STO 20 - THE - Metropolitan Borough of Stoke Newington. Report OF THE Medical Officer of Health and Public Analyst, FOR THE YEAR 1911. BY HENRY KENWOOD, m.b., f.r.s.e., d.p.h., f.c.s., Chadwick Professor of Public Health, University of London, Fellow and Member of Council of the Royal Sanitary Institute, &c., Medical Ojficcr of Health and Public Analyst. london: Printed by Stephen T. Green, 6 & 9, Albion Buildings, Aldersgate Street, E.C. 1912. TABLE OF CONTENTS. Vital Statistics— Page The Census 97-98 Population of the Borough and of each of the two Divisions 98-99 Number of people to the acre 99 Births and Birth-rate 99-100 Mortality, Death-rates and causes of Mortality—with notes thereon 100-122 Infantile Mortality 105-111 Ophthalmia in the newly born 111-112 Epidemic Diarrhoea amongst children 116-119 Cancer 119 The Mortuary 120 Inquests held during the Year 122 Infectious Diseases and the Measures taken to Prevent their spread— The Infectious Sickness Returns for the Year 122-135 Scarlet Fever 127 Erysipelas 127-128 Enteric Fever 128-129 Diphtheria 129-131 Measles and Whooping Cough 131-135 Puerperal Fever 135 Consumption 135-147 Cerebro-Spinal Fever and Acute Polio-Myelitis 147-150 Small-Pox and Vaccination 150-153 The Disinfecting and Cleansing Station 153-154 Meteorology of the Year 154 Notes upon Sanitary Work Performed during the Year 155 Food Inspection 155-157 Houses let in Lodgings 157-158 The Housing and Town Planning Act 158-159 Factories and Workshops 160-164 The Public Health Legislation of 1911 164 Food and Drugs 164-176 Chemical Antiseptics 172-176 Report of the Chief Sanitary Inspector 177-188 Streets in the Borough of Stoke Newington—(Appendix) 189-19 REPORT OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1911. To the Mayor, Aldermen, and Councillors of the Metropolitan 'Borough of Stoke Newington. Gentlemen, The vital statistics of the Borough for the year 1911 were not of the usual satisfactory nature, and the special circumstance of last summer's heat and drought w,as mainly responsible for this. The general death-rate of 12.5 compares favourably with the corresponding rate of 15.0 for the Metropolis as a whole, but it was higher than the rates of the preceding two years. The death-rate from the chief infectious diseases (1.69) was the highest since the year 1903, although it is considerably below the rate for the whole of the Metropolis (2.20). The rate of infantile mortality (the number of deaths under one year of age to every thousand births) amounted to 101.2, as against 128 for the Metropolis, and there were only five other Metropolitan Boroughs with lower rates. It is obvious, however, from our experience, that sustained efforts are necessary in order to permanently stem the wastage of infant life, and I would direct your particular attention to the reference to the subject of infant mortality on pp. 105-110 of this Report. There is nothing noteworthy with reference to the notifications of infectious diseases during 1911, save that while they exceeded those for the two preceding years, there were only five other Metropolitan Boroughs with lower rates. With the 1911 Census figure available, it has been possible to calculate the yearly populations with greater precision than has been the case since 1901. These have been recalculated, and the rates given for previous years in this Report are therefore revised rates. 96 Again I would direct your special attention to the remarks and suggestions on pp. 136-147 concerning Consumption. I feel very strongly that there is a need for increased .and improved measures for reducing the prevalence of this disease in the Borough. During the year a large amount of work has been carried out, in a thoroughly satisfactory manner, by each of the workers in the Public Health Department. I am Gentlemen, Your obedient Servant, HENRY KENWOOD. February 14th, 1912. 97 THE CENSUS. In England and Wales the population increased since 1901 from 32,527,843 to 36,075,269, a percentage increase of 10.9. This is the lowest rate of increase on record, the rates for the two previous decennia being 11.65 and 12.17, respectively. The rate of increase of population depends upon two factors: (1) the balance between births and deaths; and (2) the balance between outward and inward passenger movement. The net gain by excess of births over deaths was slightly higher than in the previous decennium (12.44 as against 12.39 per cent.), a result due to the counterbalancing of a large reduction on the birth-rate by a still larger reduction of the death-rate. The loss by balance of passenger movement was nearly half a million persons as compared with about 68,000 in 1891-1901, and over 600,000 in 1881-1891. With regard to the counties in which there has been a considerable rise ox fall in the population it appears that some of the highest increases occurred in counties immediately surrounding the metropolis; Kent, however, showed an increase of only 8.8 per cent. The distribution of population in urban and rural districts, respectively, and their relative changes in the last intercensal period, are as fallows: In 1901, the urban population of England and Wales was 77 per cent, of the total, and the rural population 23 per cent. For 1911, the figures are 78.1 and 21.9. The rate of increase in Rural Districts has risen from 2.9 to 10.2 per cent., and the rate in Urban Districts has fallen from 15.2 to 11.1 per cent. It should, however, be noted that the rates represent an actual increase of 2,818,072 persons in the Urban and of only 729,354 in the Rural Districts. Three metropolitan boroughs show a percentage increase in population of more than io, namely, Wandsworth (+34.3), Lewisham (+26.2), and Fulham (+11.7). On the other hand, six show a decrease of more than 10 per cent., namely, City of London (-27.0), Holborn (-16.9), Finsbury (-13.3), City of Westminster (-12.4), 98 St. Marylebone (-11.3), and Chelsea (-10.1). Only one constituent of London's “Outer Ring” actually decreased in population, namely, the urban district of Penge (-0.6). The population in the rural part of the “Outer Ring” increased by 54,799, no less than 14,591 of this change being credited to the rural parish of Mitcham. Nearly all the larger towns showed a conspicuous diminution of the population in their central parts; and in some cases, where municipal boundaries enclose a minimum of “suburb,” the population of the town as a whole had diminished. In London, the population of the administrative county was 4,522,961, less by 13,306 than that in 1901. In. so-called “Greater London,” however, there were 7,252,963 inhabitants; over half a million more than at the previous Census. The publication of the Census figures has shown that many calculated death-rates throughout the country have been serioush understated during the last few years. In the interest of accurate statistical work it may be hoped that the usual official objection to an intermediate Census may be overcome before 1916. POPULATION. According to the Census of 1901 the population of the Borough was then 51,247. By the recent Census of 1911 the population for the same area was shown to have decreased during the 10 years to the extent of nearly 600. In this Report the rates are based on the estimated population for the middle of the year 1911, and the figure, calculated 'logarithmically from the difference between the populations of 1901 and 1911, amounts to 50,669. In my last Annual Report I estimated the population by the method adopted by the Registrar-General, which assumes that the rate of increase in the population between the last two Censuses is maintained. The population thus estimated reached a figure of 54,458, which was in my opinion too high; and I stated that it was 99 “an over-estimate” and that “my estimate of the population is some 2,000 lower.” But the Census Returns of 1911 show that even the latter estimate was too high by nearly 2,000. The estimated population for each of the Sub-districts is as follows:— The Northern Division of the Borough (lying North of the middle line of Church Street) has a population of 17,040 ; and in the Southern Division the population is 33,629. The natural increase of population by excess of births over deaths during the year amounted to 413, as against 355 in the preceding year. Alumber of people to the acre.—The area of the Borough amounts to 863 acres, and this, divided among the residents. furnishes 59 people to the acre. Births—Birth-rate.—During the year 1911 there were 1,047 births registered in the Borough, viz.—534 males and 513 females. The birth-rate per 1,000 per annum was therefore 20.7, as against 18.3 for the preceding year. The births in the Northern Division of the Borough numbered 189 and the birth-rate w;is 11.1, while those in tlnj Southern Division were 809, and the birth-rate was 24.0. Year. Birth-rate. Rate for London generally. Kate lor England and Wales. 1 901 21.6 29.0 28.5 1902 22.0 28.5 28.6 1903 21.5 28.5 28.4 1904 22.3 28.0 27.9 1905 20.9 27.1 27.2 1906 21.2 26.6 27.0 1907 20.5 25.8 26.3 1908 20.2 25.4 26.5 1909 19.5 24.4 256 1910 18.8 23.6 24.8 1911 20.7 25.0 24.4 100 The Registrar-General has made arrangements whereby particulars of those births (of Stoke Newington parents) which occurred outside the Borough, and were not therefore locally registered, are now transferred to us, so that for the first time 49 such births have to be added to the number registered within the Borough in 1911. It was impossible in former years to make this addition, and so the birth-rate for Stoke Newington for 1911 must not be taken as comparable with that of former years, and the increase shown in the birth-rate is not a real one. The part which the low birth-rate plays in favouring the low general death-rate of the Borough is duly accounted for in arriving at the corrected death-rate. More especially in the population of the Southern part of the Borough, which embraces many temporary residents of the poorer classes, is this circumstance of a low birth-rate an important factor determining a low death-rate. It may be noted that, in Stoke Newington, excess of the birthrate over the death-rate for the year 1901 was 8.5; whereas for the year 1911 (both rates being considerably lower), the figure was 8.2. During the year the births notified under the Notification of Births Act have been compared with the births registered by the Registrar of Births, and the comparison has revealed the fact that the requirements of the Notification of Births Act are still not fully complied with, notwithstanding the efforts we have made to /make these requirements known. It should, however, be added that the excess of registered births over notified births in Stoke Newington during 1911 was very small, and that in each case I have taken steps to ascertain the Cause of the failure of notification and to draw the attention of the responsible party to his or her legal default. MORTALITY. General Mortality.—There were 432 deaths of residents registered in the Borough, and 202 of residents who died in Public 101 Institutions outside of the Borough, making a total of 634 deaths. Of these 330 were of females and 304 were of males. Year. General Death-rate. Rate for London generally. Rate for England and Wales. 1901 13.1 17. 6 16.0 1902 13.3 17.2 16.3 1903 12.6 15.2 15.4 1904 13.4 16.1 16.2 1905 13.0 15.1 15.2 1906 12.0 15.7 15.4 1907 11.8 14.6 15.0 1908 12.9 13.8 14.7 1909 11.7 14.0 14.5 1910 11.8 12.7 13.4 1911 12.5 15.0 14.6 The recorded general death-rate is therefore 12.5, as against 11.8 for the preceding year. This ordinary death-rate, however, cannot be taken as a true index of the healthiness of the Borough, nor can it be justly compared with the rates of other Sanitary areas, unless some allowance is made for the relative proportions of males and females at different ages in the districts compared. Death-rates vary very much in different districts according to the nature of the populations of these districts; for instance, in a district containing a large number of very young or very old people the rate would be considerably higher than in a district containing a larger proportion of people of middle age. 102 There is, therefore, calculated hv the Registrar-General from the Government Census returns, a corrective factor for each district in the County of London, according to the sex and age distribution of the population of that district; the multiplication of the recorded death-rate of the district by this factor gives the death-rate which would obtain in that district if the sex and age distribution of the population of the district were in the same proportions as it is in the country as a whole—thus eliminating the accidental differences due to sex and age, and affording a fairer means of comparison and a truer test of the healthiness of the district. The death-rate so ascertained is known as the corrected death-rate. The so-called “factor for correction” for the Borough of Stoke Newington is 1.0438, and the death-rate corrected for age and sex distribution is 12.5× 1.0438= 13.0 per 1,000 per annum. In arriving at this corrected death-rate the deaths of non-residents who have died in Public Institutions within the Borough have, of course, been excluded. The rate is somewhat higher than those recorded for the previous two years. The death-rate for the whole of London was 15.0. District Mortality.- The deaths among residents of the Northern Division of the Borough numbered 161 and furnished a recorded death-rate of 9.4 per 1,000 per annum. The deaths among the residents of the Southern Division of the Borough nurrtbered 473, and furnished a recorded death-rate of 14.1 per 1,000 per annum. 103 TABLE I. CAUSES OF AND AGES AT DEATH DURING THE YEAR 1911. Causes of Death. Nett Deaths at the subjoined ages of " Residents" whether occurring within or without the Borough. Total Deaths whether of “Residents” or “Non-Residents” in Institutions in the Borough. All Ages. Under 1 year. 1 and under 2 years. 2 and under 5 years. 5 and under 15 years. 15 and under 25 years. 25 and under 45 years. 45 and under 65 years. 65 and upwards. 1 2 4 5 6 7 8 9 10 11 All cases Certified - - - - - - - - - - Uncertified - - - - - - - - - - Enteric Fever 1 - - - 1 - - - - - Small Pox - - - - - - - - - - Measles 27 7 8 8 3 - 1 - - - Scarlet Fever 3 - 1 1 - 1 - - - - Whooping Cough 19 6 7 5 1 - - - - - Diphtheria and Croup 3 1 — 1 1 - - - - - Influenza 2 - - - - - 1 1 — — Erysipelas 7 1 — — — — 1 3 2 - Cerebro-Spinal Fever - - - - - - - - - - Phthisis (Pulmonary Tuberculosis) 52 - - - 1 6 28 14 3 1 Tuberculous Meningitis 1 - — 1 — — — — — 1 Other Tuberculous Diseases 10 1 - 2 4 1 1 - 1 1 Rheumatic Fever 1 — — — 1 — — - — - Cancer, malignant disease 56 — — — — 1 3 24 28 3 Bronchitis 52 8 — 1 — — 2 14 27 3 Broncho-Pneumonia 5 2 1 1 — — — 1 — — Pneumonia (all other forms) 36 7 2 1 1 2 8 7 7 2 Other Diseases of Respiratory organs 6 1 1 2 2 2 Diarrhoea and Enteritis 33 25 4 1 — — — 2 1 — Appendicitis and Typhlitis 2 - - - - - 1 — 1 — Alcoholism 6 - - - - - 3 3 — — Cirrhosis of Liver 11 - - - - - 1 7 3 1 Nephritis and Bright’s Disease 18 - - - - - 6 3 9 1 Puerperal Fever - - - - - - - - - - Other accidents and eases of Pregnancy and Parturition 1 - - - - - 1 - - - Congenital Debility and Malformation, including Premature Birth 27 27 - - - - - - - - Violent Deaths, excluding - - - - - - - - - - Suicide 9 — — — 1 1 6 1 — - Suicides 1 — — — — 1 — — — — Other Defined Diseases 246 21 2 1 8 6 28 53 127 23 Diseases ill-defined or known - - - - - - - - - — 634 106 25 23 22 20 92 135 211 38 104 TABLE II. SHOWING THE DISTRIBUTION OF THE DEATHS IN THE NORTHERN AND SOUTHERN DIVISIONS OF THE BOROUGH DURING EACH OF THE QUARTERS OF THE YEAR 1911. DISEASES. NORTH. SOUTH. Quarters Total Quarters. Total 1 2 3 4 1 2 3 4 Measles — 1 - — 1 17 6 2 1 26 Scarlet Fever - - - - - 1 — 1 1 3 Whooping-cough - - - - - 12 4 3 — 19 Diphtheria and Membranous Croup — 1 — 1 2 — — — 1 1 Enteric Fever - - - - - - - - 1 1 Epidemic Influenza 1 — — 1 2 — — — — — Diarrhoea — — 1 — 1 — 1 23 2 26 Enteritis — — 1 — 1 — — 5 — 5 Peurperal Fever - - - - - - - - - - Erysipelas — — 1 — 1 1 2 — 3 6 Other Septic Diseases - 2 — — 2 1 — 6 3 10 Phthisis 2 4 3 5 14 14 6 12 6 38 Other Tubercular Diseases 2 — — 1 3 — 4 - 3 7 Cancer 7 5 7 7 26 6 9 7 8 30 Bronchitis 2 1 — 3 6 20 4 4 18 46 Pneumonia 4 6 1 1 12 11 8 3 6 28 Other Respiratory Diseases — 1 2 — 3 — 2 — 1 3 Alcoholism and Cirrhosis 2 — 1 2 5 1 1 4 1 7 Venereal Diseases — — — 1 1 — — 1 — 1 Diseases of the Nervous System 8 4 1 6 19 18 13 8 5 44 Premature Birth 1 — 2 — 3 5 1 — 3 9 Heart Disease 5 2 5 5 17 9 13 6 9 37 Accidents 2 2 — 1 5 1 3 2 5 11 Suicides 1 — — — 1 — — — — — Old Age 4 1 1 5 11 13 13 10 13 49 All other Causes 8 6 3 8 25 21 10 14 21 66 Totals 49 36 29 47 161 151 100 111 111 473 105 DISTRICT MORTALITY 1st Quarter. 2nd Quarter. 3rd Quarter. 4th Quarter. Totals. Rate per 1,000 per annum. Northern Division 49 36 29 47 161 9.4 Southern Division 151 100 111 111 473 14.1 Totals 200 136 140 158 634 12.5 INFANTILE MORTALITY. There were 106 deaths registered of infants under one year of age, as against 998 births; the proportion which the deaths under 1 year of age bear to 1,000 births is, therefore, 106.2, as against 66.1 in the preceding year. The deaths under 1 year of age form 16.7 per cent, of the total deaths of all ages, whereas those for the preceding year formed 10.6 per cent. Year. Rate of Infantile Mortality. Rate for London generally. Rate for England and Wales. 1901 117.9 149 151 1902 114.7 139 133 1903 120.3 130 132 1904 115.6 144 146 1905 124.7 129 128 1906 108.0 130 133 1907 97.9 115 118 1908 98.3 113 121 1909 84.9 107 109 1910 66.1 103 106 1911 106.2 128 130 106 TABLE III.-INFANT MORTALITY. 1911. Nett Deaths from stated causes at various Ages under 1 Year ot Age. CAUSE OK DEATH. Under 1 week 1-2 weeks 2-3 weeks 3-4 weeks Total under 1 month 1-3 months 3-6 months 6-9 months 9-12 months Total deaths under 1year All causes Certified - - - - - - - - - - Uncertified - - - - - - - - - - Small Pox - - - - - - - - - - Chicken-pox - - - - - - - - - Measles - - - - - - 1 3 3 7 Scarlet Fever - - - - - - - - - - Diphtheria and Croup - - - - - - — 1 — 1 Whooping-cough — — — 1 1 — — 3 2 6 Diarrhoea — — 1 — 1 3 9 l 5 22 Enteritis — 1 — — 1 - — 2 — 3 Tuberculous Meningitis - - - - - - — 1 — 1 AbdominalTuberculosis - - - - - - - - - - Other TubTerculous Diseases - - - - - - 1 - - 1 Congenital Malformations 1 — - - 1 1 1 - - 3 Premature Births 10 — — 1 11 1 — — — 12 Atrophy, Debility and Marasmus - 1 - 4 5 5 2 - - 12 Atelectasis - - - - - - - - - - Injury at birth - - - - - - - - - - Erysipelas - - - - - - - - - 1 Syphilis — — — — — 1 — — — 1 Rickets — — — — — — — — — — Meningitis (not Tuberculous) - - - - - - - - 1 1 Convulsions 1 1 2 1 5 — 1 1 1 8 Gastritis - - - - - - - - - - Laryngitis - - - - - - - - - - Bronchitis — — 1 — 1 4 1 1 1 8 Pneumonia, all forms - - - - - 2 1 5 1 9 Suffocation, overlaying 1 — — — 1 — — - — 1 Other causes 1 2 1 — 4 1 2 1 1 9 14 5 5 7 31 18 20 22 15 106 107 DKATHS UNDER ONE YEAR OF AGE IN THE DIFFERENT WARDS OF I'HE BOROUGH DURING THE YEARS 1903, 1904, l905, 1906, 1907, 1908, 1909, 1910 and 1911. Name of Ward. 1903 1904 1905 1906 1907 1908 1909 1910 1911 Lordship Ward 4 6 9 8 1 6 2 1 2 Clissold Ward 7 8 12 6 11 4 5 4 6 Church Ward 30 24 24 18 23 19 18 18 27 Manor Ward 10 9 8 3 8 3 6 3 4 South Hornsey Ward 65 66 66 56 36 47 35 32 48 Palatine Ward 20 21 14 26 23 22 18 5 19 Totals 136 134 133 117 102 101 84 63 106 A comparison of the causes of infantile mortality in 1911 with those of the preceding year shows an increase during last year in the deaths from diarrhoeal diseases, measles, whooping cough, and diseases of the lungs. The appointment of a whole-time salaried official, to pay prompt visits to advise the poorer mothers, and who is able as necessity demands to keep in touch with the voluntary workers, hns enabled the work undertaken to preserve infant life to be coordinated and promoted in a manner which was found impossible when no such official existed. THE WORK OF THE OFFICIAL AND VOjLUNTARY HEALTH WORKERS. Birth Inquiries.—During 1911, 546 infants were visited shortly after birth. Fifty-one of these were visited by the Voluntary Health Workers. These visits were followed by 698 revisits. “The advice given has been much appreciated and often much needed. It is in B 108 the homes of the more generally enlightened parents that the visits are most welcomed; the more ignorant parents have first to be im pressed with the importance of proper infant rearing; they have necessarily lower ideals, to raise which is often verv uphill work. Still, they learn slowly and the results are often very encouraging.” Miss Aldridge gives below a few of the conditions which she has found, to illustrate the necessity of these visits:— (1) A baby aged 3 months fed entirely on barley-water from a filthy bottle. The child was very exhausted and cried incessantly. The home was very dirty and the children were neglected and insufficiently clothed. (2) A baby aged 6 months. Father at home with no work; mother out at work; the child encouraged to sleep during the day by being given opium. The child was discovered on a very hot day smothered with flies and sound asleep, having previously been given a bottle of milk containing opium. (3) Twin babies delicate from birth and hand-fed. They were given unsuitable food from a very dirty bottle. The children were insufficiently .clothed and were found to be in a very dirty and neglected condition; and their state of health was very unsatisfactory. The Infant Weighing Machine, purchased at the end of 1910, proved of great value throughout last year. Seventy-one infants were brought to be weighed and the scale was used on 341 occasions. The weight of each child is recorded on a card, which the mother is allowed to take home with her; and great interest is shown by the mothers in the children's progress. Foster-parents also bring the children under their charge to be weighed, as they consider a good weekly gain recorded on the card is proof to the parents that the child is well cared for. 109 The following are the kind of cases in which the Weighing Machine has often been of great value:— (1) An adopted baby aged 6 months, said to be suffering from indigestion, and not thriving. The child was fed on cow’s milk diluted with very thick barley-water (in the proportion of 5 of milk to 9 of barley-water) and was 4½ lbs. below the normal weight. The milk was properly diluted and cream was added, and the child gained 10 oz. the following week. (2) A baby aged 3½ weeks weighed 6 lbs. 10 oz. and was fed on a patent food. The food was changed to properly diluted milk and the child gained an average of 7 oz. a week for rhe next 15 weeks. (3) A baby aged 5 weeks weighed 7 lbs. 8 oz. and was put out to nurse. The child’s food consisted of very weak condensed milk. The milk was gradually given stronger, and later on this was substituted by diluted fresh milk and cream. The child gained in weight from its first visit an average of over 6 oz. a week. The largest amount gained by a baby in one week was 1 lbs. The average gain was nearly 5 oz. “Most of the children brought to be wieghed have been very insufficiently clothed, particularly about the neck and shoulders, and it is not uncommon to find very young infants clothed entirely in cotton, even in the cold weather. To mitigate this evil I have been able to arrange, through the kindness of some of the Head Teachers of the Schools, for the elder girls to knit woollen vests for babies. The wool for these is supplied by us and the vests are sold to the mothers at cost price, and are much appreciated.” The extent to which Public Health work has concentrated upon the problem of Infantile Mortality during recent years is due not only to the marked decline in the birth-rate, but also to the realisation of B2 110 the great influence which the conditions of childhood exercise upon the subsequent life of the individual. Certainly Public Health Authorities may take credit for having reduced the Rate of Infantile Mortality in London during recent years. Even in poor districts, such as Shoreditch and Southwark. there has been a redtiction of some 20 per cent, in .this rate, if the mean rate for the past six years, 1905-1910. are compared with those of the previous five years ending 1904, and a very similar reduction is to be noted in Boroughs such as Hampstead and Kensington, which are, generally speaking, occupied bv a more well-to-do community. The reduction in the rate of infantile mortality cannot be wholly attributed to the colder and wetter summers of recent years; nor can it be explained as the consequence of the reduction in the birth-rate, although both circumstances together would probably account for a considerable proportion of the reduction mentioned. It is possible that the actual reduction in the rate of infantile mortality is masked by the circumstances that the birth-rate is becoming increasingly a class rate, and has become more and more disproportionately a rate affecting the poor people, among whom infantile mortality has always been high. This view is borne out by comparing the relative decreases in the number of children dying under one year of age in the Northern and Southern Divisions of the Borough respectively. The actual number of births registered during the past five years are fewer than those registered during the previous five years, despite the increased population, and this should favour a lower infant mortality. The circumstance that the rate of infantile mortality for rural Wiltshire is only a little more than half of that for the Urban County of Durham, suggests that much remains to be done throughout the country to reduce a mortality rate which is in no small measure preventable. The summer of 1911 w:as one of the most disastrous to child-life of any for several years. The steady decline in infantile mortality, which had been noteworthy for some years, was not only checked, but, owing to the phenomenal weather, it reached1 a figure which was considerably above the mean figure for the past five years. The extent of 1ll the loss in London alone is impressively testified to by the following facts: During the week which ended on July 22 the deaths of children tinder one year of age numbered 173, and there were 41 deaths of children between one and two years of age, and the subsequent weeks show a tragic progression: Week ended Under 1 year. 1 to 2 years. July 29 304 73 August 5 462 101 August 12 636 138 August 19 705 155 August 26 712 143 2,819 610 The solution of the problem of infant mortality is to be found in the circumstances surrounding the life of the mothers of the poorer classes, and especially of the poorest class which is fighting year in and year out against destitution and want. 1 have often noted that with many such mothers their greatest need is not advice and instruction bv health visitors so much as some practical assistance so as to make a possibility of what they already realise to be the proper thing to do. OPHTHALMIA IN THE NEWLY-BORN. This disease, which accounts for a large amount of preventable blindness, was made compulsorily notifiable by the London County Council, with the approval of the Local Government Board, in March, 1911. Arrangements were made by the County Council that cases of inflammation of the eyes in the newly-born, which are notified to the Medical Officer of Health for the County Council by Midwives, shall be visited in the first instance by the London County Council Inspectors under the Midwives Act, when if hospital treatment is urgently necessary the Inspectors will take immediate steps to obtain it. The name and address of each case is then sent to the Medical Officer of Health of the Borough in which the case occurs, so that subsequent supervision and advice may be supplied locally. 112 Arrangements have been made by the London County Council with certain Nursing Associations in London for the nursing of cases which require special care, on account of the severity of the symptoms or on account of the home conditions making this assistance desirable; and the services of nurses from one or two Institutions have also been utilised. Of those Institutions, the North London Associa tion for Nursing the Sick Poor, 413, Holloway Road, N., is the most available for Stoke Newington cases. The Metropolitan Asylums Board has undertaken to supply an ambulance for the removal of cases without charge, but not to provide a nurse. SENILE MORTALITY.—Of the 634 deaths, 211 were of persons over 65 years of age. The proportion of deaths occurring among those of over 65 years of age to the total deaths is, therefore, 33.3 per cent. There were 150 deaths of persons over 70 years of age, and 57 of persons over 80, 8 of whom reached go years of age—the oldest being 97. The actual number of deaths certified as due to old age amounted to 60, or 9.5 per cent, of the total deaths. This is a remarkably high proportion, which indicates that there is a relatively large number of old persons in the Borough, and that the conditions, atmospheric and otherwise, which obtained during last year, were somewhat unfavourable to them. SENILE MORTALITY DURING 1911. 65 to 70 70 to 80 80 to 90 90 and over. Total. 61 93 49 8 211 The respective ages of those over 90 were 90, 91, 91, 91, 93, 93, 94, 97. The Causes of Death.—These are fully set forth in Table I, in which it will be noted that the deaths are also apportioned to 113 different age periods. Table II is supplementary to Table I, and sets forth the deaths in each Division of the Borough during each of the four quarters of the year. Comparing these tables with the corresponding tables of the preceding year, the following facts are noteworthy:—A considerable increase in the deaths from Measles, Whooping Cough, and Zymotic or Summer Diarrhoea. It will be noted (Table II) that the mortality of the Southern Division exceeds that of the Northern (after due allowance is made for the different figures of the population in each Division), mainly in respect to the deaths from Tuberculosis, Measles, Whooping Cough, Diarrhceal Diseases, Premature Birth, Accidents .and Lung Diseases. The Cancer death-rate is, however, disproportionately high in the Northern Division. 114 TABLE IV. DEATHS IN PUBLIC INSTI TUTIONS WITHIN THE BOROUGH, 1911. St. Anne’s House, Manor Road. Northumberland House, Green Lanes. Nursing Home, 6/8, Alexandra Road. Nursing 1 loine, 21, Slam lord Hill. Total. 14 7 9 7 37 I. Institutions within the Borough receiving sick and infirm persons from outside the Borough. St. Anne's House, Manor Road. Northumberland House, Green Lanes. Nursing Home, 6/8, Alexandra Road. Nursing Home, 21, Stamford Hill. II. Institutions outside the Borough receiving sick and infirm persons from the Borough. London Hospital. Hackney Infirmary. Islington Infirmary. Mildmay Cottage Hospital. German Hospital. Children’s Hospital, Great Ormond Street. Great Northern Hospital. North Eastern Hospital for Children. St. Bartholinew’s Hospital Metropolitan Hospital. Royal Free Hospital. St. Luke’s House. Shoreditch Infirmary. Queen’s Hospital. St. Mary’s Hospital. Middlesex Hospital. St. Joseph’s Hospital. Friedenham Hospital. The Babies’ Home. Brook House. Hospital for Women (Solio). Brompton Hospital. St. Fancras Infirmary. St. Mark’s Hospital. Holborn Infirmary. St. Fancras Infirmary. III. Other Institutions, the deaths in which have been distributed among the two divisions of the Borough. N.E. Fever Hospital. Claybury Asylum. Darenth Asylum. Tooting Bee Asylum. Colney Hatch Asylum. Banstead Asylum. Caterham Asylum. Leavesden Asylum. S.E. Fever Hospital. Long Grove Asylum. 115 ZYMOTIC MORTALITY. Included in the Zymotic death-rate are the deaths from the seven principal Zymotic Diseases, viz., Small-pox, Measles, Scarlet Fever, Diphtheria, Whooping Cough, "Fever" (including Enteric Fever, Typhus Fever, and Simple Continued Fever), and Diarrhoea. In Table IV the deaths from each of the Zymotic Diseases (including Erysipelas, Puerperal Fever, and Influenza) are given. The Zymotic Death-rate for the Borough was 1.69 per 1,000 per annum, as against 0.50 in the preceding year. Year. Zymotic Death-rate. Rate for London generally. Rate for England and Walts. 1901 1-26 - 2-25 2-05 1902 1 -56 2-21 1-64 1903 1-70 1-76 1-46 1904 1-62 2-14 1-94 1905 1-35 1-70 1-52 1906 1-39 1-94 1-73 1907 1 -33 1-42 1-26 1908 118 1-35 1-29 1909 0-87 1-30 112 1910 0-93 1-14 0-99 1911 1-69 2-20 1-88 Bv comparison with the preceding year there were more deaths from Measles, Whooping Cough, Scarlet Fever,, Erysipelas, and Diarrhoeal Diseases, but somewhat less from Influenza and EntericFever. The great summer heat and exceptional drought were indirectly responsible for the increase in the Diarrhoeal group of diseases. 116 Deaths from Zvmotio Diseases (including Influenza and Erysipelas) in the Year 1911. Scarlet Fever. Diphtheria. Small Pox. Enteric Fever. Puerperal Fever. Measles. Whooping Cough. Diarrhoea and D3'sentery. Influenza. Erysipelas. Total. First Quarter 1 - - - - 17 12 - 1 1 32 Second „ - 1 - - - 7 4 1 - 2 15 Third „ 1 - - - - 2 3 24 - 1 31 Fourth „ 1 2 - 1 - 1 - 2 1 3 11 3 3 - 1 - 27 19 27 2 7 89 1910 1 2 - 2 2 12 7 1 7 2 36 ZYMOTIC DIARRHOEA. In London, during the week ended July 22, the number of deaths of children under two years from “ Diarrhoea and Enteritis” was 56. In the following ten weeks the deaths averaged 419 per week. Thus in the summer of last year a disease was epidemic which, in London alone, killed over 4,000 children under 2 years of age within a period of 10 weeks; and there must have been tens of thousands of sufferers from this disease. It is certain that we do too little to cope against the ravages of this complaint. It is surprising the extent to which public concern differentiates between the mortality from one cause and another. Doubtless the fact that public alarm would have been at least 100 times greater if only a small proportion of the deaths from Zymotic Diarrhoea had been caused by Enteric Fever, may partly be explained by the circumstance that the latter disease attacks and kills those within the working periods of life 117 (whereas the ravages of Zymotic Diarrhoea are almost entirely restricted to infants and old people), and partly by the fact that the former disease has become recognised as more preventible than the latter. This is a disease which mainly produces mortality among handfed infants reared under unsatisfactory home conditions. It is largelydependent on the tilth contamination of food. In this connection I would emphasise what I stated in my last Annual Report in reference to the public health importance of keeping down the number of flies in and around dwellings (more especially by the prompt removal and destruction of all dust and refuse matter) and of protecting food from them. We have good reasons to believe that these precautions play an important part in the reduction of infantile mortality and even of preventable adult sickness during the summer months. It was formerly believed that the sole means of conveyance of infection by flies was by the hairy legs and feet of the insect; dirt, and maybe infection, retained by the legs and feet being left behind on the food when the fly crawls over it. But more recent experiments have demonstrated that the dejecta of flies may contain the germs which have been taken in by food, and that such germs may remain for many days in the crop or intestine of the fly. Thus the Sanitary Authority itself may be indirectly responsible for fatal Diarrhoea, by its failure to provide efficient scavenging and watering in the summer months; for among the chief breeding places of the house-fly are collections of decaying and fermenting matter, such as are to be found in middens containing horse manure, and ashpits or dustbins containing fermenting vegetable matter. At the meeting of the Public Health Committee on July 12, 1911, I urged the desirability, on public health grounds, of providing for the collection of the household refuse twice weekly from the poor- 118 class area in the Southern portion of the Borough. In this area the houses are largely tenemented and the dustbins are sometimes full in two or three da\s after they have been emptied. I advised that this should be started at once and carried out for two months, as it was in the hot summer months that prompt removal of this material was so important. It was decided that, if the experiment did not result in much extra cost, the period might be extended and, on a subsequent occasion, the area too. I was instructed to furnish a list of the streets which should be dealt with from date to the end of August. This 1 drew out on July 13, and gave a copy to the Surveyor and to the Dust Knocker, and the extra scavenging was carried on until the end of September. I should like to see this a recognised annual provision in the poorer part of the Borough, at least for the two months ending the middle of September. On August 18, 1911, a Circular was issued by the Local Government Board dealing with the prevalence of Diarrhoea. The Circular contained suggestions upon the measures which should be undertaken to reduce undue prevalence and fatality. It was pointed out that advice should be given as to the feeding and management of children, and more generally as to preventing the exposure of their food to contamination from decomposing organic matter. The distribution of simply-worded leaflets, and, better still, personal visits and the offer of practical advice to mothers of infants, were advocated. Special importance was attached to “ efficient scavenging; the frequent and, if practicable, daily removal of house and stable refuse; and domestic cleanliness.” It was also pointed out that the Council should promptly ascertain in which parts of their district Diarrhoea was especially prevalent, and should devote close attention to street and court scavenging, and to the removal of stable and domestic refuse in these areas. The above-mentioned provisions were very largely made within the Borough of Stoke Newington several weeks before the receipt of the Circular; but it was not before the middle of August that some 119 1,500 handbills upon the prevention of Infantile Diarrhoea were distributed. With the assistance of Dr. Herdman, who kindly volunteered his aid, the farts with reference to the incidence of Summer Diarrhoea on the different areas of Stoke Newington were investigated, not only during the early part of the summer of last year, but for each year since 1904. The mortality returns being our only guides to incidence, and the deaths for the eight years only totalled 88—the data are too few to justify conclusions beyond the broad fact that there is a district which is (roughly speaking) enclosed by Church Path, Clissold Road, Cowper Road, and Watson Street, inside of which almost half of the total deaths during the past eight vears have occurred, and that a large .proportion of the deaths occur in the month of August, and practically the whole of the mortality occurred in August and September. M iss Aldridge reports that:—“Only one baby who died during last summer from Diarrhoea was entirely breast-fed, 3 were partly breast-fed, and the rest were entirely hand-fed. Ten of the mothers of these babies had previously lost children.” CANCER. For the purpose of (enabling the incidence of Cancer on the several (populations of the London sanitary areas to be more precisely stated, factors have been calculated for correcting the death-rates, as far as possible, for the differences in the age and sex constitution of the several populations concerned. Certain predisposing factors in the causation of Cancer are now pretty generally accepted. Some of these are be\ond individual control; others, however, such as occupation .and habits of life (determining a localised chronic irritation or inflammation), and suspicious growths in connection with old scars and simple Tumours, call for a more general recognition among the general public, in order that preventive measures and early treatment may be put in operation- more especially by those with an hereditary predisposition to the disease. 120 TABLE V. The chief vital statistics of the Borough of Stoke Newington since its formation. Year. Population estimated to middle of year. Birth-rate. Rate of Infantile Mortality. General Death-rate. Zymotic Death-rate. infectious Sickness rate. 1901 51,328 21.6 117.9 13.1 1.26 7.9 1902 51,188 22.0 114.7 13.3 1.56 7.8 1903 51,130 21.5 120.3 12.6 1.70 3.8 1904 51,072 22.3 115.6 13.4 1.62 5.7 1905 51,015 20.9 124.7 13.0 1.35 5.8 1906 50,957 21.2 108.0 12.0 1.39 5.1 1907 50,899 20 .5 97.9 11.8 1.33 7.8 1908 50,841 20.2 98.3 12.9 1.18 5.8 1909 50,784 19.5 84.9 11.7 0.87 3.5 1910 50,726 18.8 66.1 11.8 0.93 3.6 1911 50,669 20.7 106.2 12.5 1 .69 4. 4 THE MORTUARY. During the year 85 bodies were deposited in the Public Mortuary; 12 of these were females and 23 were males. Post mortem examinations were performed upon 24 of these cases, and inquests were held upon 30. 121 TABLE VA. Analysis of the Vital Statistics of the Metropolitan Boroughs and of the City of London, after Distribution of Deaths occurring in Public Institutions, for the Year 1911. Cities and Boroughs Estimated Population in the middle of 1911 Annual Rate per 1,000 Living Deaths of Children under one year of age to 1,000 Births Birth-rate Corrected Death rate Principal Infectious Diseases Notifiable Diseases Attack-rate LONDON 4,522,628 25.0 15.0 2.2 5.4 128 West Districts. Paddington 142,541 19.8 13.3 1.7 3.9 137 Kensington 172,296 17.7 13.7 1.9 3.5 142 Hammersmith 121,887 23.1 15.6 2.4 4.7 153 Fulham 153,726 26.2 14.4 2.3 5.7 129 Chelsea 66,218 18.0 15.5 1.5 4.4 116 City of Westminster 159,709 13.2 12.5 0.8 3.3 116 North Districts. St. Marylebone 117,844 34.7 15.1 1.6 5.1 63 Hampstead 85,599 14.0 9.6 0.7 4.2 83 St. Pancras 218,031 23.6 15.5 1.9 5.3 122 Islington 327,234 23.7 14.9 2.0 5.4 134 Stoke Newington 50,669 20.7 13.0 1.6 4.4 106 Hackney 222,674 24.2 14.3 2.0 6.2 115 Cent at Districts. Holbora 49,084 26.0 15.7 1.2 5.2 86 Finsbury 87,639 37.3 19.8 3.2 7.6 128 City of London 19,475 21.1 15.1 0.7 3.6 68 East Districts. Shoreditch 111,284 30.7 20.1 3.7 5.5 177 Bethnal Green 128,247 30.3 18.2 3.6 5.8 158 Stepney 279,560 32-6 17-4 31 59 139 Poplar 162,290 30.1 18.9 4.0 6.0 161 South Districts. Southwark 191,595 28.3 18.4 2.7 6.1 151 Bermondsey 125,840 30.5 18.4 2.7 6.0 159 Lambeth 298,032 28-3 14-9 1-9 51 107 Battersea 167,765 24.8 14.3 2.4 4.8 130 Wandsworth 313,389 21.1 12.0 2.1 5.4 125 CamberweH 261,407 24.0 14.3 1.8 5.0 111 Deptford 109,475 26.8 15.6 2.8 6.8 146 Greenwich 95,982 24.9 14.7 2.4 8.1 128 Lewisham 161,677 21.1 11.3 1.3 5.3 104 Woolwich 121,509 23.5 12.8 1.2 7.2 96 122 INQUESTS. 1 The following Inquests upon deatlis of Parishioners were held during the year 1911. 1st Quarter. 2nd Quarter. 3rd Quarter. 4th Quarter. Totals. Accidents (Due to Falls) 3 1 - 4 8 „ (Motor) - 1 - — 1 „ (Operation) - 1 - — 1 „ (Burns) - - 1 - 1 „ (Stomach Injury) - - - 1 1 „ (Suffocation by Gases) - 1 - - 1 „ (Suffocation) 1 — - 1 2 Tubercular Meningitis 1 - - - 1 Old Age 1 - 1 1 3 Heart Disease - 1 - 6 7 Acute Mania - - 1 - 1 Acute Bronchitis — - — 1 1 Acute Pneumonia 2 1 1 — 4 Alcoholic Poisoning - — 2 1 8 Inanition — - 1 1 2 Septic Pneumonia — — 1 — 1 Septic Ulcer — - 1 - 1 Apoplexy 2 - - — 2 Haemoptysis 1 - — — 1 Whooping Cough 1 - - — 1 Suicide (Bullet Wound) 1 - — - 1 Kidney Disease 1 — — 1 Syncope—due to exertion 1 - - - 1 Totals 15 6 9 16 46 INFECTIOUS DISEASES AND THE MEASURES TAKEN TO PREVENT THEIR SPREAD. It will be seen from Table VI. that 846 Notification Certificates of Infections Illness were received from medical practitioners, as against 221 during the preceding year. These figures include notifications of Consumption, Chicken-Pox and Ophthalmia Neonatorum; and they represent an increase in the prevalence of communicable disease, as compared with the figures for 1910, even when allowance is made for the effects of the extension of the scheme for the compulsory notification of Consumption, and the notifications of Chicken-Pox and of Ophthalmia in the newly born. 123 TABLE VI. CASES OF INFECTIOUS DISEASE NOTIFIED DURING THE YEAR 1911. NOTIFIABLE DISEASE. At all Ages Number of Cases Notified. Total Cases Notified in each Locality—(e.g., Parish or Ward) of the District Total Cases removed to Hospital At Ages—Years. Under 1 1 to 5 5 to 15 15 to 25 25 to 45 15 to 65 65 and upwards 1 North Division. 2 South Division. Small Pox — — — — — - - - - - Cholera - - - - - - - — - - — Diphtheria, including Membranous croup 78 2 22 49 1 4 — — 20 58 51 Erysipelas 41 1 2 4 4 11 15 4 11 30 9 Scarlet Fever 97 — 17 71 6 3 - - 30 67 79 Typhus Fever — - - - - - - - - - - Enteric Fever 6 - — 3 1 1 1 — — 6 5 Relapsing Fever - - - - - - - - - - - Continued Fever - - - - - - - - - - - Puerperal Fever - - - - - - - - - - - Plague - - - - - - - - - - - Phthisis j Under Tuberculosis Regulations, 1908 21 — — - 2 12 5 2 2 19 20 Under Tuberculosis Regulations, 1911 60 1 - - 12 35 9 1 7 53 14 Others 10 — — - 3 5 2 — 4 6 5 Chicken Pox 29 2 19 6 2 - — - 5 24 — Ophthalmia Neonatorum 4 4 — - — - — — - 4 1 Totals 346 10 60 135 31 71 32 7 79 267 184 124 These 346 cases represent infection in 261 different houses. In 203 homes the disinfection was performed by the Sanitary Authority. A visit was paid to every house, and it was ascertained that cases of infectious illness occurred in 5 houses where there were “grave” sanitary defects, and in'15 where the sanitary defects were “slight.” In arriving at these conclusions I have considered whether any sanitary defect was of a nature which is generally held by health officers to predispose to, or directly bring about, the particular disease in question. Thus, apart from the measures that have been taken to prevent the'spread of infectious illness, the notification of euch illness was the means during the year of bringing about a sanitary inspection of 261 premises. Table VII shows the number of cases, and of deaths, from the Infectious Diseases notified during each year since the constitution of the Borough; and Table Vlll the cases of Infectious Diseases notified during each month of the year 1911. The Infectious Sickness Hate of the Borough, excluding the notifications from Consumption, Chicken-pox, and Ophthalmia, so as to make the rate comparable with that of former years, was 4.4 to each 1,000 of the population, as against 3.3 for the preceding yea.'. The rate in the Northern Division was 3.5, while that in the Southern Division was 4.8. Year. Infectious Sickness Rate. Rate for Londo generally. 1901 7.9 8.9 1902 7.8 9.9 1903 3.8 6.0 1904 5.7 6.1 1905 5.8 7.0 1906 5.1 7.5 1907 7.8 8.6 1908 5.8 7.4 1909 3.5 6.1 1910 3.6 4.5 1911 4.4 5.3 125 TABLE VII Table showing the number of Cases and Deaths from the Infectious Diseases notified from among residents since the constitution of the Borough. Small-pox. Scarlet Fever. Diphtheria. Erysipelas. Cases. Deaths. Cases. Deaths. Cases. Deaths. Cases. Deaths. 1901 - 26 3 174 4 137 14 29 - 1902 - 41 8 192 5 91 5 50 3 1903 - 1 — 88 - 37 7 30 - 1904 - 8 — 153 - 60 10 53 7 1905 - 1 — 178 3 75 4 28 1 1906 - — — 137 1 45 4 48 3 1907 - — — 238 7 109 6 29 1 1908 - - — 195 5 60 1 24 2 1909 - — — 108 2 28 1 28 2 1910 - - — 84 1 53 2 31 2 1911 - - - 97 3 77 3 41 7 Puerperal Fever. Enteric Fever. Membranous Croup. Cerebrospinal Fever. Cases. Deaths. Cases. Deaths. Cases. Deaths. Cases. Deaths. 1901 4 2 26 4 4 1 1902 1 — 22 4 2 — — — 1903 2 2 34 5 2 — — — 1904 3 3 14 6 2 — — — 1905 1 — 10 - 4 1 — — 1906 1 1 10 — 1 — — - 1907 2 1 14 3 - 1 1 1908 4 2 10 4 - — 2 - 1909 4 1 11 1 1 1 — — 1910 3 2 10 2 - — 1 - 1911 - - 6 1 1 - - - c2 126 TABLE VIII. Cases of Infectious Diseases notified during each month of the year 1911. Small-pox. Scarlet Fever. Diphtheria. Membranous Croup. Enteric Fever. Puerperal Fever. Continued Fever. Erysipelas. Cerebro-Spinal Fever. Phthisis. Chicken-pox. Ophthalmia Neonatorum. Totals. J anuary — 10 12 — — - - 4 - 2 - — 28 February — 5 5 — — — - 2 — 05 — 17 March — 6 1 — - - - 4 - 3 6 20 April — 5 4 - 1 - — - - 2 8 1 21 May — 4 7 — 5 — 25 11 — 52 June — 5 6 - - - - - - 11 4 - 29 July — 8 1 - — — 1 - 8 - 1 19 August — 8 1 — 1 — - 4 — 8 - - 22 September — 11 6 — 3 — — 4 - 6 - 1 31 October — 16 15 1 - — — 5 — 6 - 1 44 November — 8 10 — — — — 7 — 6 - - 31 December — 11 9 — 1 — — 2 - 9 - - 32 Totals — 97 77 1 6 — — 41 - 91 29 4 346 The Infectious Sickness Rate for London generally was 5.4. Of the 29 Sanitary Areas situated within the Metropolis, the lowest rates were those of City of Westminster (3.3), Kensington (3.5), City of London (3.6); and the highest rates were those of Greenwich (8.1), Finsbury (7.6), and Woolwich (7.2). 184 of the cases notified were removed from their homes to Isolation Hospitals, 127 SCARLET FEVER. The 97 cases of Scarlet Fever occurred in 85 houses, in 2 oi which there were grave insanitary conditions ; in 4 the insanitary conditions were slight, and in the remaining houses there was an absence of such conditions. Year. Death-Rate for Stoke Newington. Rale for London generally. Rate for England and Wales. 1901 0.08 0.13 0.13 1902 0.09 0.12 0.15 1903 o.oo 0.08 0.12 1904 0.06 0.08 0.11 1905 0.06 0.12 0.11 1906 0.02 0.11 0.10 1907 0.13 0.14 0.09 1908 0.09 0.11 0.08 1909 0.04 0.08 0.08 1910 0.02 0.04 0.06 1911 0.06 0.04 0.05 School attendance was ascribed as the origin of the infection in 6 cases; and in one case it was possible that the infection was communicated by a patient recently dismissed from a fever hospital. The infection was imported into the Borough in at least 2 instances. In at least 9 cases the infection appeared to be secondary to the infection in another member of the household. ERYSIPELAS. The 41 cases of this disease represent infection in 41 different 128 premises. In 2 of these, insanitary conditions of a slight nature existed, and in no case were the sanitary defects grave. In 4 cases there was previous local injury (which in one case was due to an insect bite) and in 4 a history of previous attacks. ENTERIC OR TYPHOID FEVER. The 6 cases notified during the year all occurred in different houses. In none of these houses did grave insanitary conditions exist, in 1 slight insanitary conditions existed; while in the remaining 5 there were no insanitary conditions. Two of the cases doubtless contracted the disease outside of London during the summer and autumn holidays. The origin of the infection remained quite obscure in the majority of cases, and in several instances, as I pointed out in a previous Report, the patient had been ailing for several weeks before he took to his bed and the disease was diagnosed. Year. Death-Rale for Stoke Newington. Rate for London generally. Rate for England and Wales. 1901 0.08 0.12 0.15 1902 0.08 0.12 0.13 1903 0.09 0.08 0.10 1904 O.1l 0.06 0.09 1905 0.00 0.05 0.09 1906 0.00 0.05 0.09 1907 0.06 0.04 0.07 1908 0.08 0.05 0.07 1909 0.02 0.03 0.06 1910 0.04 0.04 0.05 1911 0.02 0.03 0.07 129 In the Decennium 1871-80 England lost by Enteric Fever 33 in every 100,000 persons living, but in the Decennium ending 1910 the loss was only 9 in the same number living. In the last Annual Report of the Medical Officer of the Local Government Board it is pointed out that had the death-rate for the year 1910 been the same as the mean-rate for the period 1871-80, the deaths from Enteric Fever would have amounted to over 11,000 instead of the 1848 for 1910. The saving of nearly 10,000 lives in a single year implies the non occurrence of 70,000 fewer cases of a disabling illness and a correspondingly diminished loss of national efficiency. It is further calculated that the total money saving in respect of Enteric Fever alone cannot be less than £3,000,000 sterling. Prominent among the causes of this enormous reduction of Enteric Fever prevalence is undoubtedly the general provision of safer water supplies. A sufficient isolation hospital provision for Enteric Fever plavs a most important role in reducing the prevalence of the disease; for, although it is not infectious in the same way th.at Scarlet Fever is. the danger, to those in attendance upon the patient far exceeds that involved in Scarlet Fever, or even Diphtheria; hence it is a matter of very common occurrence that cases nursed at home are responsible for secondary cases subsequently occurring in the same households. DIPHTHERIA. The 77 cases of Diphtheria occurred in 72 houses, 10 of which were more or less insanitary. The 'sanitary defects were grave in 3 and slight in 7 instances. Year. Death-Rate for Stoke Newington. Rate for London generally. Rate for England and Wales. 1901 0.27 0.30 0.27 1902 0.09 0.25 0.23 1903 0.13 0.16 0.18 1904 0.19 0.16 0.17 1905 0.09 0.12 0.16 1906 0.08 0.14 0.17 1907 0.11 0.16 0.16 1908 0.02 0.15 0.16 1909 0.02 0.13 0.14 1910 0.04 0.09 0.12 1911 0.06 0.l3 0.13 130 School attendance is either alleged by the parents or surmised by myself, on good grounds, to be the cause of at least 3 attacks during the year. At least 5 appear to have caught the infection from previous cases in the same household. In 4 cases it was verv clear that a preceding Tonsiilitis predisposed to an attack of Diphtheria. In several cases there was a history of previous throat trouble, frequently recurring; and in 2 cases parents had previously had sore throats. One case was imported into the Borough. Many aipplications have been made at the office for tubes of antitoxin, which I store for the convenience of local practitioners. In this disease the spread of the infection (and by consequence the mortality) are largely due to the unfortunate circumstance that the early diagnosis of the disease from clinical symptoms is frequently difficult or impossible, and bacteriology alone pan solve the difficulty in many cases. The diagnosis outfits supplied by the Council to the medical practitioners in Stoke Newington continue to be much appreciated. Every practitioner has been kept provided, during the year with such an outfit, and has thus had at his disposal the means of procuring a bacteriological diagnosis of Diphtheria, Enteric Fever, and Consumption. The following is a list of the applications received during 1911, together with the results of the examinations performed at the Lister Institute of Preventive Medicine, London Disease. Results. Total. Positive. Negative. Phthisis 6 88 44 Diphtheria 57 88 145 Enteric 3 10 13 Total 66 136 202 131 Since the Local Government Board has placed the matter on a satisfactory basis, by issuing an Order authorising this provision of antitoxin for both curative and prophylactic purposes, the Borough Council has availed itself of the power in necessitous cases: for the prompt administration of the remedy, before patients are removed to hospital and pending report of the bacteriological examination of swabs taken from the throats, often goes far in the direction of preventing a fatal termination to the disease. In the Report of the Metropolitan Asylums Board for the year 1910 some instructive tables are shown, which demonstrate the influence of antitoxin upon the death-rate of Diphtheria. As it has been suggested that the decline in the mortality from this disease, which has followed the introduction of antitoxin treatment, is due to the inclusion of numbers of cases which had been certified as Diphtheria after the bacteriological test only, such cases have been dealt with separately in the statistical analyses, and the decline is noteworthy even after the exclusion of the above cases. The deathrate, calculated on the admissions to hospitals for 1910. was the lowest on record—namely, 7.83, as compared with 30 percent, before the introduction of antitoxin. As shown on the graphic charts, the fall of the death-rate is striking in all types of diphtheria cases. MEASLES AND WHOOPING COUGIL. Measles. Year. Death-Rate for Stoke Newington. Rate for London generally. Rate for England and Wales. 1901 0.17 0.43 0.28 1902 0.08 0.51 0.38 1903 0.39 0.44 0.27 1904 0.13 0.49 0.36 1905 0.21 0.37 0.32 1906 0.19 0.40 0.27 1907 0.13 0.38 0.36 1908 0.19 0.32 0.23 1909 0.17 0.48 0.35 1910 0.22 0.41 0.23 1911 0.53 0.57 0.36 132 Whooping Cough. Year. Dea til-Rate for Stoke Newington. Rate for London generally. Rate for England and Wales. 1901 0.04 0.35 0.31 1902 0.27 0.41 0.29 1903 0.36 0.35 0.27 1904 0.25 0.32 0.34 1905 0.17 0.32 0.25 1906 0.32 0.26 0.23 1907 0.36 0.37 0.29 1908 0.13 0.20 0.28 1909 0.24 0.26 0.20 1910 0.13 0.28 0.24 1911 0.37 0.23 0.21 ZYMOTIC DIARRHCEA. Year. Death-Rate for Stoke Newington. Rate for London generally. Rate for England and Wales. 1901 0.31 0.87 0.92 1902 0.39 0.54 0.38 1903 0.25 0.63 0.50 1904 0.49 1.03 0.86 1905 0.74 0.72 0.59 1906 0.50 0.95 0.87 1907 0.24 0.32 0.30 1908 0.35 0.54 0.51 1909 0.11 0.33 0.29 1910 0.22 0.28 0.29 *1911 0.57 1.18 1.06 * Calculated from deaths occurring under two years of age. MEASLES. Measles continued to be extremely prevalent in London during the early months of 1911; and at the end of March a Conference was called at the Local Government Board Offices, where the President of the Local Government Board and Dr. Newsholme discussed with the 133 Metropolitan Medical Officers of Health the measures which may be employed for dealing with the disease, The compulsory notification of the disease was discussed; but owing to the fact that a very large number of cases are not attended by a doctor and that the provision of the notification of Measles has been tried and abandoned in a large number of towns as useless, the view was fairly generally entertained that information of the existence of the disease through the school attendance department of the London Education Authority, was perhaps the best available means of obtaining information of the cases. This information, however, has been rather belated in the past; and the Local Government Board was able to arrange that, so long as the emergency lasted, the school attendance officers should give speedy information to the Medical Officers of Health of cases of illness coming under their notice. The Board was also able to obtain from the Metropolitan Asylums Board an agreement to receive cases of Measles into their Hospitals on the recommendation of the Medical Officer of Health, preference to be given to those most needing hospital treatment. A few Stoke Newington children were removed to Hospital; and whilst the prevalence of the disease was at its height in Stoke Newington Miss Aldridge was instructed to practically abandon all other work in the Borough and to devote her time exclusively to visiting the cases of Measles known to us. At the same time certain voluntary health workers co-operated in this work. For reasons which I fully discussed in my last Annual Report, the infant departments of all our Elementary Schools should be closed during the epidemic prevalence of this disease. Miss Aldridge reports that:— “In each case of Measles which came to out knowledge the home was at once visited and suitable advice given. The system of notification, however, is very inadequate to deal with serious outbreaks, for of the 25 young children who died during the outbreak, in only 9 cases did we receive a notification of the attack, the death-returns furnishing the only information.” In London during the 5 years 1905-09, Measles caused 9,301 deaths, while all of the infectious diseases which were compulsorih 134 notifiable caused 8,585 deaths; and when it is borne in mind that attacks of this disease are not infrequently followed by interference with development, the lighting up of latent tuberculosis, deafness, and other serious disturbances, it is obvious that the mortality from Measles is by no means a measure of the mischief which the disease produces. The death-rate due to Measles cannot be measured in terms of the deaths directly attributed to the disease. It is like Influenza in that respect; being a disease which is indirectly responsible for many deaths from Bronchitis, Pneumonia, etc. In Stoke Newington the measureable part of the death-rate from Measles is alone equal to the death-rates from Scarlet Fever, Diphtheria, and Enteric f ever combined. This excessive death-rate is due to the ignorance, neglect, and poverty of the poorer section of the community. Although over the country as a whole the crude mortality from Measles and Whooping Cough shows a diminution in recent years, yet when the deaths are calculated as a rate per thousand births there is shown an increase in the Measles rate and a very small diminution in the case of the Whooping Cough rate. This circumstance is due to the difficulty of controlling these diseases. Notification is costly and furnishes unsatisfactory results, owing to the doctor being called in too late or not at all, and measures of advice, assistance, and isolation are rendered very difficult owing to the fact that the epidemics are so explosive in their origin that it is impossible for the existing staff to deal with the large number of cases which suddenly occur. The bringing together of children under 5 in school class-rooms plays a great part in the spread of the disease amongst that section of the population in which Measles is especially fatal, by determining a high attack-rate within an age-period in which the children are least able to meet it. It would be a great gain if much of the attack-rate could be postponed to a later age-period; and, in my opinion, the most effectual step that could be taken to reduce the mortality rate from Measles would be the exclusion of all children under 5 years of age from the infant departments of elementary schools. 135 It is, moreover, most important to protect the young child from preventible disease, and to guard its physique during the crucial years of rapid development; and the exposure to cold and damp involved in school attendance through the winter months ,could doubtless be shown, were the facts available, to be the cause of a great deal of unnecessary sickness amongst these infants. If, in addition to the exclusion of children under 5 years of age from elementary schools, all parents could be impressed with the advantage of making efforts to protect their offspring from Measles for as long as possible, and to regard the disease as one which demands an anxious care to keep the child warm and protected from chills for several weeks even after the rash has disappeared, I am confident that the deaui-rate from Measles would be very considerably reduced. PUERPERAL FEVER. Under Puerperal Fever are included the deaths from Pyaemia and Septicaemia occurring in the lying-in women. No case was notified during the year. It is satisfactory to note that the mortality among puerperal women, both from puerperal sepsis and from accidents at childbirth, is steadily decreasing. PHTHISIS (CONSUMPTION). Year. Death-Rate for Stoke Newington. Rate for London generally. 1901 1.30 1.58 1902 1.24 1.62 1903 1.30 1.50 1904 1.70 1.63 1905 1.31 1.46 1906 0.90 1.44 1907 0.88 1.14 1908 1.04 1.11 1909 0.80 1.31 1910 0.92 1.14 1911 1.02 1.34 136 The 91 cases of Consumption notified embraced 10 which were voluntarily notified and 8r notified under the Public Health (Tuberculosis) Regulations, 1908, 1911. In 7 cases of single lodgers and others who were notified under the Public Health Tuberculosis Regulations, it was impossible to ascertain the facts as to family history, occupation, etc., for the patients had either left their previous .address or had been removed to the Infirmary before the notification was received. In the remaining cases a reference to the inquiry forms discloses the following facts: There was no history of Consumption in parents or other relatives in 12 instances; in 12 instances parents were alleged to have died from Bronchitis and Asthma, and these cases may or may not have been phthisical; and in a further 16 cases there was a family history of Phthisis. The dwellings occupied by the sufferers were, with 3 exceptions, fairly satisfactory, in a sanitary sense; and the occupations of the notified cases embraced a great variety of employment. In several cases want of sufficient and suitable food and exposure to wet and cold predisposed to the infection. Although my visits were promptly paid, in 5 instances death had occurred before the visit. When inquiry is made as to the duration of the attack, it is seldom that precise information is obtained, and sometimes it is impossible to ascertain whether the actual period is three months or three years. But without attaching much importance to the results, I calculated that in respect to 22 cases with fairly definite periods of attack, the average period of illness prior to my visit was about 8 months a fact which is sufficient testimony to the need for further provisions for the more early diagnosis and notification of the disease. In a Circular issued by the Local Government Board (November 16, 1911), which deals with the Compulsory Notification of Pulmonary Tuberculosis, it is pointed out that Pulmonary Tuberculosis is now generally recognised as a communicable disease. It has, however, certain special characteristics which raise new administrative problems and some of the measures which were appropriate to diseases 137 notifiable under the Infectious Disease (Notification) Act, 1889, and the Public Health (London) Act, 1891, are hardly applicable to Pulmonary Tuberculosis. It is necessary, therefore, that special methods should be applied to this disease, and the Board felt, as they explained in a previous Circular-letter, that the objects in view could be best attained if the procedure of compulsory notification were by stages and by a gradual development of administrative machinery. Accordingly in 1908 they issued regulations limiting the notification to cases of Pulmonary Tuberculosis occurring among the inmates of Poor Law institutions or amongst other persons under the care of District Medical Officers. In March of last year further regulations were made extending the system of notification to cases occurring amongst the in-patients or out-patients at hospitals, or other similar institutions, for the treatment of the sick, which are supported wholly or partially otherwise than by the contributions of the patients (or of their relatives or guardians) and otherwise than from rates and taxes. The Public Health (Tuberculosis) Regulations, 1911, complete the system of notification which was inaugurated in 1908, for after January 1, 1912, it will be the duty of every Medical Practitioner to notify within 48 hours every case of Pulmonary Tuberculosis occurring in the course either of his public or of his private practice; but a Medical Practitioner is relieved of the duty of notifying a case of Pulmonary Tuberculosis which has to his knowledge already been notified to the proper authority. The Order is not a consolidating Order, but supplements and in some respects extends the Poor Law and Hospital Regulations already issued. It is worthy of note that the death-rate from Pulmonary Tuberculosis, though still far higher than that resulting from any other disease to which the principle of notification has hitherto been applied, has, nevertheless, shown a marked decline in the last thirty years. In 1881 the death-rate per 10,000 of the population was 18.25, in 1891 it was 15.99, in 1901 it was 12.64 and in 1909 it was 10.93. This decrease has coincided with a marked increase in the activities 138 of Local Authorities, including greatly improved sanitary administration and the treatment of the sick under more satisfactory conditions, ft is impossible to estimate precisely the influence of these causes on the diminution of the death-rate, but there can be no doubt that they have been powerful factors in bringing about the reduction. With the information obtained by means of general notification, Local Authorities will be able to take action in individual cases with a view to preventing the spread of infection or removing conditions favourable to infection. The Board have, by the Order, given a general power to the Local Authority, on the advice of their Medical Officer of Health, to supply such medical assistance, facilities, and articles as may be necessary for detecting Pulmonary Tuberculosis, for preventing the spread of infection, and for removing conditions favourable to infection. The Local Authority are also empowered to appoint any necessary additional officers. The financial aspect of the problem has been considerably altered by proposals which have recently been laid before Parliament. Under the Finance and National Insurance Bills it is proposed that a capital sum of one and a half million pounds shall be made available for grants for the provision of sanatoria and other institutions. The National Insurance Bill also makes provision for defraying expenses of sanatorium treatment of insured persons, and it is proposed in certain circumstances to enable this treatment to be given to the dependent^ of the insured. It is, of course, unnecessary and undesirable that notification should involve publicity. The Local Government Board suggests that Local Authorities and their Officers should avoid doing anything which would cause pain or annoyance to patients or their friends. By Article XIII of the Regulations nothing in these Regulations shall have effect so as to apply, or so as to authorise or require a 139 Medical Officer of Health or a Council, or any other person or authority, directly or indirectly, to put in force with respect to any patient in relation to whorrt a notification in pursuance of these Regulations has been transmitted to a Medical Officer of Health, any enactment which renders the patient, or a person in charge of the patient, or any other person, liable to a penalty, or subjects the patient to any restriction, prohibition, or disability affecting himself, or his employment, occupation, or means of livelihood, on the ground of his suffering from Pulmonary Tuberculosis. A School Medical Inspector is required to notify all cases of Pulmonary Tuberculosis of which he becomes aware in the course of an inspection held by him at a public elementary school or elsewhere, and valuable results may be anticipated from the co-operation of Sanitary and Local Education Authorities. In many instances it will be practicable for the Medical Officer of Health to acquaint the School Medical Inspector with th'e names of children coming from houses in'which cases of Pulmonary Tuberculosis have been notified. The latter will then be able to pay special attention to such children at his periodical inspections, and to call them up for inspection more frequently than would otherwise be the case, thus supplementing any action taken by the Sanitary Authority. The Medical Officer of Health is required to keep a register of "ill cases of Pulmonary Tuberculosis notified to him under the regulations in force, and relating to patients whose residences are situate within the area f^r which he is Medical Officer of Health. In this register he must enter the name, address, age, and sex of the person notified, the date of the notification, and the name of the notifying practitioner. It will be convenient for the register to contain also a statement of any action taken by the Medical Officer of Health in regard to the patierit. It is suggested that he will also find it desirable to keep a separate record of all particulars bearing on the probable factors concerned in producing the disease, on the existence of the disease in persons in contact witth the patient, and on action taken to obviate infection, to remove insanitary conditions, and to aid the patient himself or any additional patients who may be discovered. D 140 The Medical Officer of Health for an area within the Administra tive County of London is required to send to the Medical Officer of Health for the County a weekly statement of the notificatoins received by him under this Order. Poverty, drink, ,a.nd ignorance of the laws of hygiene are largely responsible for the prevalence of Consumption, and it is not easy to exaggerate the influence of badly-ventilated, dusty and over-heated rooms, whether in the dwelling or the factory, in inducing the disease and favouring its spread. Having regard to the considerable decline in Consumption during past years, which decline is to be attributed tc better wages, better dwelling-houses, and increased temperance, we must attach a prime importance to the provision of more healthy dwellings for the poorer classes and a more general practice of the laws of health, and a subsidiary importance to the provision of sanatoria. In my judgment, even more important than the provision of sanatoria is the provision of the means for the removal to a place of safety of advanced cases among the poorer people, for nothing can exceed the danger of infection which comes from the advanced case nursed at home in bad surroundings, to which he contributes a maximum of infection day by day. The care of advanced cases is not incompatible with the provision of sanatorio and other measures; and, of course, the reco-very of a sufferer who is detected in the early stages of the disease prevents the occurrence later on of one of these active foci of infection. Indeed, logically, the attack must be a combined one. It seems that the only prospect in the immediate future of obtaining the isolation of advanced cases in London will be through the Metropolitan Asylums Board, who may make the provision of one or two thousand beds, as they did last year in the case of Measles. In his Last Annual Report, Dr. Newsholme concludes his reference to the prevalence of this disease with the following weighty words: “The continuing national loss of health and wealth still caused by Tuberculosis is owing in large measure to the fact that Local Authorities and others concerned have not yet utilised all available means fcr its prevention.” 141 Judging from the deaths from Consumption, which numbered 52, there must have been, at least, some 300 sufferers from the disease in the Borough during the year, and of those only 91 were notified under the voluntary system and the Public Health (Tuberculosis) Regulations of 1908-1911, combined. As I have so frequently pointed out in previous reports, the clamant need for the isolation of the advanced cases of this disease amongst poor people was demonstrated in many cases which were notified in Stoke Newington during last year. Although the Workhouse Infirmary plays an important part in providing isolation of this sort, it, of course, only partially meets the needs. At the present time, in the great majority of cases, we find it impossible to get advanced sufferers from surroundings which are bad for themselves and highly dangerous to their families. There are no Institutions available for these people, and a proportion of them prefer to die in their squalid surroundings than enter a Poor Law Institution. So long as these potent sources of infection continue to exist in our midst, so long must the evil remain. We are spending large sums in the cure of early cases, but we neglect the most obvious preventive measure. The disease generally begins in an insidious manner, and the working man does not give up his work or even consult a medical man on account of these early symptoms. He has no money to spend on medical advice for slight ailments; and as he has a family to support, he fights against the disease so long as he is physically capable oif doing so: meanwhile the disease reaches a stage at which a cure is almost impossible or in which sanatorium treatment (if available) cannot be expected to have a permanently good result. Consumption is as deadly as it is amongst the poor because in most cases the disease is well advanced before a proper remedy is sought. It must be realised that a proportion of the approximately 300 sufferers in Stoke Newington are disseminating infection. In the earlier stages of the disease there is relatively little danger of conveying infection, but later the danger is very considerable, unless the D2 142 patient has been trained to take the necessary precautions; for at no stage of the disease need the educated consumptive be a danger to anyone. Therefore, in the absence of any provision to isolate or even to adequately supervise the advanced cases which are notified to me, the process of infection doubtless continues to go on in dozens of homes in Stoke Newington. and this will remain so until more com prehensive measures are adopted. At present the preventive measures practised in the Borough are insufficient—more especially in regard to the detection of early cases and the isolation and supervision of the dangerous advanced cases. The measures that we have been able to adopt up to the present are the following: The cases notified to us are almost without exception in an advanced stage of the disease, and it is comparatively rare that one gets to hear of a case which is suitable for admission to a sanatorium. An inspection of the dwelling of the person notified is made and an inquiry is instituted as to the famih and personal histon and present occupational and home circumstances of the patient. I personally visit all cases and give verbal instructions and suggestions, but at the same time a printed handbill of advice is given to some member of the family. In necessitous cases the Borough Council supplies a disinfectant gratuitously, and the premises are disinfected, occasionally during their occupancy by the patient but always on removal or death. Assisted by the official woman health visitor and occasionally by voluntary health visitors, it has been possible to keep some of the worst cases under a limited degree of observation ; but it has not been possible to undertake systematic visitation and observation of the patients, nor the clinical examination of all those who have been in close contact with the sufferer. Thus the notification of Consumption has impressed upon all those who have thereby been brought in contract with many cases of this disease among the poorer people, one outstanding circumstance demanding remedial measures, viz., that a large proportion of those notified are suffering from the disease in too advanced a stage for sanatorium or other treatment to afford much prospect of success 143 and an essential development of our campaign against the disease is to do what is possible to provide for the early discovery of infection, so that persons may be given the benefit of medical supervision and advice and other help at the earliest possible moment. With the early knowledge of the disease the chances of restoration to work for many years become very good, even with the poor; so that in our campaign against the disease among the poorer classes it is important that these very early cases should be sought out and taken in hand almost before they know themselves to be ill. There can be no doubt that the system which provides for the detection of early cases, which enables a man to continue his work during his treatment (because his case has not progressed too far and which supervises his home arrangements during his treatment), is the one which presents the most favourable prospects for establishing such an amount of control over the disease as may in future lead to a great reduction in the suffering and death which it entails. Now that the disease has been made compulsorily notifiable we shall be able to apply the above measures far more generally than hitherto; and a scheme for extending our work to better meet the requirements of the situation is at present under the consideration of the Public Health Committee. In the absence of an invalidity insurance scheme among British workers, sanatorium provision is robbed of much of its value for the poorer classes, because of the great difficulty of getting them into these institutions at a sufficiently early stage. In many parts of the country the empty Small-pox Hospitals are being utilised for the isolation and education of some of the more necessitous cases of Pulmonary Tuberculosis. At first sight it seems that some danger and inconvenience might arise in connection with such an arrangement, but the somewhat extensive experience now available points to no drawbacks beyond the occasional need for the sudden removal of the consumptive patients to their homes ; but even 144 then the tuberculous patients have reaped a great advantage, not only of better health but also of a useful knowledge of how best to regulate their lives in future. The Sanatorium is an important link, but only a link, in a comparatively long chain of preventive measures. By itself it can do little to prevent Consumption; with the working-classes it cannot accomplish much in the way of cure of the disease; the disease will often be arrested, but if the individual is allowed to return to those conditions under which he contracted the disease he will almost certainly relapse. A great deal is being done, but our efforts are quite insufficient for the great purpose in hand and absurdly inadequate in many respects, and this is largely so because we have neither the resolution not the statesmanship to make them adequate. The dreadful scourge would be almost eradicated within a few years if the importance of this effort to the individual and the State were fully appreciated, for our knowledge of all the circumstances which favour the disease and promote its spread has reached a very complete stage. The lines upon which the campaign should proceed are in the direction of forming public opinion in favour of a better housing and better living, a milk-supply free from the germ, and a better provision for the early discovery of cases and the sufficient isolation of the late cases of the disease. All this must necessarily involve a great expenditure, but, then, on the computation of the great statistician, Farr, who estimated the average value of a human life at £150, the money loss to England and Wales from these preventible deaths (quite apart from the 3 or 4 years of previous sickness) amounts to nearly six millions of pounds annually. The fact that over 30 per cent, of the deaths from Consumption occur in Poor Law Institutions is testimony of the pauperising effects of the disease. As almost all the sufferers are admitted at a late stage of the disease, these Institutions have doubtless played a useful part in isolating cases which are the most dangerous to others. 145 Under the provisions of the National Insurance Bill, Sanatorium benefit is defined as treatment in Sanatoria or other Institutions of persons suffering from Tuberculosis or such other diseases as the Local Government Board, with the approval of the Treasury, may appoint. The Sanatorium benefit will be administered by the Local Insurance Committees, who have to make arrangements with persons or Local Authorities having the management of such Institutions, for the treatment therein of insured persons. Grants will also be made to erect and maintain Sanatoria. It is obvious that the Act cannot lead to much extension of Sanatorium provision for another 18 months at the earliest, but as this provision increases, our work in the direction of detecting early incipient cases among the poor will become more profitable than at present, because it will gradually become more and more possible to get such cases put under suitable conditions for cure. The " Sanatorium Grant " of the Act and the Sickness Insurance provisions are useful contributions towards the difficult problem of helping the poor consumptive. But the time must be far distant when the expectations which have been raised that all or most cases of consumption among the poor will be suitably dealt with in Sanatoria or in Hospital, can be realised; and if in the meantime the Act has the effect of causing any relaxation in our local endeavours to extend the measures of dealing with the disease, or in the withdrawal of support to the existing voluntary agencies for relief, it will have done more harm than good for some years to come. The Royal Commission on Human and Animal Tuberculosis issued its final report in July, 1911. The essential identity of Tuberculosis in man and cattle, and their inter-communicability under certain conditions, had been testified to in previous (Interim) reports, in which the large amount of experimental work recorded finally disposes of the contention that the risk to man of infection from cattle is nonexistent or of very minor importance. The Royal Commission, after most elaborate researches and experiments, has unanimously agreed 146 that bovine and human Tuberculosis are manifestations of the same disease. It has also shown that a large proportion of the Tuberculosis of early life must be attributed to infection of bovine origin, and that even Pulmonary Tuberculosis in man may be occasionally attributed to bovine infection. An animal closely related to manthe chimpanzee—has been shown to be equally susceptible to the bovine and human tubercle germ ; the effects produced by these germs in this animal, both by feeding and inoculation, with parallel doses, being closely similar. The Commissioners state in their final report : "Of young children dying from Abdominal Tuberculosis, the fatal lesions can in nearly half of the cases be referred to the bovine bacillus and to that germ alone. In children, too, and often also in adults, suffering from Servical Gland Tuberculosis, a large proportion of the cases examined by us can be referred to the bovine type of tubercle bacillus." Then again: "The evidence which we have accumulated goes to demonstrate that a considerable amount of the Tuberculosis of childhood is to be ascribed to infection with bacilli of the bovine type, transmitted to children in meals consisting largely of the milk of the cow." Again : "Bovine tubercle bacilli are apt to be abundantly present in milk as sold to the public when there is tuberculous disease of the udder of the cow from which it was obtained." This fact is, we believe, generally recognised, though not adequately guarded against. But this bacilli may also be present in the milk of tuberculous cows presenting no evidence whatever of disease of the udder, even when examined post-mortem. Further, the milk of tuberculous cows not containing bacilli as it leaves the udder may and frequently does become infected by being contaminated with the fæces or uterine discharges of such diseased animal. " We are convinced that measures for securing the prevention of ingestion of living bovine tubercle bacilli with milk would greatly reduce the number of cases of Abdominal and Cervical Gland Tuberculosis in children, and that such measures should include the exclusion from the food supply of the milk of the recognisable tuberculous cow, irrespective of the site of the disease, whether in the udder or in the internal organs." 147 Hitherto the Government has done but little to safeguard the public health against the dangers of tuberculous milk. The Order which it issued in 1899, requiring that milk from a cow with Tuberculosis of the udder must not be used for human food, etc., made no provision calling for the inspection of cows in order to detect the existence of the condition, nor did it empower Local Authorities to cause the animals found to be so affected to be slaughtered. The consequence is that a dairyman who finds one of his cows so affected often passes it on to his neighbour. As I have stated in a former report, the provisions called for in the interests of the public health embrace (a) the inspection of all milch-cows by the County Council, to include a frequent examination by a veterinary surgeon ; (b) the compulsory notification by the owner of every obviously diseased cow; (c) every cow with Tuberculosis to be branded on the hoof so as to prevent it from being sold as a milk-producer. As a matter both of justice and of policy some compensation should be provided at least in the case of those tuberculous animals which furnish no obvious symptoms of the disease, and which have been kept under reasonable sanatary conditions. Such compensation need only be provided for a limited number of years, during which time it will be possible for the farmer to eradicate the disease from his herd. But the farmer should be made to suffer some loss in respect of every cow condemned, because the effect of this would be to impress the need for better preventive action in the future. As the matter is a national one, the Exchequer should contribute the necessary funds for compensation and any scheme should be made to apply to the whole of the country. ACUTE POLIO-MYELITIS. The recognition of this disease, which has long been known under the name of Infantile Paralysis, as a communicable disease liable at times to take on localised epidemic prevalence, has come tardily in this country. But in America and Northern Europe such outbreaks have been not uncommon. Our present knowledge with reference to the disease is well summarised in a recently issued 148 randum of the Local Government Board, from which many of the following facts have been taken. Already a number of local outbreaks have occurred in this country and during the past year an outbreak of considerable dimensions occurred in the West of England. The symptoms of the disease vary with the localisation of the virus, and may be very diverse in character; and in certain cases the difficulty of diagnosis is great. Commonly 10 to 12 per cent, of the attacks prove fatal; but in such an estimate much depends on the proportion of mild or so-called " abortive " cases, which have been recognised. Half of the patients who survive an attack of Polio-myelitis are crippled for life. Experimental research on monkeys has shown that it can be communicated through the respiratory and digestive tracts. The disease presents an erratic character as regards infectivity ; in some instances it has developed after only slight or temporary contact with a sufferer, and multiple attacks in households are not uncommon ; in other instances children have been known to sleep in the same bed with a patient and to escape infection. The Chief Medical Officer of the Local Government Board advises that Sanitary Authorities should be prepared to give facilities for the examination, by competent bacteriologists, of material derived from the sick. It is important that precautionary measures should be taken in all suspected cases. As the virus is present in the nasa. passages an antiseptic solution should be applied by means of a spray, not only to the nose and throat of the patient but of all persons brought into contact. A solution of permanganate of potassium, 1 in 500, suffices to kill the virus, experimentally. All discharges from the patient as well as all articles which may be soiled by such discharges should be immediately disinfected. The sick should be isolated from the healthy; and if appropriate isolation and nursing cannot be obtained at home, the patient should be treated in an Isolation Hospital. The sick room and its contents should be disinfected at the end of the illness. No child should be allowed to attend school from an infected family 149 Owing to possible confusion between Cerebro-spinal Fever (Spotted Fever) and Polio-myelitis, it is advised that both should be considered together, and added to the Schedule of Compulsory Notifiable Diseases, as the first step towards administrative control. This is necessary in order to obtain early information of the presence of one or other of these diseases in a district. It seems that, as regards its degree of infectiousness, the method of spread and the nature of the preventive measures demanded, Cerebro-spinal Fever is closely similar to Polio-myelitis. The symptoms of the two diseases in typical cases present marked points of difference, but experience has taught that Cerebro-spinal Fever may also appear in mild or anonymous forms which render its identification difficult. This circumstance has led to its being mistaken in this country for Sunstroke, Enteric Fever, Pneumonia, and Influenza. It is therefore necessary to be on the outlook for such cases when Cerebro-spinal Fever occurs in a locality; or when agencies not clearly referable to a definable cause prevail in a particular neighbourhood. While it is generally believed that Infantile Paralysis is becoming of more frequent occurrence, this belief may be due to the fact that the condition is getting more frequently recognised, It should also be added that our knowledge with reference to the cause and methods of spread of this disease are anything but complete. There does not seem to be any marked association between the sanitary condition of the houses and the disease. Outbreaks generally occur during the hottest months of the year. Several of those who have had an experience of the disease in its epidemic form take the view that it is largely disseminated through dust; others maintain that there is evidence of flies acting as disseminators of the infection ; and the measures adopted in the outbreaks in the West of England have comprised: (1) The compulsory notification of the disease. 150 (2) The isolation of the patient and disinfection of the dejecta, etc. (3) Destruction of flies. (4) The watering of the streets to lay the dust. (5) The spraying of the nose and throat of all contacts, more especially those in attendance on the sick; and (6) An effort to reduce the accumulation of refuse in the near vicinity of dwellings. This disease was made compulsorily notifiably by the London County Council, with the approval of the Local Government Board, from September 1 of last year; and Cerebro-spinal Fever was made compulsorily notifiable for a further period of twelve months from March 13, 1911. SMALL-POX. There was a localised outbreak of this disease in the early part of the year. The first known case in the outbreak was that of a young girl who became an inmate of the Mile End Infirmary on February 5, and was removed, with six other patients, to the Board's Small-pox Hospital on February 21, 1911. For a little over seven months previous to the latter date no case of Small-pox had occurred in London. Of the seven cases referred to above, five were in-patients at that infirmary, one was a scrubber employed there, and the seventh was a sister of the first case and living in Mile End. On February 22, four, and on the 23rd, fourteen, patients were removed from the infirmary or from houses in contiguous districts, and from that date onward until the middle of May cases continued to arise from day to day. 151 In all 70 cases of Small.pox were received, 33 from the district of Mile End (28 of these from the infirmary where the first cases arose), 24 from eight other districts of London, and 13 from beyond the Metropolitan area. The following table gives particulars as to the ages of the 70 Small.pox cases admitted, their condition in relation to vaccination, and the mortality per cent: Ages. Vaccinated. Doubtful. Unvaccinated. Cases. Deaths. Mortality per cent. j Cases. Deaths. Mortality per cent. Cases. Deaths. Mortality percent. Under 1 - - - - - - 1 1 100.0 1 to 5 2 - - - - - 7 4 57.14 5 „ 10 1 - - - - - 6 3 500 10 „ 15 2 — — — - — 3 — - 15 „ 20 4 — — 1 — — 3 - — Total under 20 9 — — 1 — — 20 8 40.0 20 to 25 9 - - - - - 2 1 500 25 „ 30 3 - - - - - - - - 30 „ 35 3 - - - - - - - - 35 ,, 40 5 - - - - - - - - 40 „ 50 11 1 9 09 *1 1 1000 — — — 50 ,, 60 4 — - — — — - — — 60 „ 70 2 — — — — — — — — Total between 20 and 70 37 1 2.70 1 1 1000 2 1 500 Grand Total 46 1 218 2 1 50.0 22 9 40.91 * This patient had mild discrete smallpox and died of cancer of uterus. Of the cases included in the foregoing table three were said to have been re-vaccinated before infection with smallpox ; one, aged 37, when about 10 years old ; one, also 37 years of age, when about 12 years old; and one, 53 years of age, when about 44 years of age. All these recovered. 152 If the cases treated in the Small-pox hospitals of London during the epidemic of 1901-1902 are similarly examined, it is found that, out of a total of 9,659 admissions to hospital, of vaccinated cases under 10 years of age, only 2 died out of 134; of 33 doubtful cases 6 died; and of 1,274 unvaccinated cases, 442 died—a percentage of 34.69. Thus only 134 vaccinated children under 10 years of age were admitted and they furnished a mortality of only 1.4 per cent. ; whereas 1,274 unvaccinated children were admitted under to years of age, among whom the mortality was 34.7 per cent. The difficulty of diagnosis of modified Small-pox in the vaccinated is often very considerable, and this may be responsible for much spread of the disease, attended by much mortality, in an unvaccinated community. That was the lesson of the outbreak above referred to. But I fear that it will have to be repeated on a much larger scale before it is acted upon. Owing to the prevalence of the disease the London County Council, with the approval of the Local Government Board, made Chicken-pox a compulsorily notifiable disease in March, 1911, on the assumption that in the case of any doubtful cases certified the practitioner will confer with the Medical Officer of Health of the Borough, or with Dr. Wanklyn, who is expert in the diagnosis of Small-pox and an Assistant Medical Officer of Health to the London County Council. The returns for England and Wales for 1909, when compared with the returns for 1908, show a reduction (from 63.2 to 59.8) in the percentage of children born who are vaccinated ; and it is clear that ''he Vaccination Act of 1907 has been followed by a considerable increase in the number of children exempted by Statutory Declaration, obtained mainly at the expense of children who in the past would have been vaccinated and protected. As matters stand at present the average parent cannot But take the view that the Government has no serious desire for the vaccination of his child; and even if he has no " conscientious objection " he often gets exempted so as to wait until a more convenient time arrives or until the danger of 153 Small-pox threatens. It is cause for considerable anxiety to Medical Officers of Health that the country threatens to become a practically unvaccinated community; for many of the children who are nominally vaccinated are but very imperfectly protected by the growing practice of one-mark vaccination. It is often contended that our sanitary administration has reached such a stage of efficiency that we have little to fear from Small-pox, but out comparatively recent experience in London taught us that the notification of the disease (including the temporary notification of Chicken-pox), and our arrangements for vaccinating contacts and promptly isolating sufferers, did not suffice to prevent a considerable amount of spread of the disease, a great dislocation of trade, and an enormous expense to the community. THE DISINFECTING AND CLEANSING STATION. During the year ending December 31, 1911, the following disinfecting and cleansing work was performed at the station:— Total number of textile articles disinfected 9,795 Total number of books from Public Library disinfected 114 Total number of verminous persons cleansed 256 Of the verminous persons cleansed, 254 were children, mostly of school ages; the 2 adults being 2 males. In addition to the disinfection of rooms on account of the compulsory notifiable diseases, 76 rooms were fumigated on account of vermin, 33 on account of consumption, and 7 on account of cancer. During the year the Borough Council continued its agreement with the Education Department of the London County Council to bathe and cleanse verminous school children, resident in Stoke Newington, on payment of 2s. for the cleansing of each child; but in the event of any one child requiring more than one bath a minimum charge of 2s. for a series of 3 baths, or for each subsequent series or part of a series, no series to extend over a period of more than 4 weeks. 154 The Shelter has been maintained during the year. The Borough Council is under a statutory obligation to maintain this provision, and in the event of an epidemic of certain diseases, it will prove a most useful auxiliary means of checking the spread. Meteorological observations taken during the year 1911, at Camden Square (by H. S. Wallis, Esq.) The observations have been reduced to mean values by Glaisher's Barometrical and Diurnal Range Tables, and the Hygrometrical results from the Sixth Edition of his Hygrometrical Tables. Month. Temperature of Air. Highest. Lowest. Mean. Mean Temperature of Air. Rainfall. Relative Humidity. Saturation. 100. Of all Highest. Of all Lowest. January o 52 o 26 o 424 o 34.6 o 38.5 ins. 1.38 % 90 February 56 21 46.7 35.2 410 1.48 83 March 62 29 49.2 36.4 42.8 1.73 87 April 68 26 561 39.7 47.9 1.80 78 May 82 38 69.2 47.9 58.6 1.80 76 June 88 42 71.8 52.2 62.0 2.69 75 July 93 49 81.7 56'9 69.3 1.17 64 August 97 48 80.8 57.9 69.4 0 49 73 September 92 39 73.0 50.0 61.5 1.31 79 October 63 29 58.1 43.9 51.0 3.12 90 November 59 28 49.9 39.3 44.6 3.62 87 December | 55 28 49.3 39.5 44.4 4.22 91 155 NOTES UPON SANITARY WORK PERFORMED DURING THE YEAR 1911. It will be seen from the accompanying Report of the Chief Sanitary Inspector that a large amount of sanitary work has been performed during the year; 3,746 premises were inspected for conditions injurious or dangerous to health, and insanitary conditions varying in their nature from slight to very grave were discovered in a large number of instances; 598 Intimation Notices, followed in 12 cases by Statutory Notices, were complied with. Of 3,746 premises inspected, only 178 inspections were made as the result of complaints by householders and others, and this circumstance will serve to accentuate the importance of prosecuting a fairly constant system of house-to-house inspection in at least the poorer parts of the Borough. In the case of 34 of the complaints received, no nuisance existed at the time of inspection. It is found that in Stoke Newington, whenever an Intimation Notice is served as the result of house-to-house inspection, the Inspector has to pay on an average between four and five visits in order to see that the work required is properly carried out. The slaughter-houses, bakehouses, cowsheds and dairies, the common lodging-house, and the registered houses let in lodgings, situated in the Borough, were all inspected throughout the year. FOOD INSPECTION. The amount of unwholesome food seized in Stoke Newington is very small, even when regard is had to the size of the Borough. On the other hand, a not inconsiderable amount of unwholesome food has been surrendered for destruction during the year, the particulars of which are shown in the Report of the Chief Sanitary Inspector. It is to be hoped that in the near future all obviously unsound food will be thus surrendered. E 156 During the year many systematic efforts have been made to detect the sale of diseased meat within the Borough, and I am. glad to saythat almost without exception our inspections have not called for the seizure of unwholesome meat. At the present time the purchaser of meat in London has no means of knowing whether it has been subjected to inspection. In the Fortieth Annual Report of the Local Government Board, 1910-11, it is stated that "cases have been brought to our notice in which cattle suffering from Tuberculosis or other diseases have been brought into towns, where they are slaughtered and sold for human food. We have been aware of the danger of this practice for some years past, and have drawn the attention of Local Authorities to the matter. We suggested that the condition of all cows coming under the notice of the Authority's Officers should be particularly observed, and all practicable steps taken to ensure that, if any diseased animal should be slaughtered, it was not sold for human food." In this matter of meat inspection the Local Sanitary Authorities are charged with a duty which it is quite impossible to adequately carry out in default of public abattoirs; and the public is in quite a false position in believing that the sanitary officials, appointed to administer the provisions of the Public Health Act which aim at protecting the public from unsound food, are capable of doing their duty under existing circumstances. The difficulty is, that with the existing private slaughter-house we are quite unable to inspect them adequately. Their number, the distances apart, and the various times at which slaughtering takes place, combine to make it quite impossible for an official to make that inspection immediately prior to slaughter, at the time of slaughter, and immediately afterwards, which alone suffices to detect most of those diseases which render flesh unwholesome as food. It is quite impossible for an inspector, however skilful he may be, to detect unwholesome conditions of meat when this has been trimmed and prepared for sale in the shops. As 157 a consequence comparatively little diseased meat is seized in butchers' shops; the majority of the meat seized is on account of indicated putrefaction; and I am confident that the very small amount of diseased meat which is seized represents but a small proportion of the amount which gets into the shops and which is consumed. of course, in this matter, as in so many others, precautions must be taken to deal with the dishonest individuals, who represent a small minority. The large majority of butchers may be trusted to sell the right sort of meat. Therefore the latter have nothing to lose by advocating that the slaughtering of cattle for food shall only be permitted in public abattoirs. The public and Sanitary Authorities have a recognised legal right to control, in a great measure, the conduction of the meat trade, and it seems to me a remarkable circumstance that we have not demanded more strongly that we should be placed under conditions which will enable us to control it properly. The preparation of the people's food is a public service; and trade opposition should not be allowed to stand in the way of the interests of the community, and I believe of the butchers themselves. Indeed, the time has come when the meat in this country should be freed from the reproach that it is not inspected, and that its genuineness or wholesomaness cannot always be guaranteed; because while it remains under this ban it is under a disadvantage as compared with foreign meat, which is almost in its entirety at the present time inspected at the time of slaughter. STABLE MANURE. In recent years there has been a constant decrease in the amount of stable manure in London owing to the displacement of horse by motor traffic. Nuisance from this source is therefore very much less than formerly, a fact which may also be due to the enforcement of the regulations requiring periodical removal. HOUSES LET IN LODGINGS. In the Borough of Stoke Newington, more especially in the Southern Division, there is a considerable number of houses let in E2 158 lodgings under circumstances and conditions which render it desirable, in the interest of public health, that they should be registered and inspected at frequent intervals. By the end of the year 1911, 217 premises were on the Register. HOUSING AND TOWN PLANNING ACT, 1909 During the year 1911 most of the least satisfactory dwellings within the Borough were inspected, reported upon to the Public Health and Housing Committee, and the facts duly entered in the special Register kept. The inspections covered Hornsey Place, Philp Street and Thomas Place (now Hewling Street), the Nevill Road Tenements, Rochester Place, Mason's Court, Mason's Place, White Hart Court, and Chapel Place. As the result of representations made to the Committee some improvements in the conditions of occupancy of the basement rooms of the Nevill Road Tenements were required, and radical improvements were demanded in Rochester Place; but no action beyond the abatement of the nuisances discovered was demanded in respect to the other dwellings inspected under this Act. During the year, under the threat of a Closing Order, some very material improvements were effected in the five old houses of Rochester Place. Rochester Place, High Street, is approached by a covered passage-way only 3 ft. 10 in. wide, and of the five dwellings one contains two small rooms and a scullery; the other four containing three small rooms and a scullery. The premises had got into a very dilapidated condition; two possessed no backyard and had no back windows to the house, and one had only a very small yard 15 ft. by 5 ft. Two of the dwellings were wooden structures, and these were damp; no water supply was laid on to the house, the water being obtained from a standpipe in the courtyard. The roofs on much of this property were defective and the guttering also. One wooden dustbin was provided in the courtyard for the use of the five houses. This property was very considerably improved by the removal of the wooden dwelling, No. 3, which was the least satisfactory of the dwellings. The result of this has been to let in light and air at the sides of Nos. 2 and 4. In addition all the roofs have been thoroughly 159 overhauled and renewed, where necessary, including the guttering and stack-pipes; all outside walls (front and back) have been lined with compo (with washed sand and cement, two coats); window-sills have been renewed in cement; the inside plastering to all the walls and ceilings has been renewed; all floors, staircases, sashes, frames, etc., were restored; and the paving of the courtyards and yards was renewed in places. Further provision was made for ventilating the rooms; water was laid on; sinks were provided to the houses requiring these provisions; and a metal receptacle for household refuse replaced the old and somewhat dilapidated wooden one. The Underground Dwellings at Nos. 14, 16, and 18, Nevill Road have (under our requirements) been improved during past years; but during the year 1911 it was found necessary to impose further conditions upon their continued occupancy as dwellings. The basements of Nos. 16 and 18 contain two separate tenements; but as the result of our inspections we have found that from time to time a room in these tenements has been occupied by someone who is not a member of the family, and that this circumstance has added materially to the unsatisfactory conditions under which they were occupied. The owners have now undertaken that each tenement shall be let to one family only; that the front rooms of these tenements are no longer to be used for sleeping purposes; and that the basement under the shop at No. 14 is no longer to be let as a tenement dwelling. The owner has furthermore undertaken to use every vigilance and to assist us in every way so as to ensure that these arrangements are carried out. Owing to the unsatisfactory standard of cubic space adopted Dy magistrates as constituting "overcrowding," it is not easy to find instances of this form of nuisance which can be legally dealt with. Of course in fixing limits of cubic space many considerations arise in addition to those of public health and public morality, but I believe that it would now be practicable and advantageous to extend the pre sent unsatisfactory limits adopted for sleeping rooms, namely, from 300 cubic feet for those over 10 years of age and 150 for those under 10 years of age to 400 and 250 respectively. 160 FACTORIES AND WORKSHOPS. At the end of the year 1911 there were on the Register 225 factories, workshops, and work-places. 1—INSPECTION OF FACTORIES, WORKSHOPS AND WORKPLACES. Including Inspections made by Samtary Inspectors or Inspectors of Nuisances. Premises. Number of Inspections. Written Prosecutions. 1 2 3 4 Factories (including Factory Laundries) 37 ... ... Workshops (including Workshop Laundries) 172 47 ... Workplaces (Other than Outworkers' premises included in Part 3 of this Report). 16 ... ... Total 225 47 Nil 2—DEFECTS FOUND IN FACTORIES, WORKSHOPS AND WORKPLACES. Particulars. Number of Defects. Number of Prosecutions. Found Remedied. Referred to H.M. Inspector. 1 2 3 4 5 Nuisances under the Public Health Acts:—* Want of Cleanliness 16 16 ... ... Want of Ventilation ... ... ... ... Overcrowding ... ... ... ... Want of drainage of floors 2 2 ... ... Other nuisances 16 16 ... ... Sanitary accommodation insufficient 4 4 ... ... unsuitable or defective 36 36 ... ... not separate for sexes ... ... ... ... Offences under the Factory and Workshop Act:— Illegal occupation of underground bakehouse (S. 101) ... ... ... ... Breach of special sanitary requirements for bakehouses (ss. 97 to 100) ... ... ... ... Other Offences (Excluding offences relating to outwork which are included in Part 3 of this Report) ... ... ... ... Total 74 74 Nil Nil Including those specified in sections 2, 3, 7 and 8 of the Factory and Workshops Act as remediable under the Public Health Acts. 3—HOME WORK. NATURE OF WORK.* OUTWORKERS' LISTS, SECTION 107. Outwork in Unwholesome Premises, Sec'ion 108. Outwork in Infected Premises, Sections 109, 110. Lists received from Employers. Notices served on Occupiers as to keeping or sending lists. Prosecutions. Instances. Notices served. Prosecutions. Instances. Orders made S. (110). Prosecutions (Sections 109, 110) Sending twice in the year. Sending once in the year. Failing to keep or permit inspection of Lists. Failing to send lists. Lists.t Outworkers. Lists. Outworkers. Contractors Workmen. Contractors Workmen. (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) Wearing Apparel— (1) making, &c,. 45 362 47 (2) cleaning and washing Household Linen Lace, lace curtains and nets Curtains and furniture hangings Furniture and Upholstery 2 9 Electro-plate File making Brass and brass articles Fur pulling Cables ana Chains Anchors and Grapnels Cart Gear Locks, Latches and Keys Umbrellas, &c Artificial Flowers Nets, other than Wire Nets Tents Sacks Racquet and Tennis Balls Paper Bags and Boxes Brush making Pea Picking Feather sorting Carding, &c., of Buttons, &c. Stuffed Toys Basket making Total 47 371 47 * If an occupier gives out work of more than one of the classes specified in column I, and subdivides his list in such a way as to show the number of workers in each class of work, the list should be included among those in column a (or 5 as the case may be) against the principle class ONLY, but the outworkers should be assigned in columns 3 and 4 (or 6 and 7) into their respective classes. A footnote should be added to show that this has been done. t The figures required in columns a, 3 and 4 are the TOTAL number of the lists received from those employers who comply strictly with the statutory duty of sending TWO lists each year and of the entries of names of outworkers in those lists. The entries in column 2 must necessarily be EVEN numbers, as there will be two lists for each employer—in some previous returns odd numbers have been inserted. The figures in columns 3 and 4 will usually be (approximately) double of the number of individual outworkers whose names are given, since in the February and August lists of the same employer the same outworker's name will often be repeated 162 4—REGISTERED WORKSHOPS. Workshops on the Register (s. 131) at the end of the year. Number (1) (2) Important classes of workshops, such as workshop bake houses, may be enumerated here Miscellaneous 188 Bakehouses 24 Total number of workshops on Register 212 5—OTHER MATTERS. Class. Number (1) (2) Matters notified to H.M. Inspector of Factories— Failure to affix Abstract of the Factory and Workshop Act (s 133) 6 Action taken in matters referred by H.M. Inspector as remediable under the Public Healths Acts, but not under the Factory and Workshop Act (s. 5) Notified to H.M. Inspector - Reports (ot action taken) sent to H.M. Inspector Other 2 Underground Bakehouses (s. 101)— Certificates granted during the year Nil In use at the end of the year 19 Caramel Wrapping and Packing.—In the spring of last year I received an anonymous complaint to the effect that caramel wrapping was being carried on, for trade purposes, by certain outworkers dwelling within the Borough, under conditions which were highly unsatisfactory and possibly dangerous to health. In some cases quite young children were employed amidst very insanitary surroundings. A similar complaint reached Dr. Harris, the Medical Officer of Health for the Borough of Islington. He also had the opportunity of investigating the conditions in several dwellings within the neighbouring Borough. He found little children of five years of age putting on the wrappers; and in one family the children were put to work directly 163 they came in from school and were kept at it until 9 or 10 o'clock at night. In one case a boy recovering from a recent illness was sitting up in bed at work, and the wrapping was being done on the bed. The Islington Borough Council brought these facts to the knowledge of the Secretary of State, and our own Town Clerk also wrote to inquire whether any Order had been made by the Secretary of State applying the provisions of Section 107 of the Factory and Workshops Act of 1901, to caramel wrapping. We were informed in December last that the Secretary of State proposes to make such an Order. The effect of this will be that the names and addresses of all those who do this work in their homes and return it to the factory owners, will have to be supplied to the Health Authority twice a. year, and the conditions of the home-work can then be inspected and supervised byus. As the result of the inspection of the workrooms and work-places in the Borough, it was found that for the most part they were in a satisfactory condition, and that the requirements of the Factory and Workshops Act of 1901 were duly observed. There was no case of overcrowding to be dealt with, and there were 16 instances in which it was necessary to require cleansing. There were four occasions to require an increase in the water-closet accommodation, and 36 in which the accommodation was unsuitable or defective. In six cases the Abstract of the Factory Act was not affixed in the workrooms, and the Home Office was notified accordingly. There are altogether about 750 domestic workrooms in the Borough in which textile material of various kinds is being dealt with. A complete list of all out-workers has been kept in the office ; the information has often been obtained by calling at the workshops, for some employers still fail to realise their duty to send in a list of out-workers twice a vear, viz., in February and August, as the Act directs. All the premises occupied by out-workers were inspected during the year. 164 Miss Aldridge reports as follows:— " Workrooms.— These have all been inspected during the year. They are, on the whole, in a very satisfactory condition. " Out-workers.- In addition to the Out-workers' premises already on the Register, 269 new out-workers whose homes were in this Borough were reported to us during last year. Of these only 108 were actually working at the time of inspection; the rest had either temporarily ceased working, or had removed to addresses unknown. "Sixteen were employing hands; and where no Abstract was affixed in the Workroom notice was at once sent to the Home Office. The kitchens of the restaurants and public dining-rooms in the Borough have been thoroughly inspected throughout the year, with satisfactory results. PUBLIC HEALTH LEGISLATION DURING 1911. Besides the National Insurance Bill and various local Bills one measure bearing on- Public Health Administration has passed through Parliament during the year under review. The Milk Bill was not introduced and the Health Visitors and Midwives Act Amendment Bills were dropped. Mr. Burns's Bill, providing for the washing and cleansing of the rag-flock used in stuffing mattresses and pillows, passed through all its stages and will take effect after 1912. FOOD AND DRUGS. Under the Sale of Food and Drugs Act, 156 samples of food and drugs were taken and analysed. The results are shown in Table IX. 165 TABLE IX. ANALYSES PERFORMED UNDER THE SALE OF FOOD AND DRUGS ACTS DURING THE YEAR 1911. No. Sample Analysed. Opinion Formed. Action Taken. 1 Milk Genuine Nil. 2 Milk ,, ,, 3 Milk ,, ,, 4 Butter ,, ,, 5 Lard ,, ,, 6 Butter ,, ,, 7 Lard ,, ,, *8 Milk ,, ,, *9 Milk ,, ,, *10 Milk 2.4% of added water Vendor cautioned. *11 Milk Genuine Nil. *12 Milk 3¾% of added water Vendor cautioned. *13 Milk Genuine Nil. 14 Butter ,, ,, 15 Butter Equal parts of Margarine and Butter Defendant fined £5 and £2 2s. costs. 16 Butter Genuine Nil. 17 Butter ,, ,, 18 Milk ,, ,, 19 Butter ,, ,, 20 Butter ,, ,, 21 Butter ,, ,, 22 Butter ,, ,, 23 Milk ,, ,, 24 Butter ,, ,, 25 Butter ,, ,, 26 Milk 3¾% of added water Vendor cautioned. 27 Milk 2% of added water Vendor cautioned. 28 Margarine (Unlabelled) Trace of boric acid Vendor fined £2 and 12s. 6d. costs 29 Milk 11% deficiency in butter-fat Vendor fined £2 and 12s. 6d. costs. 30 Stout (Informal) Trace of coal tar product Nil. 31 Gin Genuine ,, *32 Milk ,, ,, *33 Milk ,, ,, *34 Milk ,, ,, *35 Milk ,, ,, *36 Milk ,, ,, *37 Milk ,, ,, *38 Milk ,, ,, 39 Paregoric ,, ,, 40 Cream of Tartar ,, ,, 41 White Pepper ,, ,, 42 Mustard ,, ,, 43 Butter ,, ,, * Sunday Samples, 166 TABLE IX.—continued. No. Sample Analysed. Opinion Formed. Action Taken. 44 Butter Genuine Nil. 45 Coffee „ „ 46 Demarara Sugar „ „ 47 Sweet Spirit Nitre „ „ 48 Lard „ „ 49 Mixed Sweets „ „ 50 Scotch Whisky „ „ 51 Milk „ „ 52 Milk „ „ 53 Milk „ „ 54 Milk „ „ 55 Milk „ „ 56 Milk „ „ 57 Milk Trace of boric acid 58 Milk „ „ „ „ 59 Milk „ „ „ „ 60 Milk Genuine " 61 Milk Trace of boric acid " 62 Milk 4% less than the legal limit for fat. Trace of boric acid Vendor cautioned. 63 Butter Genuine Nil. 64 Flour „ „ 65 Seidlitz Powders „ „ 66 Butter „ „ 67 Vinegar „ „ 68a Saveloys „9.4 grains to pound of boric acid " 68 Milk Genuine Trace of boric acid „ 69 Milk Genuine „ 70 Butter „ „ 71 Milk „ „ 72 Milk „ „ 73 Butter „ „ 74 Milk „ „ 75 Milk „ „ 76 Beef Sausage 8'4 grains per pound of boric acid „ 77 Milk Trace of boric acid „ 78 Milk „ „ 79 Cream „ „ 80 Milk (Informal Samples) Genuine „ 81 Pork Sausage 9-4 grains per pound of boric acid „ 82 Butter Genuine „ 83 Butter „ Trace of boric acid „ 84 Gin Genuine „ 85 Milk „ „ Sunday samples. 167 TABLE IX.—continued. No. Sample Analysed. Opinion Formed. Action Taken. 86 Milk Genuine Nil. 87 Milk l%¾ of added water Vendor cautioned. 88 Scotch Whisky Genuine Nil. 89 Milk „ Trace of boric acid „ 90 Lard Genuine „ 91 Milk 11% less than the legal limit for fat. Summons withdrawn—Warranty Pleaded. 92 Milk Genuine Nil. 93 Butter „ „ 94 Vinegar „ „ 95 Vinegar „ „ 96 Margarine Trace of boric acid ,, 97 Milk „ „ „ ,, 98 Milk „ „ „ ,, 99 Milk „ „ „ „ 100 Milk 1-2% of added water ,, 101 Milk Genuine ,, 102 Milk „ ,, 103 Milk „ Trace of boric acid ,, 104 Milk Genuine ,, 105 Butter ,, ,, 106 Flour ,, ,, 107 Milk ,, ,, 108 Milk „ Trace of boric acid ,, 109 Milk Genuine ,, 110 Milk 111 Margarine „ Trace of boric acid ,, 112 Milk Genuine ,, 113 Milk ,, ,, 114 Milk „ 115 Milk ,, *116 Milk „ Trace of boric acid ,, *117 Milk Genuine ,, *118 Milk ,, ,, *119 Milk Slight deficiency in fat ,, *120 Milk Slight deficiency in fat ,, *121 Milk Genuine ,, 122 Cheese ,, ,, 123 Flour ,, ,, 124 Coffee ,, ,, 125 Whisky 2.3% of added water Protected by label 126 Butter Genuine Nil 127 Milk „ „ * Sunday samples. 168 TABLE I IX.—continued. No. Sample Analysed. Opinion Formed. Action Taken. 128 Butter Water above 16% (sold irregularly as "milk-blended'' butter) Nil. 129 Butter Genuine „ *130 Milk „ „ *131 Butter „ „ *132 Milk „ „ *133 Butter „ „ *134 Milk „ „ *135 Milk „ „ *136 Milk 74% less than legal limit for fat Defendant fined £10 and 23s. costs. 137 Milk Slight deficiency of solids non-fat Vendor cautioned. 138 Butter Genuine Nil. 139 Milk „ „ 140 Mixed Sweets „ „ 141 Ground Rice „ „ 142 Olive Oil „ „ 143 Liquorice Powder „ „ 144 Seidlitz Powders ,, ,, 145 Lard „ „ 146 White Pepper „ „ 147 Mustard „ „ 148 Fine Oatmeal „ ,, 149 Flour „ „ 150 Milk „ ,, 151 Milk „ „ 152 Milk „ „ 153 Milk „ „ 154 Milk „ „ 155 Separated Milk „ ,, * Sunday samples. 169 TABLE X. Showing the results of Analysis of Samples taken under the Sale of Food and Drugs Acts, during the years 1909-10 in England and Wales:— Percentage Adulterated. 1910. 1909. Milk 11.1 9.7 Butter 5.1 5.7 Cheese 3.1 0.6 Margarine 3.2 3.6 Lard 1.8 1.3 Bread 0.0 0.6 Flour 1.1 0.2 Tea 1.4 0.0 Coffee 5.1 5.1 Cocoa 14.0 3.7 Sugar 3.3 5.9 Mustard 2.6 4.0 Confectionery and Jam 4.7 3.4 Pepper 0.5 0.4 Wine 5.3 10.6 Beer 3.0 0.9 Spirits 10.3 9.9 Drugs 6.8 6.9 Other Articles 9.0 8.6 All Articles 8.2 7.5 In Metropolitan London, as a whole, one sample was analysed lor every 184 persons, being at the rate of 5.4 per 1,000 of the 170 population of 1911. In Stoke Newington the proportion was one sample to every 325, being at the rate of 3 per 1,000 of the present population. 13 of the samples purchased in the Borough in 1911 were not satisfactory; and, therefore the percentage of non-genuine samples amounted to about 8.3 per cent., a figure which is markedly above that of the preceding year, when it was 5.8 per cent. The figure for the whole country was 8.2 per cent, during the year 1910. 10.7 per cent, of the milk samples were unsatisfactory, as against 9.9 per cent, during the preceding year; but in some cases the deficiency below the legal limits was very slight. 27 per cent, of the milk samples were purchased on Sundays. The percentage of adulteration of milk for the whole country during 1910 was 11.1. In London the percentage reported against was 9.9. Many of the samples purchased under the Sale of Food and Drugs Acts have been obtained through the employment of a deputy, for the sanitary inspectors are well known to tradesmen and others. In a few instances we have purchased samples without going through the formalities prescribed by the Acts; the object being to submit these to analysis, and, if they proved unsatisfactory, to subsequently take samples under the prescribed formalities, so that proceedings might be instituted against the vendor. All the samples of Milk, Butter, Cream, and Margarine were tested for antiseptics, with the result that 15 of the samples of Milk, 2 of Butter, 1 of Cream, and 3 of Margarine were found to contain them. In no case was the amount sufficient to warrant a prosecution, but in one or two instances the vendors were cautioned. Two samples of Sausages contained boric acid in amounts which called for cautionary letters to the vendors. In London the proportion of milk samples reported against has shown a fairly steady diminution for some years past, being 8.4 in 171 1910, as compared with 15.6 in 1902. It should, however, be added that (as in Stoke Newington) many of the samples purchased are below the quality of the average milk supply of London, although they are a trifle above the low legal limits which have been fixed. It is not easy to check the practice of reducing genuine milk to milk of inferior quality, when the reduction does not bring it below the legal limits of composition. Although the Public Analyst knows that many milk samples are thus adulterated, he cannot report them as such, so long as they are not adulterated to the extent in reference to milk that an adequate punishment for fraudulent practices is demanded. Magistrates often do not realise this and it is common to find a far heavier fine inflicted for whiskey adulterated with water than for milk which has been similarly adulterated. It has often been raised in defence that the excessive drinking of water by cows has been responsible for the analyst's opinion that the milk contains added water. The Board of Agriculture has recently had some experiments made in order to ascertain if there is any justification for this view; and the result of 'the experiments point to the conclusion that the amount of water consumed by cows has no direct bearing on the composition of their yield. Further experiments upon this matter are contemplated. A special reference to milk is justified by the vital importance of this material as infant food and also by the exceptional possibilities of fraud in connection with its retail sale. Of course, the percentages of adulterated milk sold in London is not fairly represented by the samples obtained for analysis, because (very properly) a large proportion of the samples taken are obtained from individuals who may be under suspicion, while relatively few are taken of the reputable salesmen; but if we were to assume that the whole of milk is adulterated on the scale of the samples taken for analysis, the enormous proportion of water added and fat extracted from the Metropolitan milk supply would be very appalling. But even under the most favourable estimate a great many thousand gallons of water 172 are added to milk and sold under the guise of " milk " each year, at a cost to the general public running into many thousands of pounds. The objectionable practice of adding preservatives to milk is very much in evidence in the summer months : and of the 23 samples purchased in Stoke Xewington during July, August, and September. 1911, eleven were found to have been so drugged. The employment of chemical agents which will prevent the development of the micro-organisms concerned in putrefaction, and termed "antiseptics," is extensively practised. The increasing use of these substances for the preservation of articles of food, and the necessity of keeping a rigid control over this practice in the interest of public health, have rendered the detection and estimation of such substances a very important matter. It is certain that boric acid, salicylic acid, formic aldehyde, etc., are foreign to the animal body, and their presence must necessitate a departure from the normal chemistry of life. Being antiseptics, and therefore inimical to the life of the organisms that cause putrefaction, they must exercise a retarding effect upon the activity of the enzymes concerned in ordinary digestion. They, moreover, facilitate an uncleanly, slovenly, treatment of food, and render it possible to preserve articles in incipient decomposition for some time with even appearance of freshness. Boric acid in the amounts commonly employed prevents objective decomposition, such as is detected by smell; but if decomposition has reached a stage in which odour is appreciable it inhibits further changes of this kind, and possibly leads to a diminution in the odour. There is almost a consensus of opinion in the medical profession that these agents, as often employed, may be injurious to health. The writer has on two separate occasions seriously disturbed his digestion bv taking 20 grains of boric acid daily, with food, for three days. Doubtless injury to health would follow upon the use of even a few grains daily when administered to babies in milk. Experiments upon human beings Have produced conflicting results; but the 173 positive evidence of harm adduced by many, far outweighs in importance the negative results which have been obtained by others, and this conflict of experience is explained by the varying degree of susceptibility of different individuals. The experiments have almost all of them been upon healthy adults and for brief periods; and there is no evidence whatever which points to the harmlessness of these drugs upon infants under one year of age when the milk (which is almost the sole article of their diet) is dosed with boric acid for long periods, or upon adults with weak stomachs or kidneys, who take 10 to 15 grains several times a week in food. The use of chemical antiseptics in food is not necessary. Even dairy produce is brought from Denmark, New Zealand, etc., without such addition; and no difficulty is experienced by milk vendors in this country and abroad in selling to the consumer, even in the summer months, milk in a perfectly fresh state and to which no chemicals have been added. But it is not only in milk and cream that one takes in chemical preservatives. In one meal—say breakfast—one may consume them in milk, butter, ham or bacon, and jam. Thus, though the quantity of boric acid in any one article might not be sufficient to affect health, the aggregate amount of the drug taken in the various articles of the meal may suffice; and obscure cases of impaired digestion and nutrition, or more serious disturbance, result. There is no evidence in support of the argument that material sold as fresh, such as milk and fresh sausages, needs an antiseptic to prevent it from going bad in the homes of the poor. The poor quickly consume what they purchase; they do not buy to store. Certainly, if the use of these chemical preservatives is to be sanctioned, the amounts should lie limited by law . and the individual who is not desirous of continuously dosing himself with drugs should have a means of escape from them. Their presence, nature, and amount, together with the date on which they were added, should 2 174 be legibly set out upon a label; and their use ought certainly to be prohibited in infants' foods. It may be said, however, that even the safeguard of a label assumes an amount of knowledge and discrimination on the part of the general purchaser which is unreasonable. In the Fortieth Annual Report of the Local Government Board, 1910-11, the following reference to this subject appears:—"We stated in our last Report that we considered that milk should at all times be entirely free from preservatives. This is in the interest of public health; and we observe that a similar recommendation was made at a recent Conference of Dairy Farmers, who recognised that preservatives not only acted as a cloak to dirt and dirty management, but, if allowed to be used, opened the door to the development of unlimited competition from abroad." During the year a sample of cream was submitted to me for examination, by a resident in the Borough, because it was under strong suspicion of having caused the following sickness in his household:—After consuming some of the cream on the previous day, a child of seven years broke out in a slight rash on the cheeks and arms, and there was some swelling of the cheeks, especially around the eyes. There was at the same time some constitutional disturbance. I was informed that the doctor in attendance considered the rash to be "a form of eczema due to some poisoning." The boy ate a considerable amount of cream on the Sunday and he woke up with these symptoms on the Monday morning. On the following Sunday the mother ate cream and suffered from similar symptoms on the following morning. The house was a perfectly sanitary one, and it was impossible for the occupants to suggest any other cause for this mysterious indisposition. It should be stated that the cream tasted perfectly good and sweet. On examining the cream it was found to contain boric acid in the proportion of about 12 grains to the pound. Since these occurrences the family have either consumed no cream or consumed it in much smaller amount, and I am informed that there has been no repetition of the indisposition. 175 The circumstances seem to indicate that the boric acid present in the cream was responsible for the occurrence of these symptoms in two exceptionally susceptible individuals, who possibly may have consumed a further amount of boric acid during the day in other articles of food. The Butter samples throughout the year were found to be satisfactory. I have not succeeded, in the limited number of samples with which I have had to deal, in discovering anything to take exception to. Since the use of coconut oil has extended in connection with the adulteration of butter, a careful test for this material has been made, but always with negative results. In addition to the employment of this oil in the making of Margarine it has been retailed as a substitute for lard. It has been observed by many analysts that the average proportion of water in butter has increased during recent years. Formerly the amount seldom exceeded 12 per cent., but of the samples which are purchased nowadays a good proportion of them contain water amounting to 14 or 15 per cent. In October of last year the following resolutions were forwarded to the Local Government Board and to the Board of Agriculture and Fisheries:— The Council of the Metropolitan Borough of Stoke Newington urges the necessity for immediate action to be taken in the direction of introducing legislation for the purpose (a) of amending and consolidating the Sale of Food and Drugs Acts; (b) of laying down, for the guidance of Local Authorities, definite standards or limits in respect to the composition of the principal classes of foods in common use and the addition of antiseptic and harmful colouring agents to food; (c) of establishing a Court of Reference, as mentioned in the recommendations of the Departmental Committee of 1901; and (d) of adequately dealing with the defects surrounding the matter of Warranties or Disclosures, as protecting the vendor of an adulterated article of food. 176 During the past few years some valuaLble inquiries have been undertaken by the Local Government Board with reference to the composition, preparation, and sale of certain foodstuffs, and these inquiries have been followed by most instructive reports, prepared by the Medical Inspectors who have been charged with the inquiries. It is to be hoped that some of the recommendations contained in these reports will be acted upon by the Local Government Board. It would be of great assistance to those who have to guard the food supply of the population if they had more specific and definite legal guidance or authoritative.pronouncements on many points. Little has been done by way of Informal Sampling to detect those who are guilty of fraud, and this method should be extended in the future within the Borough. This practice of purchasing samples for analysis without disclosing to the vendor the purpose for which the sample is required, is often of service in the detection of habitual offenders. Fraudulent vendors will often supply a casual purchaser with a genuine article, but after they become personally acquainted with the individual they consider it safe to serve him with the non-genuine article; and the informal purchase of samples serves to temporarily establish such regular customers. When, of course, informal samples are found to be unsatisfactory then a sample is purchased under the formalities of the Act so that a prosecution may follow. There is no doubt that retailers are resorting more and more to declaratory- notices when they supply articles which are not "of the nature, substance, and quality demanded." If one demands Demerara sugar, malt vinegar, or coffee, in a large proportion of cases the material is given in a paper, tin, or bottle, which contains a declaration to the effect that the article supplied is not precisely what is asked for. This method of trading cannot be considered satisfactory, more especially as the declaration sometimes takes a form which must be quite unintelligible to any but the most enlightened purchasers. 177 REPORT OF CHIEF SANITARY INSPECTOR FOR THE YEAR 1911. To the Mayor, Aldermen, and Councillors of the Metropolitan Borough of Stoke Newington. Gentlemen, I beg to present my Annual Report for the year ending December 31, 1911:— HOUSES AND PREMISES INSPECTED. By house-to-house inspection 453 Upon complaint, under Sec. 107 (3), Public Health Act, 1891 178 After notification of infectious disease 346 After Notices from builders, under By-law 14 (London County Council) 131 238 Slaughter houses 19 Milkshops, dairies, and cowsheds 99 Bakehouses 31 Factories and workshops 564 Other premises inspected 1,687 3,746 Re-inspections made to examine and test work 3.760 Total inspections 7,5 06 178 INTIMATION NOTICES SERVED. (Sec. 3, Public Health Act, 1891.) After house-to-house inspection 201 After inspection on account of complaint 144 After infectious illness 42 With reference to stables and mews 2 ,, ,, milkshops, dairies, and cowsheds 1 ,, ,, bakehouses 10 ,, ,, factories and workshops 47 ,, ,, slaughter houses — After sundry other inspections 151 598 STATUTORY NOTICES Twelve statutory notices, authorised by your Committee, were served under Sec. 4, Public Health (London) Act, 1891. In every instance the work specified in the notice was carried out. PROSECUTIONS. There were no prosecutions under the Public Health (London) Act, 1891, or under the Bye-laws of the London County Council, during the year. NUISANCES ABATED AND SANITARY DEFECTS REMEDIED. Dirty premises, cleansed and whitewashed 145 Dampness in dwellings remedied 80 Dilapidated ceilings, stairs, etc., repaired 45 Bell-traps and small dip-traps removed and replaced by stoneware gulleys 2 Carried forward 272 179 Brought forward 27 2 Foul traps and pans of w.c.'s cleansed or new ones substituted Public-house urinals cleansed (after intimation) 91 Flushing cisterns to w.c.'s provided or repaired, and w.c.'s with insufficient water supply made satisfactory 43 Defective w.c. basins and traps removed and replaced by approved patterns 88 Stopped or choked w.c. traps cleared 12 External ventilation to w.c.'s improved 4 W.c.'s removed to more sanitar) positions 4 Separate flushing cisterns fixed to w.c.'s which were previously flushed directly from dietary cistern 1 Additional w.c.'s provided in case af insufficient w.c. accommodation 17 Defective soil-pipes reconstructed 22 Soil-pipes improperly ventilated, improved 28 Unventilated soil-pipes ventilated Dirty yards cleansed 12 Yards paved or re-paved with impervious material 54 Yards drained 10 Gully and other traps inside houses Sink waste-pipes directly connected to drain, made to discharge in open-air over proper syphon gullies 2 Long lengths of sink, bath, and lavatory waste-pipes trapped, and made to discharge in open-air over gullies 45 Defective waste-pipes repaired 13 Foul water-cisterns cleansed Water-cisterns without close-fitting covers provided with 34 proper coverings Defects in water-cisterns remedied 3 Cisterns removed to more sanitary position 3 Defective dust-bins pulled down and new portable dust-bins provided 45 Defective drainage re-constructed in accordance with the bylaws of London County Council 150 Choked or stopped drains cleared and repaired 125 Carried forward 1,078 180 Brought forward 1,078 Drains ventilated or defective ventilating pipes renewed 14 Rain water pipes disconnected from drains or soil-pipes and made to discharge over gully-traps 16 Proper water supply provided to houses 22 Defective roofs repaired 49 Defective guttering and rain water pipes repaired or renewed 61 Defective paving to floors of wash-houses repaired or renewed 16 Dirty walls of work-rooms cleansed 16 Proper manure receptacles provided (London County Council by-laws) 3 Cases of over crowding abated 10 Accumulations of refuse, etc., removed 5 Areas re-paved and drained 2 Insufficiently ventilated space under wooden floors, remedied by insertion in outer walls of proper air bricks 26 Underground dwellings improved 10 Nuisances from animals abated 9 Smoke nuisance abated 6 Total number of nuisances abated 1,343 The above list does not include a large number of improvements which have been made by owners of houses and premises on which Notices were served. In most cases where the drainage is repaired or reconstructed the yards and areas are paved, cement plinths provided to foot of walls, or pointing made good, and the ventilation under floors improved. SLAUGHTER-HOUSES. There are only four Licensed Slaughter-houses at present in use in the Borough, viz.:—118, Church Street; 165, High Street; 70. Mountgrove Road; 55, Neville Road. The license of the slaughter house at No. 97, Church Street, has been withdrawn by the London 181 County Council, the premises having been empty for a considerable time. Each of the Slaughter-houses was inspected several times during the year, the result of inspection being satisfactory in each case. COMMON LODGING-HOUSE. The one Common Lodging-house in the Borough, situate at No. 18, Church Street, is under the control of the London County Council, and is conducted in accordance with the by-laws. BAKEHOUSES. There are 24 Bakehouses in use in the Borough. Thirty-one inspections were made. Ten intimation notices were served for limewhiting and cleansing. DAIRIES, COWSHEDS, AND MILKSHOPS. 99 visits were paid to the Milkshops and Cowsheds. In most instances the premises were found to be in a satisfactory condition. It was only necessary to serve one intimation notice for cleansing. There are 53 milk vendors registered in the Borough and two licensed cowkeepers. COMPLAINTS. Sec. 107 (3) Public Health Act, 1891. 178 complaints were received during the year, relating to 185 premises. In 30 cases, on inspection of the premises to which the complaint related, no nuisance which could be dealt with under the Public Health Acts was found. 182 144 intimation notices were served on the owners and occupiers of premises complained of, and in every case the nuisances found were promptly abated. STABLES AND MEWS. 238 inspections were made of the Stables and Mews in the Borough. Only two Intimation Notices were served on Occupiers to remove accumulations of manure, showing that the Council's Regulations have been well observed. HOUSES LET IN LODGINGS. There were 217 premises on the Register at the end of the year. SALE OF FOODS AND DRUGS ACTS, 1875-1901. 156 Samples of Food and Drugs were submitted to the Public Analyst during the year. A table will be found on page 188 showing the result of proceedings taken in respect of adulterated samples. BUTTER AND MARGARINE ACT, 1907. Two firms in the Borough are registered under the above Acts as Wholesale Dealers in Margarine or Butter-substitutes. HOUSE-TO-HOUSE INSPECTION. Inspections have been made in the following roads and streets during the year:— Barn Street. Lordship Park Mews. Barrett's Grove (Tenements). Matthias Road. Boleyn Road (Tenements). Nevill Road (Tenements). Chalmers Terrace. Nevill Road. Church Street. Shakespeare Road. Cressington Road. Shipway Terrace. 183 Edward's Lane. St. Andrew's Road. Howard Road. White Hart Court. Hawksley Road. Woodland Road. Leonard's Place. Several of the Courts and Places which have been included in this list in former reports have been specially inspected under the Housing, Town Planning, etc., Act,1909. HOUSING AND TOWN PLANNING Etc., ACT, 1909. To comply with the provisions of the above Act a Register is being kept and the following places were inspected and reported upon to your Committee. Details of the inspections are recorded in the Register. Hornsey Place. Mason's Place. Philp Street. Mason's Court. now Hewling Street. Thomas Place. White Hart Court. Nevill Road Tenements. Chapel Place. Rochester Place. Regulations were also made and approved relating to the occupation of Underground rooms. As the result of representations made to you, improvements have been made with respect to the manner of letting the Underground rooms (as sleeping rooms ) at Nevill Road. Improvements have also been carried out at Rochester Place. No. 2, Rochester Place, a wooden structure, has been rebuilt in brick. No. 3, also a wooden building which stood at right angles to, and was built partly in front of No. 4, has been demolished. Nos. 4, 5, and 6, brick cottages, have been thoroughly repaired and re-drained, and the courtvard repaved and drained. No action beyond the abatement of nuisances noted during inspection were taken in respect to the other places. 184 BUTCHERS', GREENGROCERS', AND FISHMONGERS' SHOPS, STALLS, Etc. The following is a list of articles of food seized or surrendered during the year :— Tinned Food. No. of Tins. cwts. qrs. lbs. Beef 27 0 2 I 7 Mutton 3 - 1 5 Milk 241 2 0 17 Salmon 5 - - 5 Apricot Pulp 30 3 0 Pineapple 7 - - 21 313 Other Articles:— Beef 4 3 8 Mutton - 1 0 Fish (Mixed) 2 0 0 Bacon - 2 0 Onion - 2 0 Apples - - 6 Pears - - 6 Tomatoes - - 4 Cwt. 16 2 5 Eggs, 17.600; Kippers, 1 box ; Bloaters, 160. 585 inspections were made during the year of premises where food is sold or prepared for sale in the Borough, the food and materials being thoroughly examined. These inspections were made mostly of an evening. The wares of a large number of itinerant vendors were also examined, with satisfactory results. 185 SMOKE ABATEMENT. Numerous observations have been made of the factory and bakehouse chimneys in the Borough during the year. Special attention was given to several chimneys of which complaint had been received. Six intimation notices were served. ICE CREAM MANUFACTURERS AND VENDORS. A Register is kept of all premises where ice cream is manufactured, and these are frequently inspected during the summer months. The conditions under which the manufacture was carried on were in every case found to be satisfactory. The barrows and utensils of itinerant vendors are also inspected. The results of the inspections were satisfactory. RESTAURANTS AND EATING HOUSES. There are 27 of these premises in the Borough. The results of the inspections, both of the food and the kitchens, have been satisfactory. FACTORIES AND WORKSHOPS. The Register of Factories and Workshops has been maintained. There are at present 225 Factories, Workshops, and Workplaces in the Borough. These have all been inspected during the year. In addition 239 homes of outworkers have been inspected. It was found necessary to serve 47 Intimation Notices and Statutory Notices, principally for cleansing and unsuitable or defective W.C. accommodation. In every case the nuisances were abated. 186 Of the outworkers notified from firms whose places of business are in Stoke Newington— 158 reside in Stoke Newington. 79 ,, ,, Hackney. 3 ,, ,, Hornsey. 43 „ ,, Islington. 51 ,, ,, Tottenham. 16 ,, ,, Stepney. 2 ,, ,, Edmonton. 7 ,, ,, Shoreditch. 2 ,, ,, llford. 1 ,, ,, Wood Green, 9 ,, ,, Walthamstow. Total 371 Notifications were received from Medical Officers of Health of persons residing in Stoke Newington but who work for firms in other Districts, as follows :— Battersea 1 Bermondsey 1 Bethnal Green 6 Camberwell 2 Chelsea 2 City of London 259 Finsbury 142 Hackney 90 Hornsey 4 llford 5 Islington 128 Kensington 4 Paddington 2 Poplar 2 Shoreditch 22 Southwark 2 187 St. Marylebone 10 Stepney 5 St. Pancras 1 Tottenham 4 Wandsworth 2 Westminster 2 Total 696 Outworkers' addresses received in error from other Boroughs, etc., and forwarded to the proper destination :— 1 forwarded to Camberwell 145 ,, „ Hackney. 15,,Islington 5 ,, ,, Tottenham. 1 ,, ,, Wood Green. 2 ,, ,, Hornsey. Total 169 NOTIFICATION OF INFECTIOUS DISEASE. 346 cases were notified during the year, and in every instance an inspection of the infected premises was made; 4.2 intimation notices were served for insanitary conditions found. All the houses where the cases of infectious illness occurred have been disinfected; 203 by the Department. and the remainder under the supervision of the Medical Practitioner attending the case. The bedding, clothing, etc., were removed, steam disinfected, and returned in 178 instances. 184 patients were removed to Hospital. It was found necessary to strip and cleanse 22 rooms after removal 01 recover of patients. 14 books which had been borrowed from the Public Library were collected from infected houses, disinfected, and returned to the Public Library 188 DRAINAGE PLANS AND APPLICATIONS. Thirty-six drainage plans and applications were considered by your Committee ; all of which were approved. Ten of these applications were for combined systems of drainage. URINALS IN CONNECTION WITH LICENSED PREMISES. There are 26 of these conveniences in the Borough, 15 of which are cleansed daily by the Borough Council's men. Frequent inspections were made and generally they were found to be in a satisfactory condition. TABLE OF PROSECUTIONS UNDER THE SALE OF FOOD AND DRUGS AND MARGARINE ACTS. No. of Sample Article Purchased. Result of Analysis. Result of Proceedings. 15 Butter Equal parts of Margarine and Butter Defendant fined £5 and £2 2s. costs. 28 Margarine (Unlabelled) Margarine Defendant fined £2 and 12s. 6d. costs. 29 Milk 11 % deficiency in butter-fat Defendant fined £2 and 12s. 6d. costs. 91 Milk 11 % less than the legal limit for fat Summons withdrawn Warranty Pleader. 136 Milk 7½ % less than the legal limit for fat Defendant fined £10 and 23s. costs. By your direction, several vendors of poor samples of food taken under the above Acts have been cautioned by the Medical Officer of Health. I am, Gentlemen, Your obedient Servant, D. W. Matthews. 189 A LIST OF THE STREETS SITUATED IN THE BOROUGH OF STOKE NEWINGTON. (For the Guidance of Medical Practitioners, Midwives, &c.) A DEN Grove Aden Terrace Adolphus Road Allen Road Allerton Road Albion Road ,, Grove Alexandra Road Amhurst Park (90-100 even Nos. and 93) Arthur Road Ayrsome Road Aldham Place BARN Street Barrett's Grove Bethune Road (1 to 145) „ (2 to 106) Blackstock Road (5 to 175) Bouverie Road Boleyn Road (94 to 192) Brighton Road Brodia Road Broughton Road Brownswood Park ,, Road Burma Road ASTLE Street C (1 to 30) N. Side Carysfort Road Chalmers Terrace Chapel Place Chesholm Road Church Path ,, Road „ Street Clonbrock Road Clissold Road Coronation Avenue Cowper Road Cressington Road DEFOE Road Digby Road Dumont Road Dynevor Road EADE Road (2 to 66) and 1 to 27 odd Nos. Edward's Lane FAIRHOLT Road Finsbury Park Road Fleetwood Street GAINSBORO Road Gloucester Road Goldsmith Square Gordon Road Grange Court Road Grazebrook Road Grayling Road Green Lanes „ ,, (from 2 to 388) ,, ,, ( „ 45 „ 107) „ „ (271 to 327) Grove Lodge Yard HAMILTON Place Harcombe Road Hawksley Road Hayling Road Heathland Road Henry Road Hermitage Road 1 to 25a 2 to 14 Hewling Street High Street (17-217) Hornsey Place Howard Road I MPERIAL Avenue 190 KERSLEY Road King's Road Knebworth Road Kynaston Road ,, Avenue LANCELL Street Laver's Road Lavell Street Leconfield Road (1-33) Leonard Place Lid field Road Lillian Street Listria Park Londesborough Road Lordship Road „ Grove „ Park „ Terrace Lordship Park Mews MANOR Road Martaban Road Marton Road Mason's Court ,, Place Matthias Road (2-122) Millard Road Milton Road Mountgrove Road (2-98) NEVILL Road Newington Green (33-42) OLDFIELD Road Osterley Road PAGET Road Painsthorpe Road Palatine Road Paradise Row Park Crescent ,, Lane ,, ,, Terrace ,, Street Pellerin Road Petherton Road (106-138) Portland Road Prince George Road Princess Road „ May Road QUEEN Elizabeth's Walk Queens Road REEDHOLM Road Rochester Place Riversdale Road (92-104) CANDBROOK Road Salcombe Road Seven Sisters Road :—From Blackstock Road to Amhurst Park Shakespeare Road Shelgrove Road Shipway Terrace Somerfield Road Spenser Road Springdale Road St. Kilda's Road St. Andrew's Road „ Mews ,, Pavement, S. Side Selsea Place Stamford Hill (1-39) Stoke Newington Road (1-135) Statham Grove Summerhouse Road TRUMAN'S Road VCTORIA Grove Victoria Grove West Victoria Road WALFORD Road Warwickshire Road Watson Street White Hart Court Wiesbaden Road Wilberforce Road Winston Road Wordsworth Road Woodland Road Woodlea Road Woodberry Down ,, Grove