AC 4349 The Medical Officer OF Health PUBLIC HEALTH DEPARTMENT. ANNUAL REPORT OF The Medical Officer of Health . For the Yeer 1900. i LONDON: HENDERSON & SPALDING, Printers, 1,3 & 5. MARYLEBONE LANE, W. 1901. Metropolitan Borough of Paddington. REPORT ON The Vital Statistics AND Sanitary Work For the Year 19OO. REGINALD DUDFIELD, M.B., D.P.H., Medical Officer of Health. " Where you promote health and arrest disease, where you convert an unhealthy citizen into a healthy one, where you exercise your authority to promote sanitary conditions and suppress those which are the reverse, you, in doing your duty, are also working for the Empire. ' Sanitas sanitatum, omnia sanitas. said one of your dead Rectors, and he did not greatly exaggerate. Health of mind and body exalt a nation in the competition of the universe." —Lord Rosebery, Rectorial Address, Glasgow, 1900. CONTENTS. PAGE Population, Estimates of 1 Births and Birth.rates 2 Vaccination 4 page Notification of Infectious Disease 6 Deaths and Death.rates 35 Administrative Work 78 SUB.APPENDICES. A. Tables of Births, Deaths, Causes of Death, &c 91 B. Return Cases: Prof. Simpson's Report 103 SPECIAL SUBJECTS. PAGE Bacteriological Diagnosis, Results 34 Canal Boats Acts 88 Cancer, Increased Prevalence of 63 „ Mortality from, 1900 63 Causes of Death, General Table of 94 „ „ Selected, Table of 42 Childbed, Mortality in 52 Cholera, Notification of 14 Combined Drainage Reconstructed, &c. 87 Cutting off of Water Supply 83 Diphtheria, Mortality from 49 „ Notification of 14 Disinfection, Clothes, &c. 78 ,, Premises 79 Enteric Fever, Insanitary Conditions and 21 ,, ,, Mortality from 51 ,, „ Notification of 20 Erysipelas, Notification of 21 Family Shelter, Admissions to 78 " Fever," Mortality from 51 Food, Supervision over 88 ,, Cases, Results of Proceedings 90 House Drainage, Work done 86 „ „ Bye.laws re 87 Houses Let in Lodgings, Bye.laws re 80 Housing of Working Classes Act, 1890 82 Illegitimates, Births of 3 ,, Deaths of 74 Infantile Mortality 70 Infectious Diseases, Schools closed on account of 78 Inhabited House Duty, Applications re 86 Institutions, Deaths in 77 Legal Proceedings, Results of Cases 89 Measles, Disinfection after 31 ,, Epidemic of 28 ,, Mortality from 40 page Measles, Need of Legislation to Control 31 Mortality Rate, 0.5 Years, and Measles 39 Natural Increment of Population 2 Plague, Precautions against 26 ,, Suspected Case of, Notes on 26 Powers of Water Companies 83 Puerperal Fever, Action taken respecting 25 „ ,, Difficulties in Certifying 23 ,, ,, Mortality from 51 „ ,, Notification of 22 Removal of Dust and Offensive Refuse 82 ,, to Hospital, Compulsory 79 Return Cases, 1900 103, 110 Scarlet Fever, Mortality from 48 ,, ,, Notification of 17 ,, „ Special Cases, Notes on 18 Small.pox, History of Outbreak 12 Schools, Scholars excluded from 33 Smoke Prevention 88 Storage Cisterns for Water 85 Tuberculosis, House Incidence of 59 „ In Special Areas 60 „ Milk Supply and 61 ,, Mortality from, 1900 53 1875.1900 55 ,, Overcrowding and 59 Typhoid Fever (see Enteric Fever) Typhus Fever, Notes on Reported Cases, 1900 25 ,, ,, Notification of 25 Vaccination, Conscientious Objectors, Return of 4 ,, Increase in Practice of 5 Violence, Deaths from 76 Water Regulations, Proposed New 86 ,, Supply, Cutting off of 83 Whooping Cough, Mortality from 52 Workshop Supervision 87 To His Worship the Mayor, the Aldermen, and Councillors of the Metropolitan Borough of Paddington. Mr. Mayor and Gentlemen, I have the honour to submit my Annual Report on the health of the (late) Parish of Paddington during 1900, being the seventh Annual Report prepared by me on the subject. In accordance with an arrangement made with my colleagues, the Medical Officers of Health of the other Metropolitan Districts, the statistics included in this Report refer to the area of the Parish of Paddington. The Registrar.General has also adopted this plan in his Annual Summary for 1900. I have thought it better to defer all reference to the changes due to the formation of the Borough until the next Annual Report. Whilst this Report has been in the press the Preliminary Report of the Census, held in March last, has been published. The enumerated population of the Parish (old area) at the Census has not been included in the Report, but was approximately 127,315 persons. On re.calculating the estimate of the population of the middle of 1900, it is found to be 126,590,* or about 4,000 below the estimate used in this Report. The numbers of males and females living at the various ages are not yet known. To arrive at rates on the (provisionally) revised estimate of the population at the middle of 1900, it will be necessary to multiply the figures given in this Report by 1031. The factor can only be applied to rates at all ages, and as the corrections have not been applied to all the years of the decennium, it is useless to pursue the subject further, except to say that last year's "nett" death.rate of the Parish would be raised from 15 78 per 1,000 to l6.28, an increase of 0.50 per 1,000. Taking the statistics as recorded, they may be deemed to be satisfactory, and to show a continued improvement in the general health of the Parish. The reduction in the prevalence of sickness and mortality from diphtheria is particularly gratifying. So much cannot be said of the infantile mortality. The increase in the local rate last year is remarkable as being an exception to the reductions recorded in nearly all the adjacent districts. Taken in conjunction with the decline in the birth.rate which has prevailed for some years past, not only in Paddington, but throughout the whole of England and Wales, any increase in the mortality of infants becomes a question of national import. The prevailing high mortality is largely due to lack of education on the part of parents. Until infant hygiene is recognized as a part of the school training of all girls, the only practical method of obviating the evils arising from such ignorance is to employ women trained in nursing and the rudiments of sanitary science to visit the homes of the poor and advise and guide the unskilled parents. Secure cleanliness in the homes and persuade the parents to limit infants' diets to the natural food, and a very considerable reduction in the infantile mortality will at once ensue. The Sanitary Committee of the late Vestry requested me some time back to inquire into the reduction, if any, in the mortality from the tubercular diseases, and the increase, if any, in that from. "cancer." It has taken many months' interrupted work to collect the necessary information, and I have included in the Report (the last of the nineteenth century) some preliminary observations on these points. With regard to the tubercular diseases, I think the evidence collated demonstrates * This figure can only be regarded as approximate. Sufficient information has not been published to arrive at an absolutely final estimate. that the sanitary work of the last 30 years has done much to reduce the mortality from phthisis, and I believe that still better results will be attained when a stricter supervision can be exercised over the inhabitants of tenement houses, to obviate overcrowding and dirt. To reduce the mortality from the tubercular diseases of young children, I think more attention will be required to be given to the milk supply. I am of opinion that the time has come when milk should be systematically examined by the bacteriologist—not only to prevent the spread of tuberculosis and other diseases, but also to secure the supply being clean and wholesome. The duty is laid upon me by the Local Government Board to point out what I consider to be.the directions in which the hygienic control of the Borough requires to be extended. At the present time I would respectfully urge upon your consideration three questions. I refer to (a) the undue proportion of infants dying in the first year of life; (b) the supervision of houses let in lodgings, or tenements; and (c) the supervision of workplaces. To deal with the first, I believe one, if not two, female inspectors are required. They should be nurses as well as inspectors,, women who can not only point out mistakes in feeding and tending infants, but give instruction in right methods. From the work which has been accomplished during the past four or five years in the registration and supervision of tenement homes, I am convinced that good results can be obtained by a full use of the powers vested in the Council under the Public Health (London) Act, 1891. I should, however, like to see this work of supervision carried out concurrently with the provision of more homes, and I may perhaps be permitted to express my satisfaction that this latter subject has already engaged your attention. At the same time, I hope that you will place me in a position to carry out the proper supervision of all tenement houses. If this is to be done, the Staff of the Department must be increased, and I would respectfully commend this matter to your consideration.* The present office accommodation is quite inadequate to the work which has to be carried out, but that defect will, I hope, be shortly remedied. The Officers and Staff of the Department have done their work well during the year. It affords me much pleasure to refer to the sympathy and co.operation which I continue to receive from my professional brethren practising in the Borough. In closing these introductory remarks, I desire to place on record my sense of gratitude to the members of the late Sanitary Committee of the Yestry and of the Public Health Committee of the Council. I am especially indebted to the Chairman of both the Committees, Sir George D. Harris, J.P., &c., for his cordial sympathy and support. If I may be permitted to say so, it has been a pleasure to serve and work with the Chairman and the Committee, and I trust that our present relations will continue for many years to come. I have the honour to be, Mr. Mayor and Gentlemen, Your most obedient Servant, m.a., m.b., d.p.h., Medical Officer of Health. Public Health Department, Town Hall, Paddington. June, 1901. * The inspection of workplaces has hitherto been very imperfectly carried out, being attended to only when, other work could be safely set aside for the time being. POPULATION. The population of the Parish at the middle of the year 1900 was estimated at 130,596* persons, which figure was arrived at in the manner described in previous Reports. The estimate comprised 97,237 residents of North Paddington, and 33,359 of South. The numbers of males and females estimated to be contained in the age.groups used in these Reports, in the whole Parish and its two Sub.Districts,t will be found in Table 1. TABLE 1. Sex.Age.Constitution of Populations estimated to middle of 1900. Age Groups. Paddington. St. Mary. St. John. London. PERSONS, All ages 130,596 97,237 33,359 4,589,129 0.1 2,766 2,376 390 118,558 1.5 9,686 8,109 1,577 428,365 5.15 21,748 17,739 4,009 948,412 15.25 27,879 19,615 8,264 921,073 25.65 62,385 44,908 17,477 1,990,815 65 and over 6,132 4,490 1,642 181,906 0.5 12,452 10,485 1,967 546,923 5 and over 118,144 86,752 31,392 4,042,206 MALES. All ages 54.102 42,220 11,882 2,169,281 0.1 1,355 1,166 189 58,788 1.5 4,781 4,010 771 213,240 5.15 10,495 8,634 1,861 470,734 15.25 10,737 8,072 2,665 426,698 25.65 24,645 18,835 5,810 928,018 65 and over 2,089 1,503 586 71,803 0.5 6,136 5,176 960 272.028 5 and over 47,966 37,044 10,922 1,897,253 FEMALES. All ages 76,494 55,017 21,477 2,419,848 0.1 1,411 1,210 201 59,770 1.5 4,905 4,099 806 215,125 5.15 11,253 9,105 2,148 477,678 15.25 17,142 11,543 5,599 494,375 25.65 37,740 26,073 11,667 1,062,797 65 and over 4,043 2,987 1,056 110,103 0.5 6,316 5,309 1,007 274,895 5 and over 70,178 49,708 20,470 2,144,953 * The preliminary Census return of this year (1901) states that the enumerated population of the new Borough was 143,054, compared with 135,955 in 1801. This indicates a smaller rate of growth than has been allowed for in the estimates. † The Administrative Parish is co.terminous with the Registration District "No. 1a (Paddington)," and is made lip of the two Registration Sub.Districts, "St. Mary" and "St. John, Paddington." The Sub.Districts are not co.terminous with the Parliamentary Divisions of North and South Paddington, but the terms "North Paddington " or "St. Mary," and "South Paddington" or "St. John," are used indifferently throughout this Report, and refer to the Registration Sub.Districts only. 2 [Appendix IV. The natural increment of the population, i.e., the excess of births registered during the year over deaths of "residents," amounted to 829 persons last year, compared with 878, 935, 1,210, 1,126, and 880 in five preceding years. The average increment for the complete decennium (1890.99) was at the rate of 936 persons per annum. BIRTHS. During the fifty.two weeks of the registration year, 2,890 births were recorded in the Parish, viz., 1,460 of boys and 1,430 of girls, equivalent to a rate of 22*13 per 1,000 persons of all ages. In North Paddington, 2,479 births were registered (1,254 of boys and 1,225 of girls), equivalent to a rate of 25*48 per 1,000 inhabitants of the Sub.District. In South Paddington there were registered 411 births (206 of boys and 205 of girls), equivalent to a rate of 12.31. In Table 2 the figures for each quarter of the year are given, as well as the annual and mean rates for each sex for the five years 1895.99. In comparison with the quinquennial mean rates, the changes were as follow :— Paddington. St. Mary. St. John. Males ... —1.03 —1.22 —072 Females ... —0.50 —0.85 +0.28 Persons ... —1.53 —2.07 —044 In comparison with the figures for the preceding decennium (see Table 3), last year's total for the Parish (2,890) was 69 below the average (2,959), while the rate (22*13) was 1'97 below the TABLE 2. Births registered and Birth.rates, 1900. Births registered during Paddington. St. Mary. St. John. Males. Females. Both Sexes. Males. Females. Both Sexes. Males. Females. Both Sexes. 1st Quarter 387 369 756 334 317 651 53 52 105 2nd ,, 359 346 705 314 291 605 45 55 100 3rd 366 389 755 300 335 635 66 54 120 4th „ 348 326 674 306 282 588 42 44 86 Year 1,460 1,430 2,890 1,254 1,225 2,479 206 205 411 » Birth.rates* 1900 11.18 10.95 22.13 12.89 12.59 25.48 6.17 6.14 12.31 Mean rates, 1895.9 12.23 11.46 23.70 14.16 13.50 27.65 6.85 5.82 12.68 Bates 1899 11.77 10.98 22.76 13.84 12.84 26.68 5.86 5.65 11.52 1898 11.85 11.37 23.22 13.72 13.41 27.14 6.55 5.62 12.17 1897 11.97 11.86 23.84 13.96 13.90 27.86 6.45 6.21 12.66 1896 13.30 11.27 24.57 15.21 13.38 28.60 8.09 5.49 13.58 1895 12.27 11.85 24.12 14.11 13.97 28.08 7.33 6.17 13.50 * All rates are calculated per 1,000 persons in each District. Effort of Medical Officer of Health.] 3 mean rate (24'10). Fewer births were recorded in 1894 (2,834), but the rate for that year (23.2) was 1.1 per 1,000 higher. Last year's birth.rate (22.13) was the lowest recorded in the eleven years, and was 0.7 below that for 1899. In St. Mary, the births last year (2,479) were 30 below the average (2,509), while the birth.rate (25.48), 2.61 below the mean rate (28.09), was the lowest rate recorded in the eleven years 1890.1900. In South Paddington, 411 births were registered, being 39 below the decennial average (450). Fewer births were registered in 1898 (407) and in 1899 (385). The total for 1894 was the same as that for last year. The birth.rate in this Sub.District was 12.31 per 1,000, 1.08 below the mean rate, and the third lowest rate for the eleven years. The birth.rate for England and Wales was 28'9 per 1,000 persons last year, as compared with a decennial mean of 30.1, last year's rate being the lowest for the eleven years. In London a rate of 28.9 was recorded, being 0.6 less than the decennial mean (30.5), and 0.5 less than the rate (29.4) for 1899. Of the 2,890 children whose births were registered in the Parish last year, 138 (61 of boys and 77 of girls) were illegitimate. The proportion of illegitimate to legitimate births was 5.01 of the former to 100 of the latter, a ratio which has been exceeded twice only during the eleven years (1890.1900), viz., in 1890, when it was 5.51, and in 1894 when it stood at 5.22. The legitimate birth.rate was 21.07 per 1,000 persons, 1.96 below the mean rate (23.03), and the illegitimate rate 1.05, or 0.02 below the mean (1.07). The complete returns for the past eleven years will be found in Table 4. TABLE 3. Births and Birth.rates, 1890.1900. Year. Paddington. St. Mary. St. John. Birth.rates. Regd. Rates. Regd. Rates. Regd. Rates. England and Wales. London. 1890 2,901 24.8 2,389 28.7 512 15.0 30.2 30.7 1891 2,952 25.0 2,420 28.7 532 15.8 31.4 31.9 1892 2,934 24.6 2,456 28.6 478 14.2 30.5 31 0 1893 3,011 24.9 2,567. 29.4 444 13.2 30.8 30.9 1894 2,834 23.2 2,423 27.2 411 12.2 29.6 30.3 1895 2,979 24.1 2,526 28.0 453 13.5 30.4 30.6 1896 3,068 24.6 2,613 28.6 455 13.6 29.7 30.2 1897 3,010 23.8 2,586 27.9 424 12.7 29.7 30.1 1898 2,965 23.2 2,558 27.1 407 12.2 29.4 29.5 1899 2,940 22.8 2,555 26.7 385 11.5 29.3 29.4 Averages 1890.99 2,959 24.10 2,509 28.09 450 13.39 30.1 30.5 1900 2,890 22.13 2,479 25.48 411 12.31 28.9 28.9 4 [Appendix IV. TABLE 4. Illegitimate Births and Birth.rates. Year. Births Registered. Birth.rates per 1,000 of Population. Illegitimate Births per 100 Legitimate. Legitimate. Illegitimate. Total. Legitimate. Illegitimate. Total. 1890 2,741 160 2,901 23.4 1.36 24.8 5.51 1891 2,807 145 2,952 23.7 1.22 25.0 4.91 1892 2,792 142 2,934 23.4 1.18 24.6 4.77 1893 2,885 126 3,011 23.9 1.04 24.9 4.18 1894 2,686 148 2,834 21.9 1.21 23.2 5.22 1895 2,854 125 2,979 23.1 1.01 24.1 4.19 1896 2,949 119 3,068 23.6 0.94 24.6 4.03 1897 2,903 107 3,010 23.0 0.84 23.8 3.68 1898 2,844 121 2,965 22.3 0.95 23.2 4.25 1899 2,811 129 2,940 21.8 0.99 22.8 4.58 Averages 1890.99 2,827 132 2,959 23.01 1.04 24.10 4.67 1900 2,752 138 2,890 21.07 1.05 22.13 5.01 VACCINATION. The returns of vaccination during the past year are not yet complete. Those for 1899 are very nearly the same as those of 1898, and show that 14.6 per cent.* of the children born (in 1899) escaped vaccination from one cause or another, compared with 14.7 in 1898. In the first half of 1900 the percentage unaccounted for (see Table 5) was 16.6, a somewhat lower figure than that of 1899 (18.2). The slight increase in vaccination .was probably due to the presence of small.pox in the Parish.† Towards the end of last summer a Parliamentary Paper was issued (H.C. 354, Session 1900) showing the number of certificates of conscientious objection received by the vaccination officers during the year 1899, and the number of certificates of successful primary vaccinations received during the years 1898 and 1899. With respect to certificates of conscientious objection, it appeared that no certificates were received in 21 Unions, that under 100 certificates were received in each of 544 Unions, in numbers ranging from 100 to 500 in 77 Unions, and in excess of 500 in 10 Unions. The children thus left exposed to the full virulence of small.pox numbered 32,357, or 3 48 per cent, of those whope births were registered during the year. * It should be noted that the percentages "unaccounted for " are based on total births, and consequently understate the proportion of children surviving unvaccinated. † The influence which the occurrence of small.pox has on the amount of vaccination performed was indicated in the Annual Report for 1898, pp. 10 and 11. 5 Report of Medical Officer of Health.] TABLE 5. Vaccination Returns, 1881.1899. Year. Births. Successfully vaccinated. Insusceptible of vaccination. Had Small.pox. Died unvaccinated. Vaccination postponed. Remaining (not traced, &c., &c..)* Children not accounted for (including postponed cases) % of births. 1881 2,845 2,415 8 ... 203 7 212 7.7 1882 2,897 2,411 8 ... 212 17 249 9.2 1883 2,873 2,381 7 ... 231 16 238 8.8 1884 2,955 2,460 13 ... 239 43 200 8.2 1885 3,019 2,489 12 ... 252 38 228 8.8 1886 2,923 2,409 7 ... 213 26 268 10.1 1887 2,915 2,440 11 ... 220 40 204 8.4 1888 2,855 2,293 22 ... 216 38 286 11.3 1889 2,870 2,275 7 ... 223 68 297 12.7 1890 2,845 2,255 7 ... 254 29 300 11.6 1891 2,968 2,172 16 ... 254 32 494 17.7 1892 2,957 2,374 7 ... 202 16 358 12.6 1893 3,015 2,421 27 ... 265 10 292 10.0 1894 2,853 2,369 24 ... 203 21 236 8.2 1895 2,986 2,378 24 ... 302 21 261 8.8 1896 3,042 2,443 28 ... 286 11 274 90 1897 3,039 2,461 10 ... 262 31 275 10.0 1898 2,966 2,223 16 ... 290 34 403† 14.7 1899 2,933 2,167 17 ... 319 47 383‡ 14.6 January to) June, 19001 1,068 1 ... 150 64 180§ 16.6 * Gone away, false addresses, " unaccounted for." J Including 39 exempted under Act. † Including 75 exempted under Act. § Including 12 exempted under Act. The number of certificates of successful vaccination received during the two years show a considerable increase, as is seen from the subjoined figures :— 1898. 1899. January 1st to June 30th. July 1st to December 31st. January 1st to June 30th. July 1st to December 31st 277,839 222,475 355,552 313,797 Year 1898 500,314 „ 1899 669,349 The increase in the ratio of successful vaccinations to births in 1899 (72.1) compared with that of 1898 (54.2) was equal to 33 per cent. The increase in the proportion of children "successfully" vaccinated is generally regarded as a proof of the good effect of the Act of 1898. There is a very grave doubt as to the value of some of these "successful" vaccinations. It is notorious that a large proportion of such vaccinations fall far 6 [Appendix IV. short of the standard recommended by the Royal Commission on Yaecination. There is also a steadily increasing population which is totally unprotected against small.pox. When that population has attained the requisite proportion to the whole population, an epidemic of small.pox may be expected of proportions which will do more to remove the present prejudice against vaccination than any arguments which the most eloquent pen can urge. SICKNESS. The (648) cases of infectious disease reported in pursuance of Sec. 55 (4) of the Public Health (London) Act, 1891, were fewer by 189 than in 1899, a reduction equal to 22.6 per cent, compared with a reduction of 16'6 per cent, recorded in the Metropolis as a whole. The increases and decreases in the recorded cases of each disease in Paddington and the Metropolis are indicated in Table 6. In 1898, 772 cases were recorded in the Parish, in 1897, 1,008, and in 1896, 1,226. TABLE 6. Comparison of Notification Returns for 1899 and 1900. Paddington. London. 1900. 1899. Increase (+). 1900. 1899. Increase (+). Decrease (—). Decrease (—). Small.pox 5 ... + 5 89 29 + 60 Cholera ... ... 0 5 15 —10 Diphtheria 151 201 —50 11,799 13,366 —1,537 Membranous Croup 3 2 + 1 210 339 —129 Erysipelas 120 146 —26 4,781 5,615 —834 Fevers. Scarlet 302 382 —80 13,819 18,113 —4,294 Typhus 2 1 + 1 7 14 —7 Enteric 56 97 —41 4,314 4,463 —149 Relapsing ... ... 0 ... 1 —1 Continued 3 1 + 2 73 69 + 4 Puerperal 6 7 —1 283 330 —47 In comparison with the mean for the preceding ten years, the local returns show a reduction of 338 cases in all, equal to 32.3 per cent., and the Metropolitan of 9,530 cases, equal to 21.3 per cent. An examination of Table 7 will show that, as regards Paddington, the recorded eases of all diseases, except those of typhus (increase unreal) and continued fevers, were below the corrected and adjusted averages. In the Metropolis the recorded cases of diphtheria and enteric fever were above the averages. In the same Table will be found the morbidity rates for the past four years. The most satisfactory item under this head, as regards both Paddington and the Metropolis, is the reduction in the diphtheria rate. There has also been a reduction in the rate for 7 Report of Medical Officer of Health.] scarlet fever, but not equal to that for diphtheria. The local rate for 1900 from enteric fever, while below the rates for the two years 1899 and 1898, was higher than the rate for 1897. In the whole Metropolis, last year's rate from this disease was markedly in excess of the rates for 1897 and 1898, but below that for 1899. The rate for puerperal fever remains practically unchanged both in the Parish and in the Metropolis. TABLE 7. Notifications. Comparison of Returns for Paddington and London, with the respective averages for 1890.99. (Corrected for duplicates.) Notifications. Sickness.rates. Paddington. London. Paddington. London. 1900 Difference from Average. 1900 Difference from Average. 1900 1899 1898 1897 1900 1899 1898 1897 Small.pox 5 —9 89 —540 004 ... ... o.oo 0.02 0.00 0.00 0.02 Cholera ... —0 5 —29 ... ... ... 0.00 o.oo o.oo o.oo 0.00 Diphtheria 151 — 113 11,799 + 748 1.16 1.55 1.98 2.47 2.57 2.93 2.56 2.87 Membr. Croup.. 3 .3. 210 —290 0.02 0.01 0.03 0.07 0.05 0.07 0.06 0.08 Erysipelas 120 —24 4,781 .1,605 0.92 1.13 1.01 1.07 1.04 1.23 1.12 1.29 Fevers. Scarlet 302 —176 13,819 .8,516 2.31 2.95 2.37 3.88 3.01 3.98 3.75 5.12 Typhus 2 + 2 7 —12 0.01 0.00 ... ... 0.00 0.00 0.00 0.00 Enteric 56 —14 4,314 + 840 0.43 0.75 0.57 0.35 0.94 0.98 0.67 0.69 Relapsing ... .0 ... —7 ... ... ... ... ... 0.00 0.00 0.00 Continued 3 + 1 73 —64 0.02 0.00 0.01 ... 0.01 0. 01 0.01 0.01 Puerperal 6 —2 238 —54 0.05 0.05 0.03 0.05 0.05 0.07 0.05 0.05 Bubonic Plague* ... ... 1 ... ... ... ... ... 0.00 ... ... ... Totals 648 —338 35,336 —9,530 4.96 6.44 6.04 7.94 7.69 9.31 8.29 10.18 * Bubonic Plague was added to the schedule during the autumn of 1900. The prevalence of infectious diseases in the Parish is intimately connected with that of adjacent districts. In Table 8 comparison is made between the cases reported and morbidity rates for the Parish and the adjacent districts. The total rate for the Parish during 1900 (4.98) was lower than that of any other of the districts, except St. Greorge, Hanover Square, where the rate was 4.52. The Parish was therefore in a better position relatively and absolutely than in 1899. The 8 [Appendix IY. increase (+) or decrease (—) in prevalence of certain of the diseases included in the Table during 1900 as compared with 1899, but not the amounts thereof, in each of tbe districts, is indicated below:— Diphtheria. Erysipelas. Scarlet Fever. Enteric Fever. Puerperal Fever. Paddington — — — — 0 St. Marylebone + — — — — St. George, Hanover Square + — — + Kensington + — — — + Chelsea — — — + — Willesden — + — — + Ranged in order according to rates (the district with the lowest rate being placed at top of list) the positions of the various districts for last year were:— Diphtheria. Erysipelas. Scarlet Fever. Enteric Fever. Puerperal Fever. St. George, Hanover Square. St. George, Hanover Square. St. George, Hanover Square. Paddington. St. George, Hanover Square. Paddington. Chelsea. Kensington. St. Marylebone. St. Marylebone. St. Marylebone. Willesden. Paddington. Willesden. Paddington. Chelsea. Kensington. Chelsea. Kensington. Kensington. Kensington. Paddington. St. Marylebone. St. George, Hanover Square. Chelsea. Willesden. St. Marylebone. Willesden. Chelsea. Willesden. The incidence of the various diseases as regards sex and age in the whole Parish and in the two Sub.Districts is shown in Table 9. The actual numbers indicate an apparently heavier incidence on females, except as regards enteric fever. When, however, the rates are calculated, the incidence is found to be heavier upon males (see Table 10). For the sake of simplicity the rates in this Table have been calculated at " All ages," " Under 5 years," and " 5 years and upwards " only, and the rates for 1900 are compared with the mean rates for the preceding five years. It is satisfactory to record that, with one or two very trifling exceptions, the rates for last year are uniformly below the respective mean rates. 9 Report of Medical Officer of Health.] TABLE 8. Notification of Infectious Diseases in Districts co-terminous with Paddington. District. Population, 1900. 1900. Small-pox. Cholera. Diphtheria. Membr. Croup. Erysipelas. Fever. All Diseases. Scarlet. Typhus. Enteric. Relapsing. Continued. Puerperal. PADDINGTON. 130,104 1st Quarter - - 38 1 31 60 1 9 - 1 2 143 2nd ,, 5 37 1 32 49 — 12 - 1 1 138 3rd „ - - 28 — 29 86 1 13 - 1 1 159 4th — - 48 1 28 107 — 22 - - 2 208 Year 5 - 151 3 19,0 302 2 56 3 6 648 Ratest 1900 0.04 1.16 0.02 0.92 2.32 0.01 0.43 - 0.02 0.05 4.98 1899 - - 1.56 0.01 1.13 2.96 0.00 0.75 - o.oo 0.05 6.49 1898 - - 2.00 0.03 1.02 2.38 - 0-58 - 0.01 0.04 6.05 ST. MARYLEBONE. 139,777 1st Quarter - - 34 - 56 59 - 23 - - - 172 2nd ,, 5 54 1 57 95 - 11 - - 1 224 3rd ,, - - 67 1 40 80 - 9 - - 4 201 4th ,, — — 59 1 47 150 - 39 - — — 296 Year 5 - 214 3 200 384 - 82 - — 5 893 Ratest 1900 0.03 - 1.53 0.02 1.43 2.75 - 0.59 - — 0.03 6.38 1899 0.01 - 1.37 0.02 1.44 2.85 - 0.84 - o.oo 0.04 6.60 1898 0.00 - 1.67 0.00 1.29 2.22 - 0.72 - 0.01 0.06 6.98 ST. GEORGE, Hanover Square. 81,133 1st Quarter 1 - 28 1 14 49 - 13 - - - 106 2nd ,, 1 - 15 1 12 49 - 16 - 1 - 95 3rd ,, - - 20 - 8 28 - 8 - 2 - 66 4th „ - - 26 1 12 42 - 18 - - 1 100 Year - - 89 3 46 168 - 55 - 3 1 367 0.02 - 1.10 0.04 0.57 2.07 - 0.67 - 0.04 0.01 4.52 1899 - - 1.07 0.04 0.91 2.44 - 0.56 - - 0.02 5.08 1898 0.01 — 1.37 0.01 0.53 2.74 - 0.48 - 0.01 0.03 5.18 KENSINGTON. 173,603 1st Quarter ... - - 93 - 50 94 - 20 - 5 2 264 2nd ,, 7 - 72 3 36 87 - 19 - - 1 225 3rd ,, - - 65 - 31 81 - 23 - 2 2 204 4th ,, - — 105 1 43 109 - 45 - 3 4 310 7 - 335 4 160 371 - 107 - 10 9 1003 Ratest 1900 0.04 1.93 0.02 0.92 2.14 - 0.61 - 0.06 0.06 5.78 1899 - - 1.44 0.01 1.20 2.57 o.oo 0.68 0.00 0.08 0.05 6.09 1898 - 0.00 1.25 0.04 1.05 2.75 0.05 0.60 - 0.02 0-06 5.83 WILLESDEN. 114,905 1st Quarter - - 62 - 22 82 - 17 - - 1 184 2nd ,, - - 55 - 18 66 - 12 - — 1 152 3rd ,, - - 52 - 24 99 — 16 — — 2 193 4th ,, — — 61 1 27 87 — 30 — — 4 210 Year - - 230 1 91 334 - 75 — — 8 739 Ratest 1900 - - 2.00 0.01 0.79 2.91 - 0.65 — — 0.07 6.43 1899 - 0.00 2.98 0.01 0.74 3.87 0.72 — — 0.05 8.42 1898 0.01 - 3.34 0.02 0.74 3.63 — 0.67 — 0.02 8.43 CHELSEA* 96,715 1st Quarter - - 32 - 18 54 6 — — 2 112 2nd ,, 1 — 52 1 20 64 — 7 — — 2 147 3rd - 1 46 - 17 55 1 28 — 1 - 149 4th 1 - 48 1 17 60 — 41 — 1 2 171 Year 2 1 178 2 72 233 1 82 — 2 6 579 Ratest 1900 0-02 0.01 1.84 0.02 0.75 2.41 0.01 0.85 — 0.02 0.06 5.99 1899 - 0.01 2.41 0.05 0.84 2.91 — 0.66 — 0.04 0.09 7.04 1898 — - 2.77 0.05 0.97 3.47 — 0.57 — 0.01 0.05 7.89 * Only the " Kensal Town " part of Chelsea touches Paddington, but the figures for that area are not available, t Rates per 1,000 of the estimated population in each case. " O'OO " indicates a rate below 0*01 per 1,000. 10 [Appendix IV. TABLE 9. Notifications, 1900. Numbers for each Sex and Age. Ages. Diphtheria and Membranous Croup. Erysipelas. Scarlet Fever. Enteric and Continued Fevers. Puerperal Fever. M. F. P. M. F. P. M. F. P. M. F. P. F. PADINGTON 0- 1 1 2 3 4 7 3 3 6 — — — 1- 8 4 12 — — — 7 4 11 — — — — 2- 9 5 14 1 — 1 13 11 24 — — — — 3- 13 5 18 — — — 10 9 19 — 1 1 — 4- 5 11 16 — 1 1 9 11 20 — — — — 5- 24 34 58 5 3 8 60 75 135 7 4 11 — 13- 2 2 1 1 2 8 9 17 — 2 2 — 15- 4 11 15 7 11 18 23 27 50 8 7 15 — 25- 1 8 9 11 10 21 7 10 17 10 7 17 5 35- - 4 4 11 9 20 3 — 3 3 3 6 1 45- 1 2 3 3 17 20 — — — 1 4 5 — 55- - 1 1 3 9 12 — — — — 2 2 — 65- - - — 2 4 6 - - - - - - - 75- — - — 2 2 4 - - - - - - - 85- - - - - - - - - - - - - - All ages 68 86 154 49 71 120 143 159 302 29 30 59 6 ST. MARY. 0- - 1 1 3 4 7 2 2 4 - - - - 1- 7 4 11 — — — 6 4 10 — — — — 2- 8 5 13 1 — 1 10 8 18 — — — — 3- 10 5 15 — — — 10 9 19 — - — — 4- 5 11 16 — 1 1 8 11 19 — — — — 5- 21 31 52 4 3 7 53 68 121 7 3 10 — 13- 1 — 1 1 1 2 8 7 15 — 2 2 — 15- 3 7 10 6 10 16 17 19 36 8 5 13 — 25- 1 6 7 11 9 20 5 6 11 9 7 16 5 35- - 3 3 11 6 17 1 - 1 3 3 6 1 45- - 1 1 2 16 18 — — - 1 4 5 — 55- - 1 1 2 6 8 — — — — 2 2 — 65- - — — 2 1 3 - - - - - - - 75- - - — 2 2 4 - - - - - - - 85- - - - - - - - - - - - - - All ages 56 75 131 45 59 104 120 134 254 28 26 54 6 ST. JOHN. 0- 1 - 1 - - - 1 1 2 - - - - 1- 1 - 1 - - - 1 - 1 — — — — 2- 1 - 1 - - - 3 3 6 — — —, — 3- 3 - 3 - - - - - - - 1 1 - 4- - - - - - - 1 — 1 - — — — 5- 3 3 6 1 - 1 7 7 14 — 1 1 — 13- 1 - 1 - - - - 2 2 — — — — 15- 1 4 5 1 1 2 6 8 14 — 2 2 — 25- - 2 2 - 1 1 2 4 6 1 — 1 — 35- - 1 1 — 3 3 2 — 2 — — — — 45- 1 1 2 1 1 2 - - - - - - - 55- - - - 1 3 4 - - - - - - - 65- - - - - 3 3 - - — — — — — 75- - - - - - - - - - - - - - 85- - - - - - - - - - - - - - All ages 12 11 23 4 12 16 23 25 48 1 4 5 — Notes.—There were also reported 5 cases of small.pox—viz., 1 Male (15.25), St. Mary, 4 Females [3 (15.25) : 1 (25.35)], St. John, and 2 cases of typhus fever—viz., 1 Male (55.65), St. Mary. 1 Female (65.65), ( 11 Report of Medical, Officer of Health.] TABLE 10. Notification Hates (per 1,000 individuals in each group) for 1900, compared with mean lates for 5 years, 1895.99. District. Age. Males. Females. Small-pox. Diphtheria and Memb. Croup. Erysipelas. Fevers. *All Diseases. Small-pox. Diphtheria and Memb. Croup. Erysipelas. Fevers. *All Diseases. Scarlet. Enteric and Continued. Scarlet. Enteric and Continued. Puerperal. PADDINGTON. Under 5 years. 1900 — 5.9 0.7 6.8 — 13.4 — 4.1 0.8 6.0 0.1 — 11.0 mean. 8.8 1.2 10.6 0.3 21.1 — 7.7 0.7 10.9 0.2 — 19.6 5 yrs. and upwards. 1900 0.0 0.7 0.9 2.1 0.6 4.3 0.0 0.9 0.9 1.7 0.4 01 30 mean. 0.0 1.3 0.9 3.5 0.8 7.0 0.0 1.3 1.0 2.7 0.4 0.1 5.6 All ages. 1900 0.0 1.3 0.9 2.6 0.5 5.3 0.0 1.1 0.9 2.1 0.4 0.1 4.6 mean. 0.0 2.1 0.9 4.3 0.7 8.1 0.0 1.8 1.0 3.3 0.4 0.1 6.7 ST. MAEY. Under 5 years. 1900 0.0 5.8 0.8 6.9 - 13.0 4.9 0.9 6.4 - 12.2 mean. — 9.7 1.1 11.2 0.3 22.5 - 8.4 0.8 11.5 0.2 - 21.1 5 yrs. and upwards. 1900 0.0 0.7 1.1 2.3 0.7 4.8 — 1.0 1.1 2.0 0.5 0.1 4.7 mean. 0.0 1.5 1.0 3.8 0.7 7.5 0.0 1.5 1.2 3.0 0.4 0.l 6.6 All ages. 1900 0.0 1.3 11 2.8 0.7 5.9 — 1.4 1.1 2.4 0.5 o.l 5.5 mean. 0.0 24 1.0 4.7 0.7 9.1 0.0 2.1 1.2 3.9 0.4 0.1 8.0 ST. JOHN. Under 5 years. 1900 — 6.2 — 6.2 - 12.5 — — — 4.0 1.0 - 5.0 mean. — 6 0 0.6 7.0 0.2 13.9 — 4.1 0.2 7.9 — 12.2 5 yrs. and upwards. 1900 — 0.5 0.4 1.5 0.1 2.5 0.2 0.5 0.6 1.0 0.1 — 2.4 mean. — 0.8 0.5 2.1 0.7 4.8 0.0 0.7 0.5 1.6 0.3 — 3.2 All ages. 1900 — 1.0 0.3 1.9 0.1 3.3 0.2 0.5 0.5 1.2 0.2 — 2.6 mean — 1.2 0.5 2.9 0.7 5.6 0.0 0.8 0.5 1.8 0.3 - 3 6 * In certain instances the rates in these columns have been calculated on totals including cases of diseases in addition to those specified. " 0.0 " represents a rate less than 0.1 per 1,000. 12 [Appendix IV. SMALL-POX. Paddington. London. Cases reported, 1900 5 ... 89 Average annual number, 1890-99 14 ... 629 Case-rate*, 1900 0.04 ... 0.02 After an interval of upwards of four years this disease re-appeared in the Parish last year, but it is satisfactory to state that all the cases were clearly accounted for. So far as Paddington was concerned, all the cases were correctly diagnosed. What the proportion of error was as regards the Metropolis is at present unknown. The proportion has of late years been somewhere about 25 per cent. The 5 cases occurred during the second quarter of the year, all in connection with St. Mary's Hospital. The sex and ages of the patients were:— E. O., f. set. 21, in-patient; notified June loth S. G., f. set. 24, do. ; do. 15th C. B., m. set. 21, medical student; do. 16th A. S., f. set. 21, ward-maid; do. 16th M. M.,f. set. 26, nurse ; do. 18th All had been vaccinated in infancy, but nothing is known of any subsequent re-vaccinations. The first 4 cases were removed to the Asylums Board Hospital on the day of notification, and the fifth on the 16th (a Saturday). The medical student alone resided outside the hospital. The inquiries made elicited the following history:— A widow, E. D., was admitted to the Hospital (Victoria Ward) on May 11th, for pneumonia following influenza. The bacillus influenza; was found present in the sputum. She had fever on admission, but that had disappeared by May 16th, when she appeared to he convalescent. On May 25th (after being in hospital 14 days) persistent vomiting set in, and the fever returned (temperature 102° F.). On the 27th a rash, papular but not "shotty," appeared on the chest, abdomen, face, and neck. Next day the rash was described as " macular," and the fever continued. She was transferred to the Isolation Ward of the Hospital on this the 17th day after her admission to hospital. On May 31st the rash was " shotty," and was present all over the body, including the palms of the hands. On the night of June 1st and 2nd the rash was (apparently) " hemorrhagic." The patient died on June 4th, the cause of death being certified as " erythema multiforme." S. G. was a patient in the Isolation Block, but not in the same ward as E. D. S. G. sickened with smallpox on June 12th, the rash developing on June 15th. On June 12th E. O., in the same ward as S. G., developed a rash, which was pronounced to be that of small-pox when S. G.'s rash appeared. A. S. and M. M., were members of the staff on duty in the Isolation Block.† With the occurrence of the case of recognized small-pox, the diagnosis of the case of E. D. required to be reviewed, and there could be no doubt that her case was one of hæmorrhagic small-pox. It is believed that she had been vaccinated in infancy only. E . D. came from Westminster (2, M -T-), where she was in service as a housekeeper. No. 2, M--- T--- is a block of flats, and in the flat immediately under that where E. D. resided there occurred a death, on May 9th, in the person of a valet, J. D.J The cause of death of J. D. was certified as "measles,9 days; bronchitis,4 days; exhaustion." His case presented very unusual features, and he was seen by six medical men. * All rates, except when otherwise indicated, are calculated per 1,000 persons of all ages. | The Isolation Block consists of a number of small wards (1 or 2 beds), with a staff common to the Block, but kept apart from that of the rest of the Hospital. t E. D. and J. D. were in no way related to each other. Report of Medical Officer of Health.] 13 L. D., the widow of J. D., was admitted to St. George's Workhouse, Fulham, on May 10th. She was discharged thence May 16th, and went to B --- St., Fulham Road, whence she went on May 18th to S --- St., Chelsea. From the latter house she was removed to the Hospital Ships ill with small-pox on May 21st. An attendant of the ward to which L. D. was admitted at the Workhouse was sent to hospital with small-pox on May 23rd. Two cases of small-pox were admitted to the Ships (on May -30th and June 1st) from B —— St., both being grandchildren of L. D. J. D.'s funeral on May 12th was attended by his son — D., from Northampton. On May 25th the son ( — D.) was taken ill, and his illness was diagnosed as " eczema," and a nurse sent for to attend to him. — D.'s baby was taken ill on June 8th, and his servant on June 9th. The latter went to her home and was seen by an independent practitioner, who diagnosed her illness as smallpox. This led to the correct diagnosis of the two earlier cases. The nurse who was called to attend to — D. sickened on June 13th, and was diagnosed ill with hemorrhagic small-pox on June 18th. Her case terminated fatally. The linen of the household in which J. D. was in service was sent to a laundry in one of the western suburbs. Four girls, J. M., II. W., N. B., and B. L., employed in sorting dirty linen at the laundry, were taken ill with what was at the time thought to be " chicken-pox." The cases of H. W. and N. B. were not notified, and the patients remained at home, but no further cases were traced back to them. J. M. infected her sister-in-law and her mother, both cases being recognized as small-pox and sent to the Ships. J. M. was not removed to hospital at first, but a month later she went to the Ships to see her mother, and was then detained as infectious with small-pox by the Acting Medical Superintendent. B. L. was not removed to hospital, and infected four of her relatives who resided with her. Although the death of J. D. was certified as due to measles, the conclusion that his illness was really htemorrhagic small-pox is irresistible, having regard to the succession of undoubted cases traceable to his death. How E. D., who died in St. Mary's Hospital, became infected has not been explained. J. D. and L. D., his wife, were on friendly terms with E. D., but the latter had been ill for some weeks prior to her admission to St. Mary's Hospital, and, so far as could be ascertained, L. D. had only once (date unknown) visited E. D.'s flat during the illness of J. D., and on that occasion it is said that L. D. did not enter the flat. On the other hand, it is said that E. D., who was in a state of fear that she would die of the same complaint as J. D., frequently remarked after the death of J. D., that she saw him with his swollen face beckoning her to come to him. If that be so, especially if E. D. spoke of J. D.'s " swollen face," it is eminently suggestive of E. D. having seen J. D. just before or after his death. It was stated that when the room occupied by J. D. was disinfected (sulphur fumigation), the fumes found their way up into the bedroom which E. D. had occupied prior to May 11th, the latter room being immediately over J. D.'s room. Too long an interval had elapsed after J. D.'s death to trace the source of his illness. It can only be said that small-pox had been present in London at intervals since the beginning of the year, but no case had been reported between March 17th and April 10th. J. D. sickened April 30th, and according to the usual experience with small-pox, he would have been infected some time between 14th and 18th of that month, most probably on 16th Between April 10th and 23rd, cases occurred in St. Pancras (1) and Marylebone (2), due to infection brought home by R.M.S. Caledonia, and on April 20th a man, F. A., passed through London on his way from Moscow to Stalybridge with the eruption of small-pox full out. This man is known to have given rise to something like 40 or 50 cases in the North of England. In the absence of any clue from J. D., all attempts to trace the origin of his case, made by the medical officers of health of the various districts in which the cases detailed occurred, proved futile. 14 [Appendix IV. CHOLERA. Paddington. London. Cases reported, 1900 — 5 Average annual number, 1890-99 — 34 Case-rate, 1900 — 0.00 It is satisfactory to note that, in spite of the abnormally hot summer, there were fewer cases of illness reported as "cholera" in the Metropolis. So far as is known, none of them were cases of true or Asiatic cholera. No ease of that disease has ever been certified in the Parish, while only 2 cases of any form of cholera have been reported in the eleven years 1890-1900. In one case, when inquiry was made as to the patient on the day the certificate was received, she was found to be about, apparently well and eating fruit. DIPHTHERIA.* Paddington. London. Cases reported, 1900 154 12,009 Average annual number, 1890-99 270 11,551 Case-rate, 1900 1.18 2.62 In the last report a "continued decrease in the prevalence" of this disease in the Parish was recorded, a decrease which not only continued, but became more marked during the year under review. In 1899 the recorded cases (203) were 72 below the annual average (275) for the nine years 1890-98, showing a reduction equivalent to 26*2 per cent. Last year the 154 recorded cases were 116 below the annual average (270) for the preceding ten years, showing a reduction of 43'0 per cent. In the Metropolis the cases reported in 1899 were 2,524 above the annual average for 1890-98, an increase of 22'5 per cent., and although the cases reported last year were 1,696 fewer tban in 1899, yet the total was nearly 4*0 per cent, above the decennial average. As regards the Parish, last year's total was the lowest on record, and was 19 below the total for 1892 (173), the previous lowest record. The maximum recorded in the eleven years 1890-1900 was that of 1894 (382). In the Metropolis the lowest annual total was that of 1892 (6,412), which was 5,597 fewer than the total of last year, while the maximum record was that of 1896 (13,820), which exceeded that of last year by 1,811 cases. In St. Mary's Sub-District 131 cases were recorded last year, being less than half the decennial average (270), and 3 less than the previous minimum (134) recorded in 1892. In 1894 (the maximal year) 340 cases were recorded. In St. John's Sub-District 23 cases were reported last year, compared with a decennial average of 34 cases. In 1899, 22 cases were recorded, the minimum record, and in 1893, 57 (the maximum). Of the districts mentioned in Table 8, St. George, Hanover Square alone had a diphtheria rate (1*14) lower than that of the Parish (1"18). The relative preponderance of the incidence of the disease on children at school ages is clearly indicated in Table 9. Thus of the 86 cases reported in the Parish among males at all ages, 44 were children at ages between 3 and 15 years, while of the 86 cases reported among females at all ages, 50 occurred at those special ages. The complete comparison is set out below, the cases reported at " all ages " being taken as 100 in each group:— Males. Females. All ages. 3 to 15. All ages. 3 to 15. Padaington 100 64 100 58 St. Mary 100 66 100 62 St. John 100 58 100 27 * Including cases certified as Membranous Croup. Report of Medical Officer of Health.] 15 The rates given in Table 10 do not show a reduction equal to that exhibited by the numbers already dealt with, as the mean taken as a basis of comparison is that for the years 1895-99, during' which there had been a less prevalence than in the years 1890-94. In the former period 1,257 cases in all were recorded, in the latter, 1,262, while the mean estimated populations were 120,118 and 125,937 respectively. Bearing this in mind, the comparison of the rates for 1900 to the mean rates cannot, expect perhaps as regards St. John, males, be regarded otherwise than as satisfactory. The cases as recorded require to be corrected for errors of diagnosis, &c., although this has not been considered in the foregoing paragraphs owing to the lack of information as regards the earlier years. Last year the official inquiries enable the reported cases to be grouped thus:— St. Mary. St. John. Imported cases, primary 6 5 ,, „ secondary 3 - Return cases, primary 1 1 ,, ,, secondary — — Errors of diagnosis 12 5 Remaining cases, primary* 92 11 „ „ secondary 17 1 In 1899, 7 cases out of 203 (3.4 per cent.) were found to be erroneously diagnosed, as compared with 17 out of 154 (11.0 per cent.) during the past year. Part of the apparent increase in the percentage of error was probably due to an extended use of the bacteriological test—in some cases not resorted to until after notification—but more so to the increased number of the certificates forwarded by the Medical Superintendents of the Metropolitan Asylums Board. Even now it is highly probable that the complete measure of error has not been obtained. From the very short periods of isolation imposed in many cases, and the very slight nature of attacks observed in others, it appears probable that, however much the naked-eye signs may simulate diphtheria, the cases are not such in fact, i.e., are not due to infection by the bacillus diphtheria'. No doubt many of these cases are infectious, and should be isolated, but it seems desirable that they should not be confounded with diphtheria. With regard to "imported cases," it should be observed that actual contact with diphtheria patients is rarely demonstrated, but the inquiries go to prove that the patient either came from some outside district at so recent a date as to raise a presumption that he (or she) was infected at the date of arrival in the Parish, or that there had been illness in the house whence the patient came. In 1899, 154 primary cases were due to infection apparently contracted in the Parish, being 75 per cent. of all the cases. Last year there were 103 such cases out of a total of 154, equal to 66.8 per cent. The secondary cases arising from these cases constituted 8.3 per cent. and 11.6 of all cases respectively. In the Reports for 1898 and 1899 attention was specially called to certain streets in the northern section of the Parish from which an unduly large proportion of cases was reported. The figures for last year are set out below in comparison with those of the two preceding years:— 1898. 1899. 1900. Cases. Houses. Cases. Houses. Cases. Houses. Ashmore Road 11 10 11 10 4 4 Bravington Road 22 15 13 12 10 8 Chippenham Road 6 5 3 3 1 1 Fernhead Road 8 4 4 1 1 Kilburn Park Road 16 14 13 12 3 2 Portnall Road 9 9 18 14 8 4 Saltram Crescent 5 4 8 8 6 6 Shirland Road 11 10 10 8 4 3 Walterton Road 4 3 5 3 2 2 92 75 85 74 39 31 These streets contain approximately 1,700 houses. * Including 1 case in which the disease was contracted in hospital. 16 [Appendix IV. In the remainder of North Paddington, 3 or more cases were reported from— Cases. Houses. Cases. Houses. Ashmore Road 4 4 Kilburn Park Road 3 2 Bravington Road 10 8 Portnall Road 8 5 Clarendon Street 9 6 Saltram Crescent 6 6 Elgin Terrace 5 4 Shirland Road 4 3 Hall Place 5 4 Westbourne Park Road 4 1 Harrow Road 3 3 The frequency of multiple infection in the homes in each of the last three years is indicated below:— Houses with 1900. 1899. 1898. 1 case 117 140 167 2 cases 13 11 21 3 „ 1 5 2 4 „ 2 1 2 5 „ — — 1 From 4 of the 13 houses where 2 cases occurred, both the cases were certified on the same day; in one, the second case was presumably a "return" case; in another, the second case was the woman who nursed the first; and in a third, the second case was in another family living on the same floor as the first case. With the exception of the return case just mentioned, the circumstances indicated direct personal infection from the first to the second case. Of the 2 groups of 4 cases, one was a family in which the failure to diagnose the first case led to the 4 cases being reported together, while the other group was due to the same cause, but the eases were not reported on the same day. So far as can be ascertained, the intervals between the secondary and primary cases were as follow:— In the 13 groups of 2 cases— Patients sickened on same day. 2 groups. Interval between onsets of first and second cases— 1 day 1 2 days 1 5 „ 2 6 „ 3 7 „ 2 9 „ 1 Second case followed return of first from hospital. 1 case. In the 1 group of 3 cases— The first case occurred in August, and was removed to hospital on the second day of illness. The second case was in a member of another family occupying same tenement, and occurred in December, that is, 4 months later. The third case sickened 9 days after the second. Of the 2 groups of 4 cases— In one, the first case was not certified until the fourth day, when the second patient was taken ill, and the 2 cases sent to hospital together. The third case followed next day, and the fourth 4 days later. In the other, the intervals between the onsets were 1 and 2 days (2 patients sickening together). Attention has on former occasion been called to the occurrence of death at or very nearly the same date as notification. Last year 1 patient died before the case was reported, 5 died the same day, and 4 on the day following. Report of Medical Officer of Health.] 17 The percentages of reported cases removed from their homes for isolation during each of the past five years were:— 1900. 1899. 1898. 1897. 1896. Parish 71.4 82.7 64.3 63.9 50.0 St. Mary 77.1 83.9 65.3 61.4 41.5 St. John 52.1 72.7 56.6 78.7 63.8 SCARLET FEVER. Paddington. London. Cases reported in 1900 302 13,819 Average annual number, 1890-99 478 22,335 Case-rate, 1900 2.31 3.01 There was a decrease amounting to 80 cases in the number of attacks of scarlet fever reported in the Borough during the past year as compared with 1899. The annual totals were fewer in 1890 (215), 1891 (263), and 1894 (289). The maximum for any year was 790 cases in 1896. The cases reported in the Metropolis last year (13,819) constituted a smaller annual total than that of any year except 1891 (11,398 cases). In comparison with the decennial averages the reduction in the total for Paddington was equal to 36.9 per cent., and that for the Metropolis, 38.2 per cent. In North Paddington 254 cases were recorded, being 59 fewer than in 1899, and 149 less than the decennial average (403). Fewer cases were recorded in 1890 (183), 1891 (217), 1894 (238), and 1898 (253). The maximum record was that of 1896 (664 cases). In South Paddington 48 cases were recorded, compared with 69 in 1899 and a decennial average of 75. The reductions in the numbers for last year, compared with the respective decennial averages, were: North Paddington, 37.0 per cent.; South, 36.0. The sickness-rates (all ages) in comparison with the mean rates for 1895-99 were as follow:— Paddington. North Paddington. South Paddington. Males. Females. Males. Females. Males. Females. 1900 2.6 2.1 2.8 2.4 1.9 1.2 Mean 4.3 3.3 4.7 3.9 2.9 1.8 According to the returns in Table 8 (p. 9), 3 of the adjacent districts had higher rates for this disease than Paddington, and 2 lower. The highest rate was that of Willesden (2.91), and the lowest that of St. George, Hanover Square (2.07). The incidence of the disease on children of school ages is shown in the following statement, in which the cases recorded at "all ages " are in each group taken as 100:— Males. Females. All ages. 3 to 15. All ages. 3 to 15. Paddington 100 61 100 65 St. Mary 100 66 100 71 St. John 100 40 100 36 The proportions are very nearly the same as those for diphtheria (see p. 14). The inquiries made enable the cases reported to be grouped thus:— St. Mary. St. John. Imported cases, primary 19 9 „ „ secondary 6 — Return cases, primary 10 2 „ „ secondary 3 — Errors in diagnosis 4 2 Disease contracted in hospital 1 2 Remaining cases, primary 163 25 ,, „ secondary 48 8 18 [Appendix IV. The results of the inquiries in 1899 are compared with those of last year for the whole Parish in the following statement:— 1899. 1900. Total cases 382 302 Imported cases, primary 24 28 ,, ,, secondary — 6 Return cases, primary 11 12 ,, ,, secondary 3 3 Errors in diagnosis 8 6 Remaining cases, primary 269 188 „ „ secondary 67 56 The "remaining cases, primary" constituted 70 per cent. of the cases in 1899 as compared with 62 per cent. last year. The frequency of multiple infections in a house varies to a certain extent with the prevalence of the disease in the district. The analyses for the past 3 years are set out below:— Houses with 1898. 1899. 1900. 1 case 178 241 186 2 cases 25 43 37 3 „ 7 10 7 4 „ 2 2 5 5 „ — 1 1 6 „ 1 — — 8 „ 1 — — Without entering into a long explanation of the house-incidence during the past year, it may he stated that from 12 out of the 50 houses with more than 1 case, all the recorded cases were reported on the same day; that 12 return cases* are included among the multiple infections; and that in 3 cases home nursing appeared to be the explanation of the subsequent cases. Of the houses with 4 cases— (a) The second case occurred 1 month after the first, and was probably due to an pendent source of infection; the third and fourth cases were "return" cases. (b) All 4 cases were reported on the same day. (c) The first case was removed to hospital; the second case occurred 2 days later and was kept at home; the third and fourth cases occurred 6 days after the second. (d) The first case was kept at home, and the subsequent cases occurred on the fourth, fifth, and sixth day. (e) All the cases were removed to hospital as reported, and all were apparently due to independent infections. In the 1 house with 5 cases— The first case sickened on August 2nd, but was not reported until August 22nd, when the second patient had already succumbed; the third and fourth patients sickened on August 30th, and the fifth on September 3rd. Each case was removed to hospital as reported, but it was evident that the infection was passed direct from child to child. An outbreak in connection with a high-class girls' school requires to be specially dealt with. F. C., who was out to see the C.I.V. come home on October 27th and 29th last, was taken ill with a sore throat on November 1st. There was no history of any rash being seen. The girl was "isolated" in an open dormitory (she was a boarder) from November 1st to 6th. From the 6th to 9th she was back in school and continued to mix with the boarders until the 11th. She was then set apart for a day or so, allowed out again, and finally confined entirely to the sick-room, and properly * A special note on return cases will be found at the end of this Report—see Appendix B. Report of Medical Officer of Health.] 19 isolated on the 13th. She remained there until she went to a convalescent home. There was no idea that the girl was ill with scarlet fever, and it was only after a considerable amount of persuasion that the advice given to completely quarantine her was acted upon. After her removal to a convalescent home for scarlet fever patients she desquamated freely. D. C., another boarder, but not of the same house as F. C., visited F. C. during the early days of the latter's illness. D. C. sickened with well-marked scarlet fever on November 10th, and was removed to hospital on the 13th. L. W., a day scholar, had been absent from school for some unexplained reason from November 2nd to 6th. She then attended until the 9th. She was taken ill with scarlet fever on the 11th and certified on the 12th. She was kept at home, but gave rise to no other cases. This child was taught in part by M. H. (the next case), and it was thought also by D. C. M. H., a pupil teacher, residing in same house as D. C., sickened between November 12th and 14th (the onset was too vague to secure an exact date), and sent to hospital on the 15th. K. F., a day scholar, was reported ill with scarlet fever on the 16th, but was subsequently found not to have the disease. R. W., a housemaid at house where D. C. and M. H. lived, sickened on the 16th and was sent to the hospital on the 18th. This patient visited the room where one or both of the previous patients were lying whilst waiting for the ambulance. Such visits were paid in defiance of orders. E. C., a pupil teacher, sickened on November 26th, and went to the hospital on the 30th. She had taught L. W., but the interval was too long to warrant any presumption that that child was the source of infection. S. I., a day scholar, sickened November 27th. She had not attended school since 9th of that month, but had received examination papers from the school. One of her usual teachers was E. J., who sickened on November 30th. This patient acted as secretary to the school, and the opportunities for contact with any of the other patients were numerous. M. W., a boarder in same house as all the cases except F. C., was certified to be ill with scarlet fever on December 3rd. This case was discovered in consequence of a general examination made on request of the Medical Officer of Health. The girl had had an ill-defined illness about November 15th, but, although isolated and watched, a diagnosis of scarlet fever could not be made. The steps taken to limit the spread of the disease included (a) Removal of each case to hospital, and subsequent disinfection of room and contents. (b) Quarantine of all girls in contact with each patient. (c) Disinfection of all school-rooms. (d) Temporary closure of school for a fortnight, afterwards continued, without re-opening, until after Christmas vacation. (e) Careful examination of all persons residing in the houses. Fortunately only 2 cases occurred outside the school premises. The origin of the outbreak could not be traced. There was ultimately no room to doubt that F. C. had a mild and unrecognized attack of the disease, and there was strong presumption that she caused the earlier of the reported cases. How F. C. became infected is not known. There was a history of vague illnesses among the teaching staff, supposed to be of the nature of influenza, for same months previous to the occurrence of F. C.'s case. It is possible that F. C. contracted her illness in the crowd when out to see the C.I.V. Previous experience has indicated the possibility of such an occurrence. The outbreak is of interest in another respect. All the patients had passed the age when scarlet fever has hitherto been most frequent. The youngest patient was 8 years of age, and the eldest 28. There seems to be reason to suspect that when an individual is protected from an attack of this disease in extreme youth, an attack at a subsequent age may present unusual features. It seems almost as if the disease in elder patients does not develop in so characteristic a form as it does in young children. In certain of the cases in the outbreak under review the symptoms were very 20 [Appendix IV. defined, and, but for the occurrence of well-marked cases and the expectation of others, such cases would probably have escaped diagnosis. It is to these cases, notably to the last, that of M. W., that the spread of infection was probably due. Yery similar circumstances were noted in an outbreak which occurred during 1899 among the employes of a large commercial establishment in the Parish. At another girls' school, mixed day and boarding, two children (day scholars) in the kindergarten class were reported ill with scarlet fever. The patients were residents in Kensington, and the dates obtained were— F. C. Last attended school November 8th. Certified 12th. H. T. „ „ 23rd. „ 25th. The kindergarten class was held in a large room, which was divided into two sections by a movable wooden partition reaching from floor to ceiling. The second half of the room was used as a diningroom for the boarders. There was a door communicating between the two sections of the room. The infants of the kindergarten class and the boarders used the same play-rooms in the basement of the building. Four cases were reported on the same day among the girl boarders, viz.:— F. C. sickened November 23rd. L. H. „ ,, 25th. M. S. „ „ 27th. M. H. „ „ 27th. There were no further cases either among the day scholars or boarders after these patients had been removed and the place disinfected. Omitting from consideration the 3 cases reported in patients already under treatment in hospital, 251 cases were removed from their homes to hospital for isolation, and 2 to other districts (under proper supervision). Of the cases in North Paddington, 215 were isolated outside the Parish (equal to 85 per cent. of the reported cases in the district), and of those in South Paddington, 38 (equal to 82.6 per cent.). The proportions for the past five years are given below:— 1900. 1899. 1898. 1897. 1896. Paddington 84.6 71.6 80.1 77.3 78.7 St. Mary 85.0 83.7 81.4 79.6 59.9 St. John 82.6 59.4 74.0 61.6 71.4 The proportions of cases removed were the highest on record. ENTERIC (Typhoid) FEVER.* Paddington. London. Cases reported in 1900 59 4,387 Average annual number, 1890-99 72 3,571 Case-rate, 1900 0.45 0.95 The 59 cases of this disease were 39 fewer than the number recorded in 1899 (98), and 13 less than the average. The reduction is the more satisfactory as the returns for the Metropolis (4,387 cases), although below those of 1899 to the extent of 105 cases, were 816 in excess of the decennial average. In North Paddington 54 cases were recorded last year, compared with 81 in 1899 and a decennial average of 56. In South Paddington only 5 cases were recorded in the year, compared with 17 in 1899 and a decennial average of 16. Last year's return for South Paddington is the minimum on record. Of the districts included in Table 8, Paddington had the lowest enteric case-rate (0.45 per 1,000), and Chelsea the highest (0.87). * Including cases certified as Continued Fever. Report of Medical Officer of Health.] 21 The inquiries made enable the reported cases to be grouped thus:— North Paddington. South Paddington. Errors in diagnosis ... 5 2 Imported cases, primary 16 2 „ „ secondary 2 — Return case 1(?) — Remaining cases, primary 30 — „ „ secondary — 1 Many of the "imported cases" were patients who came to the district ill with the disease. Of the 30 "remaining cases," histories of the consumption of oysters, whelks, &c., were obtained in 11, and of ice-creams in 2. Of the 17 patients not included in these figures, 3 were in the habit of taking meals in other parts of the Metropolis, 1 did so occasionally, and another, a guard on the G.W.R., probably had meals in various parts of the country. The 30 "remaining cases" may also be arranged according to the water company supplying their homes. Nineteen resided in houses supplied by the Grand Junction Water Works Company, and 11 by the West Middlesex. The ratios of supplies of the two companies is something like 55 by the West Middlesex Company to every 100 by the Grand Junction, and the ratio of the cases in houses supplied by the respective companies, 58 to 100—a difference which may be purely accidental. Mention has been made in former Reports of the direct communicability of infection from the patient to those in contact with him. This danger is not generally recognized. Three times during the past year did such direct spread come to the knowledge of the Department, in one case from the husband to the wife, in the second from a child to the (domestic) nurse, and in the third at a boarding house to a second inhabitant. A fourth instance was also reported in the person of a nurse at St. Mary's Hospital, who was in charge of a patient ill with enteric fever. At 13 of the 30 houses where the 30 "remaining cases" resided, the sanitary arrangements (drains, closets, &c.) were found to be in good order; at 10 the arrangements were radically bad ; at 3 the general arrangements were good, but defects were found; and at 1 they were good, but the drain was choked.* The water supply for dietetic purposes was taken direct off the main at houses; from cisterns at 19 houses; and could be obtained either off the main or from cisterns at 2 houses. Two of the cisterns (the only source of supply) were found to be dirty, and 1 was in direct communication with the water closet. Of the 54 cases in North Paddington, 42 were removed to hospital or nursing homes for treatment, and of the 5 in South Paddington, 3. The percentages removed from their homes during the last five years are indicated below:— 1900. 1899. 1898. 1897. 1896. Paddington 76.1 77.5 60.0 51.1 58.0 St. Mary 77.7 72.8 77.6 50.0 59.0 St. John 60.0 64.7 46.1 54.5 55.5 ERYSIPELAS. Paddington. London. Cases reported in 1900 120 4,781 Average annual number, 1890-99 144 6,386 Case-rate, 1900 0.92 1.04 It is difficult to say what may be the value of the notifications of this disease. Strictly interpreted, "erysipelas" is a septic infection of a wound, but the bulk of the cases are of a very * Note.—Three houses are not included in this list, 1 because the patient had not recovered at the time of writing ; 1 because it was a new house just occupied; and the third as it had previously been reported upon. 22 [Appendix IV. trifling character and call for no active interference on the part of the Department. In former Reports attention has been called to the periodical recurrence of cases of erysipelas in the same individual. No such case came under the notice of the Department during the past year. As will be seen by the figures above, there was a reduction of the number of cases reported last year compared with the decennial average, but the rates given in Table 10 (p. 11) show that the rates for last year differed only to a very slight extent from the mean rates for the previous five years. In North Paddington 104 cases were reported, compared with 125 in 1899 and a decennial average of 125, while in South Paddington 16 cases occurred, or 1 less than in 1897 and 3 less than the average. The local rate (0.92) was very nearly midway between the highest rate prevailing in the adjacent districts (1.43 in Marylebone) and the lowest (0.57 in St. Greorge, Hanover Square). PUERPERAL FEVER. Paddington. London. Cases reported in 1900 6 238 Average annual number, 1890-99 8 292 Case-rate, 1900 0.05 0.05 There has not been any material reduction in the prevalence of this disease, although, perhaps, the number of cases recorded last year was slightly increased in consequence of a circular letter sent out by direction of the Public Health Committee, to which letter more particular reference will be made later. The cases reported last year were 1 fewer than the total for 1899 (7) and 2 less than the decennial average. Fewer cases were recorded in 1890 and 1898 (5 cases in each year), and in 1891 and 1894 (4 cases in each year). All the cases reported last year occurred in North Paddington. No case has been reported from South Paddington for the past six years. A reference to Table 10 will show that the sicknessrate for this disease, calculated on the number of females estimated living, was last year equal to the mean rate, and was 0.1 per 1,000 females in each case. Having regard to the reduction in the numbers of births registered in recent years, it will be more instructive to inquire as to the ratio of notified cases to births registered.* A comparison is instituted below:— Rates per 1,000 births registered. 1890. 1891. 1892. 1893. 1894. 1895. 1896. 1897. 1898. 1899. 1900. Paddington 1.72 1.35 2.38 5.97 1.41 2.68 3.58 2.32 1.68 2.38 2.07 St. Mary 2.09 1.65 2.85 5.84 1.23 3.16 4.20 2.70 1.95 2.73 2.42 St. John — — — 6.75 2.43 — — — — — — It is worthy of note that in 1893 and 1896 scarlet fever was exceptionally prevalent in Paddington. The inquiries made enable the cases recorded last year to be tabulated as below:— Illness after neglected miscarriage 1 case. Illness after confinements 5 cases. Including, child born dead ; instrument case ; and child abnormal in formation, 1 each. All the confinements were reported to have been conducted by medical men, while of the nurses or midwives in attendance, 3 were trained women. In all 5 houses the sanitary arrangements were defective, some being very bad. In 3 cases there was evidence of the escape of drain (or sewer) effluvia into the rooms where the patients were confined, In 1 house, where the case terminated fatally, 2 cases of scarlet fever (children of the deceased woman) had been treated * As a certain number of reported cases occur in connection with miscarriages and abortions, this comparison overstates the case, but it gives the best information available. Report of Medical Officer of Health.] 23 at home for scarlet fever. Disinfection had been carried out 8 days prior to the confinement, the period of isolation having been 35 days. In the Report for 1899 the following paragraph occurs :— "The exact interpretation of the term 'puerperal fever' has been a subject of discussion since the introduction of notification in 1890. There is no doubt that the term as commonly used includes not one, but many diseases, so much so that the last edition of the 'Nomenclature of Diseases' recommended that the term should be abandoned and the disease more correctly described according to the phenomena presented. The difficulty experienced in defining the term has resulted in neglect to notify many cases which were intended to be reported. The only argument which could justify such neglect has now been put out of court by the official opinions given at the beginning of the year by the Royal College of Physicians of London and the Obstetrical Society. Briefly put, the opinions were to the effect that 'puerperal fever' included 'septicaemia, pyaemia, septic peritonitis, septic metritis, and other septic inflammations in the pelvis occurring as a direct result of child-birth.' " In the course of the past year the Public Health Committee directed that the attention of the medical practitioners in the Parish should be called to the opinion given by the Royal College and the Obstetrical Society, and that the practitioners should be requested to notify all cases coming within the term of puerperal fever as defined above. It is easy to say what terms should be included in a name such as puerperal fever, but there will still remain some doubt as to the cases which exactly agree with the terms specified. The difficulties experienced in practice are to a certain extent indicated in the following correspondence between one of the practitioners in the Parish and the Medical Officer of Health. On the issue of the circular letter, Dr. X. wrote thus:— "I do not know whether any special reason exists in Paddington for the issue of your letter on the notification of puerperal fever, but it seems to me that the difficulties in obtaining such notification are insuperable. In the first place, what is puerperal fever? Do the opinions of the College of Physicians and the Obstetrical Society bring us any nearer to a definition ? The septic conditions mentioned by those bodies are of too uncertain limits to lead to uniform notification. I know of a case, not in my own practice, which occurred a long time ago, in which the woman on the third day after confinement had an attack of sapraemia. I say 'sapræmia,' and not 'septicæmia,' because the term usefully distinguishes cases of absorption of a large dose of toxin from those in which there is a multiplication of the poisonous agent in the blood. At any rate, this hypothesis held good in this case. The patient had rigors and a high temperature. Foetid clots were cleared out of the uterus, the temperature came down, and the patient recovered uninterruptedly. This was not a case of septicaemia, or pyaemia, or septic peritonitis; possibly, however, there may have been slight temporary septic metritis, but it disappeared at once on removal of the clots. In any case, the condition was septic. "To take another case. A patient three weeks after confinement suffered from a white leg, apparently owing to undue exertion. There are some gynaecologists who hold that phlegmasia is due to the entrance of germs through the uterine veins. Although I think that the length of time after the confinement negatives such an explanation in this patient, yet a man who maintained this view might notify such a case as one of 'acute septic inflammation in the pelvis.' This, of course, is an exaggerated view of sepsis; a remark which will apply also to the opinion of another gynaecologist of my acquaintance, that any rise of temperature in the puerperium is due to sepsis. However, these opinions show the difficulty of defining septic inflammation. "I now turn to the hope you express that medical men will co-operate with the Committee in endeavouring to reduce puerperal mortality. The question arises, in what way the Sanitary Committee proposes to deal with this mortality. The causes of puerperal sepsis must be found either in (1) the patient herself; (2) her medical attendant; (3) her nurse; or (4) her general surroundings. May I ask if the Committee proposes to deal with all these sources of possible infection, or only with some of them? As far as I can see, the only point with which the Committee can deal is that numbered (4), viz., the general surroundings; and in this case, too, very little could be dealt with except the condition of the drains and such 24 [Appendix IV. sanitary matters. But does the cause of puerperal septicaemia reside chiefly in drains? I am afraid that text-books have been rather inclined of late to attach the blame to some of the other possible sources of infection. Let us suppose a case has been notified to you, and that your inspector has found the sanitary condition of the premises good. What steps does the Committee propose to take next ? Will inquiries be made about the nurse? And if she is above suspicion, will a bacteriological examination of the doctor be made? I presume that the patient herself is not always an impossible source of the disease. But whatever the cause, the task of tracing it might be invidious in some cases. "I am afraid that I have written rather a long letter. My first reason for so doing is to bring to your notice the difficulties that occur to me. Secondly, I still want to know what puerperal fever is for purposes of notification? In the third place, although no case of puerperal fever infection has yet occurred in my practice, it is impossible to predict that such a calamity will never happen. I am therefore desirous of learning what steps the Committeeproposes to adopt on receipt of a notification of a case of puerperal fever." In his reply the Medical Officer of Health observed:— "All my Committee desire is that practitioners should consider the term to include the cases which fall within the definitions (practically identical) drawn up by the Royal College of Physicians and the Obstetrical Society. I may say that my own opinion is that all febrile conditions during the puerperium not being due to specific infection, such as scarlet fever, diphtheria, &c., are really septic. "As to what the Committee desire to accomplish by notification, I may say, on behalf" of the Committee, that, as regards the medical practitioner, we leave him to adopt every precaution which medical science indicates as necessary. That, as regards the nurse, a special communication is sent to her pointing out her duties with regard to infection. For some time past I have seen every woman, be she nurse, midwife, or 'friend,' who has had anything to do with a notified case of puerperal fever. The clothes, instruments, &c., of the nurse are always disinfected, and I think that I can say that for some years past no secondary case has occurred which could be attributed to infection carried by a nurse who has carried out my instructions. As regards the house (although here the action is, in my opinion, toolate), a full inspection is made and steps taken to remedy any defects found. Disinfection, &c., of the bedding and premises is carried out. As to the patient herself, I do not believe in 'auto-infection,' as taught by some gynaecologists, and regard all cases of sepsis as due to conditions external to the patient. Consequently there is nothing in this connection requiring action by my Authority, except disinfection at the conclusion of the case. "I cannot help thinking that the efforts which have been made by the Authority of this Borough have accomplished something in the past, and I think that better results will be obtained in the future if practitioners will extend the interpretation of the words 'puerperal fever ' to the limits of the definitions of the Royal College of Physicians and the Obstetrical Society. By so doing the case of sapraemia you mentioned would be one for notification. "White leg'' is, I believe, usually due to thrombosis, and not of aseptic nature. Consequently notification of such a case would not be asked for.'' Dr. X. replied:— "I wrote to you because I take a good deal of interest in the subject of infectious diseases, and for the same reason I venture to reply to some of your remarks. "I still think the definition of the College and the Obstetrical Society unsatisfactory, nor do I think that they really include the sapræmic case I mentioned, although I should have notified it as puerperal fever myself. I cannot regard all febrile conditions during the puerperium as really septic, as I am certain that the temperature of lying-in women may go up from very slight cause to 100°, or exceptionally much higher. I know of an interesting case in which fright due to a fire sent the temperature for a short while up to 104°. A foul discharge is generally a much better criterion than fever. "The communications made to the nurse are admirable, and of undoubted value, I should think, amongst the lower classes, in which case untrained women frequently, I believe, make examinations on their own account. The inspection of drains and the disinfection are excellent in a general way, but not likely to affect the mortality from puerperal fever to any extent. As regards auto-infection, it is obviously possible to introduce septic germs from the vulva, if they exist there; and if the bedding may carry them, so may the woman. The practitioner amongst the lower classes is not likely to shave and disinfect every patient. Report of Medical Officer of Health.] 25 "I hope that you are right in thinking that the Authority has accomplished something with regard to puerperal fever; but, to my mind, the medical practitioner is probably responsible in the vast majority of cases; and where such a feeling exists, it must be a little hard to obtain notification, as no man likes giving himself away. However, it may be useful to call his attention to notification of the disease." It cannot be denied that not only is it difficult to decide what cases may be septic, and therefore to be notified, but also that an often unmerited opprobrium rests on the practitioner in charge of such a case. The actual routine followed with respect to such cases may be usefully recorded in connection with this correspondence. As soon as a case of puerperal fever has been reported, steps are taken to obtain information as to previous cases attended by the practitioner, midwife, and nurse, and the following letter is sent to the nurse or midwife:— Madam,—I am informed that you attended of during her recent confinement. The said has been certified to me to be ill with puerperal fever, and I have therefore to warn you not to attend any other confinement until all necessary disinfection and cleansing of yourself, your clothes, instruments, &c., shall have been done, and certificate as to the sufficiency of such disinfection obtained from me or some other Medical Officer of Health. Should you neglect to observe this caution, you will render yourself liable to prosecution under the 68th section of the Public Health (London) Act, 1891. I shall be pleased to advise and assist you in this matter, on which you can see me if you will call here on between the hours of I am, Madam, Your obedient servant, Medical Officer of Health. The nurse's clothing, instruments, &c., are disinfected by the Department, and she is advised to take a complete bath, not forgetting to wash her head. No case has been brought to the knowledge of the Department attributable to infection conveyed by any nurse or midwife who has followed the instructions given to her. At the termination of the case, the patient's room, bedding, &c., are disinfected, and any defects in the sanitary arrangements are remedied. TYPHUS FEYER. Paddington. London. Cases reported in 1900 2 7 Average annual number, 1890-99 0 19 Case-rate, 1900 001 000 The 2 cases of this disease reported during the year were both erroneously diagnosed. Although cases have from time to time been reported in the past year, none have been found to be typhus fever when closely investigated. The disease does, however, continue to occur at rare intervals in other parts of the Metropolis. The particulars of the 2 cases reported were as follow:— The first case was that of a man, aged 55, reported on January 23rd. He resided in Portnall Road. He was visited by the Medical Officer of Health, after conference with the certifying practitioner, on the day the notification was received. The symptoms and rash were not those of typhus fever, but more like those of acute rheumatism. As the patient was not housed suitably to allow of his case being watched, he was sent to one of the Asylums Board's Hospitals as a "possible" ease of typhus fever. The ultimate diagnosis was one of rheumatic fever with sudamina. 26 [Appendix IV. Immediately after the removal of the patient his room, bed, &c., were completely disinfected, just as if the original diagnosis had been accepted. The second case was that of a woman, aged 58, who died in the Infirmary on August 13th, five days after admission from a house in Crompton Street. The deceased was a cook, who had been in service at a public-house in Oxford Street. She gave up her situation on account of ill health on July 27th, and went to Crompton Street, where she retained a room always at her disposal. Her movements between July 27th and August 8th could not be traced, as the case was not reported during the life of the patient, the diagnosis of typhus fever being made only after post mortem examination.* The history obtained at the Infirmary indicated that the illness commenced some three weeks before deceased's admission. The onset appeared to have been gradual, associated with "pains all over" the body, but no definite symptoms. The deceased had not been confined to bed. The clinical examination was practically negative. On the 10th, drowsiness was observed in the afternoon, and a large hæemorrhagic bulla was observed on the second finger of the right hand. On the 11th, deceased was less drowsy; the breath was very foul; tongue thickly furred and tending to dryness; another "blister" was found on the hand; and the right eye was bloodshot and the eyelids swollen. On the 12th, a mottled rash was found on backs of wrists, but nowhere else; the face was congested; the right eye was bloodshot and the conjunctiva swollen. She was drowsy, and became practically comatose in the afternoon. She died at 6 a.m. on the 13th. The temperature, which had ranged between 103° (afternoon of 8th) and 98° (afternoon of l2th) since her admission, rose to 106.6° just before death. At the post mortem examination the only pathological appearances noted were a congested state of the lungs and patchy congestion of the mucous membrane of the intestines. The deceased admitted being a drinker, but not a drunkard. The diagnosis of typhus was made faut de mieux. Two somewhat similar cases came to the knowledge of the Medical Officer of Health in the summer of 1899, and were briefly described in the Annual Report for that year.† It would seem more probable that the present case was one of ptomaine poisoning, but, for reasons already given, the point could not be cleared up. PLAGUE. In consequence of the outbreak of this disease in Glasgow in September of last year, this disease was added to the schedule of diseases to be notified in pursuance of Sec. 55 of the Public Health (London) Act, 1891, by Order of the Local Government Board, as from September 20th. One case was notified in the Metropolis during the last two months of the year, but the diagnosis was not confirmed by bacteriological examination. On receipt of the Order of the Local Government Board, a circular letter was issued to the local practitioners, informing them of the Order, and asking them to report all suspicious cases to the Medical Officer of Health, and arrangements were made for bacteriological examination. The Asylums Board set apart accommodation for the disease, and the London County Council retained the services of Mr. Cantlie, F.R.C.S., who obtained special experience in the diagnosis of the disease during the Hong Kong epidemic, and made arrangements for the segregation of "contacts." All persons arriving over sea from an infected port are subject to medical inspection at the port of entry, and the names and addresses of all who land are taken and forwarded to the local authorities of the districts to which such persons are proceeding. The assistance of the Medical Officer of Health was sought once before the close of the year with reference to a case which was thought to simulate plague. The case was so peculiar that a * This case was reported during the vacation, and was, in consequence, not fully investigated until some weeks after its occurrence. † See p. 39. Report of Medical Officer of Health.] 27 short note on it will be of general interest. Moreover, there has been no case recorded of exactly the same kind. J. A., male, aged 37, a carman, residing in Kensal Eoad, had been ailing for about two weeks prior to date of inquiry (October 30th). He had felt cold and stiff, but had not had any rigors until 29th, and then only very slightly. He had been under treatment since October 25th for "nasal and bronchial catarrh." He had also complained of his throat, which, however, to the naked eye presented no abnormality except slight redness. On October 29th he could not swallow well. His condition then was: "Temperature 99°, pulse fair and not rapid; glands of neck swollen, but not the tonsils; considerable infiltration of cellular tissues of neck, shoulders, and trunk (back and front), extending slightly down the thighs; inguinal glands not enlarged; nasal catarrh very marked; bronchial catarrh better." When seen by the Medical Officer of Health on the 30th, the two features which drew the attention were, first, the profuse discharge from the nose and the pachydermatous condition of the skin. The actual note on the latter was " skin of neck (all round) infiltrated, slightly red, and board-like; skin of chest and abdomen in same state, also that of upper arms." The skin was too resistent to pressure to allow any of the lymphatic glands to be made out. An examination of the nose revealed nothing. There was some difficulty in breathing, and the heart's action was somewhat laboured—both being evidently due to the state of the skin. The man's occupation naturally brought him into contact with horses, and although he stated that there had not been any cases of glanders in the yard where he worked, the result of the examination led to a suspicion that that was the disease he was suffering from. As however the case was altogether novel, it was decided to take steps to absolutely exclude all possibility of plague infection. Accordingly the Medical Officer of Health of the County was consulted, and Mr. Cantlie and Dr. Hamer, Assistant Medical Officer of the County, saw the patient on the evening of the 30th. The examination then made had the same results as already recorded, but two small somewhat-inflamed sores were then noted, one on each hand. There were no lines indicative of inflamed lymphatics. Samples of blood, sputum, &c., were taken for bacteriological examination. Mr. Cantlie decided that the case was not one of plague, and was inclined to agree to the possibility of its being glanders. The man was sent to University College Hospital, where he remained for some time, and whence he was subsequently discharged much improved in health. The specimens mentioned were examined at the London School of Tropical Medicine and at the Jenner Institute of Preventive Medicine. The report from the former was that the bacillus mallei (glanders) had been identified, but in a motile form. From the latter, it was reported that the specimens from the nasal secretion had been cultivated with negative results. The serum from the blood gave a "Widal reaction" with bacillus mallei, but the value of such reaction is doubtful. Bacteriological tests at the hospital were entirely negative as regards glanders. It may be memtioned here that the case was ultimately diagnosed by the hospital authorities as "scleroderma." In consequence of the suspicions aroused, the Veterinary Inspector of the Council was directed to visit the yard where J. A. was employed. The yard is jointly occupied by seven horse-owners, the total number of horses standing there being 23 (more or less). All the horses, except those of one owner, used the watering trough in common. In the stud of E. A.'s employer was found a recently purchased horse which presented suspicious symptoms and reacted to the mallein test. The horse was slaughtered and was found to be glandered. In the absence of compulsory powers the Veterinary Inspector was unable to say whether any of the other horses in the yard were similarly affected. 28 [Appendix iv. MEASLES. Although this disease is not included in the schedule for certification by practitioners or notification by householders, it will be useful to place on record some of the information as to its prevalence during the past year.* Last year, the disease apparently entered the Parish through Hall Park, the Head Mistress of the Infant Department of the Campbell Street Board School being the first to report any number of cases. The earliest returns were received from her on February 14th. The outbreak did not follow any definite course through the Parish, and the various schools were infected in an erratic and apparently independent order. At the same time it has to be recognized that most teachers delay calling attention to the disease until the attendances have markedly fallen off. Long intervals elapse in the majority of reported cases between the onset of the illness and the date of the report of the case. Many factors contribute to this, among them being the irregular attendance common to very young children, statements by the parent that the absentee has only a cold, and delay in placing the case of the absent scholar in the hands of the Attendance Officer. During the months when the schools were in session 1,191 cases of measles were brought to the knowledge of the Department, excluding 108 cases reported by the school teachers, but not confirmed by the statements of the parents and others. The patients were members of 825 families, living in 708 houses. From the inquiries made the statistics in the following Tables have been compiled, the figures for 1898, the last epidemic year, being added for comparison. (See Tables 11, 12, and 13.) The first point worthy of notice is the fact that the number of cases reported in each epidemic is almost identical, viz., 1,191 in 1900 and 1,196 in 1898. This suggests that a definite proportion of the whole cases, at least, comes to the knowledge of the Department and enhances the value of the statistics collated. From Table 11 it will be seen that the outbreak was later last year than in 1898, and that it was of shorter duration, lasting (at its worst) for three months, viz., April, May, and June, or two months less than in 1898, when it extended from February to June.† At the same time the total number of attacks in May of last year (541) greatly exceeded the maximum of any month in 1898. This was in part owing to the absence of information of new cases during the Easter holidays. Having regard to the fact that the most common cause of death in this disease is either bronchitis or pneumonia brought about by exposure before complete recovery, the postponement of the main outburst until the onset of milder weather was a distinct advantage. "With the commencement of the summer holidays, at the end of June, came the end of information of fresh centres of infection. When the schools re-opened the epidemic had spent itself. The efforts made to limit the spread of infection can hardly, owing to the peculiarity in the disease, he expected to prevent the recurrence of multiple cases in infected households. It is desired to prevent the spread of infection to other households. The frequency of multiple cases (as shown in Table 12) is therefore not of much importance. What is wanted, is to reduce, if possible, the number of houses infected, and to a certain extent the increase in the total for last year, compared with that of 1898, is disappointing. In connection with multiple infections it should be stated that 442 secondary cases out of a total of 483 were infected prior to the first visit of inquiry, i.e., before the case came to the knowledge of the Department. * The sources of information and the regime consequent thereon are fully described in the Annual Report for 1898. Vide p. 60 et seq. † In 1898 the outbreak had got pretty well out of hand before it was brought to the knowledge of the Department. Efforts to limit its spread were not initiated until the middle of March. 29 Report of Medical Officer of Health.] TABLE 11. Measles. Dates of known attacks, in months. Paddington. St. Mary. St. John. 1900. 1898. 1900. 1898. 1900. 1898. January 11 11 9 11 9 6 February 43 244 34 244 9 5 March 67 367 58 343 20 19 April 146 231 126 202 48 26 May 541 178 493 148 46 13 June 327 122 281 109 4 9 July 33 20 29 19 — 2 August 1 — 1 — — 3 September 1 — 1 — — 1 October 13 1 13 4 — — November 8 3 8 3 — — December — — — — — — No date recorded — 16 — 14 — — Year 1,191 1,196 1,053 1,097 138 84 TABLE 12. Frequency of multiple infection of houses. Cases per house. Paddington. St. Mary. St. John. 1900. 1898. 1900. 1898. 1900. 1898. 1 415 352 349 313 66 39 2 172 160 147 148 25 12 3 78 69 74 64 4 5 4 28 29 27 26 1 3 5 7 22 7 22 — — 6 5 5 4 5 1 — 7 3 4 3 4 — — 8 — 3 — 3 — — 9 — 1 — — — 1 Total houses infected 708 645 611 585 97 60 30 TABLE 13. Sex-Age Distribution. Ages. PADDINGTON. ST. MARY. ST. JOHN. PADDINGTON. Males. Females. Males. Females. Males. Females. Persons. 1900. 1898. 1900. 1898. 1900. 1898. 1900. 1898. 1900. 1898. 1900. 1898. 1900. 1898. Months. 0- 1 2 - 1 1 2 - 1 - - - - 1 3 3- 3 1 4 2 3 1 4 2 - - - - 7 3 6- 16 16 12 16 15 16 12 15 1 - - 1 28 32 9- 17 18 14 13 15 16 13 13 2 2 1 - 31 31 Under 1 year 37 37 30 32 34 35 29 31 3 2 1 1 67 69 Years. 1 1- 75 66 54 75 68 58 52 69 7 8 2 6 129 141 2- 68 58 65 52 61 54 62 49 7 4 3 3 133 110 3- 72 84 92 79 60 77 79 74 12 7 13 5 164 163 4- 122 115 111 92 112 110 106 87 10 5 5 5 233 207 Aged 1-5 years 337 323 322 298 301 299 299 279 36 24 23 19 659 621 Years. 5- 104 81 98 101 85 74 86 90 19 7 12 11 202 182 6- 72 84 80 79 60 76 71 71 12 8 9 8 152 163 7- 27 30 24 38 17 26 20 36 10 4 4 2 51 68 8- 10 19 11 11 8 17 11 10 2 2 - 1 21 30 9- 2 8 7 10 2 7 7 8 - 1 - 2 9 18 Aged 5-10 years 215 222 220 239 172 200 195 215 43 22 25 24 435 461 Years. 10- 3 17 15 11 3 15 12 10 - 2 3 1 18 28 15- 5 5 7 6 4 4 4 4 1 1 3 2 12 11 Totals 597 604 594 586 514 553 539 539 83 51 55 47 1,191 1,190 Ages not stated - 4 - 2 - 4 - 1 - - - 1 - 6 Grand Totals 597 608 594 588 514 557 539 540 83 51 55 48 1,191 1,196 [Appendix IV. Report of Medical Officer of Health.] 31 The figures in Table 13 show clearly the special liability of young school-attenders to the disease. Assuming that the school ages lie between 3 and 15 years, and that children aged 6 years pass from the infant department to the boys' (or girls') school, the cases among the two classes (both sexes, whole Parish) were:— 1900. 1898. Infants, 3-6 607 552 Boys Girls 6-15 251 307 The frequency with which medical attendance is obtained for patients ill with measles has been much discussed. Inquiries on the subject were made during the past year, and it appeared that at 314 out of 708 houses practitioners were in attendance on 519 (out of 1,191) children. As to the value of disinfection, no definite opinion can yet be given. The form in which the work has been recorded makes it difficult to state the facts with absolute accuracy. It appears that disinfection was done for 467 families (the patient being the only one child in 12 of the houses), and that 12 further cases occurred therein at dates varying from 2 days to 1 month after disinfection. Disinfection was refused 348 times (in 29 houses the patient was the only child in the house), and 9 cases occurred subsequently to such refusal at intervals of 4 to 40 days subsequent to the date of offer to disinfect. The two sets of cases are set out below:— Disinfection refused 348 instances. There were no other children to infect in 29 instances. In the remaining 319 households 9 cases occurred on the following days—day fixed for disinfection, 4th, 6th, 9th, 15th — 16th, 18th, 26th, and 40th days. Disinfection performed 467 instances. There were no other children to infect in 12 instances. In the remaining 445 households 12 cases occurred on the following days—2nd, 5th, 6th, 7th, 8th—33rd, 100th. Assuming, as was probably the case, that the patients who sickened on the days indicated in italics were infected at the time disinfection was done, or offered and refused, there remain 4 cases in the first group and 2 in the second apparently occurring after disinfection was due or done. The cases in the latter group occurred at intervals far in excess of the incubation of the disease, suggesting independent sources of infection. In any case the data are insufficent to base any trustworthy conclusions on. In 1898 the Medical Officer of the School Board for London directed the attention of the Board to the presence of children in the Board's schools whilst suffering from measles. This is, unfortunately, not an uncommon experience, children having been found in school with the rash fully out. In a communication to the London County Council, the School Board urged that measles ought to be declared to be a "dangerous infectious disease." No one who has had experience with the poorer classes would deem measles to be anything else; but it so happens that it is not a "dangerous infectious disease "at law. Consequently there are in the Metropolis no legal powers to compel measures to be taken with a view to reduce the prevalence and mortality of the disease. To that extent metropolitan authorities are in a more helpless position than are the provincial. In the provinces the section of the Public Health Act, 1875, which enables disinfection to be enforced, if certified by the medical officer of health to be requisite (Section 120), applies to any "infectious disease," while those relating to removal to hospital, exposure of infected person, things, &c., to any "dangerous infectious disease." There is no definition of what is an "infectious" or a "dangerous infectious" disease except that contained in the Notification Act of 1890, and there "dangerous infectious disease" is defined "for the purposes of this Act," i.e., for notification. The position of provincial local authorities who have adopted the Infectious Disease (Prevention) Act, 1890, is not quite so strong, inasmuch as the adoption of that Act repeals Section 120 of the 32 [Appendix. IV. Act of 1875—the most comprehensive section of all—and practically limits the scope of all the other sections of the Act of 1875 relating to infectious diseases to those specified in the Notification Act of 1890. The London Connty Council, in 1898, sought the views of the (then) Vestries and District Boards as to the desirability of declaring measles to be a "dangerous infectious disorder." The result appears to have been unsatisfactory, as in December last a further circular letter was sent out, addressed to the Metropolitan Boroughs, on the same question. In the event of the disease being added to the list of "dangerous infectious" disorders, it is intended that the provisions of Sections 60-66, 68-70, and 72-74 of the Public Health (London) Act, 1891, should be applied.* These sections do not include either the notification of or the provision of hospital accommodation for the disease, on both of which points there is much ground for debate. The application of the sections would, however, enable proceedings to be taken to stop the exposure of infected children in the streets and schools, and to enforce cleansing and disinfection of "premises and articles." It is more than probable that if the disease were brought within the scope of preventive legislation, parents and others would come to regard the disease as something not to be trifled with, would keep their children at home, and not expose them, as so many do now, to the vicissitudes of the English climate. Measles is a disease which every housewife can recognize, and consequently much advantage might be expected to accrue if the Legislature would accept the view of the medical profession that measles is a dangerous infectious disease, and impose penalties on those who wilfully disregard the health of their own families and of the public generally To any proposals to add the disease to the schedule for notification, it is customary to urge that only a very small proportion of the cases receive medical attention. That may be granted, but it has to be remembered that notification of infectious disease is the duty of the householder or parent (as the case may be), and that, as has already been mentioned, measles is a disease which every housewife recognizes. Consequently, were the disease notifiable, there would be a statutory obligation on the parent or householder, even if no medical practitioner were in attendance. If the public could be induced to report cases as soon as suspectcd, and to work with the local authorities in the direction of home isolation (which would mean the segregation of all the younger members of the family) and disinfection, a reduction in the prevalence and mortality of this disease might be looked for, which would repay the trouble and inconvenience gone through. There is one other inducement which can be urged. Besides the lives actually lost under present circumstances by neglect or mismanagement of the disease, there are the children who survive, with their constitutions more or less damaged. The special liability to lung disease which characterizes measles only too often leads to tuberculosis, and there are other diseases (which need not here be specified) which owe their inception to neglected attacks of measles. The adoption of measures calculated to reduce the prevalence of the disease, and the exercise of greater care of those who are attacked, mean not only the reduction in the actual number of deaths from measles, but also the protection of an unknown number of young lives from unnecessary ill-health and loss of vitality. * At the meeting of the Borough Council held on February 5th of the current year the Public Health Committee submitted the following recommendation, which was adopted nem. con. by the Council:— "That the London County Council be informed that the Council of the Borough of Paddington is in favour of the inclusion of 'measles' in the term 'dangerous and infectious diseases,' for the purposes of the Sections of the Public Health (London) Act, 1891, set out in the Council's letter of December 16th last, those of Section 66 being excepted." Report of Medical Officer of Health.] 33 SCHOOL ATTENDANCE. The customary return of cases reported in connection with the public elementary schools in the Parish will be found in Table 14. TABLE 14. Scholars Attending. Patients not Scholars. From Outside. S. F. Dip. S. F. Dip. S. F. Dip. Board. Amberley Eoad 11 3 15 10 Campbell Street 3 1 5 7 3 1 Essendine Eoad 4 1 8 4 — — Harrow Road 18 5 38 13 1 — Totals 36 10 66 34 4 1 Other Public Elementary Schools. All Saints — — — — — Bayswater Jewish 2 — 2 — — 2 Cirencester Street, R.C. 1 1 3 1 — — Holy Trinity 5 — 13 — — — St. Augustine 3 — 5 2 18 15 St. James 2 1 2 3 — — St. John 1 — — — — — St. Luke, Kilburn 3 1 7 1 4 2 St. Luke, Westbourne Park — — 1 — 2 1 St. Mary 6 2 10 6 — St. Mary of the Angels — 1 2 1 — 2 St. Mary Magdalene 9 3 16 14 — — St. Matthew 1 — 3 2 — — St. Michael 5 1 7 3 — — St. Paul 2 5 9 7 — — St. Peter 7 — 11 2 — — St. Saviour 4 1 8 3 — — St. Stephen 11 2 19 3 5 6 Saltram Crescent High School 4 5 5 7 1 — Westbourne 6 — 11 3 2 1 Woodfield 3 5 5 7 — 1 Totals 75 28 139 65 32 30 There were reductions in the numbers of children, who were scholars, attacked both with scarlet fever and diphtheria, notably the latter. On the other hand, there were increases in the numbers of households sending scholars who were required to be excluded from school on account of infectious illness in other members of the households. The figures for 1899 and 1900 are contrasted below:— Scholars attacked. Families excluded. Scarlet fever:— 1899. 1900. 1899. 1900. Board schools 56 36 14 66 Other schools 74 75 18 139 Diphtheria:— Board schools 27 10 4 34 Other schools 44 28 13 65 34 [Appendix IV. In accordance with an arrangement arrived at some years ago, duplicate school notices are exchanged with the adjacent districts. Last year 67 such notices were received from outside, 5 relating to children attending Board schools, and 62 other schools. The numbers of certificates from each of the districts during the last two years were:— Scarlet Fever. Diphtheria. 1899. 1900. 1899. 1900. Willesden 25 23 35 17 Chelsea (Kensal Town) 4 1 4 1 Kensington 7 9 3 12 Marylebone 2 3 — 1 It is not possible to distinguish between scholars attacked and scholars excluded in these returns, neither has any account been taken of the certificates received in connection with cases of enteric fever. BACTERIOLOGICAL DIAGNOSIS. There was a steady increase in the use of this valuable aid to diagnosis during the past year. In all, 68 specimens were submitted for examination, viz., 36 from suspected cases of diphtheria, 25 of enteric fever, 6 from patients just returned from hospital who gave rise to return cases, and 1 from a suspected case of plague. The results obtained from the specimens of the two first groups were:— Diphtheria. Enteric Fever. Suspicion confirmed 16 13 ,, negatived 18 12 Result doubtful 2 — It is probable that, had this aid not been available, the cases which gave the negative (and doubtful) results would have been recorded as the disease suspected. It is needless to dwell upon the gain resulting from the use of the tests in the direction of anxiety allayed, loss of business, expenditure for disinfection, &c., &c. It should be added that in each case the results were communicated to the medical attendant only. It would be eminently desirable if the tests were employed in every suspected case and certification delayed until the results were known. Of course there are instances in which it would be unsafe to delay the isolation of a suspect at home, and such cases must be certified and removed forthwith. Such cases, however, form but a comparatively small proportion of the cases notified. It would further be desirable that, where patients are treated at home, isolation should be kept up until the throats have been found free from the bacilli of diphtheria. No work has been undertaken up to the present in connection with the diagnosis of tuberculosis, except that 39 samples of milk were bacteriologically examined during the first quarter of the year. This matter will be dealt with later on in speaking of the mortality from the disease. Report of Medical Officer of Health.] 35 DEATHS. The deaths registered in the Parish during the year numhered 2,307 in all, viz., 1,144 of males and 1,163 of females, and were equivalent to an annual mortality of 17.66 per 1,000 persons of all ages. This gross total was 120 in excess of the (uncorrected) average for the preceding ten years (2,187), while the gross death-rate was 0.18 below the mean rate 17.84. (See Table I.,. Appendix A.) Of the 2,307 deaths, 1,596 (748 of males and 848 of females) were registered in St. Mary, and 711 (396 of males and 315 of females) in St. John. The deaths registered included 112 from diarrhoea, 53 from measles, 34 from whooping cough, 11 each from diphtheria and enteric fever, 2 from simple continued fever, and 1 each from scarlet and typhus fevers. There were TABLE 15. Deaths of Parishioners, 1900. Deaths recorded during Paddington. St. Mary. St. John. Males. Females. Both Sexes. Males. Females. Both Sexes. Males. Females. Both Sexes. 1st Quarter 298 332 630 242 265 507 56 67 123 2nd 255 265 520 212 217 429 43 48 91 3rd 231 228 459 191 190 381 40 38 78 4th 212 240 452 167 191 358 45 49 94 Year 996 1,065 2,061 812 863 1,675 184 202 386 Rates* 1900 18.40 13.92 15.78 19.23 15.68 17.22 15.84 9.40 11.57 Mean rates, 1895-9 18.55 13.73 15.64 19.56 15.63 17.28 15.09 9.00 11.12 Death-rates* 1899 18.23 14.36 15.96 19.24 16.78 17.85 14.71 8.7 10.57 1898 19.02 13.69 15.89 20.64 15.34 17.64 13.43 9.1 10.97 1897 17.35 12.20 14.33 17.86 14.00 15.68 15.60 7.4 10.60 1896 18.58 13.06 15.55 19.82 15.00 17.65 14.46 8.1 10.71 1895 19.58 15.34 17.00 20.26 17.05 18.58 17.27 11.10 12.76 * Rates per 1,000 individuals in each group. also registered 152 deaths from cancer, 143 from phthisis, 91 from other tubercular diseases, 283 from bronchitis, 139 from pneumonia, 91 from influenza, and 19 from gastro-enteritis. Of the deceased persons, 461 were under the age of one year, being 1 less than the decennial average, while the infantile mortality (159 per 1,000 births registered) was 4 in excess of the average (155). The deaths registered in the Parish included 401 of non-residents, chiefly in local public institutions, while 155 deaths of residents were recorded in other parts of the Metropolis. Deducting the former deaths and adding the latter, a nett total of 2,061 deaths of residents during the year is obtained,* equivalent to a nett annual mortality rate of 15.78 per 1,000 persons of all ages, compared with a mean decennial rate of 16.45—showing a reduction amounting to 0.67 per 1,000 persons, or 87 lives (see Table 16). In the five years 1890-4, the mean annual mortality was 17.16 per 1,000, or 1.38 above the rate for last year, while in the five years 1895-9, the mean annual rate was 15.64, or 0.14 below the rate for last year.† * Throughout the remainder of the Report the deaths of such persons only will be taken account of. † Much emphasis cannot be laid upon this apparent improvement, as the rates for the decennium are liable to revision when the census returns are issued. 36 [Appendix IV. The nett total of deaths is not suitable for comparison with the returns for other districts owing to the varying proportions of males and females at the different ages. By the use of factors based upon "standard death-rates" and the numbers of each sex living at each age "corrected" death-rates are obtained, suitable for such comparisons. In this way the corrected rates are given in Table 17 have been calculated. It will be found that last year's "corrected" rate for Paddington (17.18) was lower than the rates prevailing in the Western Parishes, with the exception of that of St. George, Hanover Square (14.35)—as it has been in each of the four years included in the Table. Other rates under 17.18 recorded last year were those of Hampstead (13.01), Hackney (16.91), and Wandsworth (15.80). TABLE 16. Death-rates per 1,000 persons living. Year. Paddington. St. Mary. St. John. England and Wales. London. 1900 15.78 17.22 11.57 18.3 18.8 1890 17.97 19.28 14.78 19.5 21.4 1891 17.57 18.72 14.69 20.2 21.5 1892 17.78 19.01 14.17 19.0 20.7 1893 17.63 19.33 13.24 19.2 21.3 1894 14.88 16.36 10.99 16.6 17.8 1895 17.00 18.58 12.76 18.7 19.9 1896 15.55 17.65 10.71 17.1 18.6 1897 14.33 15.68 10.60 17.4 18.2 1898 15.89 17.64 10.97 17.6 18.7 1899 15.96 17.85 10.57 18.3 19.8 Mean rates 1890-1899 16.45 18.01 12.34 18.36 19.79 In Table 18 comparison is instituted between the death-rates recorded last year and certain mean rates in the Parish, in London, and in England and Wales. It will be seen that all the local rates of last year were better than any of the other rates taken for comparison. The best comparison is that with the rate for "Rest of England and Wales," which may for present purposes be taken to represent rural England. For the sake of clearness the figures are quoted here:— "Nett" Rates per 1,000 Persons of all Ages. Rual England 17.5 Paddington 15.8 St. Mary 17.2 St. John11.6 Report of Medical Officer of Health.] 37 The nett, hut not "corrected," death-rates of Bath and Eastbourne for 1900 were 17.1 and 10.3 per 1,000 persons respectively. The 2,061 deaths of Parishioners comprised 996 of males and 1,065 of females, equal to deathrates of 18.40 and 13.92 per 1,000 of each sex estimated living at all ages, compared with mean rates of 18.55 and 13.73 for the preceding quinquennium (see Table 15). The deaths of residents TABLE 17. Comparison of "Corrected" Death-rates and Infantile Mortalities. Based on "Recorded rates," as calculated by the registrar-General. Standard Death-rate per 1,000. Recorded Deathrate, 1900. Corrected Rates. Infantile Mortality per 1,000 births. 1900. 1899. 1898. 1897. 1900. 1899. 1898. 1897. England and Wales 19.15 18.3 18.3 18.3 17.6 17.4 154 163 161 156 London 17.96 18.8 20.02 20.57 19.51 18.87 158 166 166 158 West— Paddington 17.72 15.9 17.18 17.39 17.39 15.56 165 151 161 149 Kensington 17.38 15.8 17.40 19.50 18.07 17.29 180 181 181 166 Hammersmith 18.05 17.2 18.24 20.15 19.41 17.71 162 183 183 171 Fulham 18.27 17.3 18.13 20.12 18.02 17.81 147 189 168 162 Chelsea 17.95 18.3 19.52 20.91 19.41 18.98 149 164 176 161 St. George, Hanover Sq. 17.34 13.0 14.35 15.68 14.57 14.57 107 129 120 133 North— Marylebone 17-82 18-9 20-31 19-98 19-66 19-66 125 124 132 136 Hampstead 16-63 11-3 13-01 13-35 13-47 13 58 100 129 125 127 St. Pancras 17-89 18-9 20-23 21-72 2055 20-01 160 178 170 168 Islington 17-90 16-3 17-43 19-36 17 75 16-90 145 160 159 136 Hackney 18-23 161 16-91 17-75 17-22 17-33 158 153 152 147 East— Shoreditch 18-45 21-6 22-41 24-70 23-14 22-41 186 204 196 183 Bethnal Green 18-39 22-0 22-90 23-74 23-22 22-28 168 174 184 171 Whitechapel 17-74 19-4 20-94 22-77 21-80 22-02 139 147 144 148 St. George in the East 18-43 24-4 25-35 28-15 25-76 27-43 162 200 195 197 Mile End, Old Town 18-58 20-4 21-02 21-95 20-51 19-27 158 158 155 149 Poplar 18-49 22-3 23-09 22-88 21-95 20-50 192 176 191 170 South— Newington 18.32 21.9 22.89 25.08 21.42 22.16 171 191 173 177 Lambeth 18.24 17.4 18.26 20.15 18.79 18.37 145 158 154 151 Battersea 17.80 16.8 18.07 17.96 18.18 17.42 159 162 166 162 Wandsworth 17.93 14.8 15.80 16.34 15.37 14.31 144 153 144 135 Camber well 18.10 16.3 17.24 18.40 17.35 17.56 154 158 160 159 Correspondingly "Corrected " Rates, 1900:— Croydon 15.22 Birmingham 23.79 Liverpool 28.17 Brighton 18.04 Manchester 27.34 Sheffield 25.12 in St. Mary's Sub-District (1,675) were equivalent to a rate of 17.22, being 0.06 less than the quinquennial mean (17.28), and the deaths of residents in St. John's (386) to a rate of 11.57, or 0.45 in excess of the mean (11.12). In comparison with the preceding decennium (Table 16), the death-rate for St. Mary (17.22) was 1.21 less than the mean, and that of St. John (11.57), 0.67. The number of deaths of residents in each Sub-District, and the estimated population thereof, will be found in Table II. in Appendix A. 38 [Appendix IV. The incidences of disease and death vary widely at the different ages of life, and are unequal for the two sexes. Moreover, the diseases which are most amenable to hygienic control are those of certain ages, e.g., extreme youth and young adult life. A rate based on the deaths of persons at all ages consequently gives but a very incomplete account of the success or failure attaching to the work of sanitation. The rates for 9 sex-age groups have therefore been calculated, and will be found in Tables 19 and 19a (see pp. 40 and 41). One rate may be here mentioned to illustrate what has TABLE 18. Death-rates from "All Causes" and Selected Diseases. Death-rates* from Infantile Mortality (0-1 year) per 1,000 births registered. All Causes. Small-pox. Measles. Scarlet Fever. Diphtheria. Whooping Cough. "Fever." Diarrhœa. England and Wales 1900 18.3 0.00 0.39 0.12 0.29 0.34 0.17 0.69 154 11890-99 18.4 0.01 0.41 0.17 0.25 0.39 0.18 0.70 153 33 Great Towns 1900 19.5 0.00 0.43 0.13 0.35 0.45 0.20 0.94 172 1896-99 19.3 0.00 0.57 0.17 0.35 0.44 0.20 1.11 176 67 Large Towns 1900 18.1 0.00 0.51 0.12 0.29 0.34 0.19 0.81 166 1896-99 17.4 0.04 0.44 0.14 0.26 0.35 0.20 1.01 170 Rest of England and Wales 1900 17.5 0.00 0.32 0.10 0.24 0.27 0.16 0.48 138 1896-99 16.5 0.00 0.31 0.11 0.20 0.28 0.16 0.61 134 London 1900 18.8 0.00 0.42 0.07 0.34 0.42 0.16 0.77 158 1890-99 19.8 0.01 0.61 0.20 0.49 0.53 0.14 0.74 159 PADDINGTON 19001† 15-8 - 0.40 0.04 0.20 0.26 0.08 0.79 165 1890-99‡ 16-4 0.00 0.39 0.12 0.45 0.39 0.12 0.63 151 St. Mary, North Paddington 1900† 17.2 - 0.49 0.05 0.26 0.31 0.11 0.97 171 1890-99‡ 18.0 0.01 0.48 0.13 0.53 0.48 0.11 0.76 155 St. John, South Paddington 1900‡ 11.6 - 0.12 - 0.06 0.12 - 0.27 126 1890-99+ 12.3 0.00 0.13 0.09 0.24 0.16 0.13 0.27 124 "0'00"— a rate less than 0"01 per 1,000. " — " — no death recorded. * Rates calculated per 1,000 estimated living in each year. †The "all causes" rate hero given does not agree with that mentioned elsewhere, being based on a total of 2,069 deaths obtained by the RegistrarGeneral, as compared with one of 2,061 obtained by the Department. ‡ Calculated from local statistics. All other rates are based on the published returns of the Registrar-General. already been said. The rates for children aged from 1 to 5 years were last year 22.38 per 1,000 for males and 18.96 for females, compared with corresponding rates of 17.16 and 17.34 for 1899. It will be noticed, too, that these rates for the six years 1895-1900 form two series of alternate years. The years of high rates have been years of epidemic prevalence of measles, and the years of low rates years of practical freedom from that disease. On the other hand, the death-rates all ages,. 18.40 for males and 13.92 for females, do not show any special increase in mortality—indeed, that for females is below the rate for 1899—and thus disguise the increase in loss of life from preventable, disease. Report of Medical Officer of Health.] 39 Males.—The sex-age rates, almost without exception, compare favourably with the mean rates for 1895-1899, although many of them are above the rates for 1899. The most notable departures from the means are the increases in the rates for " 65 and over," all being considerably above the respective means. The increases recorded above the rates for 1899, mostly confined to the groups " 0-1," " 1-5," were chiefly due to epidemics of measles and diarrhoea. Females.—The rates recorded last year do not compare quite so well with the mean rates, but there were no increases in the rates " 65 and upwards " as noted among males. The increases of the rates in 1900 compared with those of 1899 were more general, but not so large. Before leaving this part of the Report attention may again be called to rates for the ages 1 to 5 years. Last year, as has already been stated, was one of the epidemic years for measles, a disease which, up to 1896, was allowed to take its own course. It is of interest, therefore, to compare the mortality rates for the last three epidemic years, i.e., for a year when no action was taken except to close schools (1896), a year when an imperfect scheme of control was in operation (1898), and a year when as much as is possible under existing legislation was done to limit the spread of the disease. Mortality per 1,000 estimated living in each sex-district group. Ages 0-5 years 1896. 1898. 1900. Paddington— Males 31.92 31.54 22.38 Females 29.63 29.49 18.96 St. Mary— Males 33.51 34.98 23.94 Females 31.25 32.46 21.22 St. John— Males 24.18 14.23 14.26 Females 21.95 14.85 7.44 Even after allowing for the known variation in the virulence of the disease in successive epidemics, the figures quoted suggest that the efforts made—incomplete as they admittedly are— have done something towards reducing the mortality from this disease. For the sake of completeness, the mortality rates at ages under 1 year, based on the numbers estimated to be living at those ages, have been included in Tables 19 and 19a, but a better rate is that based on the births registered, on which standard the infantile mortality last year was at the rate of 165 per 1,000 births registered. This subject will be dealt with later on under the special title of " Infantile Mortality." CAUSES OF DEATH. The complete analysis according to sex and age of causes of death of residents during the year will be found in Table III. (Appendix A). In Tables 20 and 20a (pp. 42 and 43) the returns of deaths and mortality rates for last year are compared with the averages and mean rates respectively, the former having been corrected for the variations in the populations and adjusted to the nearest whole numbers. Attention may also be directed to Table 18 on the opposite page, where a comparison is instituted between the rates from the individual zymotic diseases in Paddington, the Metropolis, and the country generally. For reasons already given, it would have been desirable to obtain the mortality rates for age.groups of each sex, but time and space forbid such work, except in a few special instances. 40 [Appendix IV MEASLES. 1900. 1899. 1898. 1897. Number of cases recorded 1,053 52 1,196 ? Number of deaths 52 4 89 2 Fatality * 4.9 7.7 7.4 ? Mortality + 0.40 0.03 0.69 0.01 Although 1900 was one of the "epidemic" years for this disease, the number of deaths recorded (52) was only 1 in excess of the decennial average (51), and mortality (0.40 per 1,000* persons of all ages) 001 in excess of the decennial mean rate (0.39). In North Paddington the- TABLE 19. Death-rates per 1,000 estimated living at each age. Males. Age Groups. 1895. 1896. 1897. 1898. 1899. Means 1895-99. 1900. PADDINGTON. 0-1 211.18 215.57 180.21 225.58 189.97 204.50 190.40 1-5 21.42 31.92 21.29 31.54 1716 24.66 22.38 5-15 2.64 3.26 4.05 3.81 3.08 3.37 304 15-25 3.86 2.88 3 08 3.23 3.57 3.32 316 25-65 16.32 13.50 14.15 13.08 14.49 14.31 14.20 65 and over 95.62 78.39 80.57 84.14 105.03 88.75 102.92 All ages 19.58 18.58 17.35 1902 18.23 18.55 18.40 0-5 63.31 72.43 56.39 74.40 55.30 64.36 59.48 5-65 10.28 8.67 9.25 8.65 9.32 9.23 9.06 5 and over 14.00 11.72 12.37 11.95 13.50 12.71 13.15 ST. MARY. 0-1 211.59 216.03 186.71 233.42 201.21 209.79 195.54 1-5 24.08 33.51 21.69 34.98 18.99 26.65 23.94 5-15 2.73 3.52 4.00 3.82 3.17 3.45 3.24 15-25 3.72 3.25 2.98 3.83 4.27 3.61 3.59 25-65 16.47 14.27 14.57 14.13 15.26 14.94 15.18 65 and over 98.50 83.08 77.29 85.73 101.35 89.19 96.47 All ages 20.26 19.82 17.86 20.64 19.24 19.56 19.23 0-5 66.34 74.64 58.89 79.71 6004 67.92 62.59 5-65 10.23 9.44 9.37 9.28 9.83 9.63 9.65 5 and over 13.82 12.16 1213 12.39 13.54 12.81 13.17 ST. JOHN. 0-1 208.79 212.88 142.10 178.94 121.69 172.88 158.73 1-5 806 24.18 19.37 14.23 7.77 14.72 14.26 5-15 2.22 2.11 4.28 3.75 2.68 301 2.14 15-25 4.27 1.84 3.36 1.49 1.49 2.49 1.87 25-65 15.87 10.90 12.86 9.78 12.03 12.29 11.01 65 and over 88.49 67.11 88.58 80.20 114 33 87.74 119.45 All ages 17.27 14.46 15.60 13.43 14.71 15.09 15.48 0-5 47.51 61.33 43.56 46.72 30.17 45.86 42.70 5-65 10.43 7.12 8.87 6.56 7.63 8.12 7.06 5 and over 14.61 10.34 13.14 10.50 13.35 12.39 13.09 * " Fatality " represents the number of deaths per 100 cases of the disease reported. + " Mortality." the death.rate per 1,000 persons of all ages unless specially stated otherwise. Report of Medical Officer of Health. 41 excesses were the same as in the whole Parish, while in St. John the number of deaths (4) was equal to the decennial average, and the mortality (0.12) 0.01 below the mean rate (0.13). Averages for a disease which recurs in epidemics at almost equal intervals of time are liable to be vitiated by the accident of the commencement of the period averaged coinciding with an epidemic or non-epidemic year. This explains to a considerable extent the differences which will be noticed in the quinquennial averages and mean rates given in Tables 20 and 20a. Measles is so markedly a disease of young children that the mortality at all ages forms but an indifferent basis of comparison for different districts, having regard to the varying proportions of children in their populations. TABLE 19a. Death-rates per 1,000 estimated living at each age. Females. Age Groups. 1895. 1896, 1897. 1898. 1899. Means 1895-99. 1900. PADDINGTON. 0-1 168.05 144.41 157.08 129.54 135.77 146.97 155.20 1-5 23.49 29.63 15.46 29.49 17.34 23.08 18.96 5-15 3.31 4.05 3.41 2.82 2.42 3.20 3.19 15-25 2.47 2.21 1.62 2.26 1.65 2.04 2.21 25-65 9.99 8.80 7.73 8.68 10.06 9.05 9.78 65 and over 90.43 58.63 69.25 79.85 95.77 78.78 76.67 All ages 15.34 13.06 12.20 13.69 14.36 13.73 13.92 0-5 55.77 55.33 47.07 51.89 43.78 50.57 49.39 5-65 8.51 6.28 6.97 6.02 6.58 6.87 6.69 5 and over 13.23 9.29 9.09 10.27 11.72 10.72 10.72 ST. MARY. 0-1 173.91 151.84 168.97 132.13 147.77 154.92 162.81 1-5 25.92 31.25 17.12 32.46 19.07 25.16 21.22 5-15 3.53 3.57 3.10 3.17 2.56 3.18 3.62 15-25 2.97 2.63 2.08 2.68 1.84 2.44 2.33 25-65 11.03 10.67 8.64 9.49 11.84 10.33 10.96 65 and over 89.43 57.61 72.93 81.46 104.72 81.23 78.00 All ages 17.05 1500 14.00 15.34 16.78 15.63 15.68 0-5 59.62 58.74 51.71 55.18 48.40 54.73 53.49 5-65 7.58 7.30 5.94 6.57 7.56 6.99 7.40 5 and over 12.50 10.33 9.97 11.08 13.39 11.45 11.64 ST. JOHN. 0-1 134*02 102.56 8910 114.42 64.67 100.95 109.45 1-5 11.58 21.95 7.42 14.85 8.67 12.89 7.44 5-15 2.41 5.94 4.64 1.39 1.86 3.25 1.39 15-25 1.48 1.04 0.71 1.42 1.24 1.18 1.96 25-65 7.73 4 88 5.81 6.92 6.16 6.30 7.11 65 and over 93.13 61.31 59.37 75.47 70.88 72.03 72.91 All ages 11.10 8.41 7.84 9.61 8.27 9.04 9.40 0-5 36.04 38.05 23.76 34.68 19.84 30.47 37.73 5-65 5.34 3.99 4.21 4.72 4.27 4.50 4.99 5 and over 9.87 6.95 7.06 8.38 7.71 7.99 8.01 42 [Appendix IV. This will be illustrated by comparing the mortality at all ages and at ages under 15 years in the two sub-districts of the Parish:— 1900. Mortality rates per 1,000 persons. At all ages. Under 15 years of age. St. Mary 0.49 1.70 St. John 0.12 0.66 In other words, whilst the mortality per 1,000 persons at all ages showed a rate in St. Mary four times that in St. John, the true rates were only as 2.5 to 1 (approximately). It will he noted that TABLE 20. Deaths from Selected Causes. Causes of Death at all Ages (persons). Paddington. St. Mary. St. John. 1900. Averages.* 1900. Averages* 1900. Averages.* 1890 to 1894. 1895 to 1899. 1890 to 1899. 1890 to 1894. 1895 to 1899. 1890 to 1899. 1890 to 1894. 1895 to 1899. 1890 to 1899. Small-pox - 1 0 1 1 0 1 0 0 Measles 52 57 45 51 48 52 42 47 4 5 3 4 Scarlet Fever 5 17 15 16 5 14 12 13 — 3 3 3 Whooping Cough 34 63 41 51 30 55 38 46 4 8 3 5 Diphtheria 27 62 57 59 25 52 52 52 2 10 5 7 "Fever" 11 17 14 15 11 12 10 11 — 5 4 4 Diarrhœa 103 70 97 84 94 63 86 75 9 7 11 9 Totals 232 287 269 277 213 249 240 245 19 38 29 32 Puerperal Fever 4 5 4 4 4 4 4 4 1 0 0 Diseases of Parturition 5 10 9 8 4 8 7 7 1 2 2 1 Other Septic Diseases 15 14 15 14 14 10 11 11 1 4 4 3 Epidemic Influenza 89 68 68 67 61 50 50 50 28 18 18 17 Alcoholism 10 8 11 10 8 7 8 8 2 1 3 2 Cirrhosis of Liver 26 21 18 19 16 14 12 13 10 7 6 6 Malignant Dis. (Cancer) 129 115 124 119 104 83 91 88 25 32 33 32 Phthisis 142 181 156 168 120 154 129 142 22 27 27 26 Other Tubercular Diseases 74 89 71 79 65 74 63 68 9 15 8 11 Apoplexy 92 100 91 95 65 75 •69 72 27 25 22 23 Bronchitis 269 298 240 269 230 237 201 221 39 61 39 48 Pneumonia 127 185 215 149 105 143 95 119 22 42 20 30 Suicides 15 14 13 14 12 11 10 11 3 3 3 3 * Averages corrected for changes in population, and adjusted to nearest whole numbers. " 0 "—an average less than unity. " — "—no death recorded. the real mortality (that under 15 years) in St. John was more than five times the rate at all ages, hut in St. Mary not four times. This disturbing factor in rates based on population at all ages has to be kept in mind in comparing the various rates given in Table 18. As the figures stand in that Table, the comparison is highly favourable to the Parish. Report of Medical Officer of Health.] 43 In a former Report * a comparison, was made between the epidemic and non-epidemic years since 1868. Having regard to the special age incidence of the disease, the rates have for this Report been determined for persons aged 0-15 years from 1870† to last year (see Table 21). The period comprises 18 non-epidemic and 12 epidemic years. The mean death-rates for the three decennial periods were 1.523, 1.533, and 1.488 respectively, but while the mean rates for the non-epidemic years have decreased in each decennium from 1.05 in the first to 1.02 in the second and 0.38 in the third, those for the epidemic years decreased from 2.96 in the first to 2.29 in the second, but increased to 2.59 in the third. It is noteworthy, too, that in each successive period there was one more epidemic year than in the period immediately preceding it. The differentiation into epidemic TABLE 20a. Mortality Rates from Selected Causes. Causes of Death at all Ages (persons). Paddington. St. Mary. St. John. 1900. Mean Rates. 1900. Mean Rates. 1900. Mean Rates. 1890 to 1894. 1895 to 1900. 1890 to 1899. 1890 to 1894. 1895 to 1899. 1890 to 1899. 1890 to 1894. 1895 to 1899. 1890 to 1899. Small-pox - 0.01 0.00 0.00 - 0.01 0.00 0.01 — 0.01 — 0.00 Measles 0.40 0.43 0.35 0.39 0.49 0.53 0.43 0.48 012 0.16 0.10 0.13 Scarlet Fever 004 0.13 0.11 0.12 0.05 0.14 0.12 013 — 0.10 0.08 0.09 Whooping Cough 0.26 0.47 0.31 0.39 0.31 0.56 0.39 0.48 0.12 0.22 010 016 Diphtheria 0.20 0.46 0.44 0.45 0.26 0.53 0.53 0.53 0.06 0.32 016 0.24 "Fever" 0.08 0.13 0.10 0.12 0.11 0.12 0.10 0.11 — 0.14 0.11 0.13 Diarrhœa 0.79 0.52 0.74 0.63 0.97 0.64 0.89 0.76 0.27 0.22 0.32 0.27 Totals 1.77 2.15 2.05 2.10 2.19 2.53 2.46 2.50 0.57 1.17 0.87 1.02 Puerperal Fever 003 003 0.03 0 03 0.04 0.04 0.04 0 04 0.02 0.01 001 Diseases of Parturition 0.04 007 006 0.07 0.04 0.08 007 0.08 003 0.05 005 0.05 Other Septic Diseases 011 0.11 011 0.11 0.14 0.11 0.11 0.11 003 011 0.09 0.10 Epidemic Influenza 0.68 0.52 0.52 0.52 0.63 0.51 0.51 0.51 0.84 0'54 0.53 0.54 Alcoholism 0.08 0.06 009 0.07 0.08 0.07 009 0.08 0.03 0.05 009 0.07 Cirrhosis of Liver 0.20 0.16 015 0.]5 0.16 0.13 0.15 014 0'30 0.20 0.17 0.19 Malignant Dis. (Cancer) 0.99 0.84 0.95 0.92 1.07 0.85 0.94 0.89 0.75 1.00 0.97 0.98 Phthisis 1.09 1.36 1.19 1.27 1.23 1.56 1.33 1.45 0.66 0.80 0.80 0.80 Other Tubercular Diseases 0.56 0.67 054 0.60 0.67 0.75 0.65 0.70 0.27 0.45 0.24 0.35 Apoplexy 0.70 0.77 0.69 0.73 0.67 0.76 0.71 0.74 0.81 0.75 0.66 0.71 Bronchitis 2.06 2.27 1.86 2.06 2 36 2.43 2.11 2.27 1.17 1.88 1.16 1.52 Pneumonia 0.97 1.43 0.88 1.15 1.08 1.47 0.98 1.22 0.66 1.29 0.59 0.94 Suicide 0.11 0.11 0.08 0.10 0.12 0.11 0.08 0.09 0.09 011 009 0.10 All rates per 1,000 persons at all ages. " O'OO "—a rate less than 0'01 per 1,000. " — "—no death recorded. and non.epidemic years has been based on the fact of the number of deaths being above or below the mean annual average of each decennium. * Annual Report for 1898, p. 50. † This date was selected to secure three complete decennial periods. 44 [Appendix IV. TABLE 21. Mortality from Measles. Paddington: Persons. Decennium. Non.Epidemic Years. Epidemic Years. 1870-79. 7 Years. 3 Years. Total Number of Deaths 405 1870 25 Total Number of Deaths 195 Total Number of Deaths 210 1871 31 1873 33 1872 51 1875 11 1874 68 1877 39 1876 911 1878 27 1879 29 Annual Average Number of Deaths 40 28 70 Mean Death-rate * 1.523 1.05 2.96 1880-89. 6 Years. 4 Years. 1880 41 Total Number of Deaths 173 Total Number of Deaths 266 Total Number of Deathf 439 1881 20 1882 71 1883 37 1885 63 1884 31 1886 66 1887 33 1888 66 1889 11 Annual Average Number of Deaths / 44 29 66 Mean Death-rate* 1.533 1.02 2.29 1890-99.† 5 Years. 5 Years. Total Number of Deaths 474 1891... 6 Total Number of Deaths 62 1890 77 Total Number of Deaths 414 1893...30 1892 79 1895... 18 1894 66 1897... 2 1896 103 1899... 6 1898 89 Annual Average Number of Deaths 47 12 83 Mean Death-rate * 1.488 0.38 2.59 * Rate per 1,000 persons living at ages under 15 years, † The rates for this decennium are liable to revision after the publication of the returns of the new Census. 45 Report of Medical Officer of Health.] TABLE 22. Measles. Deaths and Mortality Rates (per 1,000 persons aged 0-15 years). Paddington. St. Mary. St. John. Deaths. Mortality Deaths. Mortality. Deaths. Mortality. 1875 11 0.41 9 0.48 2 0.25 1876 91 3.40 75 3.97 16 2.04 1877 39 1.45 31 1.61 8 103 1878 27 0.99 23 1.18 4 0.51 1879 29 1.06 22 1.11 7 095 Annual Averages 39 1.462 32 1.670 7 0.956 1880 41 1.49 31 1.55 10 1.31 1881 20 0.72 20 0.99 — — 1882 71 2.53 63 305 8 1.08 1883 37 1.37 28 1.32 9 1.24 1884 31 1.08 24 1.11 7 0.99 Annual Averages 40 1.438 33 1.604 7 0.924 1885 63 2.18 57 2.59 6 0.86 1886 66 2.26 56 2.50 10 1.47 1887 33 1.12 30 1.31 3 0.45 1888 66 2.22 63 2.71 3 0.46 1889 11 0.36 11 0.46 — — Annual Averages 47 1.628 43 1.914 4 0.648 1890 77 2.54 65 2.69 12 1.95 1891 6 0.19 6 0.24 — — 1892 79 2.55 71 2.85 8 1.32 1893 30 0.95 30 118 — — 1894 66 2.08 58 2.25 8 1.33 Annual Averages 52 1.662 46 1.802 6 0.920 1895 18 0 52 17 0.65 1 0 16 1896 103 3.16 93 3.50 10 1.66 1897 2 0.06 2 0.07 — — 1898 89 2.66 84 3.07 5 0.83 1899 6 0.17 6 0.21 — — Annual Averages 43 1.314 40 1.500 3 0.530 1900 52 1.52 48 1.70 4 0.66 The figures in block type indicate epidemic years. 46 [Appendix IV. The two sub-districts, St. Mary and St. John, are so different in many respects that it is useful to compare the incidence of mortality in the two. In Table 22 (see preceding page) the mortality rates from measles per 1,000 persons aged 0-15 years are set out together with the quinquennial means. The statistics prior to 1875 are unfortunately not on record. In Tables 23, 24, and 25 full particulars are given of the deaths in the last two epidemics, viz., those of 1898 and 1900. TABLE 23. Measles. Deaths according to Months. Persons. St. Mary. St. John. 1898. 1900. 1898. 1900. January 6 — —— — February 5 2 — — March 19 2 1 — April 26 1 1 — May 13 16 2 2 June 9 19 — — July 2 6 1 2 August 3 1 — — September 1 — — — October November 1 December \— — — — Totals 84 48 5 4 The published mortality rates for 1900 in the adjacent districts were:— Measles. Rates per 1,000 persons at all ages. Kensington 0.57 St.-Marylebone 0.35 Chelsea 0.34 Hampstead 0.26 St. George, Hanover Square 0.07 a Willesden 0.45 The Kegistrar-General computed the local rate to be:— Paddington 0.39. 47 Report of Medical Officer of Health.] TABLE 24. Measles. Deaths by Sex and Age. St. Mary. St. John. Paddington. Males. Females. Males. Females. Persons. 1898. 1900. 1898. 1900. 1898. 1900. 1898. 1900. 1898. 1900. Months. 0- — — — — — — — — — — 3- 1 — 1 1 — — — — 2 1 6- 3 1 2 — — — — — 5 1 9- 6 3 4 7 1 — — — 11 10 Under 1 year 10 4 7 8 1 — 18 12 Years. 1- 14 7 16 11 — — 1 — 31 18 2- 10 6 8 3 2 — 20 9 3- 5 3 5 — 1 1 1 11 5 4- 5 — 1 1 1 — — 6 2 Aged 1-5 years 34 16 30 15 1 2 3 1 68 34 Years. 5- 1 — — — — — — — 1 — 6- — 1 1 1 — — — — 1 2 7- 1 1 — 1 — — — — 1 2 8- — — — — — — — — — — 9- — — — — — — — — — — Aged 5-10 years 2 2 1 2 _ — — — 3 4 Years. 10- — — — — — — — 1 — 1 15- — 1 — — — — — — — 1 All Ages 46 23 38 25 2 2 3 2 89 52 48 [Appendix IV. TABLE 25. Measles. Fatality according to Ages. Persons. Whole Parish. Ages. 1898. 1900. Cases. Deaths. Fatality. Cases. Deaths. Fatality. Months. 0- 3 — — 1 — — 3- 3 2 66.6 7 1 14.2 6- 32 5 15.6 28 1 3.5 9- 31 11 35.4 31 10 32.2 Under 1 year 69 18 26.0 67 12 17.9 Years. 1- 141 31 21.9 129 18 13.9 2- 110 20 18.1 133 9 6.7 3- 163 11 6.7 164 5 3.0 4- 207 6 2.8 233 2 0.8 Aged 1-5 years 621 68 10.9 659 34 5.1 Years. 5- 182 1 0.5 202 6- 163 1 0.6 152 2 1.3 7- 68 1 1.4 51 2 3.9 8- 30 — — 21 — — 9- 18 — — 9 — — Aged 5-10 years 461 3 0.6 4354 0.9 Years. 10- 28 — 18 1 5.5 15- 11 — — 12 1 8.3 All ages 1,196 89 7.4 1,191 52 4.3 SCARLET FEVER. 1900. 1899. 1898. 1897. Number of cases recorded 302 382 303 491 Number of deaths 5 7 8 20 Fatality 1.6 1.8 2.6 4.0 Mortality 0.04 0.06 0.06 0.15 The 5 deaths from this disease were 11 below the decennial average (16), and the death-rate (0.04) 0.08 below the mean rate (0.12). In South Paddington no deaths were registered from this cause, the decennial average being 3 deaths per annum. In North Paddington the 5 deaths were 8 below the average, and the death-rate (0.05) 0.08 below the mean rate (0.13). The fatality has decreased from 5.0 per cent, of all cases in 1894 to 1.6 last year. In comparison with the other rates given in Table 18, those of the Parish are particularly satisfactory. 49 Report of Medical Officer of Health.] The published rates for 1900 in the adjacent districts were : — Scarlet Fever. Rates per 1,000 persons at all ages. Kensington 0.02 St. Marylebone 0.09 Chelsea 0.07 Hampstead 0.05 St. George, Hanover Square 0.07 Willesden 0.10 Of the 5 persons whose deaths were due to this disease, 4 were in persons who were removed to hospital for isolation. The comparative fatalities (per cent.) among cases treated at home and in hospital in each of the seven past years are set out below:— Fatality among— 1894. 1895. 1896. 1897. 1898. 1899. 1900. Hospital Cases 4.2 4.7 2.4 4.4 2.5 0.9 0.8 Home Cases 5.8 0.7 3.8 2.7 3.5 5.0 6.5 All Cases 5.0 3.3 2.7 4.0 2.6 1.8 1.6 Percentage of Notified Cases Removed 82.3 65.3 78.7 77.3 80.1 71.6 84.6 DIPHTHERIA. 1900. 1899. 1898. 1897. Number of cases recorded 154 203 258 322 Number of deaths 27 29 64 65 Fatality 17.5 14.2 24.8 20.1 Mortality 0.20 0.22 0.50 0.51 The 27 deaths from diphtheria (including membranous croup) were less than half the decennial average (59). The reduotion in the mortality was equally satisfactory in North Paddington (25 deaths, 52 average), and in South (2 deaths, 7 average). In comparison with the statistics of the other areas included in Table 18, those of Paddington for last year are among the lowest in the Table. The death-rates for certain sex-age groups have been calculated and will be found in Table 26. All the rates for last year were below the mean rates for 1893-99, and were, with one or two exceptions, minimal rates. The published rates for 1900 in the adjacent districts were :— Diphtheria. Rates per 1,000 persons at all ages. Kensington 0.16 St. Marylebone 0.29 Chelsea 0.19 Hampstead 0.30 St. George, Hanover Square 0.14 Willesden 0.24 The Registrar-General estimated the local rate to be:— Paddington 0.21. 50 [Appendix IV. Among the 77 persons removed to hospital, 19 deaths occurred. The mortalities among hospital and homes cases in each of the seven last years are compared below:— Fatality among— 1894. 1895. 1896. 1897. 1898. 1899. 1900. Hospital Cases 281 16.6 27.6 179 21.0 13.6 24.6 Home Cases 20.1 25.2 27.2 24.1 31.5 17.1 10.3 Total Cases 24.7 20.6 27.6 20.1 24.8 14.2 17.5 Percentage of Notified Cases Removed to Hospital 56.2 53.0 50.0 63.9 64.3 82.7 71.4 TABLE 26. Diphtheria. Sex-Age-Mortality. Rates per 1,000 of each sex at each age. Age. Paddington. St. Mary. St. John. M. F. M. F. M. F. 1900 0.73 — — — 5.29 — Mean rates, 1893.9 1.79 1.27 2.09 1.49 — — 0-1 years 1899 0.72 0.84 — — 1898 2.27 1.45 2.64 1.70 — — 1897 0.76 2.95 0.89 3.46 — — 1896 2.30 2.21 2.70 2.60 — — 1895 1.57 — 1.83 — — — 1894 2.39 - 2.80 — — — 1893 3.22 1.55 3.79 1.84 — — 1900 1.46 1.63 1.74 1.95 — — Mean rates, 1893.9 4.30 4.07 4.53 4.31 3.16 1.24 1-5 years 1899 1.48 2.48 1.77 2.97 — — 1898 5.36 2.92 6.43 3.29 — 1.23 1897 4.78 2.33 4.70 2.81 5.16 — 1896 5.64 4.44 5.75 4.86 5.09 2.43 1895 3.57 3.04 3.74 3.66 2.68 — 1894 4.97 7.05 5.72 8.26 1.32 1.27 1893 4.34 4.23 3.59 4.32 7.91 3.78 1900 0.19 0.53 0.23 0.65 — — Mean rates, 1893.9 0 .70 1.04 0.75 1.08 0.46 0.87 5-15 years 1899 0.39 0.45 0.47 0.58 — — 1898 0.88 0.63 0.95 0.79 0.53 — 1897 1.18 1.19 1.33 1.15 0.53 1.39 1896 0.29 0.64 024 0.57 0.52 091 1895 0.60 0.94 0.74 0.94 — 0.96 1894 0.72 2.30 0.63 2.30 110 1.90 1893 0.83 116 0.89 1.21 0.54 0.94 Deaths at ages over 15 years, not included in above:— 1893 5 1896 4 1899 0 1894 3 1897 2 1900 3 1895 1 1898 4 51 Report of Medical Officer of Health.] FEVER* 1900. 1899. 1898. 1897. Number of Cases reported 59 98 76 45 Number of deaths 11 10 17 7 Fatality 18.6 10.2 22.6 15.5 Mortality 0.08 0.08 0.13 0.05 The deaths from fever (11, including 1 of typhus fever—erroneously returned—and 2 of continued fever) were 4 below the average. All the deaths were among residents in North Paddington, and were equal to the average. The mortality in the Parish (0'08) was 0'04 below the decennial mean. The local figures compare very favourably with all those included in Table 18. The published rates for 1900 in the adjoining districts were:— "Fever." Rates per 1,000 persons at all ages. Kensington 0.10 St. Marylebone 0.10 Chelsea 0.20 Hampstead 0.11 St. George, Hanover Square 0.15 Willesden 0.12 Of the 11 deaths, 6 occurred in hospital and 5 at home. The mortalities among home and hospital cases in each of the past seven years are set out below:— Fatality among— 1894. 1895. 1896. 1897. 1898. 1899.  Hospital Cases 32.3 19.2 16.6 — 7.2 74 13.1 Home Cases 33.3 22.7 38.4 31.0 61.9 17.1 35.7 All Cases 32.8 21.4 25.8 15.5 22.6 10.2 18.6 Percentage of Notified Cases Removed 43.8 37.1 58.0 51.1 60.0 77.5 76.1 PUERPERAL FEVER. 1900. 1899. 1898. 1897. Number of cases recorded 6 7 5 7 Number of deaths 4 5 4 2 Fatality 66.6 71.4 80.0 28.5 Mortality † 0.04 0.06 0.04 0.02 It is to be hoped that the fatality of this disease as given above is not a correct one. In all probability only a comparatively small proportion of cases of puerperal fever come to the knowledge of the Department; + and, further, that the deaths scheduled as puerperal fever do not represent the total mortality. For this reason account is taken of all deaths reported to have occurred during the * Locally, this term is confined to enteric fever. Outside the Parish, the terra includes deaths from enteric, typhus, and continued fevers. † Mortality calculated per 1,000 females aged 15-45 years. ‡ See remarks as to difficulties of certification on p. 23 above. 52 [Appendix IV. puerperium. The total number of such deaths was 9, viz., 4 from puerperal fever and 5 from accidents and diseases of parturition. Last year's total was 3 less than the decennial average, and the mortality (0.07 per 1,000 persons of all ages) was 0.03 less than the mean (0.10). In North Paddington there were 8 deaths last year, 3 less than the average, and the mortality was 0.08, or 0.04 less than the mean. In South Paddington 1 death only was recorded, being practically equal to the average, while the mortality (0.03) was just one half the mean (0.06). The birth-rate has fallen to an extent which might account for the reduction in the mortality at all ages from these causes. The subjoined figures show, however, that there has been a slight reduction in the mortality in childbed quite independent of such influence. Mortality in Childbed. Rates calculated per 1,000 births registered. Annual average. 1890-99. 1900. Paddington 4.0 3.1 St. Mary 4.3 3.2 St. John 2.4 2.4 WHOOPING COUGH. [### ]1900. 1899. 1898. 1897. Number of cases Fatality not known Number of deaths recorded 34 43 45 40 Mortality 0.26 0.33 0.35 0.31 There was a satisfactory reduction in the number of deaths from this disease throughout the Parish. The total of 43 deaths recorded was 9 below the total for 1899, and 17 below the decennial average (51), and the mortality (0.26 per 1,000 persons at all ages) was 0.13 below the decennial mean. In North Paddington 30 deaths were recorded, 16 below the decennial average, the mortality (0.31) being 0.17 below the decennial mean. In South Paddington 4 deaths were recorded, being 1 less than the average (5), while the mortality (0.12) was 0.04 below the mean. The remarks made as to special age incidence of measles apply largely to this disease. With that reservation, it may be permitted to say that the local returns in Table 18 compare very favourably with all the other returns included therein. The published rates for the adjacent districts last year were :— Whooping Cough. Returns per 1,000 persons at all ages. Kensington 0.19 St. Marylebone 0.39 Chelsea 0.19 Hampstead 0.11 St. George, Hanover Square 0.14 Willesden 0.25 The Registrar-General estimated the local rate to be:— Paddington 0.27. 53 Report of Medical Officer of Health.] TUBERCULOSIS. The total number of deaths from all forms of tuberculosis last year was 216, or 31 less than the annual average for the decennium 1890-99. The annual average for the 5 years 1890-94 was 270, and that for the 5 years 1895-99, 227. Tuberculosis of the lungs (consumption or phthisis) caused 142 deaths last year, compared with annual averages of 168 for the decennium and 181 and 156 for the first and second quinquennium respectively. "Other forms of tuberculosis," viz., tubercular meningitis, tabes mesenterica (consumption of the bowels), scrofula, &c., caused 74 deaths, compared with annual averages of 79, 89, and 71 for the decennium and the two quinquennia. Taking the annual averages in each case as 100, the deaths recorded last year stood in the following ratios:— Deaths from Tuberculosis. Paddington. Persons at all ages. Consumption. Other forms. 1890-99. 1890-94. 1895-99. 1890-99. 1890-94. 1895-99. Annual averages 100 100 100 100 100 100 Deaths recorded, 1900 84 78 91 93 83 104 The reduction in the number of deaths recorded from "consumption" may be said to be not unsatisfactory, but so much cannot be said with regard to the deaths from "other forms." As will appear later, the incidence of "consumption" as a cause of death is heavier on adults, and that of "other forms," on young children—a fact of considerable importance in relation to questions of prevention of the disease. As regards the two Sub-Districts, the actual numbers will be found in Table 20 (p. 42), and need not be recapitulated here. The changes in the numbers recorded are indicated in the appended tabular statement:— Deaths from Tuberculosis. Persons at all ages. St. Mary. St. John. Consumption. Other forms. Consumption. Other forms. Annual averages— 1890-99. 1890-94. 1895-99. 1890-99. 1890-94. 1895-99. 1890-99. 1890-94. 1895-99. 1890-99. 1890-94. 1895-99. 100 100 100 100 100 100 100 100 100 100 100 100 Deaths recorded, 1900— 84 78 93 95 88 103 85 81 81 81 60 112 In the Metropolis the deaths registered from consumption in 1900 numbered 8,030, compared with a corrected annual average of 8,532 for the decennium 1890-99,* or a reduction of 6 per cent., against one of 16 per cent, in the Parish as a whole. There were 3,099 deaths from "other forms" of tuberculosis in the Metropolis during the past year, the decennial average being 3,485. The number of deaths from these "other forms" was therefore 12 per cent, below the average, as compared with 7 per cent, in the Parish. The actual numbers for the decennium for the various parishes and districts of the Metropolis are not available. Those for a single year are of no value for present purposes. Referring to Table 20a (p. 43), it will be seen that the mortality (per 1,000 persons at all ages) from phthisis last year was 1.09 in the Parish, 1.23 in St. Mary, and 0'66 in St. John, the corresponding decennial mean rates being 1.27, 145, and 0.80. The mortality from "other forms" was 0.56 in the Parish, 0.67 in St. Mary, and 0.27 in St. John, compared with the respective mean rates of 0.60, 0.70, and 0.35. These figures are, for the sake of emphasis, set out in the following table:— * Annual Summary of Births and Deaths and Causes of Death in London and other Large Towns, 1900. Table 15, p. xxxiv. 54 [Appendix IV. Mortality-rates from Tuberculosis. Per 1,000 persons at all ages. Phthisis. Other forms of Tuberculosis. Total Mortality from Tuberculosis. 1900 1890-99 1890-94 1895-99 1900 1890-99 1890-94 1895-99 1900 1890-99 1890-94 1895-99 Paddington 109 1.27 1.36 1.19 0.56 0.60 0.67 0.54 1.65 1.87 2.03 1.73 St. Mary 1.23 1.45 1.56 1.33 0.67 0.70 0.75 0.65 1.90 2.15 2.31 1.98 St. John 0.66 0.80 0.80 0.80 0.27 0.35 0.45 0.24 0.93 1.15 1.25 1.04 It is evident, therefore, that the reduction which has taken place in the Parish in the mortality from tubercular diseases has been largely due to the reduction in the mortality from tubercular diseases of the lungs, and that the mortality from "other forms of tuberculosis" has not only not been reduced to the extent noted in phthisis, but even shows a tendency to an increase. Before passing to a further consideration of the local mortality from these causes, note may be taken very briefly of the relative position of the local mortality from phthisis in comparison with other metropolitan districts. Since 1896 the Registrar-General has published the annual death-rate from phthisis in each of the Sanitary Districts of the Metropolis. Table 27 has been compiled from those returns. TABLE 27. Mortality-rates from Phthisis.* Per 1,000 persons at all ages. Districts. Mortality from Phthisis. Precentage of population living under conditions of overcrowding. Mean rate. 1900. (1895-99.) London 1.74 1.71 19.7 Groups of Registration Districts. Western 1.56 1.48 16.7 Northern 1.55 1.55 20.0 Central 2.65 2.82 33.7 Eastern 2.04 2.02 28.9 Southern 1.66 1.63 14.3 Paddington (1896-99.) 1.23 1.15 16.8 Kensington 1.36 1.18 17.2 St. George, Hanover Square 1.28 1.36 11.1 Westminster 2.72 2.41 20.6 Marylebone 1.87 1.99 26.7 Hampstead 0.86 0.85 10.3 * From the Registrar-General's Annual Summaries. 55 Report of Medical Officer of Health.] With the exception of 1898, the death-rate from phthisis in Paddington has been the lowest* recorded each year in the Western Sanitary Districts. Indeed, in each of 5 years (1896-1900) the local rate has been one of the lowest in the whole Metropolis. The districts with rates lower than that of the Parish are set out below:— Phthisis. Death-rates (per 1,000 persons living at all ages). 1896. 1897. 1898. 1899. 1900. Stoke ington (0.82) Hampstead (0.74) Hampstead (0.74) Hampstead (0.84) Hampstead (0.85) Wandsworth (0.97) Lewisham (0.94) Lewisham (0.88) Stoke Newington (0.88) Lee (0.96) Lewisham (1.04) Lee (1.10) Stoke Newington (1.04) Lee (1.00) Stoke Newington (1.04) Hampstead (1.12) Paddington (1.13) Lee (1.10) Lewisham (1.15) Lewisham (1.11) Paddington (1.27) Wandsworth (1.13) Paddington (1.15) Eotherhithe (1.14) Kensington (1.26) Paddington (1.15) St. George, Hanover Square (1.81) Paddington (1.38) The rates from "other forms of tuberculosis" are not available. Since 1875 the deaths from tuberculosis have been tabulated under 12 age-groups for the whole Parish, and the total deaths in each of the Sub-Districts have also been recorded. On the basis of these records the mortality has been calculated:— (a) Per 1,000 persons at all ages in the Parish and its two divisions; and (b) Per 1,000 persons estimated living at each age-period, Parish only. For the complete examination of the subject, these rates should be set out for each year and diagrams constructed to show graphically the directions in which the various curves have fluctuated. This work could not be completed for this Report, but averages have been struck for the 5 quinquennial periods in each case (see Tables 28, p. 56, and 29, p. 57). If Table 28 be examined, it will be found that the mortality from phthisis has steadily diminished in each quinquennial period, and that the rates recorded last year in each of the districts were lower than any of the corresponding averages. In St. Mary the reduction in the rate for the fifth period (1.334), as compared with that of the first (2.227), was equal to 40 per cent., while in St. John the reduction amounted to 32 per cent, (from 1.159 in the first to 0.795 in the fifth period). The mortality from tabes mesenterica has fluctuated somewhat irregularly, but the rates for the fifth period are all markedly below those for any other. Similar irregularities are noted in the mortalities from tubercular meningitis, there being, however, a much smaller mortality in the fifth than in the first period. With regard to other forms, the variations are more markedly irregular, and the rates for the fifth period are all higher than those for the first. It should, however, be observed that the numbers on which these last rates are based are comparatively small, and the rates themselves, in consequence, of less value than the others. The percentage reductions and increase in the fifth period, as compared with the first, are set out in the last line of Table 28. 56 TABLE 28. Mortality from Tuberculosis. Rates calculated per 1,000 persons of all ages living in each district. PADDINGTON. ST. MAEY. ST. JOHN. Period. Tabes Mesenterica. Tubercular Meningitis. Phthisis. Other forms of Tuberculosis. All forms of Tuberculosis. Tabes Mesenterica. Tubercular Meningitis. Phthisis. Other forms of Tuberculosis. All forms of Tuberculosis. Tabes Mesenterica. Tubercular Meningitis. Phthisis. Other forms of Tuberculosis. All forms of Tuberculosis. 5 years— 1875-79 0.168 0.465 1.842 0.093 2.568 0.219 0.542 2.227 0.118 3.106 0.080 0.330 1.159 0.047 1.616 1880-84 0.186 0.517 1.558 0.066 2.327 0.244 0.617 1.783 0.086 2.730 0.076 0.325 1.142 0.027 1.570 1885-89 0.129 0.327 1.473 0.083 2.012 0.158 0.374 1.655 0.093 2.280 0.057 0.200 0.963 0.047 1.277 1890-94 0.145 0.384 1.367 0.140 2.036 0.161 0.434 1.574 0.158 2.327 0.107 0.261 0.860 0.095 1.323 1895-99 0.104 0.276 1.191 0.162 1.733 0.133 0.343 1.334 0.175 1.985 0.024 0.089 0.795 0.125 1.033 Year— 1900 0130 0.298 1.087 0.138 1.654 0.154 0.370 1.234 0.143 1.902 0.060 0.090 0.659 0.120 0.929 Increase or decrease per cent, in mean rate of last quinquennium compared with the first —45 -41 —35 + 74 —33 —39 —37 -40 + 48 —36 -70 —73 -31 + 166 —36 [Appendix IV. 57 Report of Medical Officer of Health.] TABLE 29. Tuberculosis. Kates per 1,000 in each group. Paddington. Persons. 0- 1- 5- 15- 25- 35- 45- 55- 65- 75- 85- Tabes Mesenterica. Mean rates. 1875-79 4.058 0.573 0.061 0.009 — — — — — — — 1880-84 5.593 0.815 0.011 0.016 — — — — — — — 1885-89 3.712 0.349 0.044 — — — — — — — — 1890-94 4.505 0.385 0.020 0.007 — — 0.018 0.028 — — — 1895-99 3.340 0.288 0.028 — — — — — — — — 1900 4.152 — — — — — 0.129 — — Tubercular Meningitis. 1 Mean rates. 1875-79 4.266 3.513 0.478 0.026 — 0.021 0063 — 1880-84 7.122 2 800 0.640 0.092 0.019 — — — — — — 1885-89 3.790 2.224 0.348 0.029 0.040 — — — — — 1890-94 4.874 2.671 0.376 0.047 0.017 0.038 — — — — — 1895-99 3.882 1.808 0.278 0.035 — 0.012 — — — — — 1900 3.114 1.360 0.644 0.036 0.039 0.059 — — — — — Tuberculosis of Lungs. Mean rates. 1875-79 1.923 1.064 0.553 1.292 2.567 3.134 2.854 2.110 1.906 1.223 — 1880-84 1.037 0.686 0.322 1.022 1.962 2.830 3.104 2.121 1.402 0.671 — 1885-89 1.582 0.523 0.347 1.171 1.901 2.280 2.505 2.144 1.431 1073 — 1890-94 0.340 0.287 0.225 0.887 1.691 2.683 2.479 2.320 1.517 1.667 0.939 1895-99 0.471 0.354 0.124 0.662 1.205 2.283 2.751 1.580 1.581 0.642 0.896 1900 0.346 0.209 0.092 0.789 0.898 1.892 3.207 1.942 1.155 0.634 — Other Forms of Tuberculosis. Mean rates. 1875-79 0.620 0.573 0.061 0069 0010 — — 0.067 0.061 — — 1880-84 1.039 0.255 0.057 0.016 — 0.013 0.040 — — 0.174 — 1885-89 0.485 0.448 0.064 0.037 0.026 0.040 0.056 0.058 — 0.153 — 1890-94 1.092 0.622 0.121 0069 0.059 0077 0036 0.056 0.152 — — 1895-99 1.400 0.314 0.191 0.096 0.104 0.159 0.136 0.106 0.046 0.132 — 1900 0.346 0.523 0.138 0143 0.039 0.059 0.082 0.259 — — — *The rates at this age were calculated per 1,000 births registered in each year. 58 [Appendix IY. Table 29 shows the incidence of the mortality from tubercular diseases at various ages and the variations in the quinquennial mean rates. It must suffice on this occasion to point out the special age.incidences which are disclosed by the table. The mortality due to tabes mesenterial (tubercular disease of the digestive organs) is practically limited to children under 5 years of age, and that of tubercular meningitis (disease of the nervous system) to persons under 25 years of age. Tuberculosis of the lungs (phthisis or consumption) affects all ages of life, but the mortality is highest at ages from 25 to 65 years. Other forms of tuberculosis (scrofula, struma, tubercular diseases of organs other than digestive, nervous, or respiratory) do not apparently specially affect any particular age, but the incidence of mortality is slightly greater at ages under 15 years. In general terms it may be said that there is an indication that, at about the age of 15 years, the locality affected by tuberculosis changes, and on such an assumption the following table (Table 30) has been drawn up. It cannot be considered satisfactory, but must serve for present purposes. The table, moreover, suffers from the fact that the tabulation of deaths during the selected periods has been made by two persons, and that there is no indication of the rules which governed the work in 1875-79. Something ought probably to be allowed for differences in practice in this matter; but, from such information as exists, it is probable that any such difference has been in favour of the rates of 1875-79, i.e., shows them lower than they would have been had the rules of 1895-99 been adopted. It will be seen from this table that the mean rates for 1895-99 were lower than those for 1875-79, except in the case of " all forms, excluding phthisis " at ages over 15 years. There can be little doubt that much of the increase in this case (173 per cent.) is due to different classification. Probably the same cause has operated to some extent with regard to phthisis at ages under 15 years, where the decrease has amounted to 71 per cent. TABLE 30. Comparison of mortalities in 2 age-groups. 0-15. 15-1. All forms Mean rate,* 1875-79 3.419 2.276 Mean rate, 1895-99 1.938 1.658 increase or decrease per cent. —43 —27 All forms excluding Phthisis Mean rate, 1875-79 2.658 0.046 Mean rate, 1895-99 1.720 0.126 Increase or decrease per cent. —35 + 173 Phthisis Mean rate, 1875-79 0.761 2.229 Mean rate, 1895-99 0.218 1.531 Increase or decrease per cent. —71 —31 * Rates per 1,000 persons in each age-group. Prior to 1891 the deaths were not tabulated according to sex nor according to ages in the two Sub-Districts. Such complete tabulation has been made since that date, but the calculation of the rates based thereon has been delayed until the results of the new census are known. The differences in prevalence of mortality (as affecting persons at all ages) are shown in Table 28. The disease has been markedly more prevalent in St. Mary than in St. John, but the diminution in the mortality from all forms of tuberculosis in the fifth period, as compared with the first, has been the same (36 per cent.). In all probability, however, the diminution in St. John has been greater than that in St. Mary as the apparent great increase in mortality from other forms of tuberculosis in the former district may be due to change in system of classification. Since 1891 the deaths from tuberculosis have been allotted to the streets given as the home addresses of the deceased persons. During the 10 years 1891-1900, 2,268 deaths were recorded from all forms of tuberculosis, 1,890 of the deceased persons being returned as residents in St. Mary and 378 in St. John. Of the 1,890 deaths from St. Mary, 69 have been excluded, on account of want of, or Report of Medical. Officer of Health.] 59 insufficient information as to, home addresses, and of the 378 in St. John, 20 have been excluded for the same reason. In St. Mary the 1,821 deaths allotted were referred to 1,501 houses, 2 or more deaths being allotted to 256. In St. John the 358 deaths were allotted to 320 houses, 2 or more deaths being allotted to 32. The maximum number allotted to any house was 6 (1 house) in St. Mary, and 4 (2 houses) in St. John. The complete figures are appended below:— Tuberculosis. House Incidence. (Allocation of 2,179 deaths out of 2,268 recorded.) 1891-1900. Total Number of Deaths. Total Number of Houses. Number of Houses to which were allotted 2 3 4 Deaths 5 6 St. Mary 1,821 1,501 205 41 8 1 1 St. John 358 320 28 2 2 — — Paddington 2,179 1,821 233 43 10 1 1 According to the returns of the census of 1891, there were 9,420 inhabited houses in St. Mary and 5,053 in St. John, so that in St. Mary 15.8 per cent, of the houses were infected, as compared with 6.3 in St. John. As has been mentioned already, there are not wanting indications that there is a kind of selection in the seat of infection of tuberculosis at the various ages of life. Children suffer more from tuberculosis of the intestines and brain; adults of the lungs. The disease is an infectious one, and is transmitted from person to person, or from animals to man. In dealing with this part of the subject two factors have to be considered—(a) infection through the food, and (b) direct infection from person to person, nearly always through the air, due to living under conditions which either favour the persistence and development of the organism (the bacillus tuberculosis) in the home, workshop, school, or elsewhere, or entail living in such aggregation as leads to the direct transference of the organism from person to person by the sputum. Of inherited tuberculosis it is unnecessary to say anything. It may be taken as almost conclusively proved that no one is born infected, but it is beyond dispute that children are born highly predisposed to become so. The latter will, however, if properly cared for, in the majority of cases escape such infection. To what extent have the circumstances of life—apart from food—influenced the prevalence of the disease ? This subject cannot be dealt with here as fully as it deserves to be. A mass of information has been collected which is not yet in a form for report. One factor alone can be mentioned, that is, the relation between density of population and mortality from this disease. At the census of 1891 the average number of persons occupying an area of one statute acre in St. Mary was 105.8, and in St. John 75.8, while the number of inhabitants per house averaged 8.9 in the former to 6.6 in the latter district. Tenements of 4 rooms or less were separately scheduled, and the total number of such homes in St. Mary was 14,328 (housing 49,030 persons, equal to 58.2 per cent, of whole population of district), and 2,880 in St. John (housing 9,068 persons, equal to 26.8 of the population of the district). The average number of persons per home of 4 rooms or less was, therefore, 3 4 in St. Mary, and 3.l in St. John. Taking a standard allowance of 2 persons per room as constituting the maximum permissible without overcrowding, it is found 60 [Appendix IY. that 20.76 per cent, of the total inhabitants of St. Mary were "overcrowded" and 6.97 per cent, of those of St. John. An analysis of the conditions of housing in tenements of 4 rooms or less is set out below:— Conditions of Housing. Census 1891. Number of rooms per home. Percentage of total population living therein. N. S. Average number of persons per home. N. S. Percentage of homes overcrowded. N. S. Percentage of inhabitants of such houses living overcrowded. N. S. 1 9.6 4.5 2.0 1.7 27.9 16.5 50.5 340 2 20.0 8.1 3.6 3.1 30.0 20.8 50.4 40.4 3 19.6 7.3 3.9 3.7 11.3 8.1 22.7 170 4 8.8 6.8 4.8 4.7 7.2 6.5 14.5 13.1 " N."—St. Mary. " S."—St. John. The mean annual mortality at all ages from consumption during 1890.99 was 1.454 per 1,000 in St. Mary, and 0 831 in St. John. If the statistics for each of the items set out helow recorded in St. Mary be taken as 100, the corresponding values for St. John are:— Percentage of total population living in 4 rooms or less 46 Percentage of total population overcrowded 33 Mean annual mortality from consumption 57 Mean annual mortality from all forms of tuberculosis 54 At the last census no information as to housing was furnished for areas smaller than the Registration Sub.Districts. There are three well-defined areas in St. Mary, for which a certain amount of information has been independently obtained, and it will be useful to see how far the density of inhabitants and the mortality from tuberculosis are related. Estimated Population. Area (acres). Average number of inhabitants Mortality from Tuberculosis. Per acre. Per house. Deaths (1891-1900) Death-rate* (Mean Annual). North Wharf Area † 3,076 15.8 194 9.0 74 2.4 Hall Park Area ‡ 3,916 9.2 425 12.9 110 2.8 Clarendon Street Area § 7,895 15.2 519 14.9 271 3.4 * Rates per 1,000 persons of all ages living in the area. † North Wharf Area, a well-defined area lying to the South of Paddington Green and Harrow lioad. The northern boundary selected is the centre of the Harrow Road, the southern the middle line of the Canal Basin. ‡ Hall Park is an irregular-shaped but well-defined area, lying to the west of the Edgware Road. It has on the west an open space of about ¾ of acre, the playground of the Campbell Street Board School, and on its south and west boundaries, the Paddington Green Recreation Ground. § Clarendon Street Area.—The boundaries selected are: line down centres of Canal from Lock Bridge to the Foot Bridge; of Ranelagh Road; of Westbourne Terrace North. The area is closed by the line of the rear boundaries of properties in Harrow Road between Westbourne Terrace North and the Lock Bridge. 61 Report of Medicai. Officer of Health.] In these three areas the inhabitants reside almost entirely in tenements of 1, 2, or 3 rooms. The contrast between the mean annual mortality calculated for these areas and that of the whole district of St. Mary (1.4) is striking. As might be expected, there were a considerable number of multiple deaths in these areas. Houses with—deaths.* 2 3 4 5 Hall Park Area 12 8 1 — North Wharf Boad Area 9 4 — 1 Clarendon Street Area 46 10 2 — Table 27 (p. 54) furnishes striking confirmation of the foregoing statistics. It will be noted that (with two exceptions) the mortality from phthisis rises and falls with the percentage of inhabitants living in overcrowded tenements. The two districts which do not follow this rule are St. George, Hanover Square and St. Marylebone. With regard to the former no explanation can be offered, but with respect to the latter, it is not improbable that the exceptional (low) mortality may be in part due to the clearances which have taken place since 1891, owing to the construction of the Great Central Railway. With reference to the part played by food in the production of tuberculosis in man, only one point will be dealt with, viz., the presence of the bacillus tuberculosis in milk. The importance of tuberculosis in relation to meat is not forgotten, but the circumstances of the meat trade of the Parish, to a certain extent, place the subject beyond present consideration. The dangers associated with the consumption of milk from tuberculous cows, especially when the disease affects the udders, were strougly emphasized in the reports of the Royal Commissions ou Tuberculosis of 1895 and 1898. The dangers are the greater in this country from the almost universal custom of drinking raw or imperfectly cooked milk. Milk is much more the food of young children than of adults, and to this fact is due the greater frequency of tubercular diseases of the intestines among them. From time to time reports have been published giving the percentages of samples of milk from different sources found to be infected with tuberculosis. The following are a few such returns:†— No. of Dairies examined. x No. producing Tuberculosis. Percentage producing Tuberculosis. Cambridge (mixed milk) 16 9 56.2 Liverpool: 1st series Town milk 144 4 2.8 Country milk 24 7 29.1 2nd series Town milk 228 12 5.2 Country milk 67 9 13.4 Manchester (Country milk) 93 17 18.2 ,, (2nd series) 85 12 14.1 * These figures probably understate the case to a considerable extent. More than a proportional part of the unallotted deaths referred to on p. 58 were those of poor people coming from these areas. † From the Annual Report of the Medical Officer of Health of Brighton, quoted in Public Health, xiii., p. 639. 62 [Appendix IY. In 1899 the Vestry of Hackney caused 100 samples of milk to be examined bacteriologically for tuberculosis, and 22 per cent, were found to be infected. The sources of the milk have not been stated, but it is said that "a large proportion of the samples examined were taken from milk imported into the district." At the close of 1899 the Vestry directed samples to be taken in the Parish for a like purpose. As it was essential to know definitely the origin of each milk, the samples were taken on the milk platform at Paddington Station, the name and address of the consignor being recorded in each instance. There is no legal power to take samples for this purpose, and the work had to be done with discretion. In all 39 samples were examined, of which 2 only were found to be infected—or "just over 5 per cent." Pus cells were, however, found in varying numbers in nearly all the samples. The bacteriologist (Dr. Hewlett) was able to describe only 8 samples as " of good quality "; he, however, reported that all the samples were " clean " and " free from extraneous matters, such as sand, dirt, straw," &c. It is somewhat difficult to reconcile the very divergent results obtained by the different observers, and without desiring to minimize the importance of the results recorded, it is impossible to help doubting whether the bacillus tuberculosis has been identified in every case. It is well known that there are many organisms so closely resembling that of tuberculosis as to render their differentiation very difficult. It is almost impossible to do so without direct inocidation of animals. Whatever the explanation of the differences may be, the results obtained clearly indicate that steps should be taken to systematically verify the presence of the organism in milk, and that legal powers should be obtained for this work. Rural authorities are not likely to undertake the duty, and it can therefore only be done at the points of entry into the urban districts. There ought to be a regular intercommunication of results between the authorities of the district in which the samples are taken and of that whence the milk comes. By the Dairies, Cowsheds, and Milkshops Order milk derived from cows affected with tuberculosis of the udder may not be used for the food of man. Examination of the udder frequently fails to disclose the disease, and consequently it is necessary to fall back on bacteriological tests. 63 Report of Medical Officer of Health.] CANCER. The deaths tabulated as due to "cancer or malignant disease" include all deaths due to carcinoma, sarcoma, epithelioma, rodent ulcer, malignant disease, cancer, &c. The total number of such deaths during 1900 was 129, being 10 in excess of the decennial average (119). The deaths of residents of North Paddington numbered 104, 16 in excess of the average, and those of South Paddington, 25, 7 less than the average. The death-rates for last year per 1,000 persons at all ages were, Paddington 0.99, St. Mary 1.07, and St. John 0.75, compared with mean rates of 0.92, 0.89, and 0.98 respectively (see Tables 20 and 20a. pp. 42 and 43). In the Metropolis 4,251 deaths were registered from "cancer," being 451 in excess of the average, and equivalent to a rate of 0.92 per 1,000 persons at all ages. The deaths recorded in the Metropolis last year compared with the decennial annual average were equivalent to an increase of 12 per cent., compared with one of 8 per cent. in the Parish. The Registrar-General does not tabulate the deaths from cancer in the individual districts of the Metropolis, but the rates for 1897-99 have been kindly furnished by the Medical Officer of Health of the County. From his return the appended statement of the cancer mortalities in the adjacent districts given below has been compiled:— Cancer. Rates per 100,000 persons at all ages.* 1897. 1898. 1899. Paddington † 94 96 124 Kensington 101 108 99 St. George, Hanover Square 97 103 113 Westminster 94 105 94 Marylebone 118 118 107 Hampstead 97 100 87 The parts of the body (presumably) primarily affected by the disease are indicated in Table 31, the number of deaths from the chief forms of the disease in each sex being distinguished. In Table 32 last year's figures for "cancer" are compared with the averages based on the returns of the preceding 9 years for the two Sub-Districts, the parts affected not being distinguished so minutely. Increase in Prevalence.—At the close of the century it may not be out of place to very briefly deal with the question of the increase in the mortality from "cancer." As has already been mentioned, the number of deaths last year recorded in the Parish represents an increase of 8 per cent, above the decennial annual average, after correcting the latter for the increase in population. In St. Mary the increase last year was equal to 18 per cent, over the decennial average, while in * These rates require to be received with some reservation, owing to the long interval since the census of 1891, and owing to there being no correction for sex-age constitution of the various populations. + The Departmental rates for Paddington were 1897,90; 1898,90; 1899, 118. 64 [Appendix IV. TABLE 31. Cancer. Deaths during 1900, classified according to situation. 1900. St. Mary. St. John. C. O. C. O. m. F. m. f. m. f. m. f. 1. Nervous System 1 1 — — — — — — 2. Organs of Special Sense 3. Respiratory System 2 — — — 1 1 — — 4. Circulatory System — — — — — — — — 5. Digestive System— (a) Mouth 1 — 4 — — — — — (b) Throat 5 — — — 2 — 1 — (c) Intestines— i. Stomach 5 5 — — 1 — — — ii. Bowel 3 5 — — 1 2 — iii. Rectum 2 6 — — 1 — l — (d) Organs— i. Liver 5 5 — — — 3 — — ii. Pancreas — (e) Peritoneum — 1 — 1 — — — — (/) Omentum — — — — — — — — 6. Lymphatic System 2 — 1 — 1 — — — 7. Urinary System 3 1 1 1 — 1 — — 8. Generative System— (a) Ovary — 2 — — — — — — (b) Uterus — 14 — — — 2 — — (c) External Organs — — 1 — — — — — (d) Breast — 10 — 4 — 3 — — 9. Osseous System— (a) Head — — — 2 — — — — (b) Thorax — — 2 — — — 1 (c) Abdomen — — — — — 1 — — (d) Extremities — — 1 — — — 1 1 10. Cutaneous System — — — 1 — — — — 11. Insufficiently described 1 4 — 1 — — — — Totals 30 54 10 10 7 13 3 2 "C." includes cancer, carcinoma, and malignant disease. "0." includes sarcoma, scirrhus, epithelioma, &c. " M."—Males. " F."—Females. 65 Report of Medical Officer of Health.] TABLE 32. Cancer. Deaths recorded in 1900 compared with averages. Males. St. Mary. St. John. 1891* to 1895 1896* to 1899 1900 1891* to 1895 1896* to 1899 1900 (5 yrs.) (4 yrs.) (5 yrs.) (4 yrs.) Nervous System — — 1 0 — — Organs of Special Sense 0 — — — — — Respiratory System 2 1 2 — 0 1 Circulatory System — — — — — Digestive System 13 23 25 8 6 7 Lymphatic System 1 1 3 0 0 1 Urinary System 1 1 4 0 1 — Generative System 0 0 1 — — — Osseous and Muscular Systems 1 1 3 0 1 1 Cutaneous System 0 — — 0 — — Insufficiently located 2 3 1 1 1 — Totals 20 30 40 10 9 10 Females. Nervous System — 1 — 0 — Organs of Special Sense — — — — — — Respiratory System 0 1 — 0 0 1 Circulatory System 0 — — — — — Digestive System 17 23 23 10 9 5 Lymphatic System 1 1 — — 1 — Urinary System 1 2 2 1 1 1 Generative System 27 25 30 10 10 5 Osseous and Muscular Systems 2 2 2 1 — 3 Cutaneous System 0 — 1 — — — Insufficiently located 7 7 5 2 2 — Totals 55 61 64 24 23 15 Grand Totals 75 91 104 34 32 25 * Annual average number of deaths. 66 [Appendix IV. St. John there was a decline equal to 22 per cent. The percentage variations in the numbers of deaths recorded are indicated below:— Cancer. Paddington. St. John. St. Mary. Averages. V Averages. Averages. 1890-94 1895-99 1890-99 1900 1890-94 1895-99 1890-99 1900 1890-94 1895-99 1890-99 1900 Deaths recorded 115 124 119 129 83 91 88 104 32 33 32 25 Variation +12 +4 +8 ... +25 +14 +18 ... —22 —24 —22 ... Note.—"+" indicates increase " — " indicates decrease per cent, in the number of deaths recorded in 1900, compared with the averages. Although a few deaths are recorded each year from "cancer" in the young, yet the disease must be regarded as one of adult life. The deaths registered in the Parish since 1875 have been tabulated in the customary age-groups as well as the total numbers of deaths in each of the SubDistricts. Since 1891 the deaths have been tabulated for sex and age in each Sub-District, but it does not appear desirable to enter upon a full consideration of the prevalence in the Sub-Districts until the census (1901) returns are available. Of 2,278 deaths recorded in the 26 years 1875-1900, 25 (equal to 1.09 per cent, of the total) occurred at ages under 25 years,* and 67 at ages between 25 and 35 years.† It is evident therefore that rates based on the total population give but an imperfect idea of the mortality from cancer. In addition to age, sex should be considered, but the necessary data are not available. In Paddington, of the 101,235 persons estimated to live in the Parish in 1875, 52,404 were persons at "cancer ages," while in 1900 the estimated population at all ages (130,596) included 68,517 persons at "cancer ages." In other words, each 1,000 persons living in 1875 included 518 persons at "cancer ages," a proportion which had increased to 525 in 1900. There would, therefore, be a prima facie reason for expecting some slight increase in the number of deaths from "cancer" at all ages. The proportions of males and females at all ages and "cancer ages" in the Parish and the two Sub-Districts are given in Table 33:— TABLE 33. Proportion of Males and Females at "All Ages " and "Cancer Ages." Persons at "all ages" in each area = 1,000. Paddington. St. Mary. St. John. Males. Females. Males. Females. Males. Females. 1875 All Ages 400 600 421 579 364 636 Cancer Ages 195 322 198 298 190 364 1900 All Ages 414 586 434 566 356 644 Cancer Ages 250 320 209 299 191 381 * The maximum number of deaths at ages 0—25 years in any quinquennium was 8, recorded during the years 1895-99. + For the purposes of this report the ages from 25 years onwards are deemed to be "cancer ages." 67 Report ok Medical Officer of Health.] In Table 34 the mean mortality rates per 100,000 at all ages and at cancer ages for the Parish and the two Sub-Districts are set out.* The figures indicate a continuous increase in the TABLE 34. Mortality from Cancer. Per 100,000 persons at all ages. Quinquennia. Paddington. St. Mary. St. John. I. 1875-79 61.3 59.6 64.3 II. 1880-84 65.0 62.4 70.0 III. 1885-89 83.6 81.4 88.4 IV. 1890-94 89.1 85.2 99.1 V. 1895-99 95.0 94.3 96.8 Year 1900 98.7 106.9 74.9 Per 100,000 persons at cancer ages. Quinquennia. Paddington. St. Mary. St. John. I. 1875-79 118.4 120.1 115.9 II. 1880-84 126.0 133.9 123.0 III. 1885-89 159.6 161.4. 156.1 IV. 1890-94 169.5 167.9 173.0 V. 1895-99 180.9 185.5 168.9 Year 1900 188.2 210.5 130.7 mortality in the whole Parish and in St. Mary, but in St. John an increase up to the fourth quinquennium (1890-94), and since then a decrease. The increases per cent, in the rates for the last quinquennium and for 1900, compared with the corresponding rates for 1875-79, are indicated below:— Cancer Mortality. Per 100,000 in each case. All Ages. Cancer Ages. Paddington. St. Mary. St. John. Paddington. St. Mary. St. John. 1875-79 100 100 100 100 100 100 1895-99 +55 +58 +50 +52 +54 +45 1900 +61 +79 +16 +58 +75 +12 * These rates are based on the total numbers of deaths from cancer in each district. The error introduced in the rates for "cancer ages" by such method is slight, being not more than 2"6 per 100,000 in the case of the whole Parish, and ranging from zero to something slightly in excess of 2'6 for either of the Sub-Districts. 68 [Appendix IV. It appears, therefore, that the mortality at all ages in the Parish during 1900 was 61 per cent, in excess of the mean mortality during 1875-79, and that at cancer ages 58 per cent, in excess. In St. Mary the excess was 79 per cent, for all ages and 75 for cancer ages, and in St. John 16 and 12 respectively. To decide whether such increase has been a real one it is necessary to inquire— (a) "Whether the increase has prevailed in each of the age-periods denominated as " cancer ages"; and (b) Whether such increase, if any, (i.) be simply a feature of a general increase in the mortality at those ages; or (ii.) due to transference of deaths from other less defined causes to cancer ; that is, whether the increase represents an improvement in diagnosis. For this purpose the age-group mortalities have been calculated for (1) Cancer; (2) All causes, excluding cancer; and (3) (a) Certain selected causes with well-defined characteristics.* (b) All other causes. Finally (in Table 35) the mortalities for each age-group under each of the heads are contrasted, the rates for the first quinquenuium in each case being taken as 100. This method is admittedly imperfect, but the best available without the use of the diagrams. A complete discussion of these tables would be beyond the scope of this report. It must suffice to say that, while there has probably been some transference of deaths from less defined causes to cancer, there has also been a real increase in the mortality from this cause. To a certain extent such increase may be regarded as natural. One of the results of sanitation has been to defer the day of death to more mature ages, i.e., to protect young lives from such diseases as the zymotic, tubercular, &c., and to leave them to the accidents of old age, among which cancer probably ranks first. If that be so, the question arises as to what will be the limit in the increase in this cause of death. Happily, indications are not wanting to promise that the limit is nearly reached. As was mentioned in connection with Table 34, a decrease in the mortality has been recorded in St. John during the last 6 years. Similar checks in the upward curve of the mortality have been noted in other towns, e.g., Eastbourne and Brighton, which it is hoped will be found to be permanent. It has been suggested that cancer affects certain houses more than others, or, as it is popularly stated, that there are cancer-infected houses just as there are tubercular. A record for 10 years will neither prove nor disprove such suggestion, but it may be stated that it has been possible to allot 1,139 deaths out of 1,169 recorded during the decennium 1890-1900 to their homes (1,083 houses), 46 of the houses being credited with 2 deaths each and 5 with 3. The complete returns for the two Sub-Districts are set out below :— Cancer. House frequency, 1891-1900. St. Mary. St. John. Total deaths 817 322 Total houses 778 305 Houses with 1 death 742 290 Houses with 2 deaths 33 13 Houses with 3 deaths 3 2 * The selected causes comprise : The principal zymotic diseases; tubercular diseases; apoplexy; heart diseases: bronchitis and pneumonia: accidents and suicides. 69 Report of Medical Officer of Health.] TABLE 35. Comparison of Age-group Mortality-rates. Whole Parish: Persons. Age-groups. Quinquennium.* Cancer, † All Causes, excluding Cancer, † Selected Causes.† Other Causes.† 25 I. 100 100 100 100 II. 96 84 80 94 III. 152 89 85 97 IV. 201 84 78 97 V. 82 75 66 96 35 I. 100 100 100 100 II. 66 91 96 83 III. 104 89 91 86 IV. 124 108 109 106 v 96 96 89 107 • 45 I. 100 100 100 100 II. 116 101 99 106 III. 174 100 97 107 IV. 168 113 104 127 V. 182 106 95 124 55 I. 100 100 100 100 II. 108 88 80 100 III. 122 105 105 99 IV. 139 109 111 107 V. 137 91 78 111 65 I. 100 100 100 100 II. 105 78 70 88 III. 118 92 101 82 IV. 128 102 114 86 V. 148 93 97 89 75 I. 100 100 100 100 II. 127 92 103 84 III. 129 88 109 71 IV. 106 93 119 73 V. 178 90 97 84 85 I. 100 100 100 100 II. 164 66 95 54 III. 155 97 185 58 IV. 135 82 117 67 V. 202 66 91 55 * Refer to Table 34 for years included in each quinquennium. † The figures in these columns are to be read thus: The recorded death-rate (per 100,000 persons) in Quinquennia II., III., &c., were to the recorded rates in Quinquennium I. as 96, 152, &c., are to 100. The same may be simply but not accurately stated thus: The death-rate in Quinquennium II. fell to 96 and rose to 152 in Quinquennium III., &c. 70 [Appendix IV. INFANTILE MORTALITY. The deaths registered at ages under 1 year numbered 477 in all, 425 of the deceased children being residents of St. Mary's Sub-District and 52 of St. John's. The infantile mortality per 1,000 births registered was 165, being 14 in excess of the decennial average (see Table 18, p. 38). In St. Mary the mortality last year was 171, or 16 in excess of the average, and in St. John 126, or 2 in excess. The rate for the Parish (165) was higher last year than that for the Metropolis (158), but the average for Paddington (151) was below that for the Metropolis (159). The rates for St. John are the lowest included in Table 18, to which reference can be made for further comparison. With the exception of Westminster (189) and Kensington (180), the rate for the Parish last year was the highest recorded in the Western districts of the Metropolis. Below will be found the mean rates for 1890-99 and the rates for 1900 for those districts. A more extended list of infantile mortalities for the 4 years 1897-1900 will be found in Table 17 (p. 17). Infantile Mortalities. Per 1,000 births registered. Mean rates. 1890-99. 1900. Kensington 172 180 Fulham 172 147 Hammersmith 169 162 Chelsea 159 149 St. George, Hanover Square 134 107 Westminster 162 189 St. James, Westminster 154 154 St. Marylebone 136 125 Hampstead 120 100 Paddington 151 165 It will be seen that the last year's rates were below the decennial mean rates in the abovementioned districts, except Kensington, Westminster, and Paddington. In Table 36 the causes of death at ages under 1 year are set out for the decennium 1890-99, two quinquennia, and for 1900. The most striking changes to be noted are the increases (with a reduced birth-rate) from diarrhoea, want of breast milk, premature birth, congenital malformations, and bronchitis and pneumonia. These diseases accounted altogether for an increase of 57 deaths above the decennial average. With the possible exceptions of premature birth and congenital malformations, all these causes are amenable to hygienic control, or, to state the case in another way, are largely due to ignorance or carelessness on the part of the parents. This latter statement is specially true with regard to infants suffocated by being in bed with the parents. It is satisfactory to note the reductions in the mortality from diphtheria and the tubercular diseases. The reductions recorded in convulsions and from enteritis are probably due to greater care in certifying the causes of death. Since 1891 the deaths under 5 years of age have been tabulated more minutely. Tables 37 and 37a show the numbers and mortalities at various ages under 1 year, and Table 38 gives thenumbers at ages from 1 to 5 years. In spite of the epidemic of measles, there were satisfactory reductions in the numbers of deaths at these ages. The causes of death at the ages specified have also been separately tabulated, but are not included on this occasion. 71 Report of Medical Officer of Health.] TABLE 36. Causes of Death at Ages under One Year. Annual Averages. Recorded 1900. 1890-91. 1895-99. 1890-99 Small-pox — — — — Measles 13 8 11 12 Scarlet Fever 1 — 0 — Whooping Cough 20 18 19 14 Diphtheria 4 4 4 1 "Fever" — — — Diarrhœa 53 77 65 85 Principal Zymotic Diseases 91 107 99 112 Syphilis 7 6 7 1 Other Zymotic Diseases 3 6 4 8 All Zymotic Diseases 101 119 110 121 Want of Breast Milk 2 4 3 11 Tubercular Diseases 31 26 29 23 Premature Birth 54 62 58 62 Congenital Malformations 13 21 17 24 Convulsions 31 27 29 17 Bronchitis and Pneumonia 73 73 73 91 Dentition 8 7 7 5 Enteritis 8 36 22 18 Suffocation (Overlaid in Bed) 11 13 12 14 Other Forms of Violence 4 4 4 2 Atrophy and Debility 63 48 55 54 Above Causes 399 440 419 442 Other Causes 30 27 29 35 All Causes 429 467 448 477 Births Registered 2,926 2,992 2,959 2,890 "0" means an average less than unity. TABLE 37. Deaths at Ages under One Year. Ages at Death. St. Mary. St. John. Males. Females. Males. Females. Means. 1900. Means. 1900. Means. 1900. Means. 1900. 1891-95. 1896-99. 1891-99. 1891-95. 1896-99. 1891-99. 1891-95. 1896-99. 1891-99. 1891-95. 1896-99. 1891-99. Births 1,256 1,326 1,287 1,254 1,022 1,252 1,124 1,225 243 225 235 206 220 192 207 205 Days. 0-1 17 23 20 16 13 14 13 10 5 2 4 6 2 3 2 2 1-7 18 17 18 24 16 12 14 20 4 3 4 3 3 2 2 4 7-28 23 27 25 37 20 22 21 31 3 5 4 4 3 2 2 4 Months. 0-3 102 113 107 115 84 80 83 100 20 18 19 15 14 10 12 14 3-6 39 47 43 53 35 41 37 40 7 6 7 5 6 4 5 3 6-9 36 40 38 31 29 29 29 25 7 3 5 6 2 5 4 3 9-12 30 35 32 29 20 25 22 32 3 4 3 4 4 0 2 2 Total under 1 yr. 207 235 220 228 168 175 171 197 37 31 34 30 26 19 23 22 TABLE 37a. Mortalities at Ages under One Year.* Ages at Death. St. Mary. St. John. Males. Females. Males. Females. Means. 1900. Means. 1900. Means. 1900. Means. 1900. 1891-95. 1896-99. 1891-99. 1891-95. 1896-99. 1891-99. 1891-95. 1896-99. 1891-99. 1891-95. 1816-99. 1891-99. Days. 0-1 13 17 15 13 13 11 12 8 20 9 17 29 9 16 10 9 1-7 14 12 13 19 16 9 12 16 16 13 17 14 13 10 10 19 7-28 18 20 19 29 19 17 18 25 12 22 17 19 13 10 10 19 Months. 0-3 81 85 83 92 83 64 74 82 82 80 81 73 64 52 58 68 3-6 31 35 33 42 34 33 33 33 29 27 30 24 27 20 24 15 6-9 29 30 29 25 28 23 26 20 29 13 21 29 9 26 20 15 9-12 24 26 25 23 19 20 19 26 12 18 13 19 18 0 10 9 Total under 1 yr. 165 177 170 182 164 140 152 161 152 138 145 145 118 99 112 107 72 [Appendix IV. * Per 1,000 births. TABLE 38. Deaths at ages from 1 to 5 years. ST. MARY. ST. JOHN. Males. Females. Males. Females. Ages. 1891-95. 1896-99. 1891-99. 1900. 1891-95. 1896-99. 1891-99. 1900. 1891-95. 1896-99. 1891-99. 1900. 1891-95. 1896-99. 1891-99. 1900. Years. 1- 57 56 57 55 46 51 48 49 9 5 7 5 8 4 6 3 2- 21 23 22 20 24 21 23 20 4 2 3 2 3 3 3 2 3- 14 14 14 12 15 16 15 8 4 3 4 3 1 2 2 1 4- 11 12 11 9 11 11 11 10 2 2 2 1 2 2 2 — 1-5 103 105 104 96 96 99 97 87 19 12 16 11 14 11 13 6 73 Report of Medical Officer of Health.] 74 [Appendix IV. Deaths of Illegitimate Infants.—During the year 46 deaths of illegitimate infants were recorded, 22 of boys and 24 of girls, 39 deaths being returned from St. Mary and 7 from St John. The infantile mortality among illegitimate children under 1 year of age was equal to 319 per 1,000 births registered, compared with one of 157 per 1,000 legitimate children born. The returns for the last 6 years are appended:— Infantile Mortality. Per 1,000 births of each class. Legitimate. Illegitimate. 1895 153 408 1896 148 353 1897 141 336 1898 153 338 1899 141 356 Means 147 358 1900 157 319 TABLE 39. Deaths of Illegitimate Children. 1900. St. Mary. St. John. Ages 0-1. 1-5. 0-1. 1-5. Sex M. F. M. F. M. F. M. F. 1st Quarter 4 2 — — 2 2 — — 2nd Quarter 2 3 1 1 — 1 — — 3rd Quarter 11 7 — — 1 — — — 4th Quarter 1 7 — — — 1 — — Year 18 19 1 1 3 4 — — The occupations of the mothers were stated to be as under:— Domestic Service 24 Commercial ... 6 "Servant" 6 Dressmaker 4 " General Servant " 7 Barmaid 2 Housemaid 5 Various ... 8 Parlourmaid 2 Laundress 6 Cook 3 Charwoman 2 Housekeeper 1 No occupation ... 3 Occupation not stated ... 5 75 Report of Medical Officer of Health.] TABLE 40. Deaths of Illegitimate Children. Causes of Death. 1900. Ages 0-1. 1-5. Sex M. F. M. F. Measles — — 1 — Diphtheria — — — 1 Diarrhœa 4 6 — — Want of Breast Milk — 2 — — Tuberculous Disease — 1 — — Premature Birth 1 5 — — Congenital Malformations 1 1 — — Convulsions 2 1 — — Bronchitis, Pneumonia 2 5 — — Enteritis 4 — — — Overlaid 1 1 — — Violence 2 — — — Atrophy and Debility 3 — — — Other Causes 1 1 — — Totals 21 23 1 1 Inquests were held respecting 9 deaths. 76 [Appendix IV. DEATHS FROM VIOLENCE The deaths from violence of all forms numbered 68, viz., 37 of males and 31 of females, including 52 from accidents ("open" verdicts are tabulated under accidents), 1 from homicide, and 15 from suicides. The suicides were 1 in excess of the decennial annual average (see Table 20, p. 42). Inquests.—Inquests were held with reference to 154 deaths of parishioners, being 5 fewer than in 1899, and the same number as in 1898. The findings of the Juries and certain other particulars are set out below:— Inquests on Parishioners, 1900. Finding of Jury. Paddington. St. Mary. St. John. Natural Causes 85 70 15 Misadventure 1 — 1 Accident 48 41 7 Manslaughter — — — Murder 1 1 — Suicide 15 12 3 Open 4 2 2 Totals 154 126 28 The accidents were attributed to the following (among other) circumstances:— Vehicular traffic 6 Overlaid in bed (infants) 11 Railway traffic 2 Clothes on fire (not due to conflagrations) 6 Building operations 3 Drowning ... 2 The "open" findings were given in respect of 2 women found drowned in the canals and 2 new-born infants, 1 found in a Great Western Railway cloak-room, and 1 found in an enclosure off a street. "Wilful murder" was returned in respect of a new-born infant found on the bank of the canal. 77 Report of Medical Officer of Health.] DEATHS IN INSTITUTIONS. In the local public institutions 708 deaths occurred, 365 of the deceased persons being nonparishioners. In 1899, 606 deaths were recorded in these places, but St. Mary's Hospital was not receiving its full complement of patients during the summer months, owing to repairs, &c. In the various metropolitan hospitals, lunatic asylums, &c., there were 155 deaths of parishioners, exactly the same number as in 1899. The 479 deaths of parishioners which occurred in public institutions were equal to 23.2 per cent, of all deaths, compared with percentages of 22.3 and 23.2 in 1899 and 1898. The returns for last year were as below:— Local Institutions. Paddington Workhouse 52 including 6 Non-parishioners. Infirmary 203 ,, 11 ,, ,, Lock Hospital 4 ,, 3 ,, ,, Children's Hospital, Paddington Green 63 ,, 45 ,, ,, St. Mary's Hospital 386 ,, 300 ,, „ Outlying Institutions. Hospitals of Metropolitan Asylums Board 27 Scarlet Fever 4 Enteric Fever 2 Diphtheria 18 Measles 1 Other Diseases 2 General Hospitals 35 Cancer 2 Enteric Fever 1 Tubercular Diseases 3 Special Hospitals 22 Cancer 4 Tubercular Diseases 5 Homes 13 Cancer 2 Tubercular Diseases 4 Lunatic Asylums 36 Cancer 3 Tubercular Diseases 4 Poor Law Institutions 3 Tubercular Diseases 2 Elsewhere 19 Cancer 1 Tubercular Disease 1 Of the 479 deaths of parishioners in institutions, 304 occurred in those maintained by rates, and 175 ,, ,, voluntary contributions. 73 [Appendix IV. ADMINISTRATIVE WORK. The customary return of the number of inspections made, the class of amendments effected, &c., &c., will be found in Appendix A (Table V.), p. 102. Prevention of Infectious Disease.—The routine followed in connection with reported cases of infectious disease has been described in-former reports. The "visits of inquiry" during the year numbered 1,544, compared with 839 in 1899. In 1898, when "measles" was epidemic, the total number of visits was 2,781. The inquiries and visits made by the Medical Officer of Health are not included in the foregoing figures. In respect of patients treated at home, 83 "letters of advice," covering the prescribed extracts from the Public Health (London) Act, 1891, and the Factory and "Workshop Act, 1895, were sent out. The Department disinfected 1,002 rooms, compared with 767 in 1899 and 1,259 in 1898, and 38i tons of bedding, &c., were removed for disinfection and cleansing. Only 6 rooms were disinfected privately during the year. Hospital Accommodation.—There was no delay in the removal of patients to hospital last year. Schools.—The notices required by the Public Health (London) Act, 1891, have been duly issued to all local schools, and exchanged with the Medical Officers of Health of the adjacent Parishes, as regards outlying schools. It was necessary to close the under-mentioned schools on account of epidemic prevalence of measles, for the periods mentioned. Copies of the special report as to each school were sent to the Local Government Board, the London County Council, and the respective managers of the schools. Name of School. Date of Order. Date of Re-opening. Bayswater Jewish 28th March, 1900. 23rd April, 1900. St. Mary Magdalene 17th May, 1900. 11th June, 1900. St. Paul 24th May, 1900. 18th June, 1900. St. John, South Paddington 29th June, 1900. 23rd July, 1900. St. Stephen 29th June, 1900. 23rd July, 1900. The Medical Officer of Health was constantly in communication with the school teachers with reference to the prevalence of measles among the families of scholars, and in the course of his visits to the schools saw some of the children set apart by the teachers. It is this co-operation between the school teachers and the Department which may be expected to produce the best results in limiting the spread of measles. Such co-operation, it is believed, obviated the necessity of closing the Campbell Street Board School, and possibly certain others. Family Shelter.—Into the house provided for families displaced during the disinfection of their homes 15 families were received in 1900, 6 fewer than in 1899. The families included 45 individuals, 21 adults and 24 children. As there was (generally) less infectious disease during the year, it was a natural consequence that fewer persons required to use the accommodation provided. Moreover, there is in successive years a variation in the incidence of disease on the occupants of different classes of homes—i.e., number of rooms occupied. It is usually the inhabitants of single or two-room tenements who are admitted to the shelter. Disinfection.—Messrs. Armfield & Sons have continued to carry out the disinfection of bedding, &c. There have been no complaints as to the condition of the goods sent home, nor has there been any evidence that the processes employed have failed in their object. The expenditure 79 Report of Medical, Officer of Health.] last year on this account was £856, as compared with the amounts set out below for the preceding six years:— 1894 £875 1897 £1,109 1895 £881 1898 £1,203 1896 £1,284 1899 £947 Proposals for the erection of a disinfecting station have been discussed for some years past. A site was purchased some three years ago, on a portion of which it was proposed to erect a station, the preliminary plans of which have been prepared. It is questionable whether it would be possible to equip and maintain the staff and plant necessary to disinfect and cleanse the goods to the extent at present in vogue, except at an outlay greatly in excess of what is spent on the work. So far as is known, no other Authority sends disinfected articles home in a condition almost equal to new. The new contract has worked satisfactorily, and effected an economy. The total amount paid in the last twelvemonths (£856) was much below that paid in 1898 (£1,203) under the old schedule of prices, although the total weight of goods removed last year was only 5½ tons less than that removed in 1898. Compulsory Removal to Hospital.—For the first time in the course of some six years application was made in August last, under Sec. 66 of the Public Health (London) Act, 1891, for an Order to compel the parents to submit to the removal of their sick child to hospital. The facts of the case are briefly as follow :— On August 20th, M. M., female, aged 4 years, was certified to be ill with diphtheria. The patient's family consisted of father, mother, and 2 children, 1 over 10 years and 1 under (the patient), and resided in the basement (underground) rooms. The whole house contained 9 rooms, occupied by 5 families, in all comprising 13 individuals, 3 of whom were under 10 years of age. The father's consent to removal was obtained, but the mother refused to allow the child to go when the ambulance arrived. Application for an Order for removal was made on the next day, but the Magistrate would only grant a summons calling upon the parents to show cause why an Order should not be made. The summons was heard on the 22nd, and adjourned to 23rd, to get a further certificate from the medical practitioner who first saw the case. The certificate given was to the effect that the patient was " going on satisfactorily," and that the certifier "saw no reason for the removal." The Order was refused, and costs were awarded to the father. The child died three days later. The case occurred whilst the Medical Officer of Health was away on vacation. From the information obtained subsequently, it would appear that the Magistrate regarded the application as made for the sake of the patient, and that he lost sight of the real need to remove the ease to protect the other inhabitants of the house. The treatment and care of the patient are really secondary factors in such a case. It is to be regretted that the case was not dealt with on the 21st, or, better still, on the 20th. Verbal notice to the responsible party of the intention to apply for an Order should suffice to secure an immediate hearing, otherwise much harm might accrue from the delay. There was no known case attributable to the child in question, but it is possible that early removal to hospital might have saved her life. Parents are not, as. a rule, alive to the grave danger of sudden death in cases of diphtheria, and allow their children to sit up and do things which would not be allowed in hospital. Disinfection of Rooms.—For the fumigation of sick-rooms cake sulphur is still relied on for general use. The instructions given ensure that it is used in proportions in excess of 1 lb. to 1,000 cubic feet, the customary allowance. Formaldehyde gas and the spray machine (formalin) are used occasionally. Stripping of walls and whitewashing of ceilings after infectious illness have not been required, unless the room be dirty or the wall-paper much torn. Chloros powder (chloride of lime) and carbolic soap have been distributed gratuitously to those who cannot afford 80 [Appendix IV. to purchase the same. The use of disinfectants is not encouraged, as it is believed that they are, as commonly used, of very doubtful efficiency; cleanliness and fresh air are relied upon to keep illness away. The expenditure for disinfectants of all kinds amounted to £76 last year, £24 more than in 1899. Houses Let in Lodgings.—In consequence of the alterations proposed, and now effected, in the Bye-laws for houses let in lodgings, made under Sec. 94 of the Public Health (London) Act, 1891, the work of registration has been in abeyance since December, 1898. It will be useful to briefly record the progress of the change. At the meeting of the Sanitary Committee on November 16th, 1899, two Notices of Motion to alter the "exemption clauses" were considered,* and the Vestry was recommended to adopt the following amended Bye-law:— 2.—In either of the following cases a lodging house shall be exempt from the operation of these Bye-laws, that is to say— (a) Where the rent or charge payable by each lodger, and exclusive of any charge for the use by such lodger of any furniture, is at the rate of seven shillings and sixpence per week, or upwards. (b) Where the rent or charge payable by each lodger, and inclusive of any charge for the use by such lodger of any furniture, is at the rate of ten shillings per week, or upwards. The Committee's proposals were before the Vestry on November 21st, but were referred back for further consideration and report. The Committee after further consideration proposed that the amendment should read as follows:— 2.—In any of the following cases a lodging house shall be exempt from the operation of these Bye-laws, that is to say— (a) Where the landlord himself resides on the premises and sub-lets not more than one tenement in the house occupied by him except the Sanitary Authority by express order direct such house to be registered. (b) Where the rent or charge payable by each lodger occupying not more than one room, and exclusive of any charge for the use by such lodger of any furniture, is at the rate of four shillings and sixpence per week, and upwards. (c) Where the rent or charge payable by each lodger occupying not more than one room, and inclusive of any charge for the use by such lodger of any furniture, is at the rate of six shillings per week, and upwards. (d) Where the rent or charge payable by each lodger occupying two or more rooms, and exclusive of any charge for the use by such lodger of any furniture, is at the rate of seven shillings and sixpence per week, and upwards. (e) Where the rent or charge payable by each lodger occupying two or more rooms, and inclusive of any charge for the use by such lodger of any furniture, is at the rate of ten shillings per week, and upwards. The Committee's proposals were considered by the Vestry at a special meeting held on February 27th, 1900, when they were adopted as submitted. They were forwarded to the Local Government Board for confirmation, and on June 2nd the Board wrote forwarding a slightly altered form of Bye-law, which the Board stated they were prepared to confirm. The Bye-law as amended by the Local Government Board was as follows:— 2. In any of the following cases a lodging house shall be exempt from the operation of the Bye-laws of 1894, that is to say— (a) Where the landlord himself resides on the premises and the sub-letting by such landlord is to not more than one lodger. * The old Bye-law exempted lodgings let at the under-mentioned rentals :— 5s. per room per week, unfurnished. 7s. 6d. „ „ furnished. The Bye-law was unique in prescribing a limit per room. 81 Report of Medical Officer of Health.] (b) Where the rent or charge payable by each lodger occupying not more than one room, and exclusive of any charge for the use by such lodger of any furniture, is at the rate of four shillings and sixpence per week, and upwards, and such room is occupied by not more than two persons. (c) Where the rent or charge payable by each lodger occupying not more than one room, and inclusive of any charge for the use by such lodger of any furniture, is at the rate of six shillings per week, and upwards, and such room is occupied by not more than two persons. (d) Where the rent or charge payable by each lodger occupying two or more rooms, and exclusive of any charge for the use by such lodger of any furniture, is at the rate of seven shillings and sixpence per week, and upwards. (e) Where the rent or charge payable by each lodger occupying two or more rooms, and inclusive of any charge for the use by such lodger of any furniture, is at the rate of ten shillings per week, and upwards. The alterations suggested by the Local Government Board received full consideration from the Sanitary Committee, and the following recommendations by the Committee were adopted by the Vestry on October 16th:— The Committee, having carefully considered the alterations proposed by the Local Government Board, are of opinion that the Vestry should accept the amendments proposed by the Board, subject to the addition of the words " of ages exceeding ten years " at the end of Bye-law 2 (b) and (c), recommend that the Vestry do adopt the Bye-law as amended, that the Seal of the Vestry be attached to copy of such Bye-law, and that the same be submitted to the Local Government Board for approval. The Local Government Board declined to accept the proposed additions, and, after further consideration, the Sanitary Committee reported to the Council on December 18th last as under :— At the last meeting of the Council a letter from the Local Government Board under date of November 16th was read and referred to this Committee for consideration and report. In that letter the Board take exception to the addition of the words "of ages exceeding ten years " at the end of Bye-law 2 (b) and (c), on the ground that the addition of such words "would under certain circumstances exempt a lodging occupied by a man and wife with a family of children under ten years of age, if it consisted of one room only, while it would not exempt it if it consisted of two rooms." This was not the object which the Committee had in view when they proposed the addition in question. The Committee desired to meet the case of a woman occupying a room with two or three children, supposing such room to be adequate for their accommodation. Such room, under the Bye-law (2) as originally drafted, would, by a strict interpretation of the Bye-law, be subject to registration. The Committee are, however, of opinion that the addition of the words in question is not a matter essential to the successful and harmonious working of the Bye-laws, and therefore think that the addition need not be pressed. The Committee are particularly desirous of securing the approval of the Bye-laws at once, which can only be obtained by adopting the amended draft forwarded by the Local Government Board, which draft, with the exception of the objection dealt with here, has already been accepted by the Vestry. We therefore recommend— (a) That the Council do adopt the Bye-laws as amended, that the Seal of the Council be attached to copy of such Bye-laws, and that the same be submitted to the Local Government Board for approval. (b) That the resolution of the Vestry of the 16th October, 1900, be varied accordingly. The recommendations of the Committee were adopted by the Council, and the Local Government Board, writing under date of March 8th of this year, informed the Council that the Bye-law had been duly confirmed by the Board. Although no new houses were registered during 1900, a considerable number of registered houses were completely inspected and brought up to the standard prescribed by the Bye-laws, and the annual whitewashing and cleansing as far as possible enforced. The Inspector specially 82 [Appendix IV. appointed to work under the Bye-law was taken on to the permanent Staff of the Yestry in May, 1900, and no one has been yet appointed to replace him. A considerable amount of information as to overcrowding, &c., in the houses on the Register, and the advantages believed to have resulted from registration, was given in the Report for 1899. (See pp. 106 et seq.) Removal of Offensive Refuse.—There have been but few complaints since the last Report was made with reference to nuisance from stable refuse. The alteration of Bye-law 1, under Sec. 16 (1) of the Public Health (London) Act, 1891, referred to in the Annual Report for 1899, had not been effected at the close of the past year. Proceedings were taken against certain firms for removing trade refuse of an offensive character during prohibited hours. The particulars are set out under "Legal Proceedings " (p. 89). Dust Removal.—The house refuse of the Parish is removed once a week. Complaints as to non-removal, &c., do not come before the Department. Collections were made twice a week from certain parts of the Parish during the last summer, and in October of last year the Sanitary Committee recommended the Works Committee to permanently continue the practice from flats. The use of gas stoves in flats adds very materially to the difficulty of dealing with household refuse. In a well-ordered household, using coal ranges, all green and other wet refuse is burned in the fire, and not put into the dustbin. This cannot be done if all cooking be by gas. In many of the blocks of flats the buildings are so arranged that no proper accommodation is provided for the dustbin, while the accommodation provided is often too close to the windows of the lower flats. Given these two sets of circumstances, the only remedy which will prove effective is a more frequent removal of dust. A daily removal is in force in many of the provincial and a few metropolitan areas. Refuse Wharves.—The Wharves on the Canal Basin have been kept under constant observation to see that the work carried on thereat gives rise to no nuisance. By the provisions of Bye-law 8, under Sec. 16 (2) of the Public Health (London) Act, 1891, no refuse or any part of such refuse may remain on the wharf for more than 24 hours, while the Paddington Act of 1826 limits the time to 12 hours. The exact fulfilment of these regulations is practically impossible, and legal proceedings are in consequence not instituted, except in extreme cases. Housing of the Working Classes Act, 1890.—On November 2nd a complaint under Sec. 31 of the Act was received from " four or more householders" in the neighbourhood of Fernhead Road, calling attention to the insanitary condition of Nos. 80,82, and 84, Fernhead Road. The specific complaint was the " overcrowding of Nos. 80, 82, and 84, and especially No. 84, Fernhead Road, and the consequent inadequate and defective sanitary accommodation provided therein." The premises were inspected by the Medical Officer of Health on the day the complaint was received. He decided that the case was one to be dealt with under the Public Health (London) Act, 1891, not the Housing of the Working Classes Act, 1890. He reported to the Sanitary Committee "that none of houses are overcrowded, and the sanitary conveniences already provided are sufficient, and up to the standard prescribed by the Bye-laws of the London County Council." The houses were found to be more or less dirty and in want of repairs, the roofs defective owing to strain of telephone poles and wires, and two of the three drains unsound. Notices were issued under Sec. 4 of the Public Health (London) Act, 1891, and all defects have been remedied, and the houses put into good and substantial repair. Although no overcrowding was found to exist, the houses were somewhat densely occupied, as the appended statement shows:— 83 Report of Medical Officer of Health.]  80. 82.* 84* Cub. ft. Occupants. Cub. ft. Occupants. Occupants. Basement, front 1,430 J. 3, 1,350 2 A. 2 C. 4 A. 1 C. „ back 1,415 1,410 Ground floor, front 1,863 3A. 1,868 2 A. 4 A. 1 C. „ back 1,944 2,121 1st floor, front 2,172 2 A. 2 A. 2 A. 3 C. ,, back 1,149 2nd floor, front (a) 1,130 2 A. 2 A. 3 A. 3 C. ,, (b) 722 ,, back (a) 586 „ (b) 1,071 " A "—Adults. "C "—Children. Children over 10 reckoned as adults. Cutting off of Water Supply.—The two Water Companies supplying the Parish reported, in pursuance of Sec. 49 of the Public Health (London) Act, 1891, that the water supply had been cut off from 140 houses during the year, viz., from 100 houses supplied by the Grand Junction Waterworks Company, and from 40 within the area of the West Middlesex Waterworks Company. Each house was visited by the Inspector of the district, and from the reports made, the following alleged causes of the cutting off have been tabulated:— Reasons for Discontinuing Water Supply. Grand Junction. West Middlesex. House uninhabited 66 21 Repairs required to service pipes 27 5 Unpaid water-rates 2 6 Waste of water or defective fittings 5 — Houses in course of demolition — 3 Other cases, e.g., supply not required, &c. — 5 With respect to the inhabited houses, steps were taken to secure restoration of the supply where not already restored at the time of visit. The intervals which elapsed between the cutting off and restoration are indicated below:— Supply restored Grand Junction. West Middlesex. Same day as cut off 22† 2 Next day 2 2 After 2 days 1 — „ 3 „ 1 1 „ 4 „ - 1 „ 5 „ — 2 „ 6 „ 4 - Over more than 7 days 4 — In two cases the houses were emptied on account of want of supply of water, the intervention of the Court being required in one of the cases only. In 1898 the Grand Junction Waterworks Company reported that the water had been cut off from 100 houses, and the West Middlesex Company from 110 houses. In 1899 the total numbers reported were 86 from Grand Junction, and 43 from West Middlesex Company. Prior to November, 1899, the reasons for the discontinuance of the supply were not inquired into. Powers of Water Companies.—The legislation regulating the metropolitan water supply is * A bath (b. and c.) room is fixed in each of these houses, but the bath rooms appeared to be used chiefly as lumber rooms. † At 16 of these houses the supply was restored before the notice was received by the Department. 134 [Appendix IV. in a condition little short of chaotic. It is to he found, much of it repeated and amended, in four groups of Acts (public and private), some purely metropolitan, others metropolitan and provincial; some dealing with the water supply only, others with matters quite distinct therefrom, and containing only incidental provisions as to supply. The following list shows the variety and range of metropolitan water legislation:— i. Public Acts, relating to whole country, such as Waterworks Clauses Acts, ii. Do. relating to Metropolis only, such as Metropolis Water Acts, iii. Private Acts, promoted hy the Water Companies, either independently or conjointly. Into many of these Acts, parts of Acts included in groups i. and ii. are incorporated, vi. Miscellaneous Acts, such as Thames Conservancy Acts, Staines Reservoir Acts, Public Health (London) Act, 1891, &c. The powers of the companies to cut off the water supply appear to be limited to the following circumstances:— (a) Misuse and waste of water; (b) Refusal to admit the inspecting officer; and (c) Non-payment of rates. Misuse and Waste of Water. In the most general terms it is provided that when any person supplied with water " wrongfully does or causes or permits to be done anything in contravention of the provisions" of the Water Company's Act, "or wrongfully fails to do anything which .... ought to be done for the prevention of the waste, misuse, undue consumption, or contamination of water," the company may cut the water off, and not restore the supply until the requirement be fulfilled or the default made good, and may also recover the amount of any "loss, damage, or injury" sustained.—(Section 25 of the Metropolis Water Act, 1852.) When the supply is intermittent, every person supplied is bound, when required by the company so to do, to provide a cistern with proper ball-cock, &c., and to maintain the same in good repair, to prevent the water running to waste. Failure to perform either of these duties gives the company the power to cut off the supply until what is requisite has been done.—(Section 54 of the Waterworks Clauses Act, 1847.) When the supply is constant, any one causing or allowing fittings to be out of repair, " or to be so used or contrived .... that the water supplied .... is, or is likely to be "wasted, misused, unduly consumed, or contaminated, is liable to a penalty not exceeding £5, and the water may also be cut off.—(Section 32 of the Metropolis Water Act, 1871.) Refusal to Admit Inspector. By Section 57 of the Waterworks Clauses Act, 1847, which Section is, so far as can be ascertained, incorporated in all the Private Acts of the Water Companies, the officers of a water company must be admitted to any house supplied by that company between the hours of nine a.m. and four p.m., and if such officers be refused admission, or obstructed in their inspection, the company may cut off the water supply. Non-payment of Rates. Certain companies have special powers for dealing with failure to pay the water-rate. The general provisions are contained in Section 74 of the Waterworks Clauses Act of 1847, and in Section 21 of the Waterworks Clauses Act of 1863. By the former Section if any person supplied with water, or liable to pay the water-rate, neglect to pay such rate at the prescribed times, the water company can cut off the supply, and recover the rate, together with expenses of cutting off, and cost of recovery of rate. By the latter Section, "if any person refuses or neglects to pay" any 85 Report of Medical Officer of Health.] rate "or sum due" to the company under the Company's Act, the company may recover the same, with costs, in any court of competent jurisdiction," and their remedy under the present Section shall be in addition to their other remedies for the recovery thereof." The power to cut off the supply on the failure to pay on the part of a person liable for the rate, not being the person supplied, is now limited by Section 4 of the Water Companies (Regulation of Powers) Act, 1887. By that Section, when the owner of any house is liable "by law or by agreement with the water company" for the payment of the rates for water supplied to such dwelling-house, or part thereof if occupied separately, and subsequently fails to pay the water-rate, the supply cannot be cut off, and the rate, plus interest computed at 5 per cent, per annum, commencing at the end of a month after the rate falls due, becomes a first charge on the premises affected, and may be recovered either from the occupier by requiring him to pay to the company so much of the rent as may be due or be sufficient to liquidate the debt, or from the owner or occupier by ordinary process of the courts. Should the company cut off the water, a penalty of £5 for every day during which the supply is off may be recovered from the company. Certain companies have abandoned the practice of cutting off the water supply for the nonpayment of rates, recovering them as debts in the County Courts. By Section 49 Sub-Section 1 of the Public Health (London) Act, 1891, a company cutting off the supply, for any cause, from an inhabited dwelling-house, must give notice thereof in writing to the Sanitary Authority within four-and-twenty hours of stopping the water supply. (Such notices are dealt with as complaints, and entered into the book kept pursuant to Section 107 (3) of that Act. It is the duty of the Inspectors to examine this book daily, initial their proper entries, and investigate the complaints made.) By Section 48 (1) of the same Act, an occupied house without a proper and sufficient water supply is a nuisance which can be dealt with summarily. If notice under Section 4 (1) of the Act to supply such house be not complied with within the time specified, the Court can, under Sections 5 (7) and 48 (1) of the Act, close the house and impose a penalty not exceeding £20. One curious difficulty has occurred in connection with the cutting off of water, in the case of houses about to be demolished. In a case reported by the Medical Officer of Health of Kensington, the owner, who was liable for the water-rate, gave his tenants notice to quit, which they ignored. The owner thereupon requested the water company to cut off the supply, which was accordingly done. The tenants still continuing to occupy the houses, grave nuisance was caused by the closets, &c., becoming choked. The tenants were in illegal occupation, consequently Section 4 of the "Water Companies (Regulation of Powers) Act, 1887, did not apply. There remained for the local authority the lengthy process of getting the nuisance abated by the usual process of notice, summons, and fine. Storage Cisterns.—The abolition of all cisterns for storing water for dietic purposes has been very strongly urged in the past few years. It is argued that cisterns are only too frequently sources of pollution, and that the supply is almost universally constant and cisterns therefore unnecessary. Both these arguments are true; but against them can be set other considerations, the most important being the interruption in the supply due to accidents, repairs, &c. As the law now stands, cisterns are obligatory, as will be seen by the following Sections:— By Section 54 of 10 Yic., c. 17 (Waterworks Clauses Act, 1847), it is provided that where there is no obligation on a Water Company to provide a constant supply, the persons supplied with water " shall, when required by the undertakers, provide a proper cistern to hold the water with which he shall be so supplied," with all necessary taps and fittings. This Section is incorporated in the Private Acts of all the Metropolitan Companies. All the Companies, with one exception [the Kent Company (?)] have in their Private Acts a Section to the following effect:—* * The tvorda are from Sec. xlii. of 15 and 16 Vic., o. clvii. (Grand Junction Waterworks Act, 1852). 86 [Appendix IV. "Whenever water shall be constantly laid on ... . every person supplied . . . .. shall, when required by the Company, provide a proper cistern, or other receptacle for the water with which he shall be so supplied," with all necessary fittings. The Companies have, moreover, the power to refuse or to discontinue a supply where no cistern is provided, but except in the case of new houses and supplies, such power is not exercised. The experience of the East London Water Famine demonstrated the need of cisterns, as had they been left undisturbed, there would have been storage to maintain a partial supply during the intervals when the water was turned off. Instead of doing away with cisterns, it appears to be better to see that they are suitably designed, made of proper materials, adequately protected, and regularly cleansed. Water Regulations.—In November last the Metropolitan Water Companies issued a draft of a series of new Water Regulations to have effect throughout the Metropolis after confirmation by the Local Government Board. Under Sec. 22 of the Metropolis Water Act, 1871, a public inquiry must be held before confirmation, if demanded by certain prescribed persons. The Regulations were considered by the Electric, Gas, and Water Committee of the Council,, who, in a report dated November 27th, submitted observations and resolutions on nearly every one of the new Regulations and recommended that an inquiry should be demanded. The Council adopted the report and recommendations without alteration. The report was issued to all local authorities within "Water London," and attracted that attention to the Regulations which was required to ensure a proper representation to the Local Government Board.* The proposed Regulations contained much that was excellent, but many of the proposals were vexatious, and the Regulations as a whole gave the Companies too much power over individuals. There is practically no appeal from the interpretation put upon any Regulation by the Water Companies except to a magistrate. Such an appeal involves considerable expenditure, and the magistrate acting alone is naturally prone to rely upon the evidence of the officials, who are expected to be well skilled in the interpretation of the Regulations and in the technical details relating to water supply, unless, as rarely happens, the other side can afford to bring forward experts of greater weight to refute the water officials. There requires to be some appeal from the latter which should not require the intervention of lawyers and the consequent expenses. There does not appear to be any valid objection to entrusting the local authority with such jurisdiction. The authority's law officer would be an assessor to interpret the Regulations and guide decisions, and a friendly discussion round a table in a committee room is likely to produce more harmonious results between consumer and company (even if the decision be against the former) than the crushing out processof the Police Court. Inhabited House Duty.—Applications were received during the year for certificates of exemption under Sec. 4 of 54 and 55 Vic., c. 25 (Customs and Inland Revenue Act, 1891), for 127 houses in Bravington, Ashmore, Portnall, and Shirland Roads, by one owner; for 13 houses in Fermoy and Hormead Roads by another; and for 2 houses in Bravington Road by a third— making 142 houses in all. These applications involved a systematic inspection of each house to determine the number of occupants, their manner of occupation, rents paid, and sanitary accommodation provided. The drain of each house was tested, and notices issued for remedying of defects found above and below ground. At the close of the year no certificates had been issued, but much work was in hand for obtaining the same. House Drainage.—During the past year 512 drains were re-constructed, tested with water,, and passed as sound, and 29 old drains were tested for various reasons and found still sound. The * Although not part of the year's record, it is ancient history that the opposition offered at the inquiry was tostrong that the Water Companies abandoned their proposals in toto. As a matter of fact, the existing Regulations, made in 1872 have never been really enforced. 87 Report of Medical Officer of Health.] majority of the latter had been re-constructed under the supervision of the Department, which now possesses a record of such work dating back to the end of 1889. Many other drains have in past years been re-laid without any notice being given, over the re-construction of which no supervision has been exercised. Combined Drainage.—Between the presentation of the Report for 1899 and the close of 1900 five systems of combined drainage were referred to the Works Committee by the Sanitary Committee, and re-construction recommended. The houses drained by such systems were :— (i.) Nos. 23-35 (odd), Clifton Road. (ii.) Nos. 8-24 (even), Westbourne Terrace North; 1-7 (odd), Westbourne Park Crescent; 1-9 (odd), Wesbury Terrace. (iii.) Nos. 15, 16, and 17, Westbourne Street Mews. (iv.) Nos. 25.and 27, Blomfield Street. (v.) Nos. 22 and 12, Eastbourne Mews. By arrangement with the respective owners, the under-mentioned combined systems were broken up and independent drains constructed for each house, the Yestry bearing a considerable portion of the expense in each case:— 18 and 19, Victoria Place. 67, Queen's Road and 21, Poplar Place. The drain under No. 7, Leinster Street was re-constructed by the Yestry, with a better fall, the owner contributing a small proportion of the cost. This drain receives a part of the drainage of the cab stables in the rear of Nos. 5-8, Leinster Street, as well as that of the main building of No. 7. An order for combined drainage was made under Sec. 74 of the Metropolitan Management Act, 1855, with respect to certain stables in Stanley Mews. Byf.-laws re House Drainage.—The Bye-laws proposed to be made under Sec. 202 of the Metropolis Management Act, 1855, draft of which was submitted to the Yestry in January, 1897, are still awaiting confirmation by the Local Government Board. The delay has been due in part to the wish to allow the new Municipal Councils the opportunity of considering the draft before its confirmation. Draft Bye-laws drawn up under the "Metropolis Management Acts Amendment (Bye-laws) Act, 1899" were forwarded by the County Council to the Yestry on July 28th last, and referred to the Joint Works and Sanitary Committee. The Report of the Joint Committee was before the Yestry on October 16th last. The proposed Bye-laws, if strictly enforced, would result in the creation of a very complete and valuable record of the construction and plans of house drainage, but would involve a considerable outlay for those making only minor alterations, and an almost prohibitive one for complete re-construction. Workshop Supervision.—In pursuance of Sec. 26 of the Factory and Workshop Act, 1891, 4 notices of workrooms newly opened were received from the Chief Inspector of Factories. The rooms were measured up, entered on the Register, and cards stating the number of workers to be accommodated issued. At the close of 1900 the Register contained 207 entries of workshops and workplaces, comprising 318 separate rooms. Only 48 new workrooms were measured during the year. Complaints of insanitary conditions at 28 workshops were received from H.M. Factory Inspectors, and duly attended to. The total number of inspections of workshops during the year was 153, compared with 145 in 1899, and 67 in 1898. The amount of work which it has been possible to get through is not sufficient to the needs of the district. It is hoped that, when the Staff of the Department is re-organized by the Council of the Borough, provision will be made for adequate supervision of workshops, &c. 88 [Appendix IV. Among the matters which formed the subject of complaint by H.M. Inspector was a case of a workroom being used as a sleeping apartment by night and fully occupied by workers during the day. Such double use of a room should not be allowed, but there is nothing either in the Factory Acts or the Public Health (London) Act, 1891, which will exactly meet the case. The simplest remedy would appear to be to empower the Home Secretary, under the provisions of Sec. 1 (2) of the Factory and Workshop Act, 1895, to raise the standard of cubic space to be provided in such a workroom. This would not prevent any room being doubly used, but would reduce the number of persons working therein during the day, and to some extent minimize the effects of continuous vitiation of the atmosphere. Domestic workshops—i.e., places were only members of the same family are employed —would be exempt from any such restriction. Smoke Nuisances.—A watch has been maintained over the various shafts connected with factories, &c., in the Parish, but legal proceedings have not been necessary during the past year. Canals and Canal Boats.—The Report required under the Canal Boats Acts was presented to the Yestry in January of this year. It is satisfactory to note that no sickness was reported among the inhabitants of the boats, and no infringements of the Acts requiring legal proceedings. Food Supervision.—The customary half-yearly inspections of bakehouses, slaughter-houses^ &c., have been made. The Public Analyst has reported the results of his examinations of the 372 samples submitted to him during the year. The discovery in the early part of last year of arsenic in effervescent phosphate of soda acquired additional importance through the outbreaks of arsenical poisoning which occurred in certain parts of the country in the autumn. On the facts becoming known, special samples of beer, sweets, &c., were taken, but were all found to be free from deleterious ingredients. By the Sale of Food and Drugs Acts, 1899, vendors of margarine are required to register themselves with the local authority. Appplications for registration were received from 7 firms up to December last. A quantity of bad condensed milk and putrid dripping was seized at a baker's shop and condemned by the Magistrate, who ordered its destruction. Proceedings were instituted against the person in whose possession the articles were found. In the course of the case it was found that tins of condensed milk may be in a bad state of decomposition without manifesting the "bulging" or "blowing" usually associated with decomposed tinned foods. There is a grave risk in using unsound tinned foods, more so, perhaps, than that associated with other foods in a like condition. 89 Report of Mfdicai. Officer of Health. Legal Proceedings. Public Health {London) Act.—During the year 849 notices of all kinds were issued, as compared with 716 in 1899, and 793 in 1898. Last year's notices comprised 520 "written intimations," 158 "orders," and 161 notices under Bye-laws. Twenty-two cases were taken before the Magistrate and successfully contested. The nature of the offence and the result of each case are set out below. Summonses for Non-compliance with Notices under Sec. 4 of the Public Health (London) Act, 1891. Fine. Costs. £ s. a. £ s. d. 81, Cirencester Street Order made; case not complete 3 0 0 0 2 0 83, Cirencester Street Case not complete — — 13, Cuthbert Street Work done; summons withdrawn — 0 5 0 359, Edgware Road No water supply; house vacated; summons withdrawn — — 42, Elgin Avenue Order made — 1 0 0 59, Goldney Road Summons adjourned; work done; ordered to pay costs — 1 3 0 208, Harrow Road Work done in part by Vestry; summons adjourned sine die — — 74, Lancaster Gate Adjourned sine die; work done — — la, Shirlaud Mews Manure nuisance; cart provided during adjournment; summons withdrawn — — 56, Woodchester Street Work done before summons heard; ordered to pay costs — 0 2 0 62 and 64, Woodchester Street Work done during adjournment; ordered to pay costs 1 3 0 0 4 0 80, Westbourne Park Villas Order made — 0 2 0 Do. do. Summons for not complying with order of court; ordered to pay costs — 2 2 0 Summonses under Bye-Laws, &c. Fine. Costs. 13, Herries Street Failure to provide dustbin; bin provided after service of summons; ordered to pay costs £ s. d. £ s. d — 0 2 0 17a, Southwick Street Failure to give notice of alteration to soil-pipe, &c.; ordered to pay costs — 1 3 0 32, Albion Street Failure to give notice of alterations to soil-pipes, &c. 0 3 0 0 2 0 6, Fernhead Road 0 5 0 0 2 0 D. W. Chapman, 351, Edgware Rd. Unsound condensed skim milk and dripping 20 0 0 5 5 0 W. Eddington.Marshgate, Stratford Removing offensive refuse in prohibited hours 1 0 0 0 2 0 Wickens, Pearce & Co., 83, Queen Street, E.C. Do. do. Bound over in £5 not to repeat offence in 6 months 0 4 0 Woddington, 9, Amity Road, E. Do. do. 0 8 0 0 2 0 Shellard, 20, North Wharf Accumulation of offensive refuse; summons under Local Act of 1826 5 0 0 — Do. do. Case not completed at the close of the year — 3 3 0 90 [Appendix IY. Sale of Food and Drugs Acts.—The appended list gives the offences and results of summonses under these Acts during the past year:— Sample. Extent of Adulteration. Fine imposed. Costs imposed. £ s. d. £ s. d. Butter 100% Margarine 5 0 0 0 12 6 Do. 87% Foreign Fat 5 0 0 0 12 6 Do. 91% Do, 10 0 0 0 12 6 Do. 90% Do 2 0 0 0 17 6 Milk 8% Cream deficient 1 0 0 0 12 6 Do. 15% Do. 2 0 0 0 12 6 Do. 18% Do. Dismissed: no costs. Do. 12% Do. Whisky 9% of Water more than 25% under proof No proceedings taken; ''Notice'' displayed in the bars. Do. 15% Do. do. 1 0 0 0 12 6 Milk 23% Cream deficient 2 0 0 0 12 6 Do. 18% Do. — 2 12 6 Do. 17% Do. Vendor absconded. Do. 54% Added Water Do. Do. Effervescent Phosphate of Soda 5/105of 1% of White Arsenic 10 0 0 5 5 0 Do. ⅛ of 1% Oxide of Arsenic = 8¾ grs. of White Arsenic per lb. 10 0 0 5 5 0 Ammoniated Tincture of Quinine 80% Quinine Sulphate deficient 0 5 0 0 12 6 Do. 40% Do. do. 1 0 0 0 12 6 Milk 10% Cream deficient 1 0 0 1 3 0 Do. 13% Added Water 5 0 0 0 12 6 Butter 82°/0 Foreign Fat Dismissed: no costs. Milk 14% Cream deficient 5 0 0 1 3 0 Do. 12% Added Water 5 0 0 1 3 0 Do. 8% Do 2 0 0 1 3 0 Do. 10% Cream deficient 1 0 0 0 12 6 Do. 11% Added Water 5 0 0 0 12 6 Butter 80% Foreign Fat 4 0 0 1 3 0 Do. 84% Do. 2 0 0 1 3 0 Do. 81% Do. 3 0 0 1 3 0 Do. 82% Do. 2 0 0 1 3 0 Do. 81% Do. 3 0 0 1 3 0 Do. 87% Do. 4 0 0 0 12 6 Do. 88% Do. 2 0 0 0 12 6 Coffee 60% Chicory 2 0 0 0 12 6 Butter 45% Foreign Fat 2 0 0 0 12 6 Bread and Butter Do. 95% Margarine 95% Do. 2 0 0 0 12 6 1898. 1899. 1900. £ s. d. £ s. d. £ s. d. Averages per Conviction Fine 1 13 9 3 4 9 3 4 0 Costs 0 13 11 0 14 3 1 2 3 91 Report of Medical Officer of Health. SUB-APPENDIX A. TABLE I. Gross Returns of Births and Deaths. Year. Population estimated to middle of each Year. Births. Deaths under 1 Year of Age. Deaths at all Ages. Total. Deaths in Public Institutions. Deaths of Nonresidents registered in District. Deaths of Residents registered beyond District. Deaths at all Ages. (Nett Returns.) Number. Rate.* Number. Rate per 1,000 Births registered. Number. Rate.* Number. Rate.* 1 2 3 4 5 6 7 8 9 10 11 12 13 1890 117,049 2,901 24.78 455 156 2,326 19.87 590 322 100 2 104 17.97 1891 118,165 2,952 24.98 437 148 2,331 19.72 695 359 105 2,077 17.57 1892 119,458 2,934 24.56 435 147 2,294 19.20 610 305 120 2,109 17.78 1893 120,773 3,011 24.93 459 152 2,327 19.26 606 369 172 2,130 17.63 1894 122,109 2,834 23.20 392 138 1,918 15.70 615 293 193 1,818 14.88 1895 123,466 2,979 24.12 497 166 2,249 18.21 554 306 156 2,099 17.00 1896 124,850 3,068 24.57 499 162 2,098 16.88 672 316 160 1,942 15.55 1897 126,253 3,010 23.84 477 158 1,941 15.37 519 294 163 1,810 14.33 1898 127,678 2,965 23.22 504 170 2,186 17.12 600 330 174 2,030 15.89 1899 129,124 2,940 22.76 466 158 2,205 17.07 606 298 155 2,062 15.96 Averages for Years 1890-1899 123,086 2,959 24.10 462 155 2,187 17.84 607 319 150 2,018 16.45 1900 130,596 2,890 22.13 461 159 2,307 17.66 708 401 155 2,061 15.78 * Rates calculated per 1,000 persons living at all ages. 92 Appendix IV. TABLE II. Nett Returns of Births and Deaths. Names of Localities. 1.—PADDINGTON. 2.—ST. MARY. 3.—ST. JOHN. Year. Population estimated to middle of each Year. Births registered. Deaths at all Ages. Deaths under 1 Year. Population estimated to middle of each Year. Births registered. Deaths at all Ages. Deaths under 1 Year. Population estimated to middle of each Year. Births registered. Deaths at all Ages. Deaths under 1 Year. a. b. c. d. a. b. c. d. a. b. c. d. 1890 117,049 2,901 2,104 455 83,089 2,389 1,602 389 33,960 512 502 66 1891 118,165 2,952 2,077 430 84,487 2,420 1,582 356 33,678 532 495 74 1892 119,458 2,934 2,109 418 85,816 2,456 1,632 348 33,642 478 477 70 1893 120,773 3,011 2,130 450 87,167 2,567 1,685 407 33,606 444 445 43 1894 122,109 2,834 1,818 384 88,538 2,423 1,449 344 33,571 411 369 40 1895 123,466 2,979 2,099 490 89,931 2,526 1,671 426 33,535 453 428 64 1896 124,850 3,068 1,942 477 91,350 2,613 1,583 415 33,500 455 359 62 1897 126,253 3,010 1,810 448 92,788 2,586 1,455 403 33,465 424 355 45 1898 127,678 2,965 2,030 476 94,248 2,558 1,663 419 33,430 407 367 57 1899 129,124 2,940 2,062 443 95,730 2,555 1,709 407 33,394 385 353 36 Averages of Years 1890 to 1899. 123,086 2,959 2,018 447 89,409 2,509 1,603 391 33,677 450 415 56 1900 130,596 2,890 2,061 477 97,237 2,479 1,675 425 33,359 411 386 52 Deaths of "non-residents" dying in the Parish have been excluded, and deaths of "residents" recorded in other parts of the Metropolis, included. No corrections applied to births. 93 .Report of Medical Officer of Health. [TABLE III. will be found on pp. 94-101.] TABLE IV. Return of Deaths in Local Public Institutions. Year. Paddington Workhouse and Infirmary. St. Mary's Hospital. Lock Hospital. Children's Hospital, Paddington Green. 1900 255 386 4 63 1899 255 280* 2 69 1898 194 324 2 80 1897 192 262* 2 63 1896 188 334 2 48 1895 204 332 1 17** 1894 165 347 3 † 1893 204 399 3 † 1892 236 355 7 12 1891 257 371 5 62 1890 172 358 3 57 Averages for 1890 -99 207 336 3 59 (7 years) * Hospital closed some weeks for repairs, &c. ** Hospital recommenced work in 3rd quarter of the year. † Closed during re-construction. 94 [Appendix IY. TABLE III. MALES. WHOLE PARISH. CAUSES OF DEATHS OF RESIDENTS DURING 1900. Groups of Diseases. AGES. All Ages. 0- l- 5- 15- 25- 35- 45- 55- 65- 75- 85- Classes. I. Specific Febrile, or Zymotic Diseases 61 42 4 4 9 8 10 4 12 5 3 162 II. Parasitic Diseases ... ... ... ... ... ... ... ... ... ... ... ... III. Dietic Diseases 6 ... ... ... 2 2 1 ... ... ... ... 11 IV. Constitutional Diseases 14 13 12 17 16 26 30 25 17 9 179 V. Developmental Diseases 50 ... 1 ... ... ... ... ... 4 13 6 74 VI. Local Diseases 89 49 14 11 17 48 59 72 86 46 9 500 VII. Deaths from Violence 8 1 1 2 4 5 8 4 2 2 ... 37 VIII. Deaths from III Defined and Not Specified Causes 30 2 ... ... ... ... ... ... ... 1 ... 33 Totals 258 107 32 34 48 89 108 105 121 76 18 996 I.—SPECIFIC FEBRILE, OR ZYMOTIC DISEASES. 1.—Miasmatic Diseases. Measles 4 18 2 1 ... ... ... ... ... ... ... 25 Scarlet Fever ... 2 ... ... 1 ... ... ... ... ... ... 3 E pidemic Influenza 1 1 ... ... 6 2 6 3 12 4 2 37 Whooping Cough 5 8 ... ... ... ... ... ... ... ... ... 13 Diphtheria 1 7 2 ... ... 1 ... ... ... ... ... 11 Simple Continued and Ill-Defined Fever ... ... ... ... ... ... ... ... ... ... ... 1 Enteric or Typhoid Fever ... ... ... 3 ... 2 ... ... ... ... ... 5 Other Miasmatic Diseases ... 1 ... ... ... ... ... ... ... ... ... 1 2.—Diarrhœal Diseases. Simple Cholera ... ... ... ... ... ... 1 ... ... ... ... 1 Diarrhœœa, Dysentery 48 5 ... ... ... ... 1 ... ... 1 ... 55 3.—Malarial Diseases. Ague ... ... ... ... ... ... ... 1 ... ... ... 1 4.—Zoogenous Diseases. Cowpox and Effects of Vaccination 1 ... ... ... ... ... ... ... ... ... ... 1 5.—Venereal Diseases. Syphilis ... ... ... ... ... 1 1 ... ... ... ... 2 6.—Septic Diseases. Erysipelas ... ... ... ... 1 2 ... ... ... ... 1 4 Pyaemia, Septicaemia 1 ... ... ... ... ... 1 ... ... ... ... 2 95 Report of Medical Officer of Health. TABLE III. WHOLE PARISH. FEMALES. CAUSES OF DEATHS OF RESIDENTS DURING 1900. Groups of Diseases. AGES. All Ages. 0- 1- 5- 15- 25- 35- 45- 55- 65- 75- 85- Classes. I. Specific Febrile, or Zymotic Diseases 60 44 12 6 5 8 9 15 13 9 4 185 II. Parasitic Diseases 2 ... ... ... ... ... ... ... ... ... ... 2 III. Dietic Diseases 5 ... ... ... ... 1 1 2 1 ... ... 10 IV. Constitutional Diseases 11 14 10 12 17 24 40 34 22 17 2 203 V. Developmental Diseases 36 1 5 20 15 77 VI. Local Diseases... 73 34 13 18 24 37 60 75 91 80 24 529 VII. Deaths from Violence 8 1 2 1 4 10 2 3 ... 31 VIII. Deaths from Ill-Defined and Not Specified Causes 24 1 ... 1 ... ... ... ... ... 2 ... 28 Totals 219 93 36 38 48 71 114 136 134 131 45 1,065 I.-SPECIFIC FEBRILE, OR ZYMOTIC DISEASES. 1.—Miasmatic Diseases. Measles 8 16 3 ... ... ... ... ... ... ... ... 27 Scarlet Fever ... 1 ... 1 ... ... ... ... ... ... ... 2 Typhus ... ... ... ... ... ... ... 1 ... ... ... 1 Epidemic Influenza 2 ... ... 3 4 2 7 11 13 6 4 52 Whooping Cough 9 12 ... ... ... ... ... ... ... ... ... 21 Diphtheria ... 8 6 ... ... 1 ... 1 ... ... ... 16 Simple Continued and Ill-defined Fever ... ... ... ... ... ... ... ... ... 1 ... 1 Enteric or Typhoid Fever ... ... 1 1 ... 1 ... ... ... ... ... 3 2.—Diarrhæl Diseases. Diarrhœa, Dysentery 37 7 ... ... ... 1 1 1 ... 1 ... 48 3.—Malarial Diseases. 4.—Zoogenous Diseases. 5.—Venereal Diseases. Syphilis 1 ... ... ... ... ... ... ... ... ... ... 1 6.—Septic Diseases. Erysipelas 1 ... 1 ... ... 1 ... ... ... ... ... 3 Pyaemia, Septicæmia 2 ... 1 ... ... ... 1 1 ... 1 ... 6 Puerperal Fever ... ... ... 1 1 2 ... ... ... ... ... 4 96 [Appendix IY. Males. TABLE III.—continued. Diseases. AGES. All Ages. 0- 1- 5- 15- 25- 35- 45- 55- 65- 75- 85- II.—PARASITIC DISEASES. III.—DIETIC DISEASES. Want of Breast Milk, Starvation 6 ... ... ... ... ... ... ... ... ... ... 6 Chronic Alcoholism ... ... ... ... 1 1 1 ... ... ... ... 3 Delirium Tremens ... ... ... ... 1 1 ... ... ... ... ... 2 IV.—CONSTITUTIONAL DISEASES. Rheumatic Fever, Rheumatism of the Heart ... ... ... 1 2 2 ... ... ... ... ... 5 Rheumatism ... ... ... ... ... ... ... ... 1 ... ... 1 Gout ... ... ... ... ... ... ... 1 1 1 ... 3 Rickets 1 ... ... ... ... ... ... ... ... ... ... 1 Cancer, Malignant Disease ... 1 ... ... 2 4 8 16 12 7 ... 50 Tabes Mesenterica 6 1 ... ... ... ... ... ... ... ... ... 7 Tubercular Meningitis, Hydrocephalus 4 8 8 1 ... 1 ... ... ... ... ... 22 Phthisis 1 1 13 10 18 21 5 2 ... ... 71 Other Forms of Tuberculosis, Scrofula 1 3 3 2 1 ... 1 ... ... ... ... 11 Purpura, Haemorrhagic Diathesis 1 ... ... ... ... ... ... ... ... ... ... 1 Anaemia, Chlorosis, Leucocythaemia ... ... ... ... 1 1 ... 1 1 ... ... 4 Glycosuria, Diabetes Mellitus ... ... ... ... ... ... ... 2 ... 1 ... 3 V.-DEVELOPMENTAL DISEASES. Premature Birth 34 ... ... ... ... ... ... ... ... ... ... 34 Atelectasis 7 ... ... ... ... ... ... ... ... ... ... 7 Congenital Malformations 9 ... 1 ... ... ... ... ... ... ... ... 10 Old Age ... ... ... ... ... ... ... ... 4 13 6 23 VI.—LOCAL DISEASES. 1.—Diseases of Nervous System. ... ... ... ... ... ... ... ... ... ... ... ... Inflammation of Brain or Membranes... 3 3 1 ... 1 2 1 ... ... ... ... 11 Apoplexy, Softening of Brain, Hemiplegia, Brain Paralysis ... ... ... ... ... 3 1 8 15 13 ... 40 Insanity, General Paralysis of the Insane ... ... ... ... ... 5 2 1 3 1 ... 13 Epilepsy ... ... ... ... ... ... 2 2 ... ... ... 4 Convulsions 8 3 ... ... ... ... ... ... ... ... ... 11 Laryngismus Stridulus (Spasm of Glottis) 2 ... ... ... ... ... ... ... ... ... ... 2 Disease of Spinal Cord, Paraplegia, Paralysis Agitans ... ... ... ... ... 2 2 1 4 ... ... 9 Other Diseases of Nervous System ... ... 1 ... ... ... 1 ... ... ... ... 2 2.—Diseases of Organs of Special Sense. (e.g., of Ear, Eye, and Nose) ... ... ... 1 ... ... ... ... ... 1 ... 2 97 Report of Medical Officer of Health. TABLE III.—continued. Females. Diseases. AGES. All Ages. 0- 1- 5- 15- 25- 35- 45- 55- 65- 75- 85- II.—PARASITIC DISEASES. Thrush and other Vegetable Parasitic Diseases 1 ... ... ... ... ... ... ... ... ... ... 1 Worms, Hydatids, and other Animal Parasitic Diseases 1 ... ... ... ... ... ... ... ... ... ... 1 III.—DIETIC DISEASES. Want of Breast Milk, Starvation 5 ... ... ... ... ... ... ... ... ... ... 5 Chronic Alcoholism ... ... ... ... ... 1 1 2 1 ... ... 5 IV.—CONSTITUTIONAL DISEASES. Bheumatic Fever, Bheumatism of the Heart ... ... 3 ... 1 ... 1 ... ... ... ... 5 Bheumatism ... ... ... ... ... 1 ... ... ... 3 ... 4 Gout ... ... ... ... ... ... ... ... ... 1 ... 1 Bickets ... 1 ... ... ... ... ... ... ... ... ... 1 Cancer, Malignant Disease ... ... ... 1 2 8 20 20 16 10 ... 79 Tabes Mesenterica 6 3 ... ... ... ... ... 1 ... ... ... 10 Tubercular Meningitis, Hydrocephalus 5 5 6 ... 1 ... ... ... ... ... ... 17 Phthisis 2 1 9 13 14 18 10 3 1 ... 71 Other Forms of Tuberculosis, Scrofula ... 2 ... 2 ... 1 ... 2 ... ... ... 7 Anaemia, Chlorosis, Leucocythaemia ... 1 ... ... ... ... 1 ... ... 1 ... 3 Glycosuria, Diabetes Mellitus ... ... ... ... ... ... ... 1 3 1 ... 5 V.—DEVELOPMENTAL DISEASES. Premature Birth 28 ... ... ... ... ... ... ... ... ... ... 28 Atelectasis 6 ... ... ... ... ... ... ... ... ... ... 6 Congenital Malformations 2 ... ... 1 ... ... ... ... ... ... ... 3 Old Age ... ... ... ... ... ... ... ... 5 20 15 40 VI.—LOCAL DISEASES. 1.—Diseases of Nervous System. Inflammation of Brain or Membranes 2 2 ... l 1 1 ... ... ... ... ... 7 Apoplexy, Softening of Brain, Hemiplegia, Brain Paralysis ... ... 1 ... 1 1 3 7 24 12 3 52 Insanity, General Paralysis of the Insane ... ... ... 1 ... 1 1 3 ... ... ... 6 Epilepsy ... ... ... ... 1 ... 1 ... 1 ... ... 3 Convulsions 9 1 ... ... ... ... ... ... ... ... ... 10 Laryngismus Stridulus (Spasm of Glottis) 1 ... ... ... ... ... ... ... ... ... ... 1 Disease of Spinal Cord, Paraplegia, Paralysis Agitans ... ... ... ... ... ... ... 1 ... ... ... 1 Other Diseases of Nervous System ... ... ... ... ... 2 1 1 ... 2 ... 6 2.—Diseases of Organs of Special Sense. (e.g., of Ear, Eye, and Nose) ... ... 2 ... ... ... ... ... ... ... ... 2 98 Appendix IY. Males. TABLE III.—continued. Diseases. AGES. All Ages. 0- 1- 5- 15- 25- 35- 45- 55- 65- 75- 85- LOCAL DISEASES—continued. 3.—Diseases of Circulatory System. Acute Endocarditis 1 ... ... ... ... ... 1 ... ... ... ... 2 Valvular Disease of Heart ... l 1 ... ... 4 2 5 1 1 ... 15 Other Diseases of Heart 1 3 ... 2 7 9 17 14 3 3 59 Aneurism ... ... ... ... ... 1 ... 1 ... ... ... 2 Embolism, Thrombosis ... ... ... ... ... ... ... ... 1 ... ... 1 Other Diseases of Blood Vessels ... ... ... ... ... ... 2 1 1 1 ... 5 4.—Diseases of Respiratory System. Laryngitis ... l ... ... ... ... ... ... ... ... ... 1 Emphysema, Asthma ... ... ... ... 1 ... 1 2 ... ... ... 4 Bronchitis 40 23 2 ... 3 ... 6 9 19 12 3 117 Pneumonia 9 9 2 5 11 13 10 8 4 ... 71 Pleurisy ... ... ... 1 ... ... 1 ... 1 1 ... 4 Other Diseases of Respiratory System 1 ... ... ... ... 1 ... ... ... 1 ... 3 5.—Diseases of Digestive System. Dentition 3 2 ... ... ... ... ... ... ... ... ... 5 Sore Throat, Quinsy 1 ... ... ... ... ... ... ... ... ... 1 Diseases of Stomach 2 ... 1 1 1 ... 1 ... 1 2 ... 9 Enteritis 11 3 1 4 2 1 1 3 1 1 ... 28 Obstructive Diseases of Intestine 1 2 1 ... ... 1 1 ... ... ... ... 6 Peritonitis 1 ... 1 1 ... 1 ... ... ... ... ... 4 Cirrhosis of Liver ... ... ... ... ... 1 1 4 4 ... 1 14 Jaundice and other Diseases of Liver 3 1 ... ... ... ... ... 1 ... ... ... 5 Other Diseases of Digestive System ... ... ... ... ... ... ... ... 1 ... ... 1 6.—Diseases of Lymphatic System. (e.g., Lymphatics and of Spleen) 7.—Diseases of Gland-like Organs of Uncertain Use. (e.g., Bronchocele, Addison's Disease) ... ... ... ... ... ... 1 ... ... ... ... 1 8.—Diseases of Urinary System. Nephritis ... ... ... 1 ... 1 ... ... 1 ... ... 3 Bright's Disease, Albuminuria ... ... ... ... 1 7 6 7 5 2 1 29 Disease of Bladder or of Prostate ... ... ... ... ... ... ... ... 4 3 1 8 9.—Diseases of Reproductive System. a. Of Organs of Generation. Male Organs ... ... ... ... ... ... ... ... 1 ... ... 1 b. Of Parturition. Accidents of Child-birth 2 ... ... ... ... ... ... ... ... ... ... 2 10.—Diseases of Bones and Joints. Arthritis, Ostitis, Periostitis ... ... 1 ... ... ... ... ... ... ... ... 1 Other Diseases of Bones and Joints ... ... 1 ... ... ... ... ... ... ... ... 1 11.—Diseases of Integumentary System. Carbuncle, Phlegmon ... ... ... ... ... ... 1 ... 1 ... ... 2 Other Diseases of Integumentary System 1 ... ... ... ... ... ... ... ... ... ... 1 99 Report of Medical Officer of Health. TABLE III.—continued. Females. Diseases. AGES. All Ages. 0- 1- 5- 15- 25- 35- 45- 55- 65- 75- 85- LOCAL DISEASES—continued. 3.—Diseases of Circulatory System. Pericarditis ... 1 ... ... ... ... ... 1 ... ... ... 2 Acute Endocarditis ... ... ... 1 1 ... ... ... ... ... ... 2 Valvular Disease of Heart ... ... 3 2 2 2 3 5 1 4 1 23 Other Diseases of Heart ... 1 2 1 3 6 5 14 11 12 1 56 Aneurism ... ... ... ... ... 1 ... ... ... ... ... 1 Embolism, Thrombosis ... ... ... ... ... ... ... ... 1 1 ... 2 Other Diseases of Blood Vessels ... ... ... ... 1 ... 2 1 ... ... 1 5 4.—Diseases of Respiratory System. Emphysema, Asthma ... ... ... ... ... 1 2 1 1 1 ... 6 Bronchitis 33 14 1 1 2 4 14 19 24 26 14 152 Pneumonia 9 10 l 1 3 1 6 8 9 6 2 56 Pleurisy ... ... ... 1 1 ... 1 ... ... ... ... 3 Other Diseases of Respiratory System 1 ... ... ... ... 2 ... ... ... ... ... 3 5.—Diseases of Digestive System. Dentition ... 2 ... ... ... ... ... ... ... ... ... ... 2 Sore Throat, Quinsy 1 1 ... ... ... ... ... ... ... ... ... 2 Diseases of Stomach 4 ... ... 3 2 3 3 1 2 ... ... 18 Enteritis 7 l ... ... ... 1 2 ... 2 ... ... 13 Obstructive Diseases of Intestine 1 l 1 ... 1 1 2 1 2 5 ... 15 Peritonitis ... ... l ... ... 1 1 1 1 1 ... 6 Cirrhosis of Liver ... ... ... ... 2 1 4 4 1 ... ... 12 Jaundice and other Diseases of Liver 2 ... ... ... ... 2 2 ... 2 4 ... 12 0 Other Diseases of Digestive System ... ... ... ... ... ... ... 1 2 1 2 0 6.—Diseases of Lymphatic System. (e.g., Lymphatics and of Spleen) ... ... ... ... ... ... ... ... 1 1 ... 2 7.— Diseases of Gland-like Organs of Uncertain Use. (e.g., Bronchocele, Addison's Disease) ... ... ... ... ... ... ... ... 1 ... ... 1 8.—Diseases of Urinary System. Nephritis ... ... ... 1 ... ... ... ... ... ... ... 1 Bright's Disease, Albuminuria ... l l 2 ... 3 6 4 5 4 ... 26 9.—Diseases of Reproductive System. a. Of Organs of Generation. Female Organs ... ... ... 1 ... 1 ... 1 ... ... ... 4 b. Of Parturition. Puerperal Convulsions ... ... ... 1 ... ... ... ... ... ... ... 1 Placenta prsevia, Flooding ... ... ... ... 1 1 ... ... ... ... ... 2 Other Accidents of Child-birth 1 ... ... ... 2 ... ... ... ... ... ... 3 10.—Diseases of Bones and Joints. Arthritis, Ostitis, Periostitis ... l ... ... ... ... 1 ... ... ... ... 2 11.—Diseases of Integumentary System. Carbuncle, Phlegmon ... ... ... 1 ... ... ... ... ... ... ... 1 Other Diseases of Integumentary System ... ... ... ... ... ... ... 1 ... ... ... 1 100 Appendix IY. Males. TABLE III.—continued. Diseases. AGES. All Ages. 0- 1- 5- 15- 25- 35- 45- 55- 65- 75- 85- VII.—DEATHS FROM VIOLENCE. 1.—Accidents or Negligence. Fractures or Contusions ... ... 1 1 2 4 4 1 ... 2 ... 15 Burn, Scald ... 1 ... ... ... ... ... 1 ... ... 2 Drowning ... ... ... ... ... 1 1 ... ... ... 2 Suffocation 6 ... ... ... ... ... ... ... ... ... 6 Otherwise 1 ... ... ... ... ... ... ... ... ... ... 1 2.—Homicide. Murder 1 ... ... ... ... ... ... ... ... ... ... 1 3.—Suicide. Gunshot Wounds ... ... ... ... 1 ... ... 1 ... ... ... 2 Cut, Stab ... ... ... ... ... 1 2 ... ... ... ... 3 Poison ... ... ... 1 1 ... ... ... ... ... ... 2 Drowning ... ... ... ... ... ... 1 1 ... ... ... 2 Otherwise ... ... ... ... ... ... ... ... 1 ... ... 1 4.—Execution. VIII.—DEATHS FROM ILLDEFINED AND NOT SPECIFIED CAUSES. Debility, Atrophy, Inanition 30 2 ... ... ... ... ... ... ... ... ... 32 Uncertified Deaths ... ... ... ... ... ... ... ... ... 1 ... 1 101 Report of Medical Officer of Health. TABLE III.—continued. Females. Diseases. AGES. All Ages. 0- 1- 5- 15- 25- 35- 45- 55- 65- 75- 85- VII.-DEATHS FROM VIOLENCE. 1.—Accidents or Negligence. Fractures or Contusions ... ... ... ... 1 ... 1 6 ... 3 ... 11 Cut, Stab ... ... ... ... ... ... ... 1 ... ... ... 1 Burn, Scald ... ... 1 ... ... ... 1 1 1 ... ... 4 Drowning ... ... ... ... ... 1 l ... ... ... ... 2 Suffocation 8 ... ... ... ... ... ... ... ... ... ... 8 2.—Homicide. 3. —Suicide. Cut, Stab ... ... ... ... 1 ... ... ... ... ... ... 1 Drowning ... ... ... ... ... ... l 1 l ... ... 3 Hanging ... ... ... ... ... ... ... 1 ... ... ... 1 4.—Execution. VIII—DEATHS FROM ILLDEFINED AND NOT SPECIFIED CAUSES. Debility, Atrophy, Inanition 24 1 ... 1 ... ... ... ... ... ... ... 26 Tumour ... ... ... ... ... ... ... ... ... 1 ... 1 Cause not Specified or Ill-defined ... ... ... ... ... ... ... ... ... 1 ... 1 102 [Appendix IV TABLE V. REPORT OF THE WORKS OF THE SANITARY DEPARTMENT COMPLETED DURING THE YEAR 1900. No of Complaints received. Inspections of Dwelling Houses. Sanitary Works completed in Dwelling Houses. To Regulate Keeping of Animals. Trade Supervision. Foods Drainage, &c. Water Supply. Dust Receptacles. Miscellaneous. " House-to-House." On Complaint or after Illness. Cellar Dwellings. Re-inspection of all kinds. Entire Reconstruction. Drains Relaid, Trapped, or Ventilated. Waste Pipes Disconnected. Rain-water Pipes Disconnected. W.C., New, Provided, Repaired, &c. Soil Pipes Ventilated. Services Separated. Supplies Reinstated. Cisterns, New, Provided. Cisterns Cleansed, Repaired, &c. Cistern Overflows Disconnected. New, Provided. Repaired, &c. Drains Cleared, Flushed, Jtc. Houses or Rooms Cleansed, Whitewashed, &c. Cases of Overcrowding Abated. Cellar Dwellings Closed. Yards and Areas Paved and Drained. Manure Receptacles Reconstructed, &c. Accumulations Removed. Improperly-kept Removed. Slaughterhouses. Cowhouses, Dairies, Milk Shops. Bakehouses. Eating-Houses. Offensive Trades, Wharves. Smoke Observations. Seizures of Unsound Food. Quarters. No. 1 158 2 631 — 3,643 97 31 5 7 50 11 2 11 2 17 — 3 — 13 17 4 — 9 8 50 12 1 1 6 — 260 39 Not Tabulated. No. 2 184 — 756 — 3,444 86 46 36 29 62 18 11 10 5 6 1 5 — 27 25 6 1 12 9 85 — — 6 12 1 275 2 No. 3 177 6 733 — 3,289 97 49 8 7 38 15 1 14 2 11 1 9 4 7 14 3 — 5 16 102 1 13 3 34 2 239 2 .No. 4 139 64 823 — 3,982 123 45 27 24 105 32 10 8 11 16 — 9 — 11 53 5 1 11 14 14 1 3 2 3 1 286 3 Year 658 72 2,943 — 14,358 403 171 76 67 255 76 24 43 20 50 2 26 4 58 109 18 2 37 47 251 14 17 12 55 4 1,060 46 103 Report of Medical Officer of Health. SUB-APPENDIX B. RETURN CASES. In each Annual Report mention has been made of the occurrence of fresh cases of infectious disease following, at longer or shorter intervals of time, the return home from hospital of previous patients. During the past year, such "return cases" of scarlet fever were observed in 11 families, resulting in 15 fresh cases; and of diphtheria, in 1 family, with 2 cases. Inquiries were made in each case, and a tabulated statement of the results of such inquiries in reference to the cases of scarlet fever will be found on p. 110. With the exception of two instances which occurred during the summer vacation, the inquiries were made by the Medical Officer of Health. The results of the investigations made into the diphtheria cases were specially communicated to the Metropolitan Asylums Board in a letter, of which the material parts were as follow:— On January 31st, T. B., set. 6, was removed from 217, B. R., ill with diphtheria. He returned home March 23rd. On March 31st, F. B., set. 4 (his brother), sickened with the same disease. T. B. after his return mixed with the family and slept with his elder brother A. B., who had scarlet fever and diphtheria a year or two ago. F. B. was at school until March 30th. There had been no visiting to other houses, and no visitors had called at the house. The mother said T. B. had been well since coming home, but not so well as before his illness. When seen on April 3rd, T. B. had slight discharge from nose; his palate, tonsils, and fauces were normal to the eye; and the submaxillary glands were large and hard (especially on left side). Swabs were taken from the nose and throat. In that from the throat, a very few bacilli were found which might be B. diphtheria. There were none in the other swab. A further visit was paid on April 5th, to take other swabs. On this occasion a girl, L. G., was discovered who was working in the house. She had her neck wrapped up and spoke with difficulty. She said she had had a sore throat since March 31st. To the naked eye there were no indications of diphtheria, but a swab was found to contain the B. diphtheriee. A swab from the boy T. B. gave a negative result. Inquiry was made as to any bacteriological examination of the boy T. B. prior to discharge from hospital. The reply was— "It was not considered necessary to make a bacteriological examination .... prior to his discharge. According to the notes in the Discharge Book, the throat, glands, and nostrils were in a normal condition on the day he was removed from hospital.'' It is commonly held that the frequency of "return cases" bears some ratio to the general prevalence of the disease in question in the district. This is not, however, borne out by the figures for the past five years:— 1900. 1899. 1898. 1897. 1896. Scarlet fever:— Cases Notified 302 382 303 491 790 Return Cases 15 9 11 33 5 Diphtheria:— Cases Notified 154 203 258 322 242 Return Cases 2 5 7 8 — At the same time it has to be admitted that the "return cases" included in the above may represent but a fraction of the total cases. Endeavours have been made to obtain information of the date of return home of each patient on discharge, and until this is given, the whole circumstances attending the occurrence of such cases will not be known. This point will be reverted to later on. There is one factor which has, as yet, not received the full measure of attention which it 104 Appendix IY. deserves. For some months past it has been made a rule to fully examine the sanitary condition of the houses in which these "return cases" occur. The results have been as follows :— Of the 13 houses re-infected by the discharged patients, at 5 the drains were so bad as to require complete re-construction; at 4 the drainage system had been recently overhauled and was satisfactory when specially examined; at 2 the drainage was found good; at one the W.C.s were found choked, but no report on the general state of the house was made ; and the twelfth house was not reported on at all. The attitude of the Asylums Board with reference to the allegations of cases following the return of patients from the Board's hospitals has been somewhat striking. The allegations were at first emphatically repudiated, the possibility of their being well founded was then hesitatingly admitted, and lastly accepted and investigations authorized. In the Annual Report for 1898 it was recorded that Prof. Simpson, late Medical Officer of Health of Calcutta, had been appointed for a period of six months, to investigate the circumstances attending "return cases." His report to the Metropolitan Asylums Board, dated June 5th, 1899, was issued at the commencement of the current year (1901). The conclusions which he arrived at are worthy of record here, as they will form a basis for future investigations. In the half-year, October, 1898, to April, 1899,9,782 patients were discharged from the Board's hospitals after scarlet fever (6,507 patients) and diphtheria (3,275 patients). In connection with these discharges, return cases of scarlet fever occurred in 193 homes, giving rise to 253 cases, and of diphtheria in 64 homes, with 86 cases. During the same six months 13,955 cases of diphtheria and scarlet fever were reported in the Metropolis. The 339 return cases were therefore equal to a percentage of 2.4 on the total notifications, or 2*8 per cent, of all notified cases of scarlet fever, and 1.9 per cent. of all notified cases of diphtheria. Disease. Total Number discharged from Hospitals. Number of Homes re-infected. Number of "Return Cases." Percentage of Homes re-infected to Total Discharges. Percentage of "Return Cases" to Total Discharges. Scarlet Fever 6,507 193 253 2.9 3.8 Diphtheria 3,275 64 86 1.9 2.3 Total 9,782 257 339 2.6 3.4 As regards the frequency of return cases in the various sanitary areas, no complete statement isgiven, but Prof. Simpson says:— "The incidence of the secondary cases varied much in the 52 districts of London, or 51 districts if the Port of London be excluded, and the variations corresponded in some measure with the prevalence of the disease in the district'. "The greatest incidence was in Battersea, in which there were 56 secondary cases, representing 8 per cent. of the notified scarlet fever cases and 5 per cent. of the notifieddiphtheria cases in that district; and over 16 per cent. of the 339 cases in London arising in houses to which primary cases discharged from hospital had been sent." Proceeding to examine the 339 return cases, Prof. Simpson found that certain of them required to be excluded as being "in no way connected with the return of primary cases from hospital." The cases thus excluded were:— (a) Cases where the secondary attack oommenced prior to the arrival home of thedischarged patient. 7 cases. 105 Report of Medical Officer of Health. (b) Cases in which the secondary illness differed from the primary. In this group he includes 8 cases of diphtheria following the return of discharged scarlet fever patients, and 10 cases of scarlet fever following the return of discharged diphtheria patients. 18 cases. (c) Cases due to infection traceable to sources other than the discharged patient. 26 eases. (d) Cases due to house infection. "By house infection I include infected clothing, toys, dampness, drainage, and general insanitary condition of the house. They are, as a rule, difficult to separate, and may, I think, be best dealt with under the general term, house infection." 20 cases. (e) "Cases in which there was no evidence either in the condition of the primary case, or in the circumstances under which the illness of the secondary case took place, to show that the infection was connected with the return home of the primary." 52 cases. (f) Cases in which the alleged return case was a patient discharged from hospital who had been re-infected at the hospital. 4 cases. By such process of exclusion the original 339 "return cases" are reduced to 212. Of the 127 excluded cases, certain would not be regarded by most officials as "return cases" at all, e.g., those in groups (a) and (f), while others, e.g., some of groups (b) and (e), would not in all probability be excluded as has been done by Prof. Simpson. The report does not, unfortunately, contain particulars of the cases investigated, so that it is impossible to decide how far Prof. Simpson's decisions qua exclusion would accord with general experience. For the present purpose the results of inquiries as to the 212 remaining cases can only be considered. These are divided in the Report into 3 classes:— Class 1.—Doubtful cases in which it was impossible to decide whether the infection was caused by the primary cause or not. 36 cases. Class 2.—Cases in which it was impossible to dissociate infected clothing, &c., or house infection from personal infection. 17 cases. Class 3.—Cases which were probably due to personal infectivity of the primary case. 159 cases. In the absence of all details of the cases, this classification has to be accepted as it stands. In his detailed inquiry Prof. Simpson confines himself to the 111 primary cases which are included in Class 3 and gave rise to 159 "return cases." The primary cases included 90 cases of scarlet fever and 21 of diphtheria. These figures are equal to 1.3 and 0.5 per cent. respectively of the discharges. The percentage of cases in connection with the various hospitals varied from 0.5 at the South Western to 1.3 at the North Eastern.* The duration of hospital isolation, so far as can be judged from the small numbers dealt with, bears little or no relation to the frequency of return cases. "If any opinion may be hazarded on such data, it may be stated that the variation in frequency of such cases does not appear in any way to be connected with shorter detention of patients in the hospitals concerned, for the Brook, North Eastern and the Western, which detain their patients the longest, do not occupy so good a position as the Eastern and the Park, which detain their patients the shortest period, while Gore Farm and Winchmore Hill, the convalescent hospitals, contribute as large a percentage of 're-infecting cases.'" The inquiries made respecting the 111 re-infecting cases brought out two facts: (1) That desquamation was not apparently a factor of prime importance in the conveyance of infection, only 27 per cent, of the cases being attributable to "desquamation of the skin or eczematous eruptions" in the discharged patient; and (2) that discharges from mucous surfaces were noted in the larger proportion of discharged patients. "The remarkable fact in this analysis of the condition of the primary cases suspected of having caused secondary cases is that 80 per cent. had discharges from the mucous membranes, chiefly of the respiratory tract, and that 9 per cent. showed au unhealthy condition of the throat with corresponding secretion." † * It has to be noted here that these percentages relate to scarlet fever and diphtheria taken together. † This has been frequently alluded to in the paragraphs on "return cases" given in each Annual Report. 106 Appendix IV. An analysis showing the frequency of the various pathological conditions noted in the primary —i.e., re-infecting—cases of each disease is given below:— Disease. Discharge from Nose. Sore Nose. Discharge from Nose and Ears. Desquamation of Skin and Eczematous Eruption. Unhealthy Throat and Swollen Glands. Colds in Head. Colds in Chest. Relapse. Healthy. Other Causes. Scarlet Fever (90) 36 5 13 3 7 15 5 0 3 3 Diphtheria (21) 6 0 1 0 3 4 2 3 0 2 Total 42 5 14 3 10 19 7 3 3 5 Percentage 37.9 4.5 12.0 2.7 9.0 17.1 6.3 2.7 2.7 4.5 At the present time the bacillus of scarlet fever has not been identified, and the bacteriological examinations of the secretions from the cases examined threw no light on the question.* With regard to diphtheria, the results obtained required to be received with caution; firstly, because it is known that the B. diphtheria has not infrequently been found to persist for a long time in the throats, &c., of convalescent patients; and, secondly, because at the date of examination, after the recurrence of one or more cases of diphtheria, it was possible that re-infection of the home-coming patient might have occurred. In 5 out of 6 re-infecting patients examined who had discharge from the nose, the bacillus was found in 4; in 3 out of 4 with "colds in the head," the bacillus was also found ; but in 2 with " colds on the chest," the bacillus was not detected. Prof. Simpson observes that the bath given before discharge not only failed to remove infection in the cases referred to, but in certain cases, by causing "colds" to be taken, appeared to favour the infection of other patients. He appears to think that the "cold" may awaken the infectivity of the micro-organism, which would otherwise give rise to no accidents. In one ease quoted a " cold " apparently caused a relapse in a patient just discharged from hospital after diphtheria. After relating certain cases of extreme detention in hospital, for 8 months in one case, in which the returned patient infected others, he concludes that mere detention in hospital is no guarantee of freedom from infection. The discharges from the mucous surfaces he regarded as the carri- rs of infection, not the active agents of infection. The infection which impregnates such discharges does not apparently persist for any long time. The fact that furniture, books, &c., in a hospital ward are infected by the * During 1900 5 return cases (scarlet fever) were examined bacteriologically for the Department. The results obtained were:— (1) Report mislaid. (2) Secretion from nose: "Micrococci (probably M. jiyogenes aureus) and other cocci (probably Sarcina) present." (3) Swab from throat: "A few streptococci present." Swab from nose: "Some Klebs-Loffler bacilli (B. dipththeriee); a few pseudo-diphtheria bacilli, and large number of streptococci present."' (4) Swab from throat: "Pure culture of Klebs-Loffler bacillus obtained ; nothing else." Swab from nose: "A few Klebs-Liiffler bacilli; some staphylococci and diplococci present." (5) Swab from nose: "The pseudo-diphtheria bacillus has been recognized, together with a variety of streptococci." 107 Report of Medical Officer of Health. patients, suggests that the infection present in the mucous discharges has a similar origin. That being granted, it is evident that an extended duration of hospital isolation will not tend to prevent the occurrence of " return cases." The average duration of such isolation at the various hospitals at the time of the inquiry is indicated in the following tables:— Number and duration of detention of cases of Scarlet Fever in different hospitals discharged during the six months from October, 1898, to March, 1899. Time of Detention. South. Eastern. North. Eastern. Park. Western. N orth. Western. Fountain. Eastern. Brook. Southwestern. Under 2 weeks 0 0 0 0 1 0 1 0 0 2 weeks and under 4 weeks 0 3 1 0 5 0 0 0 0 4 „ „ 6 „ 3 8 9 1 32 16 18 5 10 6 „ ,.8 „ 67 142 98 13 115 72 64 20 89 8 „ „ 10 „ 75 190 92 80 114 166 41 145 86 10 „ „ 12 „ 42 112 46 83 71 100 25 146 66 12 ,, ii 15 „ 32 149 32 59 28 67 22 170 66 15 ,, and over 12 38 10 56 18 22 9 43 28 231 642 288 292 443 180 529 345 Percentage of cases giving rise to return cases after isolation lasting South. Eastern. North . Eastern. Park. Western. Northwestern. Fountain. Eastern. Brook. Southwestern. 4 weeks and under 6 weeks 1.2 1.2 3.1 0.3 8.3 3.6 10.0 0.9 2.9 6 ,, ,,8 „ 29.0 22.1 34.0 4.4 29.6 16.2 35.5 3.7 25.7 8 „ „ 10 „ 32.4 29.5 31.9 27.3 29.6 37.4 22.7 27.4 24.9 10 „ „ 12 „ 18.1 17.3 15.9 28.7 18.6 22.5 13.8 27.4 19.1 12 ,, ,, 15 ,, 13.8 23.0 11.1 20.2 7.2 15.1 12.2 32.1 191 15 „ and over 5.1 5.9 4.1 19.1 4.6 4.9 5.0 8.0 8.1 Percentage of primary Scarlet Fever infective cases 11.7 1.3 1.3 1.6 1.5 1.3 1.1 2.1 0.8 108 Appendix IV. A comparison between the period of isolation of cases treated at home and that at hospital shows a very marked difference in their duration, as is seen by the following statement:— Scarlet Fever. Diphtheria. Hospital. Home. Hospital. Home. No. Percentage. No. Percentage. No. Percentage. No. Percentage. "Under 2 weeks 2 0.0 22 4.5 14 0.5 153 37.6 2 weeks and under 4 weeks 11 0.3 17 16.5 95 3.9 181 44.8 4 „ ,,6 „ 102 3.0 169 36.4 543 20.5 51 12.6 6 ,, .,8 „ 680 20.3 157 33.7 835 35.3 12 2.9 8 „ „ 10 „ 989 29.6 35 7.5 479 18.1 5 1.2 10 „ „ 12 „ 691 20.3 5 10 307 11.6 2 0.4 12 „ „ 15 „ 625 18.9 0 0.0 253 9.5 0 0.0 15 ,, and over 236 7.0 0 00 122 3.9 0 0.0 3,334 — 465 — 2,648 — 404 — Note.—The period of isolation at home, being determined as that period between the notification of the illness and the date of disinfection of the house after the recovery of the patient, does not possess the same exact accuracy as the period of isolation in hospital. The error, however, is after all very small, and the figures show a very striking contrast, the importance of which is only slightly lessened by the comparatively small numbers dealt with in the home figures. (It is very probable, and acknowledged by some, that cases in all respects identical with "return cases" occur in connection with home treatment, but no such cases have been recorded by Prof. Simpson, and none have been known of in Paddington during the last seven years at least.) Without formulating definite recommendations on the subject, Prof. Simpson suggests (a) that a classification of cases with special isolation and treatment of those patients who are affected with certain affections of throat, nose, &c., should be tried, and he thinks that the duration of detention might in general be shortened; (b) that parents should be cautioned not to allow discharged patients to sleep with others immediately on their return home; and (c) that the medical officer of.health of the district to which the patient is discharged should be notified of such discharge. The Report was forwarded by the Asylums Board to the Royal College of Physicians, and the College was asked to express an opinion "as to whether, and if so, under what conditions, the present period of detention in hospital could consistently with public safety be shortened." In their Report the Committee of the College say: " That there is not sufficient evidence at present before them to enable them to lay down any definite period of time as necessary for the detention of patients recovering from scarlet fever. With the object of obtaining further evidence the Committee recommend— "(i.) That in each hospital a couple of wards identical in respect to cubic space per bed, &c., should be set aside and administered on a different principle, the sex of the children being the same, and the age as far as possible; that in one ward the cases subject to 100 Report of Medical Officer of Health. mucous discharges from nose or ear should be rigorously excluded; that immediately od the appearance of any such discharge the patient should be removed; and that all nozzles of syringes should be kept in antiseptic solutions. In the other ward no special attention should be paid to these discharges other than that hitherto adopted. The incidence of either rhinorrhcea or otorrhcea should be compared. Cases of 'septic scarlet fever' should be excluded from both. "(ii.) That, if possible, in certain hospitals, with the approval of the medical superintendents, two or more rooms previously disinfected be reserved for the isolation, after six or eight weeks' detention, of single patients who are suffering from rhinorrhcea or otorrhcea, but whose desquamation is completed. Each patient so secluded should be kept for ten days or a fortnight before returning home. During this period of detention the affected parts should be regularly irrigated or syringed with some reliable antiseptic, and great care should be taken that the nozzle of the apparatus be kept in a germicidal solution. On the expiration of the quarantine the patient should be sent home whether the discharge has ceased or not, and the room should be disinfected prior to the reception of another patient. The subsequent history of the case should be investigated. "(iii.) That the inquiry into the facts connected with the incidence of return cases at the Managers' hospitals should be continued for a further period of twelve months, and that the scope of the inquiry should include the history of the cases discharged under the conditions mentioned." The Asylums Board have authorized the carrying out of recommendations (i.) and (ii.), so far as can be done without detriment to the efficiency of the hospitals, and have decided to carry out the third recommendation. It will he noted that the Board have not accepted Prof. Simpson's suggestion to inform medical officers of health of discharges of patients to their respective districts. This recommendation ought to he pressed for, as there is reason to believe that the known "return cases" do not represent the whole of such cases. It is probable that infection is occasionally spread from recently discharged patients to those with whom they associate in schools, playgrounds, &c It is, moreover, desirable for the complete elucidation of the question that information should be collated of the circumstances under which no such cases occur as well as of those attending their occurrence. This cannot be done vintil the local medical officers of health are regularly informed of all discharges from hospital. At present it has been alleged that the hospital officials do not know to which sanitary areas the patients go, owing to the overlapping of the boundaries of poor law and sanitary districts. This overlapping will be removed in consequence of adjustments following the formation of the municipal areas. Table of Return Cases, 1900. 110 Appendix IV. HISTORIES OF scarlet fever. No. First Case (A.). Hospital. Subsequent Cases (B.), (C.). Interval Days. Initials. Sex. Age. Removed to Returned from Initials. Sex. Age. Sickened. 1 F. W. f. 4 2 xii., '99 22 xii., '99 M. W. f. 3 28 xii., '99 6 2 L. B. m. 3 16 X., '99 23 xii., '99 W. B. m. 1 3 i-, .00 11 W. E. B. m. 5 5 i., .00 13 or 2 3 F. 1. m. 14 30 xi., '99 25 i., .00 A. H. m. 17 5/6 ii., '00 11 4 "» B. C. f. 4 13 xii., '99 S5 ii., •oo W. C. f. 2 9 ii., '00 4 (2> E. C. f. 7 16 xii., '99 5 E J C. m. 3 23 iii., ♦ '00 9 vi., '00 G C. f. 1 12 vi., •oo 3 6 A. J. m. 2 25 vi., '00 2 viii., '00 C. H J. K. J. J. k. m. f. m. 4 5 6 9 12 13 viii., viii., viii., '00 '00 '00 7 10 or 3 11, 4, or 7 M. M. f. 6 8 vi., '00 4 viii., '00 A. M. m. 3 24 viii., '00 20 8 M. H. f. 6 11 vii., '00 5 ix., '00 J. H. f. 4 8 ix., '00 3 9 E. A. f. 2 19 ix., '00 21 xi., '00 A. W. f. 13 29 xi., '00 8 14 Xll '00 10 A. L. 10. 7 29 ix., '00 22 xi., '00 H. L. m. 6 13 xii., '00 21 11 V. C. f. 7 25 ix., '00 30 xi., '00 L. C. f. 13 11 xii., '00 11 111 Report of Medical Officer of Health. RETURN CASES, 1900. Notes. F. W. was removed to hospital for diphtheria, not scarlet fever. A. Discharged on cold, foggy day ; mother noted " stuffiness" in nose, which was said to have cracks on it; mixed with family on return, but slept apart until 31 xii., when slept with B. Seen 6 i., '00. Only features noted—slight hardness of submaxillary glands; clogging of nostrils with this mucus. B. and C. Have good health ; no school; visiting only an aunt's family, where no illness had occurred. A. Discharged on cold day ; came home on top of tramcar; mixed with family, but did not share room with B. until 1 ii.; mother stated he had nasal discharge and slight sore on nose on return; lad said he had a cold; he was ailing, off and on, with ill-defined symptoms until 4 ii. Seen 13 ii. Only features noted were muco-purulent nasal discharge, and some rawness at edge of nostril. B. Employed in City; not very robust; had a " cold " just before attack of scarlet fever ; is not subject to throat attacks. A. (1) and (2). Came home on bright, cold day by cab; mixed with family at once ; shared room with B., but had separate bed. (1) Good health since return; some scurf in head; mother noted nasal discharge on day of return. (2) Good health ; slight scurf in head ; no nasal discharge. Seen 12 ii. A. (1). Scurf over occiput; thick nasal discharge, and edges of nostrils sore; cracks behind both ears; some scaliness over left ear; submaxillary glands small and hard ; sores at edges of nails of left hand. A. (2). Some scurf in head ; submaxillary glands hard, otherwise nothing to note. B. Had good health except for cold during fortnight preceding return of A. (1) and (2); was cutting last double tooth at that time. A. Came home on a warm fine day; mother noticed a nasal discharge on his return, from which he was also reported to be suffering while at hospital ; mixed with family at once ; slept in separate room from B. with brother who had had scarlet fever some time ago. Seen 14 vi. Child very pale; had "snuffles," but no evidence of nasal discharge; submaxillary glands large; anterior cervical glands small and hard. B. Had very good health up to day of attack. A. Reported to have had discharge from nose on return; and bad throat. The three secondary cases were in two families occupying two houses. Patient A. slept at home of patients B. and D. on 6 viii., and had been visiting K. family frequently. (Case not fully investigated owing to vacation.) (Case not fully investigated owing to vacation.) A. No history of any abnormal features on return. Slept with B. same night. B. Good health. (Not completely investigated.) A. Discharged on cold, fine day ; home by train; was apparently quite well, and nothing was noticed ; slept apart (separate room) from B. Seen 6 xii. Child apparently quite well, and free from all indications. B. A somewhat delicate child ; had been at school up to day of sickening. Premises not too clean. A. Discharged fine, cold day; mixed with family at once; slept in same room, but separate bed, with B. Had slight cold after return. Seen 14 xii. Indications of adenoids; submaxillary and anterior cervical glands hard, but not markedly enlarged. B. Had good health. A. Discharged on fine day; home on top of 'bus; slept with B. and another sister; mother thought child had cold after return home. Seen 15 xii. Nothing to note. B. Had had good health ; attended school until 13 xii.