds ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cut, Stab ... ... ... ... ... ... ... 1 ... ... ... ... ... 1 1 Burn, Scald 1 3 2 4 1 2 1 ... 1 ... ... ... 6 9 15 Poison 1 ... ... ... ... 1 1 ... ... ... ... ... 2 1 3 Drowning 4 2 2 1 5 ... 1 ... 1 ... ... ... 13 3 16 Suffocation 1 1 1 3 ... 3 1 1 ... ... ... ... 3 8 11 Otherwise 12 1 2 3 6 3 6 2 7 5 ... ... 33 14 47 2.—Homicide. Manslaughter ... ... ... ... ... ... ... ... ... ... 1 ... 1 ... 1 Murder ... ... ... ... ... 1 ... ... ... ... ... ... ... 1 1 3—Suicide. Gunshot Wounds ... ... 1 ... 1 ... ... ... 2 ... ... ... 4 ... 4 Cut, Stab ... ... ... 1 1 ... 1 ... 1 ... ... ... 3 1 4 Poison 3 1 3 ... 1 1 1 2 1 1 ... ... 9 5 14 Drowning ... ... ... ... 1 ... 1 ... 1 1 ... ... 3 1 4 Hanging 2 ... ... 1 ... ... 2 ... 2 ... ... ... 6 1 7 Otherwise 1 1 ... ... 1 ... 1 ... ... ... ... ... 3 1 4 4.—Execution. Hanging ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... VIII.—Deaths from Ill-Defined and not Specified Causes. Dropsy ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Debility, Atrophy, Inanition 10 10 12 4 11 9 8 4 13 7 1 ... 55 34 89 Mortification ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Tumour ... ... 1 ... ... ... ... 2 ... ... ... ... 1 2 3 Abscess ... ... 1 ... 1 ... ... ... ... ... ... ... 2 ... 2 Hæmorrhage ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Sudden Death (cause not ascertained) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Causes not specified, or Ill-defined ... 1 ... ... 2 1 1 ... ... ... ... ... 3 2 5 26 27 LAMBETH BOROUGH.-Deaths Registered from all Causes during the year, 1913. Note.-The Deaths of Non-Residents occurring in Public Institutions situated in the District are excluded, and the Deaths of Residents occurring in Public Institutions situated beyond the limits of the District are included. AGES. AGES. Total. Under 1 Year. 1-2 2-5 Under 5 Years 5-15 15-20 20-25 25-40 40-45 45-60 60-65 65 and over Over 5 Years. All Ages. M F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. I. Specific Febrile, or Zymotic Diseases 111 84 58 38 35 35 204 157 14 10 1 1 1 3 7 11 2 5 15 6 8 6 18 25 66 67 270 224 494 II. Parasitic Diseases ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... III. Dietetic Diseases 1 ... ... ... ... ... 1 ... ... ... ... ... ... ... 4 3 2 ... 6 7 ... ... ... 2 12 12 13 12 25 IV. Constitutional Diseases 16 10 12 9 12 12 40 31 17 13 7 14 22 23 91 81 45 35 122 108 47 34 88 118 439 426 479 457 936 V. Developmental Diseases 82 87 1 2 1 ... 84 89 ... 1 ... 1 ... ... ... ... ... ... ... 1 1 1 47 125 48 129 132 218 350 VI. Local Diseases 122 119 45 28 32 11 199 165 25 24 20 12 11 7 97 90 43 38 215 171 105 87 393 493 909 922 1108 1087 2195 VII. Deaths from Violence 6 12 3 3 5 4 14 19 12 4 6 1 3 1 22 6 6 2 31 5 8 2 13 26 101 47 115 66 181 VIII. Deaths from Ill-defined and not specified causes 52 31 3 3 1 1 56 35 1 ... ... ... ... 1 2 ... ... ... 1 2 1 ... ... ... 5 3 61 38 99 Totals 390 343 122 83 86 70 598 496 69 52 34 29 37 35 223 191 98 80 390 300 170 130 559 789 1580 1606 2178 2102 4280 I.—Specific Febrile or Zymotic Diseases. 1.—Miasmatic Diseases. Small-pox Vaccinated ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Unvaccinated ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... No Statement ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Measles 10 13 32 11 14 14 56 38 4 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 4 ... 60 38 98 Whooping Cough 13 8 4 12 2 6 19 26 1 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 1 20 27 47 Scarlet Fever ... ... 2 ... 4 4 6 4 3 ... 1 ... ... ... ... ... ... ... ... ... ... ... ... ... 4 ... 10 4 14 Typhus ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Simple Continued and Ill-defined Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Enteric or Typhoid Fever ... ... ... ... ... ... ... ... 1 ... 1 ... ... 1 2 ... 1 1 ... ... ... ... ... 2 5 2 5 7 Diphtheria 3 1 3 3 12 4 18 8 5 4 ... ... ... ... ... ... ... ... ... ... ... ... ... 1 5 5 23 13 36 Membranous Croup ... ... ... 1 ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 1 Influenza 1 1 ... ... ... 1 1 2 1 2 ... ... 1 2 5 ... 1 1 8 5 3 3 12 20 31 33 32 35 67 Other Miasmatic Diseases 1 ... ... ... 1 ... 2 ... ... 1 ... ... ... ... ... ... ... ... ... ... 1 ... ... 1 1 2 3 2 5 Cerebro Spinal Fever ... 1 1 ... ... ... 1 1 ... 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 1 2 3 2.—Diarrhœal Diseases. Cholera Nostras ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cholera Asiatica ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diarrhœa Dysentry 77 54 13 11 2 5 92 70 ... ... ... ... ... ... ... 1 ... ... ... ... ... 1 ... 2 ... 4 92 74 166 3.—Malarial Diseases. Remittent or Relapsing Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Ague ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 4.—Zoogenous Diseases. Cowpox and effects of Vaccination ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Diseases (e.g., Hydrophobia, Glanders, Splenic Fever) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 5.—Venereal Diseases. Syphilis 5 5 2 ... ... ... 7 5 ... ... ... ... ... ... ... ... ... 1 2 1 2 ... 2 1 6 3 13 8 21 Gonorrhœa, Stricture of Urethra ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... 1 ... 1 ... ... ... 3 ... 3 ... 3 6. Septic Diseases. Erysipelas ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... 2 ... ... 2 3 ... 5 3 5 3 8 Pyæmia, Septicæmia 1 1 1 ... ... 1 2 2 ... ... ... ... ... ... 1 ... ... ... 1 ... 1 ... 1 ... 4 ... 6 2 8 Puerperal Fever ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... 7 ... 2 ... ... ... ... ... ... ... 10 ... 10 10 h 2 28 29 LAMBETH BOROUGH — Deaths Registered from all Causes during the year 1913—continued. Note.—The Deaths of Non-Residents occurring in Public Institutions situated in the District are excluded, and the Deaths of Residents occurring in Public Institutions situated beyond the limits of the District are included. AGES. AGES. Total. Under 1 Year. 1-2 2-5 Under 5 Years. 5-15 15-20 20-25 25-40 40-45 45-60 60-65 65 and over. Over 5 Years. All Ages. II.—Parasitic Diseases. M. F. M F. M. F. M. F. M. F. M. F. M F. M. F. M. F. M F. M. F. M. F. M F. M. F. Thrush, and other Vegetable Parasitic Diseases ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Worms, Hydatids, and other Animal Parasitic Diseases ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... III.—Dietetic Diseases. Want of Breast Milk, Starvation 1 ... ... ... ... ... 1... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1... 1 Scurvy ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Chronic Alcoholism ... ... ... ... ... ... ... ... ... ... ... ... 4 3 1 ... 6 7 ... ... ... 2 11 12 11 12 23 Delirium Tremens ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... 1 ... 1 ... 1 IV —Constitutional Diseases. Rheumatic Fever ... ... ... ... ... ... ... ... 1 2 ... ... 1 ... ... 1 1 2 1 1 ... 1 ... ... 4 7 4 7 11 Rheumatism of the Heart ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Rheumatism ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 2 ... ... 2 1 2 3 2 3 5 Gout ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1... ... ... ... 1 ... 1 1 2 ... 5 1 5 1 6 Rickets 3 1 1 1 ... ... 4 2 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 4 2 6 Cancer, Malignant Disease ... ... ... ... ... ... ... ... 1 ... ... ... ... 2 6 13 3 20 53 63 28 21 65 94 156 213 156 213 369 Cancum Oris (Noma) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Tabes Mesenterica 3 1 2 ... ... ... 5 1 ... 1 ... ... 1 ... 1 ... ... ... 1 ... 1 ... ... ... 4 1 9 2 11 Tubercular Meningitis, Hydrocephalus 7 5 8 3 6 10 21 18 5 2 1 ... ... ... 2 ... ... ... ... ... ... ... ... ... 8 2 29 20 49 Phthisis 1 ... ... 1 1 1 2 2 5 2 1 13 15 20 72 61 38 12 60 27 10 6 7 14 211 155 213 157 370 Scrofula ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other forms of Tuberculosis 2 3 1 3 5 1 8 7 4 5 2 1 3 ... 9 5 2 1 1 3 1 ... 2 1 24 16 32 23 55 Purpura, Hæmorrhagic Diathesis ... ... ... 1 ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... 1 ... 2 2 Anæmia, Chlorosis, Leucocythæmia ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 2 1 1 2 1 4 4 4 4 8 Glycosuria, Diabetes Mellitus ... ... ... ... ... ... ... ... 1 1 ... ... 2 1 ... 1 1 ... 3 4 5 ... 5 4 17 11 17 11 28 Other Constitutional Diseases ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 6 ... 3 3 3 4 12 4 12 16 V.—Developmental Diseases. Premature Birth 67 63 ... ... ... ... 67 63 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 67 63 130 Atelectasis 7 5 ... ... ... ... 7 5 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 7 5 12 Congenital Malformations 8 19 1 2 1 ... 10 21 ... 1 ... 1 ... ... ... ... ... ... ... ... ... ... ... 1 ... 3 10 24 34 Old Age ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 1 1 47 124 48 126 48 126 174 VI.—Local Diseases. 1.—Diseases of Nervous System. Inflammation of Brain or Membranes 2 2 ... 2 3 2 5 6 2 2 1 ... ... ... 1 ... ... ... ... 2 ... ... ... ... 4 4 9 10 19 Apoplexy, Softening of Brain, Hemiplegia, Brain Paralysis 3 ... ... ... 1 ... 4 ... ... ... ... ... ... ... 2 2 3 1 22 17 11 14 42 66 80 100 84 100 184 Insanity, General Paralysis of the Insane ... ... ... ... ... ... ... ... ... ... ... 1 ... ... 8 1 4 1 7 3 1 1 4 4 24 11 24 11 35 Epilepsy ... ... ... ... 1 ... 1 ... 2 ... ... ... ... ... 1 3 ... 1 1 6 1 1 1 2 6 13 7 13 20 Convulsions 12 8 2 2 1 ... 15 10 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 15 10 25 Laryngismus Stridulus (Spasm of Glottis) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Disease of Spinal Cord, Paraplegia, Paralysis Agitans ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 2 ... ... 4 1 2 1 7 5 13 9 13 9 22 Other Diseases of Nervous System 1 2 ... ... ... 1 1 3 1 2 2 ... 1 1 2 3 1 3 2 2 1 ... ... 3 10 14 11 17 28 2. Diseases of Organs of Special Sense. (e.g., of Ear, Eye, Nose) 1 1 ... ... ... ... 1 1 2 ... 1 1 1 ... 3 ... ... ... ... 1 ... ... 1 ... 8 2 9 3 12 30 31 LAMBETH BOROUGH.-Deaths Registered from all Causes during the year, 1913-continued. Note.-The Deaths of Non-Residents occurring in Public Institutions situated in the District are excluded, and the Deaths of Residents occurring in Public Institutions situated beyond the limits of the District are included. AGES. AGES. Total. Under 1 Year 1-2 2-5 Under 5 Years 5-15 15-20 20-25 25-40 40-45 45-60 60-65 65 and over. Over 5 Years. All Ages. 3.—Diseases of Circulatory System. M. F. M. F. M. F M F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. Pericarditis 1 ... ... ... ... ... 1 ... 1 ... ... ... ... ... ... ... ... ... ... 1 ... ... ... ... 1 1 2 1 3 Acute Endocarditis ... ... ... ... ... ... ... ... 1 ... 1 ... ... ... 1 4 ... 1 3 ... ... ... 1 1 7 6 7 6 13 Valvular Diseases of Heart ... 1 ... ... 1 ... 1 1 2 4 3 4 2 1 11 11 7 5 16 20 11 7 22 38 74 90 75 91 166 Other Diseases of Heart ... ... ... ... ... ... ... ... 2 1 1 2 ... ... 5 6 ... 3 19 15 8 15 48 46 83 88 83 88 171 Aneurism ... ... ... ... ... ... ... ... ... ... ... ... ... ... .5 ... 1 ... 8 2 4 ... 3 1 21 3 21 3 24 Embolism, Thrombosis ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... ... 1 3 2 2 2 7 5 13 5 13 18 Other Diseases of Blood Vessels ... 1 ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... ... 8 5 14 2 58 72 80 79 80 80 160 4.—Diseases of Respiratory System. Laryngitis ... ... 1 ... ... 1 1 1 ... 1 ... ... ... ... ... ... ... ... 1 ... ... ... 1 ... 2 1 3 2 5 Croup ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Emphysema, Asthma ... ... ... ... ... ... ... ... ... ... 1 ... ... 1 ... ... ... ... 4 4 1 ... 7 4 13 9 13 9 22 Bronchitis 21 27 7 5 3 2 31 34 ... 2 1 ... ... ... 2 4 8 6 21 19 11 13 86 135 129 179 160 213 373 Pneumonia 7 6 2 ... 4 1 13 7 1 4 1 1 3 1 9 5 2 2 16 4 10 4 22 20 64 41 77 48 125 Pleurisy 1 1 ... ... ... 2 1 3 ... ... ... ... ... ... ... 1 ... ... 4 1 1 ... 1 1 6 3 7 6 13 Bronchopneumonia 35 41 21 14 8 6 64 61 1 1 ... ... ... ... 3 5 1 3 1 5 3 1 6 10 15 25 79 86 165 Pleuropneumonia 3 4 5 ... ... 1 8 5 ... ... 1 1 ... ... 13 6 2 ... 8 6 4 2 11 9 39 24 47 29 76 Other Diseases of Respiratory System 2 1 ... ... 1 ... 3 1 ... 1 ... ... 1 ... 5 1 ... ... 3 ... ... 1 4 7 13 10 16 11 27 5.—Diseases of Digestive System. Aop endicitis ... ... ... ... ... ... ... ... 6 2 2 ... ... 2 5 ... ... ... 2 ... 1 1 ... 3 16 8 16 8 24 Dentition 4 6 3 ... 1 ... 8 6 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 8 6 14 Sore Throat, Quinsy ... ... ... ... 1 ... 1 ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... ... 1 1 1 2 1 3 Diseases of Stomach 5 3 ... ... 2 1 7 4 ... ... ... ... ... ... 3 3 2 1 4 6 ... 1 3 5 12 16 19 20 39 Enteritis 6 4 2 2 2 1 10 7 1 1 ... ... ... ... ... 1 2 ... ... 1 1 ... ... ... 4 3 14 10 24 Obstructive Diseases of Intestine 3 1 ... ... ... ... 3 1 ... ... ... ... ... ... ... 1 2 ... 4 2 ... 2 8 6 14 11 17 12 29 Peritonitis ... ... ... ... ... ... ... ... 1 1 ... ... ... ... ... 2 ... ... ... 1 ... ... 1 ... 2 4 2 4 6 Ascites ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cirrhosis of Liver ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 1 1 4 21 5 2 2 5 3 30 15 30 15 45 Jaundice and other Diseases of Liver 1 1 ... ... ... ... 1 1 ... ... ... ... ... ... 1 1 ... ... 4 4 ... 2 1 5 6 12 7 13 20 Diseases of the Pancreas ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Diseases of Digestive System 7 7 ... 3 ... ... 7 10 2 ... 1 ... ... ... 1 2 ... ... 3 3 ... ... 3 4 10 9 17 19 36 6.—Diseases of Lymphatic System. (e.g., of Lymphatics and of Spleen) 1 ... ... ... 1 ... 2 ... ... ... ... ... ... ... 1 ... ... ... ... ... 1 ... ... ... 2 ... 4 ... 4 7.—Diseases of Gland-like Organs of Uncertain Use. (e.g., Bronchocele, Addison's Disease) ... ... ... ... ... ... ... ... ... ... 1 ... ... ... ... 1 ... ... ... 1 ... ... ... 1 1 3 1 3 4 8-—Diseases of Urinary System. Nephritis 2 1 ... ... 1 ... 3 1 ... ... ... ... 2 ... 1 1 ... ... 1 3 ... 1 2 1 6 6 9 7 16 Bright's Disease, Albuminuria ... ... ... ... 1 ... 1 ... ... ... ... 1 1 ... 10 6 6 5 22 21 14 12 26 24 79 69 80 69 149 Disease of Bladder or of Prostate ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 3 ... ... ... 13 3 16 3 16 3 19 Calculus (Stone) ... ... ... ... ... ... ... ... ... ... 1 ... ... ... ... 2 ... ... ... 1 ... ... ... ... 1 3 1 3 4 Other Diseases of the Urinary System ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 1 ... ... ... 1 ... ... ... 2 1 2 1 3 9.—Diseases of Reproductive System. a. Of Organs of Generation. Male Organs ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Female Organs ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... 5 ... 2 ... 3 ... ... ... 2 ... 13 ... 13 13 32 33 LAMBETH BOROUGH—Deaths Registered from all Causes during the Year 1913—continued. Note.—The Deaths of Non-Residents occurring- in Public Institutions situated in the Districts are excluded, and the Deaths of Residents occurring in Public Institutions situated beyond the limits of the District are included. AGES. AGES. Total. Under 1 Year. 1-2 2-5 Under 5 Years. 5-15 15-20 20-25 25-40 40-45 45-60 60-65 65 and over. Over 5 Years. All Ages. b. Of Parturition. M. F. M. F. M. P. M. F. M. F. M F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. Abortion, Miscarriage ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Puerperal Convulsions ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 2 ... ... ... ... ... ... ... ... ... 2 ... 2 2 Placenta praevia, Flooding ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Accidents of Child Birth ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... 7 ... ... ... ... ... ... ... ... ... 8 ... 8 8 10.—Diseases of Bones and Joints. Caries, Necrosis ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... 1 ... 1 ... 1 Arthritis, Ostitis, Periostitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... ... 1 ... 1 1 ] 2 3 2 3 5 Other Diseases of Bones and Joints ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... 1 1 ... 1 2 1 2 3 11.—Diseases of Integumentary System. Carbuncle, Phlegmon ... ... 1 ... ... ... 1 ... ... ... 1 ... ... ... 1 ... ... ... ...2 2 ... ... 1 3 5 5 6 5 11 Other Diseases of Integumentary System 4 1 1 ... ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... 1 ... 6 1 7 VII.— Deaths from Violence. 1.—accident or Negligence. Fractures and Contusions ... 1 ... ... 1 ... 1 1 6 ... 1 ... 1 ... 3 ... ... ... 6 1 3 ... 8 18 28 19 29 20 49 Gunshot Wounds ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cut, Stab ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... 1 1 1 Burn, Scald ... ... 3 3 2, 3 5 6 1 1 ... ... ... ... ... ... ... ... ... ... ... ... ... 2 1 3 6 9 15 Poison ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... 1 ... ... 1 2 1 2 1 3 Drowning ... 1 ... ... ... ... ... 1 ... ... ... ... 1 ... 6 1 1 ... 3 1 2 ... ... ... 13 2 13 3 16 Suffocation 3 7 ... ... ... ... 3 7 ... 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 3 8 11 Otherwise 2 2 ... ... 2 1 4 3 5 2 5 1 1 1 7 2 1 ... 6 ... ... 2 4 3 29 11 33 14 47 2—Homicide. Manslaughter 1 ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... 1 Murder ... 1 ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 1 3.—Suicide. Gunshot Wounds ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 3 ... 1 ... ... ... 4 ... 4 ... 4 Cut, Stab ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... 2 1 ... ... ... ... 3 1 3 1 4 Poison ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 2 2 5 2 1 ... 1 ... 9 5 9 5 14 Drowning ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 1 1 ... 1 ... ... ... ... ... 3 1 3 1 4 Hanging ... ... ... ... ... ... ... ... ... ... ... ... ... ... 2 ... ... ... 4 ... ... ... ... 1 6 1 6 1 7 Otherwise ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 1 1 ... 1 ... ... ... ... ... 3 1 3 1 4 4.—Execution. Hanging ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... VIII.—Deaths from Ill-Defined and not Specified Causes. Dropsy ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Debility, Atrophy, Inanition 50 29 3 3 ... 1 53 33 1 ... ... ... ... ... ... ... ... ... ... 1 1 ... ... ... 2 1 55 34 89 Mortification ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Tumour ... ... ... ... ... ... ... ... ... ... ... ... ... 1 1 ... ... ... ... 1 ... ... ... ... 1 2 1 2 3 Abscess ... ... ... ... 1 1 ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... 1 ... 2 ... 2 Haemorrhage ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Sudden Death (cause not ascertained) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Causes not specified, or Ill-defined 2 2 ... ... ... ... 2 2 ... ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... 1 ... 3 2 5 34 SUMMARY OF TABLE. No. of Deaths. Total. No. of Deaths. Total. M. F. M. F. I.—Specific Febrile, or Zymotic Diseases. Brought forward 1873 1878 3751 1. Miasmatic Diseases 151 127 278 VI.—Local Diseases—continued 2. Diarrhccal ,, 92 74 166 6. Diseases of Lymphatic System 4 — 4 3. Malarial „ — — — 7. Diseases of Gland-like Organs of Uncertain Use 1 3 4 4. Zoogenous ,, — — — 5. Venereal „ 16 8 24 8. Diseases of Urinary System 108 83 191 6. Septic ,, 11 15 26 9. Diseases of Reproductive II.—Parasitic Diseases — — - System (a) Diseases of Organs of Generation (b) Diseases of Parturition — 13 13 III.—Dietetic Diseases 13 12 25 — 10 10 IV. —Constitutional Diseases 479 457 936 10. Diseases of Bones and Joints 4 5 9 11. Diseases of Integumentary System 12 6 18 V.—Developmental Diseases 132 218 350 VI.—Local Diseases V11 - v lolencc. 1. Accident or Negligence 86 56 142 1. Diseases of Nervous System 163 170 333 2. Homicide 1 1 2 2. Diseases of Organs of Special Sense 9 3 12 3. Suicide 28 9 37 4. Execution - - — 3. Diseases of Circulatory System 273 282 555 4. Diseases of Respiratory System 402 404 806 VIII.—III-defined and not Specified Causes 61 38 99 5. Diseases of Digestive System 132 108 240 Carried forward 1873 1878 3751 Total 2178 2102 4280 35 Metropolitan Borough of Lambeth. REPORT ON AN OUTBREAK OF MILK-BORNE DIPHTHERIA IN UPPER NORWOOD, NOVEMBER TO DECEMBER, 1913. Incidences of the disease. At the end of November and the beginning of December, 1913, the numbers of notified cases of diphtheria in Upper Norwood increased beyond the average for that time of year—not only in Lambeth, but also in the neighbouring districts of Croydon, Penge, Camberwell, Lewisham, and Beckenham. 117 cases were notified, 31 inside the Borough of Lambeth and 86 outside the Borough, viz., Croydon 42, Penge 19, Camberwell 14, Lewisham 7, and Beckenham 4. 26 of the patients were secondary or "contact" cases, i.e., cases occurring secondarily in, or in connection with, previously notified infected houses. Fortunately, there was only one death out of the total of 11 7 cases notified, whilst the type of the disease, generally speaking, was mild. Table 1. gives full details of the notified cases. Further, noticeable features of the outbreak were the ages and sex of the notified patients (chiefly women) and their social standings (the infected houses beine principally of the better, or even the best, class). Of the 117 patients notified, 17 were under 10 years of age (4 males and 13 females) and 100 were over 10 years of age (36 males and 64 females). 2 patients were under 5 years of age (1 male and 1 female), 18 over 40 years of age (3 males and 15 females), and 4 over 60 years of age (all females). Full details are set out in Table II. A comparatively large number of servants were infected, whilst the actual large number of adults infected is specially noteworthy. Onsets of Attacks. Table I. gives the dates of the onsets of the attacks in all the cases notified, and Table III. sets out the numbers of patients sickening daily, in the different districts, and shews that the incidence of the disease was greatest in the first two weeks in December. The maximum number of patients sickening on one day was 11, viz., on December 1st (9 patients having sickened on the previous day, November 30th). Arranged weekly, the growth of the outbreak is readily seen, as follows:— No. of cases Per cent, of sickening. total cases. Week ending Nov. 23rd 2 = 1.7 „Nov. 30th 27 = 23.9 29.5 „Dec 7th 41 = 35.1 „Dec. 14th 37 = 31. 6 19.2 „Dec. 21st 8 - 6.8 „ Dec. 28th 2 - 1.7 Total 147 100.0 The sudden increase of cases sickening during the last week in November still further increased during the first two weeks in December and then suddenly decreased during the third and fourth weeks in December. Channels of Infection. The incidence of the outbreak in all the affected districts was more or less localised, and appeared to point to some factor, or factors, at work over a circumscribed area or areas. The usual common channels, by which diphtheria is known to spread, were investigated in each notified case, e.g., (a) contact from person to person, (b) school influence (day, Sunday, and dancing schools), (c) insanitary house conditions, and (d) defective drainage or sewerage areas, but no satisfactory evidence could be obtained, pointing to one or other, or all, of these usual common channels of infection being the channels through which the outbreak had spread to the various districts affected—the cases notified being not sufficiently definitely localised for channels 36 (a), (b) and (c), and too irregularly localised for channel (d). I he more uncommon and rarer channels of infection in recorded diphtheria outbreaks were, consequently, investigated, viz.: (a) ordinary sore throats developing into diphtheria, (b) infected water supply, and (c) infected milk supply. Evidence was obtained of ordinary sore throats being common throughout the districts affected, but these ordinary sore throats were prevalent, too, in neighbouring districts, which were not affected with diphtheria, so that eventually this channel of infection was abandoned as a definite cause of the outbreak. Finally, the water and milk supplies came under review, and, in connection with the former (the water supply), it was decided that the outbreak was not sufficiently extensively widespread, that the cases were too irregularly localised, to warrant the water supply being suspected as the infecting cause. The milk supply, therefore, was the only probable source of infection left, after excluding all the others, and the evidence from all the affected districts appeared to point to a milk supply, or supplies, being infected, in some way or other, with the diphtheria poison. In this connection, however, there were difficulties that had to be faced at the commencement of the investigations. Assuming the existence of such an infected milk supply, or supplies, how was it (1) That the outbreak was not more sudden in onset. of a more explosive nature, and more widespread following the milk-carts generally, in all the districts sunolied with infected milk, more especially having regard to the large amount of milk distributed daily throughout the districts affected; (2) That the outbreak did not show a more rapid rate of increase, having regard to the wav in which the diphtheria bacillus grows and thrives in milk (especially raw milk) more even at comparatively low temperatures than at 37 degrees C. (98.6 degrees F-); (3) That the incidence of the disease was practically not upon milk drinkers, being chiefly upon adults, and not upon children and invalids, who are, generallv speaking the orincipal milk consumers, especially children in better (or best) class houses; 37 (4) That better (or best) class houses, though infected; (comparatively) out of proportion to others, were not more generally involved, more milk (generally uncooked) being drunk in such houses; (5) That the infection was most irregularly distributed Croydon, Penge and Lambeth suffering out of all proportion, and that the localisation of the infected houses was peculiarly limited in certain districts and parts of districts, e.g., even certain roads, and that large areas and several large Institutions, known to be supplied with the suspected milk in the infected areas, escaped the disease ? Evidence in support of infected milk supply. In Upper Norwood there are two large local dairies,, which, for convenience, may be designated in this Report as dairies X and Y, in connection with which children of distributors of milk had been officially notified, at the end of November and beginning of December, 1913, as suffering from diphtheria. These children were removed to hospital, viz.: 2 connected with dairy Y on November 27th and 1 connected with dairy X on December 3rd, 1913, respectively. Disinfection was carried out and the work (distributing milk) of the fathers was stopped. The 3 infected children had attended Woodland Road L. C. C. School (Girls' Department), and also Christchurch Sunday School, so that it is possible that they caught the disease one from the other by personal contact, coming home from or going to school, at school, or at play, whilst it may be mentioned that, in connection with the first cases notified, viz.. the 2 children of the distributor of milk from dairy Y, a local sanitary defect at the house in the living room on the first floor was discovered, viz.: a foul and defective (untrapped) sink waste, which might render the throats of the inmates of such room liable to develop diphtheria, on account of the foul air given off from such a defective appliance tending to render the throat congested and a suitable nidus for the diphtheria germ. The milk supplies of these children were obtained from dairies X and Y respectively, it being customary in the trade for distributors to be allowed each a certain amount of milk daily by their employers, for the use of themselves and their families. 38 As the cases were notified at the commencement of the outbreak, it was found, on enquiry at the notified houses, that, in all the affected districts, with few exceptions, the milk supply was the same in all, viz.: dairy X. Investigations were made, consequently, in connection therewith, including enquiries into the conditions of (1) The farms and other wholesale sources (e.g., creameries and milk factories), from which the milk supplies of dairy X were drawn, including general sanitation, water supply, the cows and the employees;* (2) The dairy X, from which the milk, obtained from the farms and other wholesale sources,* was distributed into the various affected districts, including general sanitation, water supply and the employees, especially the distributors and their particular "rounds." in connection with which they were engaged (as shewn by the books) in distributing milk from house to house at the time of, and before the outbreak. The work involved was considerable, and much patience was required in following up every hint or clue as to a possible or probable channel or channels of infection, to arrive at the ultimate truth. This was due to the fact that the milk trade in any large town, and especially so in London, is complex, having many ramifications, and an intimate knowledge of such trade became, therefore, a first necessity—not only the milk trade as a whole, but also the particular milk trade of dairy X. In these and similar investigations, no fact is too trivial to be neglected, but on the other hand, great care must be taken to prevent official action being drawn to side issues or on "false scents." Bacteriological examinations were also carried out in great numbers. 1. The Farms and other Wholesale Sources of Milk.. All the milk received from the farms and _ other wholesale sources (creameries and milk factories) is practically mixed together at dairy X before distribution. * Including nursery milk supplied from 21 cows belonging to Dairy X (vide p. 40). 39 40 For this purpose, there are 3 mixing drums, holding 100, 50 and 50 gallons respectively, and into these drums the different milks, received at Gipsy Hill Railway Station from farms and other wholesale sources, are poured and mixed together in the mixing room at the back of the dairy, the object of the mixing being to secure an uniformity of composition of milk before distribution. The milk, mixed separately in the 3 drums, is not afterwards mixed together as a whole, but is poured into the churns for distribution from each drum when mixed. The separate drums used receive different milks daily, and the mixed milk in the different drums is distributed to different districts daily. There is no uniformity of mixing and no uniformity of distribution of particular milk to particular districts. In this way, no milk from an individual farm, or farms, or other wholesale source, or sources, would be likely to be distributed in any one particular district or districts, from day to day, or from week to week. On the contrary, all the districts would be supplied differently daily from different farms or other wholesale sources. This is an important consideration in connection with the outbreak, and hence it is that the milk is described above as being practically all mixed together before final distribution amongst consumers. In addition to the milk received from the farms and other wholesale sources, nursery milk is supplied separately from special cows, pastured in the open in the neighbourhood during 9 months of the year and stalled for the remaining 3 months in cowsheds (licensed for 44 cows) at the rear of the dairy X—a total of 21 cows (14 Jerseys, 1 Guernsey, 3 shorthorns and 3 crossbreds). Inspection shewed that these cows were sanitarily housed and pastured, and veterinary examination proved that the cows themselves were in a good state of health at the time of the outbreak. The farms are 18 in number—5 in Surrey and 13 in Sussex, and the creameries and milk factories 3 in number, The creameries and milk factories draw their supplies of milk from farms in Dorsetshire, Wiltshire, Buckinghamshire, Somersetshire, and Staffordshire. Investigations were conducted at all these Farms and other Wholesale Sources, situated outside the Borough of Lambeth, through the County Medical Officers of Health, Veterinary Inspectors, Analysts and others concerned, and Table IV. gives the results. The farms are designated by the letters A to R, and the creameries or milk factories by the Roman numerals I. to III. respectively. The infected farm was finally discovered in Sussex (Farm G), where several cows were found to be ill, two with mastitis, giving milk unfit for use, and others with teat eruptions, and several milkers with sores on their hands, and one cowman (also a milker) with an ulcerated finger. The facts in regard to the last-mentioned (the cowman) are specially interesting and noteworthy (see Table VI.). On further investigation, this cowman, who also acted as a milker, was found to be suffering from an indolent ulcer on the back of one of his fingers the wound having commenced apparently with a scratch received from a thorn about 15th September, 1913, becoming ulcerated at the end of November, and remaining so until the end of December, when the finger, being a hindrance to the cowman's work (milking), was amputated on December 27th, 1913, The medical man in attendance suspected tuberculosis or a malignant growth, but bacteriological examinations of the amputated finger showed that the ulcer was simply of an inflammatory nature, probably of long-standing. Cell debris, micrococci, staphylococci, dense leucocytic infiltration and fibrous induration were noted on examination microscopically, but the ulcer was found, on bacteriological examination, to be infected, also with organisms indistinguishable culturally from true diphtheria (Klebs-Loeffler) bacilli, which prove'd, on . further examination, to be virulent, i.e., pathogenic to animals, as shown by inoculation experiments carried out on guinea pigs. There was no evidence found of tubercule, syphilis or malignant growth. It was found, further, that, prior to having his finger amputated, the cowman had been at work assisting in milking the cows, with the ulcer present upon his finger and simply wrapped round with rag or bandage. The ulcer was, therefore, diphtheria-infected and capable of adding germs to the milk and, by inoculation, transferring them to the cows and, through the cows, to the other milkers, one of whom 41 was also found afterwards, on bacteriological examination, to be infected in a sore on his hand with the true diphtheria (Klebs-Loeffler) bacillus. If the cowman infected the cows, he may have contracted the diphtheria in his ulcer from his own throat, or nose, during the well-known habit of milkers of spitting upon their hands prior to starting milking, though, in this connection, no true diphtheria (Klebs-Loeffler), nor any other suspected, bacilli, were obtained therefrom, on examination. If the view of the cowman's ulcer, being infected directly from the cowman be correct, the source of his diphtheria remains obscure, as no cases of that disease, NOT of sore throat, weTe known officially in connection with the particular farm, or in connection with the particular neighbourhood. An alternative explanation is that the cows infected the cowman and the other milkers by inoculation, but there was no direct evidence to shew that the cows' mastitis or teat eruptions were diphtheria-infected, the teat sores being dried up and scaled and giving no results, on bacteriological examination. Whichever of these views be true, the interest is purely scientific, and the conclusions drawn in this Report, are in no way affected. In any case, it is practically certain, from information received locally, that the cowman's ulcerated finger was infectious (diphtheriainfected) from about the last week in November up to the date of the amputation, viz.: December 27th, 1913, and that during that time infected milk was being sent from the farm G to the dairy X, for distribution into the different districts supplied. The milk from farm G was under contract—75 to 90 imperial gallons daily. Taking the dates of onsets of the diphtheria in the notified patients (Table III.) it will be noticed that the infection began to spread during the last week in November and continued during the first two weeks in December, whr?n it suddenly ceased, coincidently with the whole of the milk, supplied from the suspected dairy X, being nasteurised (not less than a temperature of 180 degrees F.) before distribution to the public, as a temporary oreventive measure, which was ordered by the Medical Officer of Health, pending investigations as to the actual source or sources of infection being completed and the necessary permanent preventive measures being taken. The wisdom of this temporary preventive measure cannot be gainsaid, no further case of diphtheria being notified afterwards, i.e., no case that 42 could be definitely traced to infected milk from farm G through the dairy X, in any of the districts previously affected, though a few cases were notified during the last two weeks in December (vide pages 50-53 and Table III.). Between the last week of November and the end of December, diphtheria-infected milk from farm G was being distributed in Lambeth Borough and in the surrounding districts—the infection being added, in greater or lesser quantity, daily or even twice daily, i.e., at 'each milking, by the infected cowman. There was a systematic poisoning of the milk day by day for about 5 weeks. It is difficult to understand why more cases of diphtheria were not notified, why the outbreak was not wider spread, more especially having regard to the fact that raw milk, at ordinary temperatures, is a suitable nidus for the multiplication of diphtheria bacilli, and that such germs grow and thrive more at comparatively low temperatures than at 37 degrees C. (98.6 degrees F.). i.e., at such low atmosnherig temperatures as obtained during November and December. Further, the milk population supplied daily from the suspected dairy X numbered not less than 10,000 persons. This limitation of the outbreak is still more difficult to understand in view of the fact that more or less mixing of the milks from all the farms and other wholesale sources took place at dairy X prior to distribution, so that the infected milk from farm G would get mixed with the non-infected milks from elsewhere before distribution. The infected milk from farm G was certainly not sent to one or two particular districts only. It is probable that only few (comparatively) of the diphtheria bacilli, or a small amount of toxin, gained access to the milk during the milking process, owing to the ulcer being bound up with rag or bandage, which kept back or filtered the bacilli or toxin, and. in addition, being situated on the back of the finger. Probablv on this account, and owing to the vehicle being milk, and the fact that other commoner germs, such as staphylococci and streptococci, crowded out or tended to crowd out the diphtheria germs, the latter bacillus or the toxin was attenuated and of such a mild type of virulence when distributed in the milk to customers as to cause corresponding mild attacks of 43 the disease in those affected (many even escaping infection altogether), and so mild, indeed, that probably, many patients were not even notified officially, but were treated simply as ordinary sore throats, of which there had been many reported cases in the districts affected with diphtheria as well as in other districts not affected with diphtheria. ,In this connection, the exceedingly low mortality (only one death amongst the 117 diphtheria patients notified) is noteworthy, as is also the extreme mildness of the attacks in the majority of the patients treated. It may be added that, sanitarily, farm G was also found, on inspection, to be unsatisfactory, the water supply being also reported by the Analyst as unfit for dairy purposes, being pond water containing a large amount of organic matter. The milk supply from farm G was stopped as soon as the evidence of infection was satisfactorily proved— the farmer's milk contract being suspended. In such a case, naturally, strong evidence is required before extreme official action is taken, such as the stoppage of a milk supply from being brought into a particular district, or districts. 2. The Dairy X and the Distributors of Millk. The dairy X is a model dairy, both as to construction and as to design and its sanitation and general management are up-to-date. The buildings consist of the dairy proper and shep with offices and residence attached, whilst, at the rear, there are a large mixing room, a butter store, a general washing shed, stables and cow sheds, together wi'h a large paved yard (partly covered), where the milk carts and "prams'" (or oerambulators) are drawn up for the purpose of being loaded with milk in churns, etc. In the mixing room, at the rear, there is a model pasteurising plant. The employees connected with the dairy at the time of the outbreak consisted of 22 regular distributors, 3 "odd'" men helping the regular distributors, I station man (carting the milk in churns from the station to the 44 45 dairy), 3 stablemen, 2 pasteurisers and dairymen, 2 cowmen, 4 office staff, 3 helpers in the shop, and I cook and 1 housemaid (attending upon the proprietors). For the purposes of this Report, the regular distributors are designated bv their numbers, viz., 1 to 22, and the 3 "odd" men by their initials, viz., "odd" men E.F., W.K. and S.J.A. respectively. The distribution of the miik was by means of churns carried in (a) hand prams or perambulators, and (b) horse carts—regular distributors Nos. 1, 2, 3, 4, 9, 11, 13, 15, 16, 17, 18, 19, 20, 21 using the former, and regular distributors Nos. 5, 6, 7, 8. 10, 12, 14 and 22, and "odd" man S.J.A. the latter. There were, also, the usual bottles and cans in use. The ordinary rounds are made in the mornings and afternoons, and the so-called "pudding" rounds between 10 and II a.m. The ordinary rounds do not tally with the pudding ' rounds, some distributors taking the "pudding rounds in an area or areas (or parts thereof) outside their ordinary rounds, whilst the "odd" man, S.J.A., had a special "pudding" round in parts of Beckenham, Lewisham, Camberwell and Peng* (but not in Croydon, nor in Lambeth) and the other "odd" men assisted the regular distributors as follow :— " Odd " Men. Distributors Assisted. Ordinary Rounds. "Pudding "Rounds. Morning. Afiernoon. E.F. No. 4 No. 9 "Odd" Man S.J A. W.K. — — No.12. *N.B. — "Odd " man S.J.A., who had a spccial "pudding" round of his own, was assisted by "odd" man E.F. In addition, as occasion required, "odd" man E.F. was accustomed to take butter or milk into any district, using for that purpose a bicycle. These complicated arrangements in connection with the different rounds or distribution areas made the investigations into the cause or causes of the outbreak all the more difficult. The average amount of milk dealt 'with daily is large—3,047 quarts, or 762 gallons, being distributed to 2,529 h ouses. representing a milk population of not less than 10,000 individual consumers of milk (in greater or lesser amounts). Table I. gives not only particulars of the notified cases (age, sex, address, date of onset, etc.), but shews also the ordinary and "pudding" rounds of the various distributors (regular and "odd" men) in connection with such cases, before, at the time of, and during, the outbreak. •Of the "pudding" rounds, the following houses are doubtful, i.e., the distributors did not actually call at the infccted houses, but passed down the roads, or near to, daily :—No. 1—8, No. 2—2, No. 3—2, No. 9—11, No. 12-6, No. 15—6, No. 19—20, No. 20—2, "odd" man S.J .A.—18, "odd" man E.F.—18, and "odd" man W.K.—6. t "Odd " man S.J.A. has a special "pudding" round. N.B.—"Odd" man E.F. assists daily "odd' man S.J.A. on his special "pudding" round, and regular distributors Nos. 4 and 9 on their ordinary rounds (morning and afternoon respectively). "Odd" man W.K. assists 46 Dividing the total 1 17 notified cases of diphtheria amongst the 25 distributors (both regular and "odd" men) according to their milk rounds (both ordinary and pudding '), the numbers for each individual distributor were found to vary within wide ranges, as follow, the total being, of course, double the notified cases, viz., 234, on account of the double daily rounds :— Distributors. Milk Rounds. Distributors. Milk Rounds. Regular. Ordinary "Pudding." Total. Regular. Ordinary "Pud- ding." Total No. 1 2 8* 10 2 5 10* 15 15 2 7* 9 3 4 6* 10 16 5 — 5 4 2 - 2 17 2 — 2 5 3 - 3 18 2 - 2 6 9 — 9 19 4 31* 35 7 10 — 10 20 5 3* 8 8 15 — 15 21 2 — 2 9 9 14* 23 22 3 — 3 10 8 - 8 Odd' men 11 11 - 11 S.J.A.† - 24* 24 12 12 14* 26 E.F. 11 24* 35 13 2 - 2 14 — — - W.K. — 14* 14 47 daily regular distributor No. 12 on his "pudding" round. The numbers opposite the "odd" men E.F. and W.K., are repetitions, being given also opposite regular distributors Nos. 4, 9, 12 and odd man S.J.A. respectively. From this summary it will be noted that 5 of the distributors had each more than 20 infected customers (i.e., notified cases) on their rounds, viz., regular distributors Nos. 9, 12 and 19, and "odd" men S.J.A. and E.F. In otter words. 5 of the distributors appeared to be common to several of the infected districts, and these 5 distributors are noted in leaded type in Table I. As "odd" man E.F. assists regular distributor No. 9, and "odd man" S.J.A., it is probable that foe was the cause of the apparent increased number of infected customers (i.e., notified cases) on their rounds, especially so as "odd" man E.F. showed, on bacteriological examination, the presence of the bacillus diphtheroides in his throat, whereas regular distributor No. 9 and "odd" man S.J.A. proved negative to examination. Regular distributors Nos. 12 and 19 showed the bacillus diphtheroides in their throats (No. 19, the Klebs-Lceffler bacillus also). Fuller bacteriological details will be found under the heading "bacteriological results connected with the employees of dairy X" (vide pages 52-55). 1 he 3 suspected distributors, therefore, were regular distributors Nos. 12 and 19 and "odd" man E.F. Analysing the figures more in detail, it will be seen that it was the "pudding" rounds that were chiefly affected. These "pudding" rounds would offer more chances of contact infection between the distributors and their customers or of special localised infection of a pail, from which such customers would be served, than would be the case in the ordinary rounds, which are chiefly bottle or can trade, separate bottles and cans (often sealed) being frequently used. On theoretical grounds, this would be so, and in actual practice there was evidence which seemed to point to a special localisation of cases in particular roads in connection with the special rounds or distributing areas suspected. Taking only notified cases about which the evidence of being supplied (either on the ordinary or "pudding" rounds, or on both) by one or other of the suspected distributors was definite, it was found that special roads were infected as follow:— Notified cases of Notified cases Diphtheria and the showing special Distributors. Milk Kounds in localisation in certain connection with which roads (numbers of they occurred. cases in brackets). Ordinary. "Pudding" Total. Belvedere Road 6) No. 12 12 8 20 Hamlet Road (2) Sylvan Road (3) {Beulah Hill (5) No. 19 4 11 15 .Church Road (4) Harold Road (5) Central Hill (5) College Road (2) No.9 Crystal Palace and "Od.1" man E.F.J Laurie Park Roads (2) Essex Road (3) The above figures are based on cases about which the evidence was satisfactory as to the infected houses having been served by the distributors named. There was also evidence (much less satisfactory) that, in addition, 24 other notified cases might be connected with the "pudding" rounds of regular distributors Nos. 12 and 19 (6 and 20 cases respectively) and "odd" man E.F. (12 cases, it being possible for such distributors to have supplied occasionally milk on emergency to the infected houses. The following further details are noteworthy: — 1. Of the 20 infected persons (notified cases) connected with the rounds of regular distributor No. 12, 8 occurred in houses at which he called daily (all "pudding" rounds), and the other 12 in houses at which there was a history of his having called, but not daily; 2. Of the 15 infected persons (notified cases) connected with the rounds of regular distributor No. 19, 11 occurred in houses at which he called daily (all "pudding" rounds), and the other 4 in houses at which there was a history of his having called, but not daily; 48 3. Of the 17 infected persons (notified cases) connected with the rounds of "odd" man E.F., 6 occurred in houses at which he called daily (all "pudding" rounds), and the other 11 in houses at which there was a history of his having called, but not daily; 4. Taking the middle of Church Road as a centre, 55 of the total notified cases (117), i.e., 47 per cent., occurred .within a radius of half-a-mile; and, taking an area about half-a-mile square, bounded by Central and Beulah Hills and Church and Hermitage Roads, respectively, 28 of the total notified Croydon cases (42), i.e., 66.6 per cent., occurred therein, this being, practically, the area supplied with milk by regular distributor No. 19. What was the cause of the particular grouping of cases, specially in the Croydon and Penge areas? The bacteriological results obfained in connection with the suspected distributors are instructive, and may afford the necessary explanation, at least in part:— The results were as follow:— Distributors. Bacillus isolated No. 12 b Diphtheroides (doubtful diphtheria). No. 19 b Klebs Leeffleri itrue diphtheria) and b diphtheroides (doubtful diphtheria). " Odd " Man E.F b Diphtheroides (doubtful diphtheria). The bacillus diphtheroides is regarded as a modified and attenuated form of the true Klebs-Loeffler diphtheria bacillus, so that regular distributor No. 19, was an actual "carrier," and regular distributor No. 12 and "odd" man E..F. were probable "carriers" of diphtheria germs, at least to some extent. Regular distributor No. 9 and "odd" men S.J.A. and W.K. proved negative to bacteriological examination, but these negative results must be read in conjunction with the positive result (bacillus diphtheroides) obtained from "odd" man E. F., who might have been, in that 49 way, as already suggested, the connecting link, seeing that he assisted both regular distributor No. 9 and "odd" man S.J.A. For fuller particulars, reference must be made to the heading "Bacteriological Results connected with the employees of dairy X" (vide pages 52-55). It may be mentioned that regular distributors Nos. 1 and 2 shewed a similar tendency (but not so marked) to special localisation in certain roads or small areas, viz., distributor No. 1 in Alexandra Road (5 cases), and distributor No. 2 in Alleyn Park (5 cases), and Camden Hill Road (3 cases) respectively. The facts in connection with these two distributors are interesting. Distributor No. I had his child removed to hospital suffering from diphtheria on December 3rd, 1913, and his work (distributing milk) was stopped the same day. He had, however, been distributing milk between the time when his child sickened on November 29th, 1913, and the date when diphtheria was diagnosed, and the child removed to hospital (viz., on December 3rd. 1913). A total of 8 cases of diphtheria were notified in houses on his round, and. of these 8 cases, 5 occurred in one road (Alexandra Road), the dates of onsets of the attacks being December 1st, 2nd, 3rd, 4th, 7th, 9th, 10th and 12th (th-s last 3 being secondary cases), pointing to this distributor being probably a "carrier" from his own child from November 29th to December 3rd, but the cases ceased in this particular distributor's round when his work of distributing milk was stopped, although the farm infection (farm G) must have still continued, its source not having been, at that time, discovered. Regular distributor No. 2 lived in the same house as regular distributor No. 19, but they had separate and distinct rounds or distribution areas. 15 cases were notified in connection with the round of regular distributor No. 2—5 on the ordinary and 10 on the "pudding" round—and, of these 15 cases, 8 occurred in two roads (Alleyn Park and Camden Hill Road), the dates of onsets of the attacks being November 21st, 25th, 27th, 29th, 29th, December 1st, 6th, 6th, 6th, 7th, 8th, 9th, 15th, 17th and 30th respectively. Bacteriological examinations of regulajr distributors Nos. I and 2 showed the presence of the bacillus 5° 51 diphtaeroides and the bacillus Klebs-Loeffleri in the latter (No. 2) and the bacillus Hofmanni in the former (No. 1). The peculiar localisation of these cases appears to point to a sort of contact infection between distributor and consumer, or what may be termed a limited milk can or milk pail infection as opposed to a general milk supply infection, when the localisation is more general, following practically the milk carts. These specially localised cases cannot be satisfactorily explained on the theory of farm infection alone, but can on that of farm infection as modified by contact infection (can or pail). Diphtheriainfected farm milk was sent to the dairy X, and distributed therefrom over wide areas, giving rise to cases of diphtheria in many different districts, but more or less sporadic cases, amongst the consumers of the milk. Amongst the consumers were the milk distributors, some of whom, in their turns, appear to have caused crops of cases in specially localised centres (special roads) by contact infection or milk can or milk pail infection, almost house to house infection, through distributors who were "carriers." It is somewhat difficult to allocate exactly and definitely the parts played by these two separate and distinct infecting agents. The farm infection closed with the pasteurising of the milk, and the "carrier" infection with the stopping of the distributors from work, but, as the pasteurising of the milk was commenced on a date prior to the suspected distributors being definitely proved to be "carriers" and consequently stopped from work, these two preventive measures overlapped in their beneficial effects. A few cases, however, might be exnected to occur after pasteurisation from the "carrier" infection, which, if present, would have continued during the time that elapsed between the pasteurisation of the milk being commenced and the distributors' work being stopped. On theoretical grounds this should be so, and a few of the late cases notified can, perhaps, be satisfactorily accounted for on that assumption. Pasteurisation appears to have overshadowed in its beneficial effects the beneficial effects that might have resulted from the stopping of the puspected distributors' work. The infected farm milk infected certain of the distributors, viz., regular distributors 12 and 19 and "odd" man E.F., whilst regular distributor No. 19 probably infected No. 2 (with whom he lived in the same house) and regular distributor No. I was probably infected from his own child, who sickened with the disease on November 29th, and was notified and removed to Hospital on December 3rd, 1913, the father's work being stopped on the same day. The incubation period is shorter in milk diphtheria than in other kinds, varying from a few hours to a few days (average 3 days), so that, in drawing conclusions from the dates of onsets, this fact must be borne in mind. Farm infection ceased when pasteurisation of the milk commenced (December 12th), and, allowing the average incubation period of three days, any patients sickening with diphtheria after December 15th, could not be farm infected, provided, of course, the pasteurisation was efficiently carried out, and there was no reason for supposing that such was not done, the pasteurising plant being a modern one and carefully worked. Dealing with the "carrier" infection in the same way, and allowing the same average incubation period for milk diphtheria, such infection would continue until December 21st for regular distributors Nos. 12 and 19 and for "odd" man E.F., and until December 26th for regular distributor No. 2, according to the dates when their work was stopped, so that between December 12th (pasteurisation commenced) and December 18th and 23rd (dates of stoppage of distributors' work), new patients might be expected to sicken. In connection with the rounds of regular distributor No. 1 the "carrier" infection (if any) from him would cease on December 6th, i.e., 3 days after his ceasing from work. Let the facts speak for themselves in the following summary:— 52 53 Patients notified as Dates Distributors Dates of having of as stoppage of sickened out- onsets "Carriers" work. side the of periods of farm attacks. infection. No. 1 Dec. 3 0 — No. 2 Dec 23 2 { Dec.17 Dec.30 No.12 Dec. 18 1 Dec. 16 No.19 Dec. 18 2 ( Dec 16* Dec.16 Dec. 17 "Odd" man E.F. Dec. 18 4 Dec.18 Dec.21 Dec. 26 Cases previously notified in the houses. N B.—Pasteurisation commenced December 12th. It will be noted that there are 2 cases, that sickened on December 26th and December 30th, 1913, respectively, that do not appear to fit in with the theory of a "carrier" infection, though these cases may be explained on a basis of a longer incubation period than 3 days, or of an error of observation as to the exact dates of onset. The remaining 7 cases contain 4 secondary castes, leaving 3 to be explained by "carrier" infection, the dates of onset being December 16th, December 17th, and December 18th respectively. These figures do not prove anything very satisfactorily but, in this connection, it must be remembered (1) that the pasteurisation of all farm infected milk prior to its distribution, on and from December 12th, was a very radical measure, and (2) that pasteurised milk is less likely to become infected, the diphtheria bacillus tending to die or become inoperative in such a medium. Bacteriological Results connected with the employees of Dairy X. of Dairy X. A large number of bacteriological examinations was carried out in connection with the outbreak. The whole of the employees and the proprietors of the suspected 54 dairy X were examined, some of them on several occasions, and the results obtained were as follow:— Persons examined. Bacilli found. 1—Distributors. (a) Regular. (1) b Klebs Lœffleri; (2) b Nos. 2 and 19 Diphtheroides; (3 b, coccus; (4) b, Staphylococcus (1) b Diphtheroides; (2) b, No. 12 Streptococcus; (3) b, Staphylococcus; (4) Torula. (1) b Hoffmanni; (2) b, Nos. 1, 4, 5 and 9 Streptococcus; (3) b, Staphylococcus. Nos. 1, 4, 5 and 9 18, 21, 22 (1) b Staphylococcus. No. (1) b Staphylococcus; No 17 1 (2) Torula. No, 10 (1) b Streptococcus. Nos. 3, 6, 7, 11, 13, 20 (b) "Odd" Men. (1) b Diphtheroides; (2) b, E.F. Streptococcus; (3) b, Staphylococcus. S.J.A. (1) b Staphylococcus: S.J.A. (2) Torula. W.K. (1) b Staphylococcus. 2—Proprietors' House (Inmates). One proprietor shewed bacillus Hofmanni, bacillus streptococcus and bacillus staphylococcus in his throat and nose, the other inmates (including the cook and housemaid) shewing bacillus staphylococcus or bacillus streptococcus and bacillus staphylococcus. 3—Stablembn. T.S. (1) b Mesentericus; (2) b Staphylococcus. T.L.and F.G. (1) b Staphylococcus; T .L. and F.G. (2) b streptococcus. 55 4—Others. Bacillus staphylococcus was found in connection with the following other employees, viz., I station man (calling for the milk), 2 pasteurisers and dairymen, 2 cowmen, 4 office staff and 2 shop staff, whilst the extra employee engaged in the shop temporarily shewed the presence in her throat of the bacillus staphylococcus and the bacillus streptococcus. The bacillus Hoffmanni is, in this Report, regarded as a distinct organism unconnected with the bacillus KlebsLœffleri (true diphtheria), though some bacteriologists regard it as a sign or evidence of contact with true diphtheria. The bacillus diphtheroides is, however, in this Report, regarded as a modified or attenuated form of the bacillus Klebs-Lœffleri (true diphtheria), a changed type or variant, the one form developing into the other under certain conditions. If this be the correct view, the bacteriological results obtained in connection with the outbreak are significant, as shewing that, whilst regular distributors Nos. 2 and 19 were actual "carriers" of the diphtheria germ, regular distributor No. 12 and "odd" man E.F., were probable "carriers" of the same germ (modified and attenuated as the effect of time). It will be noted that the bacillus staphylococcus and the bacillus streptococcus were also found in these distributors as also in many others of the employees, pointing to the diphtheria infected farm milk being also, probably, pus contaminated and dirty—a condition to be expected from the ulcerated finger of the cowman, and also having regard to the unsatisfactory state of the farm G and its unwholesome water supply as found on inspection. The work of all employees connected with the dairy X, who shewed, on examination, suspicious germs, was stopped. Milk is a favourable nidus for the development of the diphtheria bacillus, wihich lives and multiplies therein more at comparatively low temperatures than at 37 degrees C. (98.6 degrees F.), but so do the commoner organisms and much more rapidly, thereby tending to crowd out the diphtheria germs. The presence of the bacilli streptococcus and staphylococcus in large numbers in the majority of cases examined lends support to such having been the case in the present outbreak. 56 The conclusions to be drawn from the bacteriological results connected with the distributors may be summarised as follow:— 1. Regular distributors Nos. 2 and 19 were "carriers" (actual); 2. Regular distributor No. 12 and "odd" man E.F. were "carriers" (probable). Full particulars as to the farm infection and the bacteriological results in connection therewith will be found on pages 41 and 42 and Table VI. 4. School Influence. Enquiries made as to any school influence, or influences, at work in connection with the outbreak proved negative, though, at one time, it was thought that a private school in Lewisham and a dancing academy in Anerley were acting, in some way, at least as contributory causes, several Lambeth patients attending there prior to being notified as suffering from diphtheria. The Medical Officers of the districts concerned made enquiries, but failed to discover anything suspicious, so that these two sources of infection were discarded as even probable contributory causes. 9 of the Lambeth cases were connected with the London County Council schools, as follows: Woodland Road 5, Gipsy Road 2, Salter's Hill I, Eden Road (Wesleyan) I; 4 with the Lewisham private school: 1 with the Dulwich Coltege Preparatory; 1 with a College at Kensington, and 3 with private Lambeth schools. The Lambeth schools, as a whole, however, did not appear, upon investigation, to have caused any part of the milk borne outbreak, and. in thre other districts affected by the outbreak, the same was found to be true of the schools there. These decisions were corns to only after careful investigation and enquiry, as it is now generally recognised that school influence is often at work in 57 causing, or assisting in causing, a diphtheria outbreak owing to mild or "carrier" cases of the disease being unrecognised amongst the scholars. It may be noted, however, that the earliest notified Lambeth case (the children of a distributor of dairy Y) attended Woodland Road L.C.C. school, in the same girls' department as another Lambeth case (the child of a distributor of dairy X), and there was evidence pointing to the probability of these cases being connected, the latter arising from the former. SUMMARY. A .—Facts in javour of an ordinary infected milk supply— (1) Incidence as regards (a) social position of persons notified, and (b) class of houses infected. (2) Slightness of virulence of diphtheria poison, as shewn by (a) mildness of cases treated and lessened (practically absent) mortality (1 death only), and (b) lessened contagiousness of the diseasie (only 117 notified cases reported out of a total of not less than 10,000 milk consumers). (3) Outbreak of ordinary "sore throat" in the area affected, i.e., within the area of the diphtheria prevalence, before and during the outbreak. (4) Infection operative (a) during limited time, and (b) with rapidity of decline. N.B.—The rapidity of decline of the infection may be due to the pasteurisation of the infected milk, prior to its distribution on and from December 12th, 1913. B.—Facts against an ordinary infected milk, supply— (I) Local incidence not following exactly the milk carts or churns. 58 (2) No particular incidence on milk drinkers, i.e., no special milk age- and sex-incidence, children being specially exempt. N.B.—The children may have escaped owing to the custom in better class houses of cooking milk that is to be consumed by them, or it may be that they consumed nursery milk from the cows belonging to dairy X, this nursery milk being unmixed with the ordinary farm milks. (3) No sudden outburst of cases. (4) Notified patients scattered over widely-different parts of the districts, and many districts and large institutions, known to be supplied with infected milk from the dairy X, exempt. Conclusions. From the above facts, it will be seen that the outbreak was somewhat peculiar and did not follow the usual lines of an ordinary milk outbreak of diphtheria. It is probable that there was some other factor at work beyond the infected milk supplied from the infected farm G, causing the peculiar variation in the localisation of the disease throughout the different districts, and this factor appears from the evidence to be certain infected distributors of milk, who proved, on bacteriological examination, to be "carriers" of diphtheria. In any case, there can be little or no doubt as to the effect of distributor No. 19, who was an actual "carrier," having assisted in causing the increased local incidence in Croydon, in the area bounded by Central and Beulah Hills and Church and Hermitage Roads—an area containing 28 of the total cases (42) notified in that district, i.e., 66.6 per cent. There is evidence also that "carriers" Nos. 2 and 12 and "odd" man E.F. may have exercised a somewhat similar influence, though to a less marked extent, in other districts. Though the factor of the infected farm G is proved, the result of the infection during the outbreak is undoubtedly peculiar and anomalous in another way, viz., in the slightness of the virulence of the poison when distributed through the milk, causing the disease to spread in an exceedingly mild form as well as irregularly throughout 59 the various districts supplied, some districts of large areas and several large institutions!, as already stated, even escaping altogether. Admitting then, the factor of the infected farm G, it may be stated that the other factor, working through the distributors, who were "carriers," showed itself in a special localisation of cases in certain very small areas, e.g., separate roads. That both factors were at work, in some areas, there can be little doubt, and the details of the outbreak are, consequently, of interest epidemiologically and otherwise. It is true that the "carrier" infection takes a secondary and subordinate place in the causes of the outbreak, but, for a complete understanding of the whole of the details, it must be considered and allowed for. Idiosyncracy and susceptibility of patients, too, may have played their parts. The dates of onsets of the attacks in the notified patients, set out in Table I., are interesting in connection with both the farm infection (commencing about the last week in. November) and the "carrier" infection (commencing about the same time). These infections continued at work until the third week in December, when (they ceased—the cessation tallying with (1) the pasteurisation of all farm milk before distribution, and (2) the stopping of the suspected distributors from work. The pasteurisation of the milk commenced on December 12th, and the stopping of the suspected distributors at a later date, i.e., when the bacteriological evidence proved definitely that the distributors were, or had recently, been, "carriers" (actual or probable) of diphtheria. From December 12th, 1913, onwards, all milk was pasteurised before being distributed from dairy X, and all cases of diphtheria connected with that milk, consequently ceased. What applied to diphtheria should have applied to other infectious diseases, and it is interesting, in passing, to note the following details, collected in the Lambeth area, Norwood Ward, during the month of January, 1914:— I 2 6o No of Infected Houses obtaining Milk. Cases Notified. Diphtheria. Scarlet Fever. Typhoid Fever. (a) From Dairy X – 1 1 (b) From other Dairies 2 14 – The experiment is noteworthy in its results, but whether the small number of cases connected with dairy X customers is the direct result of pasteurisation or simply a coincidence is difficult to say definitely. On theoretical grounds, assuming that milk is the chief channel of infection in spreading infectious diseases generally throughout a district, the results could be satisfactorily explained on the pasteurisation theory, scarlet fever and typhoid fever in the same way as diphtheria. It is probable, however, that the view of coincidence is true and that the scarlet fever and typhoid fever cases arose from other sources than the milk supply, as did also the diphtheria cases, tabulated during January, 1914. The facts are interesting as a record. The Preventive Measures carried out may be tabulated as follows :— 1. Notification of patients; 2. Isolation of patients; 3. Bacteriological examinations of doubtful cases; 4. Medical inspection of "contacts" and "suspects"; 5. Pasteurisation of milk supply; 6. Stoppage from work of "carrier" distributors and those suspected of being infected; 7. Stoppage of milk supply from the proved infected farm. 61 Addendum. The Report would not be complete without acknowledging the help and assistance given to me by the Medical Officers of Health of the neighbouring districts affected, the County Medical Officers of Health, and specially the Medical Officer of Health for the West Sussex Northern Combined Sanitary District, in whose areas the farms and creameries, etc., axe situated, and finally the proprietors of the infected dairy X. who readily placed all their books at my disposal, and to whom I am indebted for details as to sources of milk supply, rounds of distribution, amounts of milk distributed, etc. To Dr. Macewen also, of the Local Government Board, my thanks are due. Without the help of all concerned, the outbreak would not have been so quickly brought to such a satisfactory ending. The statistics dealing with the districts outside Lambeth have been supplied by the Medical Officers of Health concerned. Joseph Priestley, Medical Officer of Health. Lambeth Town Hall. February 2nd, 1914. 62 63 Outbreak of Milk-borne Diphtheria in Upper Norwood. NOVEMBER TO DECEMBER, 1913. TABLE I. Shewing the Ages, Sex, and Addresses of the notified cases of Diphtheria, together with the Dates of Onsets of the Disease and the details of the Milk Rounds (both ordinary, i.e, morning and afternoon, and "pudding," i.e., 10-11 a.m.) supplying the various infected houses with milk from Dairy A, giving the numbers of the regular distributors (Nos. 1 to 22 inclusive) and the initials of the " odd" men assisting in the rounds. Regular distributors Nos. 9, 12, 19 and "odd" men S.J.A. and E.F. are printed in leaded type, being common to several of the infected districts, and having the greatest numbers of infected customers (i.e., notified cases) on their respective rounds. lambeth. (31 cases.) Addresses. Ages. Sex. No. of Cases. Dates of Onset of Disease. Milk Rounds, with particulars of Distributors serving. No. of Houses in Roads served regularly daily by the different Distributors. Primary Secondary Ordinary. Pudding. Ordinary Pudding. Alexandra Road 28 F. 1 - December 7 No. 13 ?No. 1 37 Alexandra Road 35 F. 1 - December 3 ,, 3 ? ,, 1 Alexandra Road 17 F. 1 - December 2 ,, 3 ? „ 1 15 15 Alexandra Road* 10 M. - 1 December 10* ,, 3 ? ,, 1 Alexandra Road* 19 F. - 1 December 12* ,, 3 ? ,, 1 Camden Hill Road 9 F, 1 - December 6 ,, 2 ? „ 15 Camden Hill Road* 18 M. - 1 December 9* .. 2 ? „ 15 37 2 Camden Hill Road 17 M. 1 - December 7 ,, 2 ? ,, 15 Central Hill 12 M. 1 - December 2 „ 16 ? ,, 9 14 17† (See Croydon) Central Hill (See Croydon) 36 F. 1 - December 12 No. 9 and E.F. ? „ 9 42 17 Clive Road 9 F. 1 - December 6 No. 18 ? ,, 2 27 — Gipsy Hill 16 F. 1 - December 7 ,, 11 ? ,, 1 37 5 Gipsy Hill 12 F. 1 - December 7 No. 4 and E.F. ? ,, 15 30 8 Gipsy Hill 1½ M. 1 - December 8 No. 11 ? ,, 1 37 5 Highland Road* 18 F. - 1 December 9* No. 11 ? No. 9 Highland Road 13 F. 1 - December 5 ,, 11 ? ,, 9 17 2 Highland Road 48 F. 1 - December 6 ,, ll ? ,, 9 Knights Hill* 4 F. - 1 December 3* ,, 8 ? ,, 19 Knights Hill 10 F. 1 - November 30 ,, 8 ? ,, 19 4 - Knights Hill* 12 F. - 1 December 8* ,, 8 ?,, 19 Rosendale Road* 33 F. - 1 December 1* ,, 18 ,, 19 11 3† Victoria Road* 17 F. - 1 December 4* ,, 11 ,, 2 3† Victoria Road 5 F. 1 - November 30 ,, 11 ,, 3 19† Victoria Road 8 F. 1 - November 30 ,, 11 ? ,, 3 19 Victoria Road* 22 M. - 1 December 3* ,, 11 ? ,, 3 47 19 Victoria Road 5 F. 1 - December 6 ,, 11 ? ,, 3 19† Victoria Road 49 M. 1 - December 11 ,, 11 ,, 3 19† Westow Hill 17 M. 1 - December 1 ,, l ? ,, 20 32 14 Whiteley Road* 17 F. - 1 December 9* ,, 13 ? ,, 1 47 1 Woodland Hill 7 F. 1 - November 29 ,, 2 ? „ 15 39 1 Woodland Road 8 F. 1 - December 8 „ 2 „ 20 74 10† Croydon. (42 Cases.) Beulah Hill 24 F. 1 - November 30 No.8 ?No Beulah Hill 22 F. 1 - November 30 „8 „ 19 Beulah Hill 10 F. 1 - November 30 „8 „ 19 12 Beulah Hil 12 M. 1 1 December 1* „ 8 „ 19 12† Beulah Hill 27 F. 1 - December 16 „ 8 „ 19 12† Beulah Hill 27 M. 1 - November 30 „ 8 „ 19 64 12† Beulah Hill 13 M 1 - November 26 8„ „ 19 12† Beulah Hill 26 M. 1 - December 3 8„ „ 19 12† Beulah Hill 10 M. 1 - December3 8„ „ 19 12 M. 1 - December 8 8„ „ 19 12 12 Secondary or " contact" cases, i.e., cases occurring secondarily in, or in connection with, previously notified infected houses. † Including infected houses actually supplied on the “ pudding” as well as on the ordinary round. N.B_Query mark in front of distributor means that the distributor docs not call at the house but passes down the road or near daily. lm Croydon—continued. Addresses. Ages. Sex. No. of Cases. Dates of Onset of Disease. Milk Hounds with particulars of Distributors serving. ino. oi nouses ir Roads served regularly daily by the different Distributors. Primary Secondary Ordinary. Pudding. n it Ordinary. Puddin Central Hill 56 F. 1 - December 10 No 9 and e.f. ? No. 9 ? „ 9 „ 9 42 17 (See Lambeth) ,, 9 and e.f. 17 Central Hill 50 F. 1 - December 12 (See Lambeth) ,, 9 and e.f. 17f Central Hill 20 M. 1 - November 25 (See Lambeth) Church Road§ 68 F. 1 - November 29† No. 19 ? „19 | 46 10 10f Churrh Road 20 F. 1 - December 6 19 „19 Church Road 61 F. 1 - November 29 ,, 19 ? „ 19 10 i n Church Road 14 F. 1 - December 7 ,, 19 ? „ 19 1 u Cypress Road 17 M. 1 - November 27 ,, 6 ? „ 19 1 — Cypress Road* 13 F. - 1 December 1* ,, 6 ? „ 19 Cypress Road* 16 F. - 1 December 1* ,, 6 ? ,, 19 Cypress Road* 21 M. - 1 December 16* December 9 No 9 and e.f. ? ,, 9 9 4 Essex Grove 7 F. 1 - ,, 9 and e.f. ? „ 9 Essex Grove* 5 F. - 1 December 17* ,, 9 and e.f. ? „ 9 M. . - December 14 ,,9 and e f. ? ,, 19 Essex Grove 14 M. 1 - December14 No. 6 ? ,, 19 7 1 Grange Road 25 F. 1 - ,, 19 5 } " Harold Road 35 M. 1 -- November 30 ,, 8 ,, 19 Harold Road 30 M. 1 - December 5 ,, 8 ,, 19 Harold Road 27 F. 1 - December 10 ,, 16 ,, 19 | 30 Harold Road 8 F. 1 - December 10 „ 16 ,, 19 Harold Road 54 M. - 1 December 12* ,, 16 ,, 19 5 Harold Road Highfield Hill 28 F. 1 - November 28 ,,8 ? „ 19 8 Highview'Road 19 F. 1 - November 24 No. 9 and e.f. No. 9 13 6† Mowbray Road 18 M. 1 - November 25 No. 12 No 12 & W.K. 7 3† Ross Road 28 M. 1 - December 1 „ 6 ? No. 19 2 - St. Aubyn's Road 17 M. 1 - December 4 1 ? No. 20 17 3 South Norwood Hill 72 F 1 - December 9 „ 6 ? „ 19 ? ,, 19 19 South Norwood Hill 9 F. 1 - December 10 6 1 Sunny Bank 20 F. 1 - December 14 6 ? ,, 19 2 - Sylvan Hill Sylvan Hill* Sylvan Road 27 M. 1 - December 2 ,, 12 No. 12 & W.K. „ 12 & W.K. ?„ 12 & ?W.K. 3 23 F. - 1 December 16* ,, 12 2† 10 F. 1 - December 2 ., 12 13 1 Troy Road 14 M. 1 - December 13 No. 9 and e.f. ?No. 9 5 - Vermont Road 13 M. 1 - December 1 No.6 ?„ 9 9 5 Pence. (19 Cases.) Anerley Park 14 M. 1 - December 1 No. 7 ?s.j.A.&?e.f. 2 1 Anerley Road 22 F. 1 - December 1 „ 22 s.j. A.&e.f. 16 i† Belvedere Road Belvedere Road Belvedere Road* Belvedere Road Belvedere Road* Belvedere Road Croydon Road 30 F. 1 - December 12 ,, 15 No 12 & W K 16 13† 45 M. 1 - November 29 12 ?,, 12 &?W. K. „ 12 & W.K. „ 12 & W.K. ? „ 12 &PW.K. ? „ 12 &PW.K. 24 3 17 M. - - December 12* „ 12 13† 22 F. 1 - November 30 „ 12 13† 49 F. - 1 November 28* .. 12 13 32 F. 1 - November 25 ,, 12 13 20 M. 1 - December 2 „ 22 ?s.j.a. & ?e.f. ?s.j.a. & ?e.f. 4 — Croydon Road* 15 M. - 1 December 5* „ 22 Crystal Palace Park Road 22 F. - December 5 » '/ ?s.j.a. & 13 2 (See Beckenham) ?e.e. Hamlet Road 24 M. - November 27 „ 12 No. 12 & W.K. 5 3† Hamlet Road* 45 F. 1 November 30* „ 12 No. 12 & W.K. 3† * Secondary or " contact cases, i.e., cases occurring secondarily in, or in connection with, previously notified infected houses. § Patient died, † Including infected houses actually supplied on the " pudding " as well as on the ordinary round. N.B.—Query mark in front of distributor means that the distributor does not call at the house but passes down the road or near daily. 66 67 Pence—continued. Addresses. Ages. Sex. No. of Cases. Dates of Onset of Disease. Milk Rounds with particulars of Distributors serving. No. of Houses in Roads served regularly daily by the different Distributors. Primary Secondary Ordinary. Pudding. Ordinar rlPudding Lansdowne Place 47 F. 1 ¯ December 10 No. 15 ?No.l2 & ?W.K 4 1 Maberley Road 32 F. 1 ¯ December 14 „12 ? „ 12 & ?W.K 17 3 Thickett Road* 15 M. ¯ 1 December 2* ,, 7 ?S.J.A. & ?E.F. Thickett Road 18 F. 1 — December 1 ,, 7 ?S.j.a. & ?E.F. 19 Thickett Rord 29 F. 1 — November 23 ,, 7 ?s.j a. & ?E.F. 19 Thickett Road 43 F. 1 — December 18 „ 7 -s.j.a. & ?E.F. Camberwell. (14 Cases.) Alleyn Park 40 F. 1 ­ November 29 No. 20 No. 2 Alleyn Park* 10 F. — 1 November 25* ,, 20 ,, 2 28 9† Alleyn Park 41 F. 1 ­ November 21 ,, 20 ,, 2 Alleyn Park* 29 F. ­ 1 December 15* ,, 7 ,, 2 10 Alleyn Road 16 F. 1 ­ December 17 ,, 1 7 S.J.A,&E.F. 5 11† College Road 12 M. 1 ­ November 27 ,, 5 S. J. A.&.F.E . 11 † College Road 24 F. 1 ­ December 14 ,, 21 S. J. A.&.F.E . 4 2† Crescent Wood Road, Sydcnham 16 l F. 1 ­ December 14 ,, 10 S. J. A.&.F.E . 4 2 Duhvich Wood Park 31 F. 1 ­ December 14 ,, 21 s.j.a.&e.f. 8 6† Dulwich Wood Park 60 F. 1 ­ December 13 ,, 17 ? ,, 15 5 1 Kingswood Road 11 M. 1 ­ N'ovember 27 ,, 5 ,, 2 8 2+ Kingswood Road* 32 F. — 1 December 6* ,, 5 ,, 2 South Croxted Road 10 F. 1 ­ December 30 ,,20 ,, 2 11† The Avenue 22 F. 1 ­ December 9 No. 4 and e.f. ,, 15 20 4† Lewisham. (7eCases.) Bishopsthorpe Road, Sydenham 8 M. 1 ­ December 1 No. 10 ?s.j.a. & ?e.f. Bishopsthorpe Road,* Sydenham 5 M. — 1 December 21* „ 10 ?s.j.a. & ?e.f. 3 ­ Bishopsthorpc Road, Sydenham 27 F. 1 ­ December 4 „ 10 ?s.j.a. & ?e.f. | MayowRoad,Sydenham 11 M. 1 ­ December 26 „10 ?s.j.a. & ?e.f. 1 ­ Silverdale, Sydenham 28 F. 1 ­ December 5 „ 10 ?s.j.a. & ?e.f. 1 ­ Sydenham Hill 13 M. 1 ­ December 8 „ 10 ?S.J.a&?E.F 18 4 West Hill, Sydenham ... 6 M. 1 ­ December 9 „ 10 ?S.J.a&?E.F 7 3 Beckenham. (4 Cases.) Crystal Palaee Park Road (See Penge) 35 F. 1 ­ December 7 No. 7 ?s.j.a.&?e.f. 2 Crystal Palacc Park Road (See Penge) 10 F. 1 ­ December 8 „7 ?s.j.a.&?e.f. 13 2 Crystal Palacc Park Road (Sec Penge) 40 F. 1 ­ December 14 „7 ?s.j.a.&?e.f. 2† Lawrie Park Road 49 F. 1 ­ December 13 „7 ?s.j.a.&?e.f. 6 1† * Secondary or "contact cases," i.e., cases occurring secondarily in, or in connection with, previously notified infected houses. † Including infectcd houses actually supplied on the“ pudding" as well as on the ordinary round. N.B.—Query mark in front of distributor means that the distributor does not call at the house but passes down the road or near daily. N.B.—Beckenham ceased having milk from the suspected, Dairy X on Dec. 16th, 1913, and resumed it on Jan. 5th, 1914, milk from another dealer (at New Cross) being used meanwhile. Between Dec. 16th, 1913 and Jan. 5th, 1914, 5 fresh cases of Diphtheria, and between Jan. 5th and Jan. 31st, 1914, 4 fresh cases of Diphtheria, were notified in Beckenham. 68 Outbreak of Milk-borne Diphtheria in Upper Norwood. NOVEMBER TO DECEMBER, 1913. TABLE II. Shewing the Age and Sex incidence of notified cases in the various Districts affected. Age Periods. DISTRICTS AFFF.CTED. Totals. Lambeth. Croydon. Penge. CaMBERWELL Lbwisham. Beckrnham. M. F. Total M. F. Total M. F. Total M. F. Total M. F. Total M. F. Total M. F. Total 0— 5 1 1 2 - - - - - - - - - - - - - - - 1 1 2 5—10 - 8 8 - 4 4 - - - - - - 3 - 3 - - - 3 12 15 10—15 2 2 4 6 4 10 1 - 1 2 - 2 2 - 2 - 1 1 13 7 20 15—20 3 6 9 3 2 5 3 1 4 - 2 2 - - - - - - 9 11 20 20—25 1 1 2 2 5 7 2 3 5 - 4 4 - - - - - - 5 13 18 25—30 - 1 1 4 4 8 - 1 1 - - - - 2 2 - - - 4 8 12 30—35 - 1 1 1 - 1 - 3 3 - 2 2 - - - - - - 1 6 7 35-40 - 2 2 1 - 1 - - - - 1 1 - - - - 1 1 1 4 5 40—45 - - - - - - - 1 1 - 2 2 - - - - 1 1 - 4 4 45-50 1 1 2 - - - 1 3 4 - - - - - - - 1 1 2 5 7 50—60 - - - 1 2 3 - - - - - - - - - - - - 1 2 3 60 & over - - - - 3 3 - - - - 1 1 - - - - - - - 4 4 All Ages 8 23 31 18 24 42 7 12 19 2 12 14 5 2 7 - 4 4 40 77 117 Under 10 yrs. 1 9 10 - 4 4 - - - - - - 3 - 3 - - - 4 13 17 Over 10 yrs. 7 14 21 18 20 38 7 12 19 2 12 14 2 2 4 - 4 4 36 64 100 6g Outbreak of Milk-bonne Diphtheria in Upper Norwood. NOVEMBER TO DECEMBER, 1913. TABLE III. Shewing the daily numbers of diphtheria patients sickening with the disease (as shewn by the dates of onset) in Lambeth and in the other districts affected. 1913. Lambeth. Croydon. Penge. Camberwell. Lewisham. Peckham. TOTALS Nov. 21 - - - 1 - - 1 „ 22 - - - - - - - ,, 23 - - 1 - - - 1 ,, 24 - 1 - - - - 1 „ 25 - 2 1 1 - - 4 ,, 26 - 1 - - - - 1 ,, 27 - 2 1 2 - - 5 ,, 28 - 1 1 - - - 2 ,, 29 1 2 1 1 - - 5 ,, 30 3 4 2 - - - 9 Dec. 1 2 5 3 - 1 - 11 ,, 2 2 2 2 - - - 6 3 3 1 - - - - 4 ,, 4 1 1 - - 1 - 3 ,, 5 1 1 2 - 1 - 5 ,, 6 5 1 - 1 - - 7 ,, 7 3 1 - - - 1 5 ,,8 3 1 - - 1 1 6 ,,9 3 2 - 1 1 - 7 „ 10 1 4 1 - - - 6 „11 1 - - - - 1 ,, 19 9 2 2 - - - 6 ,, 13 - 1 - 1 - 1 3 .. 14 - 3 1 3 - 1 8 ,, 15 - - - 1 - - 1 „ 16 - 3 - - - - 3 „ 17 - 1 - 1 - - 2 „ 18 - - 1 - - - 1 ,, 19 - - - - - - - ,, 20 - - - - - - - ,, 21 - - - - 1 - 1 ,, 22 - - - - - - - ,, 23 - - - - - - - ,,24 - - - - - - - ,, 25 - - - - - - ,, 26 - - - - 1 - 1 „ 27 - - - - - - - ,, 28 - - - - - - - ,, 29 - - - - - - - ., 30 - - - 1 - - 1 „ 31 - - - - - - - Totals 31 42 19 14 7 4 117 ^3 Outbreak of Milk-borne Diphtheria in Upper Norwood. NOVEMBER TO DECEMBER, 1913. TABLE IV. Shewing the Farms and other Wholesale Sources (Creameries and Factories), from which Dairy X was found at the time of the outbreak, and prior to such outbreak, to derive its milk supply, with Results of Investigations and Inspections made by Veterinary Inspectors, Analysts and County Medical Officers of Health concerned. Farms and other Wholesale Sources. Results of Investigations and Inspections made by— Counties in which situated. Veterinary Inspectors. Analysts. County Medical Officers of Health. Farms. A (37) Surrey Satisfactory Excellent water No diphtheria nor suspicious throats B (26) Surrey Satisfactory (one cow with throat gland thickened and two cows being dried off) Satisfactory Dirty pump water Ditto ditto C (50) Surrey Dirty well water Ditto ditto D (13) Surrey Ditto Excellent water Ditto ditto E (12) Surrey Ditto Good water Ditto ditto F (34) Sussex Ditto Ditto Ditto ditto G (75) Sussex Unsatisfactory, 2 cows with mastitis (milk unfit for use) and several cows with teat eruptions Pond water unfit for use Diphtheria infected cowman who acted also as a milker (ulcerated finger), other milkers with sores on their hands (one sore being found to be diphtheria-infected) ondition of farm unsatisfactory. H (14) Sussex Satisfactory Suspicious well water No diphtheri v nor suspicious throats (diphtheria 4 miles away) No diphtheria nor suspicious throats I (20) Sussex Ditto Good Spring water J (23) Sussex Ditto Good well water Ditto ditto K (59 Sussex Ditto Doubtful deep well Ditto ditto L (25) Sussex Ditto water Excellent water Ditto ditto M (6) Sussex Ditto Unsuitable well water Ditto ditto N (56) Sussex Ditto Suitable well water Ditto ditto O (43) Sussex Ditto Bad well water Ditto ditto P (47) Sussex Ditto Satisfactory water Ditto ditto Q (45) Sussex Ditto Good spring water Ditto ditto R (40 Sussex Ditto Ditto Ditto ditto Creamerie and Factories 1.(77) Buck'hamshire Staffordshire Ditto Good water Ditto ditto All milk pasteurised II (60) Dorsetshire Wi11shire Ditto Ditto Ditto ditto III. (60) Dorsetshire Somersetshire Ditto Ditto Ditto ditto N.B.—The figures inserted in brackets after each Farm, Creamery or Factory, represent the average amount of milk daily supplied therefrom (in imperial gallons . 68 imperial gallons were also obtained from another Factory and Creamery on Dcc. 19th, 1913 (one connsignment only). 72 Outbreak of Milk-borne Diphtheria in Upper Norwood. NOVEMBER TO DECEMBER, 1913. TABLE V. Shewing " rounds," numbers of houses served and average amount of milk distributed by each distributor, bacilli found on bacteriological examination in each distributor and the number of notified diphtheria patients allocated to each distributor. Rounds and distribution areas. DISTRIBUTORS No. of houses served. Average amount of milk in quarts. Notified cases of diphtheria allocated to each distributor Bacilli found in Bacteriological Examinations. Regular. b Staphylococcus No. 1 133 121 10* b Streptococcus b Hofmanni b Staphylococcus b Streptococcus ,, 2 264 173 15* b Diphtheroides b Klebs-Lœffleri b Staphylococcus ,, 3 129 128 10* b Streptococcus b Staphylococcus „ 4 (&E.F.) 150 136 2 b Streptococcus b Hofmanni b Staphylococcus „ 5 66 135 3 b Streptococcus b Hofmanni b Staphylococcus „ 6 187 198 9 b Streptococcus b Staphylococcus „ 7 78 114 10 b Streptococcus „ 8 134 212 15 b Staphylococcus b Staphylococcus „ 9(&E.F.) 152 174 23* b Streptococcus b Hofmanni „ 10 98 182 8 b Streptococcus b Staphylococcus „ 11 131 135 11 b Streptococcus * Including doubtful cases, i.e., the distributors did not actually call at the infected houses but passed down the road, or near to, daily, as follows:—No. 1—8 houses, No. 2—2 houses, No. 3— 2 houses and No. 9 — 11 houses. 73 Rounds and distribution areas. distributors No. of houses served. Average amount of milk in quarts. Notified cases of diphtheria allocated to each distributor Bacilli found in Bacteriological Examinations. N0.12I&W.K.I 109 186 26* b Staphylococcus b Streptococcus b Diphterooider Torulœ 2 b Staphylococcus „13 105 83 b Streptococcus „ 14 142 142 — b Staphylococcus „ 15 134 145 9* b Staphylococcus 16 85 145 5 b Staphylococcus „ 17 61 87 2 b Staphylococcus Toruloe „ 18 80 81 2 b Staphylococcus „ 19 67 138 35* b Staphylococcus b Streptococcus 16 b Diphtheroides b Klebs-Loeffleri „ 20 57 116 8* b Staphylococcus b Streptoeoccus .. 21 40 86 2 b Staphylococcus 22 127 112 3 b Staphylococcus Odd men. S.J.A. 22* b Staphylococcus Torulœ E.F. Included in ; above. Included in above. 35* b Staphylococcus b Streptococcus b Diphtheroides W.K. 14* b Staphylococcus 2529 3047 * Including doubtful eases, i.e., the distributor did not actually call at the infected houses but passed down the road, or near to, daily, as follows :—No. 12—6 houses, No. 15—6 houses, No. 19— 20 houses, No. 20—2 houses, "odd" man S.J.A.—18 houses, "odd" man E.F.—18 houses, and "odd" man W.K.—6 houses. 74 Outbreak of Milk-borne Diphtheria in Upper Norwood. NOVEMBER TO DECEMBER, 1913. TABLE IV. Special Bacteriological reports on the cowman's finger (ulcerated) in connection with the infected Farm G. No. ].—December 30th, 1913. Smear preparations made from the lesion shew cell debris with a fair number of diphtheroid bacilli and micrococci. Tubercle bacilli are not detected. It will be necessary to isolate the bacillus found in pure culture so that cultural tests may be made to distinguish between the Klebs-Lœffler bacillus and the common skin diphtheroid organism, if possible. We shall also proceed with a histological examination. No. 2.—January 3rd, 1914. Further Report. Histologically this ulcer is of a purely inflammatory origin, showing dense leucocytic infiltration of the tissues and much fibrous induration, as if the lesion were of long standing. There is no evidence of syphilis, tubercle or new growth. The diphtheroid bacillus found in the cultures made from this specimen is not the common skin organism of this type, but the cultural characteristics as studied in young cultures are similar to those of the Klebs-Lœffler bacillus. Considerable numbers of the staphylococcus pryogenes aureas are also present. No. 3.—January 12th, 1914. Further Report. The post-mortem examination of the guinea-pig which was inoculated with a pure culture of the isolated diphtheroid bacillus, and which was found dead, showed the characteristic appearance of one injected with virulent Klebs-Lœffler bacilli, while the control animal injected with a similar amount of the same culture, together with diphtheria antitoxin, is still alive and shows no evident symptoms. In our opinion, the organism is a virulent Klebs-Lœffler bacillus. (Signed) Director of Laboratory. Metropolitan Borough of Lambeth. Municipal Tuberculosis Dispensaries Scheme. FIRST REPORT For the Year ending December 31st, 1913, by S. NICOL GALBRAITH, M.B., Glas., D.P.H., Camb., Tuberculosis Medical Officer, Central Dispensary, and R. C. WINGFIELD, B.A., MB., Oxon, M.R.C.P.. Lond. Tuberculosis Medical Officer, Branch Dispensary, with INTRODUCTION by JOSEPH PRIESTLEY, B.A., Lond., M.D., Edin., D.P.H., Camb., Chief Executive Tuberculosis Officer and Medical Officer of Health. 76 INTRODUCTION. The Lambeth Municipal Tuberculosis Dispensaries Scheme, as approved by the Local Government Board and the National Insurance Commissioners, includes two properly equipped and officered Dispensaries, or Clinics,* both for diagnosis and treatment, for the use of the Borough, viz. (a) A Central Dispensary at 73 Effra Road, Brixton, situated near to the Town Hall in the centre of the Borough, under the care of Dr. S. Nicol Galbraith, as Tuberculosis Medical Officer. (b) A Branch Dispensary at St. Thomas's Hospital, Lambeth Palace Road (separate and distinct from the Main Out-Patient Departments), situated at the northern end of the Borough, under the care of Dr. R. C. Wingfield, as Tuberculosis Medical Officer. The Medical Officer of Health of the Borough is the Chief Executive Tuberculosis Officer, responsible to the Borough Council for the general administration and local execution of the Scheme. The Central Dispensary was opened to the public on July 23rd, 1913, and the Branch Dispensary on February 3rd, 1913, so that this First Report deals only with the work carried out since those dates, up to and including December 31st, 1913. * The American term “Clinic" is better for use than the word Dispensary," preventing confusion with existing Special and General Dispensaries, whilst, in addition, it is a term that is coming into use in connection with other Departments of Public Health Administration, e.g., treatment of school children, etc. 77 Special interest attaches to this First Report, dealing, as it does, with the commencing working of a Scheme, which depends upon a combined effort on the part of a Municipal and of a Hospital Authority. Hitherto, the Hospital Authorities have dealt with disease as met with in the individual, and not as it affects the community, as a whole, and much valuable help and material have, consequently, been wasted, or at least, diverted, in so far as Public Health Administration was concerned. The treatment and control of tuberculosis appears to be a subject specially suitable for the trial of a combined effort —the linking up of voluntary and official agencies, and this principle was, therefore, adopted as the basis of the Lambeth Scheme, and approved by the Local Government Board and the National Insurance Commissioners, and is now being adopted, after approval by the Local Government Board and the London County Council, in connection with other Tuberculosis Schemes. The two Dispensaries are administered and worked on the same lines, and the patients are interchangeable between the two, as may be found necessary, whilst the resources of the one are open to the other, a valuable arrangement, in so far as Lambeth Borough is concerned, having regard to the fact that St. Thomas's Hospital is well organised and equipped with all modern appliances and special departments (pathological, dental, chemical, laryngological. X-ray, etc.), whilst the services of the well known consulting Medical and Surgical Staffs of the Hospital may be requisitioned, as required, by the Tuberculosis Medical Officers. Further, a ten-bed Ward is attached to the St. Thomas's Hospital Tuberculosis Department, for observation and treatment purposes. The record of work carried out by the Tuberculosis Medical Officers, as shewn in their Joint Report, speaks for itself, and the details given under the various headings and tabies will prove of interest, more especially those dealing (1) with the working capacities of the patients before and after treatment, i.e., the practical results obtained, measured by the maintenance, or otherwise, of the working capacity of such patiente and (2) the systematic examinations of “contacts”. 78 The early diagnosis and treatment of patients is important, though the difficulties connected therewith are well known, e.g., the insidious onset of the disease, the reluctance of workers to stop work until the disease is too far advanced for cure or arrest, etc. Sanatorium treatment is being provided for some of the suitable (early) cases of pulmonary tuberculosis (consumption), but no proper provision, outside Poor Law Institutions, has yet been made at all for “advancing” or “advanced” cases, which are the chief cause of the spread of the disease (in the “commencing” form) to others. Satisfactory arrangements should be made for the segregation of such “advancing”or “advanced”cases as may be found necessary, and for their proper treatment in institutions other than those of the Poor Law, having regard to the infectious nature of such cases. Everything depends upon concentrating administrative (including remedial) efforts upon these cases: indeed, it is only in this way that tuberculosis will finally be eradicated. Taking the generally accepted lay classification of the disease into the usual three stages—stages i. (commencing), ii. (advancing), and iii. (advanced)—it is clear that, if patients suffering from stage i. of the disease are dealt with radically, and the disease in them is cured or arrested, so that there will be, eventually, practically no patients suffering from stage i. of the disease, stages ii. and iii. of the disease must also disappear, as these stages (ii. and iii.) are fed from stage i. Medical men and others should be encouraged to refer their patients at once to the Dispensaries for diagnosis or treatment, and all "contacts" found in infected houses should be encouraged to attend, and to continue to attend from time to time, at the Dispensaries for advice. The Tuberculosis Medical Officers are always ready to give expert assistance to medical men and others who require it, in connection with not only the diagnosis, but also the treatment, of the disease, both in its early and later stages. The remarks of the Tuberculosis Medical Officers on the subject of tuberculin (both in diagnosis and treatment) are noteworthy, their opinions, as the result of experience, coinciding with those of other experts, viz.: that tuberculin is only one of the forms of treatment and, as such, was used in 71 out of the total 486 tuberculous patients treated during 1913 in connection with the Lambeth Tuberculosis Dispensaries under the Scheme. Joseph Priestley. 79 JOINT REPORT OF THE TUBERCULOSIS MEDICAL OFFICERS. For the Year ending December 31 st, 1913. Having no precedent, the form in which to present the Report was carefully considered, and it was finally decided to use, as headings, the "functions" of a Tuberculosis Dispensary, outlined in the Interim Report of the Departmental Committee on Tuberculosis, as follow:— (1) Receiving House and Centre of Diagnosis. Total Attendances:— (a) New Patients; and (b) Old Patients. Particulars of New Patients:— (a) Age-Periods and Sex; (b) Lengths of Attendances; (c) Sources of Cases; (d) Results of diagnosis:—(l) Oidinary Patients, and (2) "Contacts." Special Methods of Diagnosis:— (a) Bacteriological; (b) X-rays; (c) Tuberculin : (1) Subcutaneous, and (2) Percutaneous. Clinical classification of, pulmonary tuberculosis cases:— (a) Inman and (b) Turban. (2) Clearing House and Centre for Observation. (3) Centre for Curative Treatment. 8o Nature and results of treatments:— (a) Routine; (b) Institutional:—(1) Sanatoria (including Tuberculosis Hospitals), (2) General Hospitals, and (3) Poor Law Institutions (c) Tuberculin. Economic classification of results of treatment. Open air schools for children. (4) Centre for the Examination of "Contacts." (5) Centre for "After-care." (6) Information Bureau and Educational Centre. (I) Receiving House and Centre of Diagnosis. The total attendances of patients at the Dispensaries, with particulars as to ages and sex, are set out in full in Table I. The patients are also tabulated urder the headings insured and "non-insured." These numbers of attendances are encouraging, viz., new patients 1,036. and old patients, 4,097—a total of 5,133. The comparatively large number of women attending as compared with men is due to what might be called the "hospital habit" amongst the former and the reluctance of the latter to be examined for fear that they should be required to give up work. The lengths of attendances of patients vary, but for the purposes of classification (see Table I.), it has been deemed advisable to sub-divide them into two main classes, viz.: (a) one month and over, and (b) under one month—the latter including (1) cases sent for opinion only. (2) cases unfit to attend personally as patients, (3) cases diagnosed as not tuberculous, or doubtful, (4) "contacts," and (5) cases belonging and transferred to other districts. Many patients were transferred to, and from, other districts, due to the migratory nature of the population— a fact which might have proved an administrative difficulty in dealing with the disease from the point of 81 view of public health, had it not been that neighbouring districts are now beginning to co-ordinate their work and to send on particulars of patients who remove to other districts to the Medical Officers concerned. The results of treatment (vide infra) have reference only to patients whose lengths of attendance were one month and over. The different sources from which the patients were drawn are set out in Table III., from which it will be noted that the Scheme is receiving support in a way, and to an extent, that must tend to make it a success. Medical men and the public are taking an interest in the Scheme. The results of diagnosis are given in Table III., shewing that, of the total 1,036 patients examined, 486 proved to be tuberculous and 550 suspected tuberculous, including "non-tuberculous" and "doubtful" cases. Of the total 1,036 patients examined, 306 were "contacts" and. of these 306 "contacts," 46 proved to be tuberculous and 260 suspected tuberculous. Further, of the 486 cases diagnosed as tuberculous, 470 were pulmonary and 16 non-pulmonary, and 251 (i.e., 51.6 per cent.), gave a tuberculous family history, shewing the susceptibility of certain families and the direct infectivity of the disease. All tuberculous patients, attending the Dispensaries, are notified to the Medical Officer of Health as a routine, whether or not previously notified by medical practitioners. The most powerful weapon in the fight against tuberculosis is early diagnosis. There is, at present, no specific diagnostic for every case. Patients are diagnosed on weight of evidence for or against and, in this connection, special and all methods of diagnosis are of value. It is now acknowledged that it is necessary to use all such methods of diagnosis, and not to trust to physical signs alone. The stethoscope, or the interpretation of what it conveys, is no longer considered to be infallible in the diagnosis of pulmonary tuberculosis. The special methods of diagnosis may be tabulated as (1) Bacteriological, (2) X-rays, and (3) Tuberculin. (1) Bacteriological. A large number of routine bacteriological examination of sputa has been carried out, and it has been 82 found that careful bacteriological examination of the sputum in several doubtful cases, and in those with secondary infections, has proved reliable. Where concentration methods have failed, repetition of the routine procedure has been successful in establishing the diagnosis. (2) X-rays. Many cases were examined by X-rays, and this examination has been of great help, but is found to be only of use when correlated with clinical examination. Tn certain cases with no physical signs, or with very indefinite ones, and with suggestive histories, X-ray photographs have shewn definite evidence of the disease. (3) Tuberculin. Diagnosis by tuberculin divides itself into (1) subcutaneous and (2) per-cutaneous. The sub-cutaneous diagnostic tuberculin injections have been used on cases in the Observation Ward only, and Koch's old tuberculin (O.T.) has been used in every case, the doses being .0002 c.c., .002 c.c., .01 c.c. Of the 12 patients injected, 9 gave postitive reactions. The experience of the Von Pirquet test (per-cutaneous) is that it is unreliable as a diagnostic measure, even in children, except possibly children in the age-period 1 to 5 years. This test was applied to 105 children, and in 38 the result was positive. A detailed clinical classification is set out in Table IV., giving the special classifications introduced by Inman and Turban with reference to pulmonary tuberculosis patients. It has long been recognised that, in any clinical classification of patients suffering from pulmonary tuberculosis, the essential fact to convey is a definite estimate of the capacity of such patients to take exercise or to work. This estimate must, of necessity, be based upon easily-recognised factors, which again must not be capable of being varied according to the judgment or point of view of the observer. The purely anatomical classification of Turban does not, in any respect, meet this requirement, as no indication of the general condition or working capacity of the patient is given, so that such a classification serves no other purpose than that of academic interest. 83 The prognosis in a given case depends not upon the extent of the local lesion, but on the degree of intoxication of the system, and this well-known fact is recognised in what is known as Philip's Classification, in which the amount of systemic disturbance is indicated by certain specific symbols added to the numbers of the respective anatomical stages. This is a step in the right direction, but .10 reliable indication is conveyed of the patient's capability of undertaking work. No standard factors are given whereby an estimate of the degree of systemic or autoinoculation resulting from any such muscular effort can be made, and, failing such factors, different observers may very easily give widely varying reports. The clinical classification devised by Inman is found to meet all requirements, as the sorting out or selection of cases for sanatorium, tuberculin, or other treatment is invariably effected by clinical methods. Further, in such classification, everything of an empirical nature is eliminated and the incontrovertible standards (temperature, rest, exercise or work) are adopted. Inman's classification is as follows: Stage or Class. I. II. III. Clinical. Resting febrile, Ambulant febrile, resting afebrile Ambulant afebrile Pathological. Excessive auto-inoculations occurring spontaneously. Excessive auto-inoculations inducible by exercise. Appropriate auto-inoculations inducible by exercise. To demonstrate the value of this method of division, all cases coming under stage or class III. (Inman) have been sub-divided into the three stages or classes of Turban (see Table IV.). Assuming that the greater the local lesion, the worse the general condition of the patient, the cases tabulated in this Report under stages 2 and 3 of Turban would be reckoned as hopeless, whereas the reverse is the case. (2) Clearing House and Centre for Observation. When the diagnosis has been made, the Tuberculosis Dispensary, or Clinic, serves as a "Clearing House," through which persons, suffering from the various types 84 of tuberculosis, are passed. The necessary arrangements are made for the course of treatment, either (1) Routine treatment, at one of the two Tuberculqsis Dispensaries, connected with the Scheme; or (2) Institutional treatment. Routine treatment includes the usual medicinal and hygienic measures, including the use of open-air shelters,* such as are in use at Tuberculosis Dispensaries throughout the Country. Institutional treatment includes that received at Sanatoria (including Tuberculosis Hospitals), at General Hospitals and at Poor Law Institutions. "Insured" persons under the National Insurance are sent to Sanatoria (including Tuberculosis Hospitals) through the London County Insurance Committee, whilst "noninsured" persons are, at present, dealt with by Charitable Agencies. This provision, especially in so far as "noninsured" persons are concerned, is limited, and great difficulty is experienced in obtaining beds. The importance of the function played by a General Hospital in any Scheme for dealing with tuberculosis is becoming increasingly evident. Not only are abundant facilities offered for diagnosis of tuberculosis by special methods, but the wards and special departments of General Hospitals provide means for treating any case of other disease or any emergency which may arise in connection with the special tuberculosis work. The dental, X-ray, and laryngological departments at St. Thomas's Hospital have been used to the greatest extent in connection with the Lambeth Scheme. This feature of the Lambeth Scheme is specially noteworthy, and its value has been proved, as shewn in this Report. The problem of the treatment and segregation of advanced cases is still largely unsolved, as far as the Metropolis is concerned. No adequate provision has yet been made, so that Poor Law Institutions have had to be used as an alternative. * Open-air shelters are in use in connection with the Branch Dispensary (St. Thomas's Hospital) and have proved to be of great use in certain cases. Similar shelters might, with advantage, be provided in connection with the Central Dispensary (73 Effra Road, Brixton). 85 All experts are agreed upon the urgent necessity for admitting bed-ridden patients to Institutions, where they will cease to be centres of infection to the community, and there is little doubt but that the Poor Law Institutions have, in the past, played an important part in this way in the reduction of the death-rate from tuberculosis. There is, however, still the difficulty, in connection with Poor Law Institutions, the so-called "poor law stigma" as a sentimental objection. For arranging for institutional treatment, a fully trained lady almoner or social worker is necessary, as she can, by her expert knowledge of the sources and means by which such treatment can be obtained, be of much help (see also "After Care"). (3) Centre for Curative Treatment. In presenting the results of treatment, vague and general terms such as "improved." "worse," "in statu quo," etc., have been avoided, and a classification has been devised according to the standard factor of capacity for work. This classification presents a method of indexing the results of treatments and these results are set out in full in Table VI., under the headings of (1) total cases treated, (2) patients treated at a sanatorium, (3) patients treated with tuberculin. Results of treatment are most important from the economic point of view, and the following classification, which has been adopted, may be described as an economic classification:— (a) Fit for Work. (1) Patients fit for work at commencement of treatment and remaining so; (2) Patients not fit for work at commencement of treatment but becoming fit; (b) Unfit for Work. (3)Patients fit for work at commencement of treatment but not remaining so; (4) Patients not fit for work at commencement of treatment and remaining so; 86 (c) Deaths. It has been difficult to find a wording sufficiently brief, and at the same time explicit, but the above description offers, at least, a working basis. For the Working Classes, this classification of the results of treatment seems to be adequate in most respects. All treatment should have one end in view, viz., to get the patient back to work. Permanent arrest of the disease is infrequent, owing to the conditions under which most of the patients live, and such patients require, therefore, constant "patching-up." To be able to keep an individual patient in class (i.) for 1 year means that the treatment has succeeded for that year. The classification adopted cuts out the personal element As the statistics accumulate, more especially if the same system be adopted in different districts and areas, these records as to fitness or unfitness for work will be useful and will enable the work done under one Scheme to be compared with that done under another, in so far as practical results are concerned. Table V. gives particulars of the natures of treatment, sub-divided into (1) Routine; (2) Institutional, and (3) Tuberculin. The value of treatment by tuberculin is still a controversial subject and the majority of experts are against its indiscriminate use, being of opinion that its value, as such, is not proved. There is no criterion enabling a decision being come to as to whether or not a patient is likely to improve, far less be cured, by means of tuberculin therapy. In connection with the Lambeth Scheme, its use, in suitable cases, has been found to be an aid to other methods of treatment, but only an aid, the patients improving up to a certain point. Even with the most careful selection of cases according to recognised principles, some patients prove to be intolerant to tuberculin in the smallest doses. The preparations of tuberculin used have been (a) bacillary emulsion (B.E.) and (b) Tuberculin Beraneck (T.Bk.) the latter 87 being useful in sensitive and in febrile cases. The tuberculins are used in dilutions made according to the Philip's scale, but no attempt is made to label each dose as containing a given quantity of dried bacillary substance. The "tuberculin content" must be empirical, especially in the case of an emulsion. No patient is put through a "course" of injections as a routine, but small and gradually increasing doses are used till the most suitable or optimum is found for the particular patient. Suitable cases improve up to a certain point, but, when the dose is increased over this, weight decreases and the condition of the patient becomes worse or remains stationary. As to the results from tuberculin treatment, the figures are too small upon which to base any definite conclusions, whilst the period has been to short to justify the detailing of individual cases. Favourable results have been obtained in some chronic advanced cases, so much so that it is difficult from practical experience to keep in accord with the accepted theories of the "mechanism" of tuberculin therapy. Vaccine treatment in some cases of mixed infection has been commenced and appears to be giving good results. Examining more in detail the figures given in Table VI., it will be noted that the results of treatment for the whole of the cases (633 treated for one month or over) are satisfactory, 494 remaining, ot becoming after treatment, fit for work (i.e., 78.04 per cent.). With regard to Institutional Treatment, the figures have reference to such treatment at a Sanatorium, and the results are certainly favourable—a total of 101 patients, of whom 87 remained, or become after treatment, on residence, at a Sanatorium, fit for work (i.e., 86.1 per cent.). 88 With further reference to the subject of Sanatorium Treatment, it may be pointed out that, prior to the opening of the two Dispensaries, or Clinics, under the Lambeth Scheme, patients had been sent previously for Sanatorium Treatment from St. Thomas's Out-Patients' Departments—a total of 87 during the past few years, and, of these, 45 (i.e.. 51.6 per cent.) are still fit to work. These figures appear to shew that the expense of Sanatorium treatment is indeed worth while. The majority of the children, who attended, were notified to the Educational Medical Officer, and, in connection therewith, it was suggested that those found on examination to be tuberculous, and all "contacts" should be taught in open air schools. Unfortunately, there is only one open air school for the whole of South London, and there appears to be a difficulty in finding suitable sites for more. A suggestion has been made that suitable cheap erections of temporary open air schools, on the large open areas in the parks, might, with advantage, be introduced by the Educational Authority and that, in that connection, in so far as Lambeth is concerned, Brockwell Park and Norwood Park might be found suitable for such a purpose, being convenient enough to allow children to go home for their meals, and being very little used by the public during what would be the teaching hours. It is reported that playground classes will shortly be held in connection with some of the schools. (4) Centre for the Examination of "Contacts." "Contacts" are persons living in close association with a patient, or patients, who have been notified as suffering from tuberculosis, and an important part of any Scheme for the prevention of the disease must deal with them systematically. A total of 306 "contacts" have been dealt with and Tables II. and III. give particulars. Of the 306 "contacts" examined, 46 proved to be tuberculous. In many districts, systematic visiting by a Tuberculosis Medical Officer and a Tuberculosis Nurse of infected houses is carried out, for the purpose 89 of discovering, and examining, "contacts" in such houses—a method that is known as "A March Past." This method has its drawbacks. Both a Medical Officer and Nurse have to visit the houses, thereby expending a large amount of valuable time; whilst there is a great danger of the Medical Officer at the house passing a contact as sound and, in consequence, unintentionally misleading, by allowing him or her to become lax in the carrying out of preventive measures, even though such contact is still living in contact with active disease. The method adopted in connection with the Lambeth Scheme is as follows:— "Contacts" attend at the Dispensaries, and continue to attend there from time to time, as may be required, such "contacts" being readily picked out for attendance at the Dispensaries by a nurse or other (non-medical) visitor, when visiting an infected house. In this way the work of medical observation is concentrated at the Dispensaries, and the "contacts" are kept under such observation and treated, as required, at the same time as are the patients in connection with whom they are "contacts." Not only are the individual patients treated, but also the whole families. The details of each family and particulars as to the house and living arrangements are obtained by the visiting official who, as far as possible, makes a periodical visit (not less than once a month) at the notified house, visiting, as required, urgent cases daily or twice weekly. The inmates of these notified houses are also educated in preventive measures by these visiting officials. (5) Centre for "After-Care." Nothing need be said here as to the importance of "after-care" of patients treated at sanatoria. The ease with which this can be carried out depends largely upon the sanatorium at which the particular patient has been treated. Some patients will come back after a stay at a sanatorium with a clear idea of the nature of their condition and of the method necessary to preserve their health and to protect their families : whilst others come K 90 back from what appears to be nothing more than a long and arduous course of treatment that has simply restored to them some measure of health, but has not impressed upon them any clear idea of the nature of their condition, or of the preventive measures that are necessary. "Aftercare" in the former case is easy; in the latter case, difficult. "After-care" cannot, however, be efficiently carried out by a Tuberculosis Medical Officer, and much less can it be done by a Medical Attendant. What is required is a social worker or lady almoner thoroughly trained and suitably equipped in. that type of work, and she would assist also in arranging for Institutional treatment, under the supervision of the Tuberculosis Medical Officer. The question of "after-care" generally resolves itself into one of suitable employment for the individual patient. Efficient "after-care" depends, therefore, upon efficiently trained visitors or nurses and, in this respect, Lambeth Borough is provided for under the Scheme. The staff of the Lady Almoner's Department at St. Thomas's Hospital visit chiefly the Inner Wards of the Borough, and report on the official cards to the Medical Officer of Health, but the Outer Wards are not yet provided with a similar Lady Almoner's Department. The Council's Female Staff, consisting of the Tuberculosis Nurse, the Female Inspectors and the Health Visitor, assist also in visiting the houses wherein patients are notified officially as suffering from tuberculosis. Patients who have had sanatorium treatment, and who do not require any further treatment, are asked to report themselves every three months. (6) Information Bureau and Educational Centre. A large amount of clinical material is now available in connection with the Lambeth Dispensaries, and the different methods of diagnosis and treatment can be watched by Medical Practitioners, and others interested in the subject. Arrangements have been made for the Tuberculosis Medical Officers to confer with Medical Practitioners in connection with the exact diagnosis (especially of early cases) and up-to-date treatment (with tuberculin, or otherwise). Until an uniform system of 91 collecting statistics throughout the country is introduced, valuable information will be lost yearly, as each Tuberculosis Medical Officer generally makes a special point of those facts which particularly interest him, making note of but few other points which may be equally important but in which he, personally, is not interested. There is no doubt that, as Tuberculosis Dispensaries are established. valuable statistics of the results of different methods of treatment and diagnosis should be soon available, and the importance, therefore, of some standardisation of method and report is obvious. Monthly or quarterly popular lectures to patients (and "contacts") have been found of use in enlisting their help, and even arousing a certain amount of enthusiasm in this direction. This is a means of education that will, in all probability, grow, and is certainly one that might, with advantage, be encouraged by Public Health Authorities. S. Nicol Galbraith. R. c. wingfield. K 2 92 93 TABLES I. to VIII. Central Dispensary. Branch Dispensary. Combined Totals. Insured. Not Insured. Total. Insured. Not Insured. Total. Males. Females. Males. Females. Males. Females. Males. Females. TABLE I. I.—Total Attendances. (a) New Patients 127 85 122 229 563 177 72 41 183 473 1036 (b) Old Patients 440 383 305 851 1979 628 201 127 1162 21 18 4097 Totals 567 468 427 1080 2542 805 273 168 1345 2591 5133 II.—Particulars of New Patients. A—Age Periods and Sex— (1) Under 15 - - 88 86 174 - - 16 23 39 213 (2) 15 and over 127 85 34 143 389 177 72 25 160 434 823 (a) 15—25 39 41 6 26 1 12 51 31 2 25 109 221 (b) 25—35 34 24 10 42 110 67 20 2 66 155 265 (c) 35—45 33 14 12 51 1 10 33 13 9 47 102 212 (d) 45-55 16 5 2 18 41 18 7 10 12 47 88 (e) 55—65 5 1 2 5 13 6 1 1 10 18 31 (f) 65 and over - - 2 1 3 2 - 1 - 3 6 Lengths of Attendances— (1) One month and over 77 50 47 117 291 118 54 26 144 342 633* (2) Under one month* 50 35 75 112 272 59 18 15 39 131 403 TABLE II. 119 C—Sources of Cases— (1) Medical Men 66 47 14 31 158 71 25 4 19 277 (2) Charitable Societies 1 1 7 10 19 2 4 6 2 14 33 (3) Out-Patients' Departments (St. Thomas' Hospital) - - - - - 50 24 12 102 188 188 (4) Others (e.g., Public Health Department, Patients, etc.) 32 17 45 86 180 16 5 3 28 52 232 (5) "Contacts" 28 20 56 102 206 38 14 16 32 100 306 TABLE III. 0—Results of Diagnosis— 1. Ordinary Patients— (a) Tuberculousf 63 33 24 41 161 98 43 22 116 279 440† (b) Suspected Tuberculous 36 32 42 86 196 41 15 3 35 94 290 2. "Contacts"— (a) Tuberculous† 7 7 7 9 30 6 2 2 6 16 46† (b) Suspected Tuberculous 21 13 49 93 176 32 12 14 26 84 260 * Including cases sent for opinion only, cases unfit or unsuitable to attend, cases classified as suspected tuberculous (including non-tuberculous or doubtful), "contacts," and cases belonging and transferred to other Districts. N.B.—Of the 486 cases (pulmonary 470, and non-pulmonary 16), diagnosed as tuberculous, 251 (i.e., 51.6 per cent.) gave a family history of tuberculosis—Central Dispensary 79 out of 191 (pulmonary 184, and non-pulmonary 7), Branch Dispensary 172 out of 295 (pulmonary 286, and non-pulmonary 9). Tables I. to VIII.—continued.  Central Dispensary. Branch Dispensary. Insured. Not Insured Total. Insured. Not Insured. Total. Combined Totals. Males. Females. Males. Females. Males. Females. Males. Females. 3. Tuberculin— Diagnostic - - 56 49 105 7 4 - 1 12 117 Positive Reaction - - 20 18 38 5 3 - 1 9 47 Negative Reaction - - 36 31 67 2 1 - - 3 70 TABLE IV. E—Clinical Classification of Pulmonary Tuberculous Cases. (a) Inman— Stage I 6 3 5 12 26 10 5 4 23 42 68 Stage II 16 10 5 13 44 20 4 4 21 49 93 Stage III 48 27 18 21 1 14 74 36 13 72 195 309 (b) Turban*— Stage I 11 16 8 8 43 17 21 5 27 70 113 Stage II 24 7 5 4 40 37 9 3 13 62 102 Stage III 13 4 5 9 31 20 6 5 32 63 94 94 TABLE V. F—Nature of Treatment— 1. Routine (total cases treated one month and over) including— 77 50 47 117 291 118 54 26 144 342 633 2. Institutional— (a) Sanatoria (including Tuberculosis Hospitals) 11 10 6 10 37 39 14 1 20 74 111 (b) General Hospitals 1 2 - - 3 2 - - - 2 5 (c) Poor Law Institutions 2 - 1 4 7 16 10 5 21 52 59 3. Tuberculin— Remedial 15 5 3 10 33 13 6 5 14 38 71 TABLE VI. C —Results of Treatment— 1. Routine (total cases treated one month and over)— (a) Fit for work 54 41 37 92 224 87 44 19 120 270 494* Fit for work and remaining so 36 31 33 90 190 74 38 18 115 245 435 Not fit for work but becoming fit 18 10 4 2 34 13 6 1 5 25 59 (b) Unfit for work 18 9 8 18 53 26 10 6 20 62 115* Fit for work but not remaining so - 1 - 8 9 2 2 - 2 6 15 Not fit for work and remaining so 18 8 8 10 44 24 8 6 18 56 100 (c) Deaths 5 - 2 7 14 5 - 1 4 10 24* 2. Institutional (Sanatorium)— (a) Fit for work 10 6 10 37 32 13 1 14 60 97 Fit for work and remaining so 10 6 4 10 30 23 9 1 12 45 75 Not fit for work but becoming fit 1 4 2 - 7 9 4 - 2 15 22 *N.B.—Cases in Stage III. of Inman only. 95 96 Tables I to VIII.—continued.  Central Dispensary. Branch Dispensary. Combined Totals. Insured. Not Insured. Total. Insured. Not Insured. Total. Males. Females. Males. Females. Males. Females. Males. Females- (b) Unfit for work - - - - - 5 1 - 5 11 11 Fit for work but not remaining so - - - - - - - - 1 1 1 Not fit for work and remaining so - - - - - 5 1 - 4 10 10 (c) Deaths - - - - - 2 - - 1 3 3 (3) Tuberculin*— (a) Fit for work 12 4 3 8 27 12 4 4 12 32 59 Fit for workand remaining so 9 3 1 8 21 8 3 4 12 27 48 Not fit for work but becoming fit 3 1 2 - 6 4 1 - - 5 11 (b) Unfit for work 3 1 - - 4 1 2 1 2 6 10 Fit for work but not remaining so - - - - - - - - - - - Not fit for work and remaining so 3 1 - - 4 1 2 1 2 6 10 (c) Deaths - - - - - - - - - - - 97 Table VII.. H—Occupations of Tuberculous and other Patients— Baker - - - - - 3 - - - 3 3 Bar Attendant 2 - - - 2 2 1 - 1 4 6 Box-maker - - - - - - - - - - - Butcher 2 - - - 2 - - - - - 2 Carman 1 - - - 1 10 - - - 10 11 Carpenter 2 - - - 2 4 - - - 4 6 Chaff-cutter - - - - - 1 - - - 1 1 Charwoman - 1 - - 1 - 4 - - 4 5 Chauffeur 2 - - - 2 1 - - - 1 3 Clerk 9 1 5 1 16 11 - 2 1 14 30 Conductor - - - - - - - - - - - Dairyman - - - - - - - - - - - Decorator 4 - - - 4 9 - 2 - 11 15 Draughtsman 1 - - - 1 - - - - - 1 Dressmaker - 7 - 2 9 - 9 - 5 14 23 Electrotype Finisher 1 - - - 1 - - - - - 1 Engineer 4 - - - 4 10 - - - 10 14 Fishmonger 1 - - - 1 2 - - - 2 3 Foreman 1 - - - 1 - - - - - 1 Gardener 1 - 1 - 2 1 - - - 1 3 General Dealer 1 - - 1 2 2 - - - 2 4 Glazier - - 1 - 1 1 - - - I 2 Housework - 4 - 30 34 - 12 - 102 1 14 148 Insurance Agent 3 - - - 3 1 - - - 1 4 Labourer 3 - 1 - 4 12 - - - 12 16 Laundry Work 1 6 - - 7 - 4 - - 4 11 Milliner - 1 - - 1 - - - 1 1 2 * N.B.—2 cases (Central Dispensary) were found to be unsuitable for tuberculin treatment and are not included. Tables I. to VIII.—continued.  Central Dispensary. Branch Dispensary. Combined Totals. Insured. Not Insured. Total. Insured. Not Insured. Total. Males. Females. Males. Females. Males. Females. Males. Females. Miner 1 - - - 1 - - - - - 1 Musician 1 - 2 - 3 - 1 1 - 2 5 Newsagent 1 - - - 1 1 - 2 - 3 4 N urse - - - - - 1 1 - - 2 2 Packer - - - - - 5 1 - - 6 6 Paper Maker 1 - - - 1 - - - - - 1 Pavior - - - - - - - - - - - Post Office Employees - - 2 - 5 - 1 - - 1 6 Potter - - - - - 2 - - - 2 2 Printer 3 - 1 - 4 4 3 1 - 8 12 Railway Employees 2 - - - 2 5 - - - 5 7 Royal Marine 1 - 1 - 2 - - - - - 2 School Children - - 10 11 21 - - 10 7 17 38 Servant 3 19 - 1 23 1 6 1 1 9 32 Sewerman - - - - - - - - - - - Shoemaker - - - - - 2 - - - 2 2 Shop Assistant 5 - 3 - 8 3 - - - 3 11 Stoker 2 - - - 2 - - - - - 2 Stone Mason - - - - - - - - - - - Tailor 2 - 1 - 3 2 - - - 2 5 Teacher - - - - - - - - - - - Tinsmith 2 - - - 2 - - - - - 2 Traveller 1 - - - 1 2 - - - 2 3 Typist - - - - - - - - - - - Waiter or Waitress 1 1 2 2 2 2 6 8 Warehouseman - - - - - 4 - - - 4 4 Welder 1 - 1 - 2 - - - - - 2 Window Cleaner 1 - - - 1 - - - - - 1 No Occupation - - 2 4 6 - - 5 2 7 13 Totals 70 40 31 50 191 104 45 24 122 295 488 Dispensary Patients. Others. Total. Dispensary Patients. Others. Total. Combined Totals. TABLE VIII. III.—Visits paid to homes of Patients by Tuberculosis Officers.* (a) Medical Officer † 190 22 212 - - - 212 (b) Nurses or Visitors † 264 197 416 218 - 218 679 * N.B.—The Tuberculosis Medical Officer attached to the Branch Dispensary, St. Thomas' Hospital, does not visit at patients' Homes, but the Lady Almoner (connected with the Hospital) does, reporting direct to the Medical Officer of Health on the official report cards. † Prior to the opening of the Central Dispensary to the Public on July 23rd, 1913, the Tuberculosis Medical Officer (attached to that Dispensary) made 632 visits (i.e., from the time of his commencing his duties on May 1st, 1913), and the Tuberculosis Nurse (attached to that Dispensary), 156 visits i.e., from the time of her commencing her duties on June, 19th, 1913). These figures are in addition to those given above. 98 99 Total Attendances and Particulars of New Patients. Total Attendances. Lengths of Attendances. Results of Diagnosis. Suspected Tuberculous. Tuberculous. Total. (a) New Patients 1032 (1) One month and over 607 (1) Ordinary Patients 608 191 799 (b) Old Patients 4573 (2) Under one month ‡ 425 (2) "Contacts " 20 213 233 Total 5605 Total 1032 Total 628 404 1032 100 N.B.— Of the 628 patients classified as tuberculous, 596 were pulmonary, and 22 non-pulmonary cases (tub. med. glands). These numbers are exclusive of the ordinary surgical tuberculosis patients who are admitted for treatment direct into the surgical wards of the Hospital and not through the Tuberculosis Department. ADDENDUM.* Table Shewing total patients dealt with at St. Thomas's Hospital Tuberculosis Out-Patients' Department (including the Lambeth Branch Dispensary), under the care of Dr. R. C. Wingfield, during the year 1913.† * The figures are supplied by Dr. Wingfield through the Secretary of the Hospital. † St. Thomas' Hospital, being a General Hospital, deals with patients coming from all parts, e.g. Lambeth and other Metropolitan areas and the Provinces. ‡ Including cases sent for opinion only, cases unfit to attend as patients, cases diagnosed as suspected tuberculous (including non-tuberculous or doubtful) and " contacts." || The remaining tuberculous ordinary patients, i.e., 22, were non-pulmonary cases, making up the total of 608, § 15 cases were found to be unsuitable for tuberculin treatment and are not included. ADDENDUM—continued. Nature and Results of Treatment. 1. Sources of Cases. Medical Men 175 Clinical Classification of Pulmonary Tuberculosis cases Routine (all cases) Institutional (Sanat'rium) Previous Institutional 8 (Sanat'rium) Tuberculin. 2. Charitable Societies 30 3. Out-patients' Departments (St. Thomas' Hospital) 491 Inman. (a) Fit for work 443 73 88 46 Fit for work and remaining so 395 46 88 36 4. Others (Public Health Department, private, recommendations of patients, &c.) 103 Stage I. 100 Not fit for work but becoming fit 48 27 - 10 Stage II. 93 (b) Unfit for work 142 18 34 9 5. "Contacts" 233 Stage III. 393 Fit for work but not remaining so 37 8 2 4 Total 1032 Total 586 Not fit for work and remaining so 105 10 32 5 (c) Deaths 22 4 3 - Total 607 95 125 55 § 101 102 ADDEN DUM—continued. Transfers of Patients to other Special Hospital Departments. Of the 799 new patients attending the Tuberculosis Department, 431 were referred or transferred for opinion or treatment to the following Special Hospital Departments:— Dental 150 Medical 35 Gynaecological 20 Others 19 Larygological 70 Surgical 21 Ophthalmic 17 X Ray 70 In-patients 21 Skin 8 Total 431 N.B. A special ward (10 beds) for diagnosis and treatment is attached to the Tuberculosis Department and from June (when the ward was opened) up to the end of the year 1913, the following patients have been dealt with:— 1. Diagnosis 20 (positive 16, negative 4) 2. Treatment 23 (1 death) Hospital Lady Almoner's Department. Houses visited : Houses visited regularly by Lady Almoner's staff 478 Houses visited by other Agencies 331 Houses not visited (common lodging houses, eases for opinion only, &c.) 77 103 ADDENDUM—continued Nature of help given. Through National Insurance. Through Charitable Societies. Total. 1. Sanatoria, Homes, Tuberculosis Hospitals, &c:— Patients sent to Sanatoria 77 58 135 Patients sent to Homes 1 38 39 Patients sent to Tuberculosis Hospitals 11 50 61 Patients boarded out in the country - 23 23 2. Other help:— Patients given extra food (milk, eggs, &c.) 12 114 126 Patients given extra clothing (blankets and bedding) - 27 27 Patients allowed the use of shelters - 10 10 Patients provided with nurses for prolonged periods - 14 14 Patients who had suitable work found for them - 12 12 Other matters (not classified above, e.g., false teeth, surgical appliances, financial help, &c., provided) - 60 60 Totals 101 406 507 INDEX. (ii.) GENERAL INDEX. PAGE. Abatement of Nuisances 90—94 „ ,, Smoke 113—114 Adulteration of Food and Drugs 115—125 Analysis of Food and Drugs 115—125 „ Water 121 Anthraxb 64 Antitoxin, Distribution of 53, 155 Area, Lambeth 89 Bacteriological Laboratory 152—155 Bakehouses 141 Bedding, etc., Disinfected 109 — 110 Bedding, etc., Destroyed 110 Births and Birth Rates 6, 9,—11 Births Notification Act 10—11 Bodies received at Mortuaries 156 By-laws, Contravention of 95 „ Houses Let in Lodgings 127 Censal Population (Lambeth) 86—87 Cerebrc-Spir.al Meningitis 46, Appendix 8—9 Certificates (Notification) received 34—35, 37—38, 70—77, 86—87, Appendix 3 Certificates (Revenue Act) 126—128 Certificates (Disinfection) 109 Children, Cleansing of 112—113 Cholea 52—53 Circulatory Diseases, Deaths of 78 Cleansing of Verminous Persons 112—113 Clerical Staff 159 Clerical Work 159 Closing Orders 133—137 Chicken-pox 46 Common Lodging Houses 126 Complaints 94 Conscientious Objectors Congenital Malformations Constitutional Diseases Consumption. (See Tuberculosis) Contacts (Suspects) Contagious Ophthalmia (Newly-born Infants) Continued Fever Conveniences (Underground) Coroners' Courts Cowhouses Critical Temperature (Earth) and Diarrhoea Croup. (See Membranous Croup) Dairies. (See Milkshops.) Deaths and Death-rates 7—8, 11—85, 88—89, Appendix 2 „ Inner and Outer Wards 14—15, 16—17 „ Corrected 16—17, 22—25 „ Uncorrected 18—20 „ In Outlying Institutions 12—14 „ Zymotic 29—78, 89 „ Under 1 year 26—28, 89, Appendix 6—7 Depot (Milk) 137—141 Depots (Refuse and Manure) 151 Developmental Diseases 78 Diagnosis (Bacteriological) 152—155 Diarrhoea 60—64 Dietetic Diseases 78 Diphtheria 53—56 „ Antitoxin in 53, 155 „ Decrease of 54 „ Bact riological Examination in 56, 154—155 „ and School Outbreaks 55 „ Milk-borne Outbreak 53, Appendix 35—78 Disinfection Certificates 109 Disinfecting Department 108—113 „ Refuge 110 Dispensaries (Tuberculosis) 65, Appendix 79—103 (iii.) PAGE. 43—45 78 78 43, 52 - 53 64—65 59 115 155—157 146—148 61 (iv.) PAGE. Drains and Infected Houses 31—33 Drainage Cases 95 Drain Testing 31—32 Drainage, Legal Proceedings 96 Drugs 119 Dust Depots 151 Earth Temperatures and Diarrhoea 61 Effluvium Nuisances 151—152 Enteric Fever. (See Typhoid.) Enumerated Populations (Lambeth) 86—87 Estimated Populations (Lambeth) 4—5, 7, 86—87, 89, Appendix ?> Enteritis 63,79 Epidemic Cerebro-Spinal Menngitis 46 Epidemic Influenza 64 Epidemic Summer Diarrhoea 60—64 Erysipelas 60 Exclusion of Children (Measles) 50 „ „ (Whooping Cough) 51—52 Expenses (Food and Drugs) 121 Factories 101 Factory and Workshops 101—105 Female Sanitary Inspectors 97—100 Female Health Visitor 107 Food and Drugs, Adulteration of 115—125 ,, „ Legal Proceedings (Summary) 115 Food, Unsound 95 Formal v. Informal Sampling 122—123 Glanders 64 Heahh Visitor 107 Home Office Tables (Factory and Work.shops) Appendix 10—14 House to House Inspections 96, 128—133 Houses Let in Lodgings 126 ,, ,, By-laws for 127 Housing of the Working Classes' 128—137 (V.) PAGE. Housing, Town Planning, etc., Act 128—137 Inspections of District 128—133 Representations and Closing Orders 133—137 Ill-defined causes (deaths from) 79 Incidence (Zymotic) 17,34- 35 Infantile Mortality 26—28, 89 Appendix 6—7 Infected Houses and Drains 31—33 Infectious Diseases (cai-es removed) 30,86—87 „ „ (notified) 34—35, 37—38, 70—77, 86—87, Appendix 3 Influenza (Epidemic) 64 Inquests 158 Inspections 95, 96, 128—133, Appendix 10, 15 „ House to House 96, 128—133 „ Market Thoroughfares 96 Inspectors, Females 97—100 „ Males 95—96 „ Food and Drugs 115—125 „ Health Visitor 107 Introductory Letter 3 Laboratory (Bacteriological) 152—155 Lambeth Statistics 89, Appendix 2—9 Lavatories (Undergroun) 115 Legal Proceedings 96, 115,120 Letter (Introductory) 3 Letters (sent and received) 158 Local iseases—Nervous System, Heart, Respiratory Organs, Digestive and Urinary Systems and Reproductive System, etc 73—79 Local Government Board, Old Tables A and B 82—87 ,, ,, ,, New Tables i., ii., iii., iv., v. Appendix 2—9 Lodging-houses (Common) 126 London County Council Table Appendix 15—17 Male Sanitary Inspectors 95—96 (vi.) PAGE. Manure Depots 151 Margarine Manufacturers (Registration) 120—121 Market Thoroughfares (Inspection) 96 Measles 49—52 „ and Schools 50 Membranous Croup 56 Meningitis (Cerebro-Spinal) 46, Appendix 8—9 Milk Depot (Municipal) 137—141 Milk Stores (See Milkshops.) Milkhops 142—146 Applications Refused 142 Applications Granted 143—116 Monthly Returns (Lambeth) Zymotic Deaths 39 Mortality (Infantile) 26—28, 89, Appendix 6—7 „ Tables Appendix 2, 4—5, 6—7, 18—34 „ Tables, Sub-Districts Appendix 18—25 ,, Tables Age Periods Appendix 26—34 Mortuary, High Street 155—157 ,, Wanless Road 155—157 „ for Norwood 156—157 Mortuaries 155—157 Keepers of 155 Natural Causes, Deaths from 157 Neonatorum, Ophthalmia 64—65 Notices Served 90—93, 94, 95 Non-notifiable Infectious Diseases 34—35, 38 Non-specified Causes (Deaths from) 79 Notification Certificates received 34—35, 37—38 70—77. 86—87 Appendix 3 ,, of Births Act 10— 11 ,, of Whooping Cough 50—51 Nuisances, Abatement of 90 94 ,, Effluvium 151-152 Offensive Trades 150 Opthalmia Neonatorum (Contagious) 64—65 Orders (Closing) 133 137 Outside Urinals (Public Houses) 96 Outworkers 106—107 (vii.) PAGE Parasitic diseases 78 Parliamentary Divisions (Populations) 5 Persons per Acre 89 Persons (Protected) in Workshops 102 Persons, Verminous 112—113 Phthisis. (See Tuberculosis.) Plague 52—53 Plans of Drainage 94 Populations, enumerated (Lambeth) 86— 87 Populations, estimated (Lambeth) 4—5, 7, 86—87, 89, Appendix 2 Post Mortems 156 Premises Disinfected 109 Protected Persons (Workshops) 102 Polio-encephalitis Acuta 46, Appendix 8—9 Polio-myelitis Acuta 46, Appendix 8—9 Public Health Acts (Milk and Cream Regulations) 121—122 „ „ (Tuberculosis) Regulations, 1908, 1911, 1912 68—77 Public Houses, Outside Urinals of 96 Public Institution, Deaths in 7—8, 12—14 Puerperal Fever 59—60 Quarterly Returns (Lambeth)— Births 6 Deaths (Zymotic and General) 18, 20, 36, 42 Health Visitor 107 Notifiable Infectious Diseases 37, 38 Disinfection Certificates 110 Rateable Value (Lambeth Borough) 89 Refuge (Infectious Diseases) 110 Refuse Depots 151 Registration of Deaths (changes) 21 „ Margarine Manufactories 120—121 Regulations, Milk and Cream 121—122 Removal of Infectious Diseases cases 30, 86—87 Re-inspections 94, 95 (viii.) PAGE. Relapsing Fever 59 Reproductive System, Diseases of 79 Revenue Act (1903), Certificates 127—128 Samples, Food and Drugs 115—125 Sampling (Formal v. Informal) 122-123 Sanitary Inspectors 95—100 Males 95-96 „ „ Females 97—100 ., Work 90—94 „ ,, S ructural 91, 93 ,, „ Non-Structural 92, 93 Scarlet Fever 46-49 „ Outbreaks at School 48 Schoul Attendance and Measles 50 Simple or Continued Fever 59 Slaughterhouses 148—150 Smallpox 43 „ Contacts 43 Smoke, Abatement of 113—114 Spotted Fever (See Cerebro-Spinal Meningitis; Staffs— Clerical 158 Inspectorial (Male) 95 „ (Female) 97 Health Visitor 107 Disinfecting 198 Mortuary Attendants 155 Underground Conveniences 115 Suffocation in Bed 79, 81 Suicide and Homicide, Deaths from 79, 158 Summary of Vital Statistics (Lambeth Borough) 1913 89 ,, Work of Sanitary Staff (Male) 95-96 ,, ,, ,, (Female) 97—100, 101—107 „ Legal Proceedings (Food and Drugs) 120 Suspects (Contacts) 43, 52—53 Syphilis 78 (ix.) PAGE. Tables (Special)— London County Council Appendix 15—17 Home Office (Factory and Workshops) Appendix 10—14 Local Government Board (old) A and B ... ... 82—87 „ ,, (new) i., ii., iii., iv., v. Appendix 2—9 Mortality (Lambeth)— Registration Sub-Districts Appendix 18—25 Age periods Appendix 26—34 Temperature (Earth) and Diarrhoea 61 Testing of Drains 31-32 Town Planning Act (See Housing, Town Planning, etc. Act). Trades (Offensive) 150 Tubercular Meningitis, Deaths from 66,78 Tuberculosis 65—77 ,, Bacteriological Examination in 66, 153—154 ,, Dispensaries 65 Appendix 75—103 „ and Preventive Measures 67 ,, Lambeth Municipal Tuberculosis Dispensaries Scheme 65 Appendix 75—103 „ Officers Appendix 75—103 ,, Notifications and Re-Notifications 68—77 „ Regulations, 1908, 1911, 1912 68—77 Typhoid Fever 57—59 „ Bacteriological Examinations in 59, 154 ,, Sources of Infection 58 Typhus 59 Underground Bakehouses 141 „ Conveniences 115 Unsound Food 95 Urinals (Public Houses) 96 Urinary Diseases, Deaths from 79 Vaccination 43—45 Value, Rateable (Lambeth) 89 Varicella. (See Chicken-pox). Vinegar 119 Verminous Persons (Cleansing of) 112—113 Violence, Deaths from 79 (x.) PAGE. Visitor, Health 107 Vital Statistics (Lambeth) 5—89 Appendix 2—9 „ ,, Summary (Lambeth) 89 Voluntary Notifications 34—35, 38 Water Analysis 121 „ Certificates 59 Whooping Cough 49—52 ,, „ Notification of 50—51 Work (Male Inspectors) 95—96 „ (Female Inspectors) 97—100,101 — 107 „ (Health Visitor) 107 „ (Tuberculosis Officers) Appendix 75—103 Workplaces. (See Workshops) Workshops 101—105 Zymotic Diseases 29—78, 89 „ Incidence 17, 34—35