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f528d3b4-69dd-4d04-9493-9c926855b117	The occurrence of an epidemic depends, so far as we know, solely upon a sufficient accumulation of susceptible children under conditions allowing the introduction of infection and free personal communication. The long incubation period, the insidious approach of the invasion period, the late appearance of the rash are all against the early recognition of the disease, and therefore against the early and successful application of preventive measures. In the year 1911, Measles was registered as the cause of 44 deaths in Acton, as compared with 19 deaths from Scarlet Fever, Diphtheria, Enteric Fever and Small-Pox together. Against Meales but little has been effected, while Scarlet Fever, Diphtheria, Enteric Fever and Small-Pox have been the subject of active and fruitful public health administration. In the Annual Report for 1907 a chart was given showing the death-rate from Measles each year for the period 1882-1906.
984298ed-75b2-4de8-a5f0-e889abfa538e	It was there shown that epidemics of Measles occurred every second year with almost automatic regularity and that the district was visited by a major epidemic at intervals of 4, 3, 4 and 6 years respectively.
69b2231b-7604-413e-8a9a-e9ef9b93d39f	The following table gives the annual number of deaths in Acton per 100,000 inhabitants for the 30 years 1882-1911 1882-1886 1887-1891 1892-1896 1897-1901 1902-1906 1907-1911 32.6 66.6 50.2 13.6 29 50 17 During the past six years the death-rate per 100,000 inhabitants has been as follows 1906 54 1907 38 1908 65 1909 71 1910 1.7 1911 75 Comparing the decennium 1902-1911 with 1882-1891, there is an appearance of a decline in the mortality from Measles. But even this decline is not a true one.
06371949-5f5a-4c59-8769-d1f5a2b8e1b3	The mortality from Measles is confined almost entirely to the first five years of life, and as the birth-rate has continuously declined since 1894, the population of children under five is smaller now than it was twenty years ago. If the mortality from Measles was stated in terms of the population under five years of age, it would be found to be as high, if not slightly higher than it was in the decennium 1881-1891. The mortality from Measles is not, moreover, a complete index of the mischief wrought by it. Measles is a frequent cause of retarded growth and development and of ill-health; it often lights up latent tuberculosis; and deafness and defects of eyesight are in many instances attributable to it. Unfortunately, the public are not aware of the serious drain upon life which an outbreak of Measles entails. The opinion generally prevailing is that a child must get Measles, and the sooner he gets it the better.
678e4286-c3de-4540-b20d-2d03d2f8b452	The truth is, that after a certain period, the older the child, the less susceptible he is to the disease, and even if they contract the disease, children over five years of age rarely 18 succumb. The age at which relatively the greatest number of children die of Measles is the second year of life; while after the third year has passed there is a rapid decrease in the proportion of children dying of the disease. The ages at death in Acton last year was as follows:— Under 1 year. l-2yrs. 2-3 3-4. 4-5. 5-10yrs. 12 16 6 6 2 2 Between 1881 and 1902 the difference between epidemic and enterepidemic periods was most marked.
502dad7b-84f3-4cda-a9b3-176e67a7d618	The major epidemic years were as follows:— 1885 with a death-rate of 120 per 100,000 inhabitants 1889 „ „ „ „ „ 115 „ ,, ,, 1892 ,, ,, ,, ,, ,, 98 „ ,, ,, 1896 „ ,, ,, ,, ,, 80 „ ,, ,, 1902 ,, ,, ,, ,, ,, 78 ,, ,, ,, 1906 „ „ „ „ „ 54 „ „ „ 1911 ,, ,, ,, ,, ,, 75 ,, ,, „ But whereas the peak observed in epidemic years has become flattened the trough in interepidemic years has become raised, so that the actual number of victims to the disease has not diminished. Following the epidemics of 1892 and 1902, there was no death from the disease in 1893 and 1903, but since 1903, not a single year has passed without a death, although in 1905 there were only four deaths and in 1910 there was only one death.
1e585c03-318c-46e0-996f-270edc7b45d1	The following table is taken from Dr. Theodores Thompson's report to the Local Government Board on the control of Measles, and shows that the incidence of attack is different from that of death. 19 Under lyr. 1.2. 2.3. 3.4. 4.5. 5.10 Over 10 Total number of persons living 1155 974 1028 1000 951 4530 25968 Number attacked by Measles 166 233 354 324 324 560 39 Deaths from Measles 16 46 36 16 5 6 0 Measles attack-rate per 1000 living 72 119 172 162 170 62 0.75 Measles death-rate per 1000 living 6.9 23.6 17.5 8 2.6 0.7 0.
8aa79caa-15b2-469f-a0b5-a0034e5e8ed8	0 Measles fatality-rate per 1000 attacked 96 197 102 49 15 11 0 The above table refers to a particular Urban District where the number of persons attacked by Measles at each of the several age periods was known, and shows that while the main incidence of death is on the second year, the incidence of attack is chiefly on the third, fourth and fifth years. 1501 cases were investigated in Acton last year, and the ages of these were:— Under 1 yr. 1-2. 2-3. 3-4. 4-5. 5-6. 6-7. 7-8. 8-9. 9-10. over 10 yrs. 32 23 35 56 180 392 356 207 78 39 103 The ages at death have already been given.
c4414e70-2099-4e1a-9099-4838fd8b1e9a	The above figures, of course, do not represent the relative number of cases at different ages which occurred last year. The majority of cases which come to the knowledge of the Sanitary Department would be children of school age, and Measles occurring among young children would remain unreported. The figures though are sufficiently suggestive that Measles is a very fatal disease when occurring among children under three years of age, but comparatively benign when it attacks children over five years old. This aspect of the question is of importance from two points of view. If the interepidemic period could be lengthened, 20 not only some children would have reached an age when they would be less susceptible to an attack, but a large number of children will, when the epidemic arrives, have reached ages at which the disease is little fatal. Any and every means should thus be used to delay or arrest a threatened epidemic, but our sphere of action is practically limited to the schools.
0b4495ed-4adb-4039-9ad3-45d94550fd1e	The other measures would be directed towards restraining the spread of Measles in invaded households. The isolation of every case of Measles from the first onset to the end of the third week would undoutedly enable an outbreak to be brought abrubptly to a close, as no second crop of cases would occur. It would also limit the cases very largely to children over school age, as in the majority of instances the disease is introduced into the house by a child attending school. This ideal of prompt isolation will not for the present be accomplished but the attention paid to invaded households, will, it is hoped, tend to secure more precaution on the part of parents. Unfortunately, it is no uncommon pratice for mothers to allow the other children to mix with the Measles patient, so that all can suffer together and reduce, as they think, the aggregate amount of necessary nursing.
a8d22c95-714f-4957-962f-713cb661c1b6	There is no greater or more pernicious superstition than that which is so widely held, namely, that a child must have Measles. No condemnation can be too strong for the practice of wilfully exposing other members of the family to this infection. The difficulty experienced in the prevention of the spread of Measles in schools is also experienced in infected households. The disease is most infectious in its earlier stages, and before the rash appears. Circulars are distributed warning parents of the early infectiousness of Measles, and until parents take precautions, during outbreaks of Measles, to isolate all children who may have running from the eyes and nose, it will be impossible to prevent the spread of the disease. 21 In last year's annual report a history was given of the cases of Measles which had occurred in the district during the last quarter of 1910. In October and November, 1910, isolated cases occurred in the northern part of the district.
827d1644-0be1-41b4-b036-6bcc6553323c	When the cases occurred amongst school children during these two months, the symptoms in all instances made their appearance towards the week end, and the children had not attended school subsequently to the appearance of the initial symptoms of Measles. In December a case occurred in the Priory School. This child attended a class in which most of the members were unprotected, and the child was in attendance after the appearance of the initial symptoms The school was closed for the Christmas holidays before the "first crop" fell. A list of the children who had been in contact with the first case was obtained, and they were visited during the holidays. It was ascertained that 13 oases had occurred between December 12th and January 9th, the date of the opening of the schools. No further cases occurred in the Priory Schools until after the Easter holidays.
e0467233-4cf6-4b0b-a873-4e47ffd79ffd	It was hoped that by the adoption of these methods an epidemic would have been delayed, at any rate, for some months, and the postponement of an epidemic from the winter to the summer would have justified almost any steps, however drastic. In industrial districts a Measles epidemic is in many ways a less formidable occurrence in the summer than in the winter. Apart from the increased severity of the initial symptoms, the liability to lung complications is much greater in the winter than in the summer. 22 Death very seldom occurs during the eruptive stage, and only six deaths occurred during the first week of the illness. The time which elapsed between the appearance of the rash and death was as follows:— 3-7 days. 7-10 days. 10-14 days. 14-21 days, over 21 days. 6 5 11 12 8 No information could be obtained in two instances.
74ea0215-56a1-4221-ba0d-91dba6cb09fd	Although closure was successful as far as the Priory School was concerned, cases occurred in January and February in some of the other schools. In the Southfield Road Infants Department, one child was excluded from Class II on January 27th. On February 6th, nine cases were reported from Class V. It was decided to close Class V during the week of February 13th—18th, so that the children falling ill of the disease might do so out of school. The children in the class were kept under observation and visited in their homes. Seven cases of Measles occurred. In the Central Infants Department several cases were notified on February 13th from Class III. A child had been excluded on January 31st on account of a "cold," which on subsequent inquiry was found to be the commencement of Measles. In February the Infants Department of the Central and Acton Schools were closed, and in March the Infants Department of the Southfield Road Schools was closed.
2e25dceb-6d81-402f-b2dd-78c5b73aa9ac	Before Easter the outbreak was confined to the northern part of the district, but on the reopening of the schools after the Easter holidays cases occurred in the Rothschild Road, 23 South Acton, Beaumont Park and Priory Schools. It was in South Acton that the majority of the deaths occurred. It is usually found that Measles increases in virulence as an epidemic progresses, but the greater mortality was probably due to causes other than increased virulence in the type of the disease. The epedemic lasted until the end of May; it then gradually subsided, but the district was not free of the disease until about the middle of July.
fd7eac87-3b1e-4e47-b0bc-a6a96a064141	The total number of cases notified from the School was 1496, distributed as follows:— Turnham Green 11 East Acton 38 Acton 59 Acton Wells 129 Priory 133 Rothschild Raad 184 Southfield Road 187 Central 188 South Acton 266 Beaumont Park 301 The spread of Measles in the district followed closely on that of its spread in the schools, and it is generally agreed that Measles is spread on the largest scale by the attendance at public elementary infant schools of children in the catarrhal stage of the disease. The occurrence of similar spread in the boys and girls departments of the same schools is prevented by the fact that most of the scholars in these departments are already protected by previous attack. This connection between school attendance and infection brings us to a consideration of the preventive measures against Measles.
f2b62133-80ef-4b7c-b247-b9045a5ca774	24 The general lines of action in regard to school closure and exclusion recommended by the Medical Officers of the Local Government Board and of the Board of Education are set out in the "Memorandum on closure of and exclusion from school" issued in 1909. In that memorandum it is recommended "that children attacked by Measles should be kept from school for four weeks." In large districts, and in the smaller districts in which the majority of children over seven years of age who are attending public elementary schools have had Measles, the practice is frequently adopted, when Measles breaks out in a household, of excluding from school attendance only those children of the same household who attend the infant school, and those older children of the same household who have not had Measles. These particular children of the same household should be excluded from school until 21 days from the date of the illness of the last patient with Measles in the house. The above procedure can be recommended as the result of experience in large districts.
5ab37886-9e11-4178-acf4-1da0159fd29d	It is a compromise which is obviously not a counsel of perfection, and may need future modification. Even under present conditions the procedure may need to be modified in accordance with the special circumstances of a particular district, with special reference to its past history as to Measles. The schedules for the medical inspection of school children, if kept carefully, will, in course of time, place at the disposal of the Medical Officer of Health and of the School Medical Officer the history of each child as to Measles, as well as to other infeotious diseases, and they will thus be able to decide, when a case of Measles occurs in a particular class, which scholars in that class should, and which should not, be excluded from attendance at school.
222a3703-b3f7-4f39-82c5-c2fc5fd225ae	School closure has probably more frequently taken place on account of epidemics of Measles than for any other disease, 25 but as the closure has been commonly deferred until a large proportion of the children are already absent, it has proved useless, in populous districts at least, for the purpose of preventing the spread cf the disease. If Measles is introduced into a school, the first crop of secondary cases will occur about 12 days after the original case, and in 12 days more there will be a second crop, comprising the majority of the unprotected children. Thus school closure as ordinarily practised after the second crop of cases has occurred fails to prevent an epidemic. In view of this experience, a class closure of short duration after the occurrence of the first case of Measles in the class may be substituted, the class being closed on the ninth day after the sickening of the first child, for a period of five days only.
4e31a3fc-e577-4da6-a218-96656c97b29b	After this period, only those who have sickened need be excluded, along with those in the same households who have not had Measles or who attend the infant school. Under different conditions, all these procedures were adopted in this district, but their success was only partial. In a majority of instances, in practical working, when it is known by notification that Measles has entered the infants department of a school it is too late to take any effectual precautionary measures; even temporary closure of the department or of a class will probably only temporarily delay further extension of the disease. The want of success following these measures has led many authorities to advocate the permanent exclusion from school of children under five years of age. In the report of the Consultative Committee of the Board of Education issued in 1908, it was decided not to recommend any change at present in the lower age limit, either of voluntary or compulsory attendance at school.
d698554e-ccc3-4d2e-8689-32eed7bb133c	26 It is doubtful if mere exclusion from school of children under five can be regarded as a real solution of the problem. It would possibly effect an improvement in the immediate mortality from measles, but in many instances the homes are so unsatisfactory that the children are better off in school, in spite of the risk of infection. As an alternative to the total exclusion of children under five, the establishment of special nursery schools has been suggested for children between the ages of three and five years. One must be able to penetrate further than the school if a permanent improvement is to result. A study of the street distribution of the deaths will show what an important part social conditions play in the casefatality of Measles. The street distribution of the deaths was as follows:— Osborne Road 5 deaths.
efa20f82-c237-48ce-bcbb-8ac3f9596dbf	Bollo Lane 3 „ Seymour Road 3 „ Colville Road 3 „ Stanley Road 3 „ All Saints Road 2 „ Berry mead Gardens 2 „ Park Road North 2 „ Packington Road 2 „ Bollo Bridge Road 2 „ Kingswood Road 2 „ Holland Terrace 2 „ Summerlands Avenue 1 death. Leamington Park Villas 1 „ York Road 1 „ Grove Road 1 „ Avenue Road 1 „ Kent Road 1 „ Berrymede Road 1 „ 27 Strafford Road 1 death. Alexandra Road 1 „ Enfield Road 1 „ Fletcher Road 1 „ Wolsey Road 1 „ One authority has advocated the general establishment of institutions for the teaching of mother craft. The teaching of mother craft on a wide scale would no doubt do much to improve home life; but an unsatisfactory home is the product of many conditions, social and economic, other than ignorance of mother craft.
49c911f5-d4b5-4d18-a88a-2fd9fd98a06d	Other measures, such as hospital treatment of selected cases, would no doubt be instrumental in saving many lives. All these measures, which are now being utilised in directly combating Measles, will result in a fall of the death-rate for Measles, but possibly more good will result from indirect measures. Improved housing, a rising standard of cleanliness, both civic and domestic, and the better appreciation of health requirements that health-visiting is now calling forth in the mass of the people—all these are influences from which a substantial result may be expected in the future. DIPHTHERIA. One hundred and fifteen cases of diphtheria were notified, and nine deaths occurred from the disease. The number of deaths is exactly the same as that in 1910. The percentage of cases occurring amongst school children remains at a fairly constant figure.
b778f480-4eda-4913-9463-3f86e2bb1f07	In 1911, 64 out of a total of 115 occurred amongst school children; in 1910, it was 66 out of 118, and in 1909, 62 out of 104 cases. 28 The incidence of the disease was highest in the Central School with 9 cases, Beaumont Park 9 cases and Southfield Road with 25. It will be noticed that it was the same schools that suffered most in 1910. The immediate causes in both years were carrier cases in attendance at school. A detailed account was given in last year's report of the action taken to detect the carrier case, and the same routine was adopted last year. If a reference be made to the tables furnished in the report on the inspection of school children, it will be found that these three schools furnish the highest percentage of enlarged tonsils and adenoids. It is probable that the association of Diphtheria and enlarged tonsils and adenoids is not an accidental one.
74461630-4717-477c-bc84-c063affa29b4	Children with enlarged tonsils furnish a fruitful soil for the implantation and growth of the Diphtheria bacillus, and these children are more liable to contract the disease when they come in contact with a "carrier" case. In two houses three cases occurred in each of them, and in four houses two cases occurred in each. In the other 101 houses one case occurred in each. ENTERIC FEVER. Seventeen cases of Enteric Fever were notified and four deaths occurred. In the first half of the year only three cases were notified Most of the "primary" cases contracted the disease outside the district. One of the cases had stayed at Shanklin from September 8th to September 16th, and whilst there had eaten oysters. She was taken ill on September 25th, and notified on October 9th. 29 Another case had been staying at Ramsgate in the last week in September and had eaten cockles there.
b5e8acc1-3970-4baf-a56d-7bd4f9895d9f	She was taken ill in the second week in October, and notified on October 19th. It is now generally held that the consumption of shell fish derived from polluted sources plays an important part in the causation of Enteric Fever. In the light of evidence already available there is reason for believing that much Enteric Fever, the source of which is still unrecognised, and in particular Enteric Fever occurring apart from considerable outbreaks, will eventually be traced to the consumption of contaminated shell fish. Three cases were notified from the same honse in Shaftesbury Road in October. The children had been ill since the first week in October. They had all eaten some shell fish which had been given away by a fish hawker in the street. The hawker was in the street on the first and second Sundays in September, and on one of these Sundays he had some winkles which he was unable to sell, and these he had given away.
4d94a36c-7f4e-42a7-bf0d-cd8ae635a6a5	In last year's report details were given of cases in which the possible source of infection was plaice, and Dr. Hamer's. report to the London County Council on the subject was quoted. Dr. Hamer analysed the facts as to certain localised prevalences of Enteric Fever in London in 1910, and arrived at the conclusion that they were best explained on the hypothesis that, these groups of cases were due to the eating of contaminated fried fish. It was suggested that the small plaice (commonly imperfectly gutted) brought their infection with them, possibiy from the estuaries in which they may have been caught. If this be the explanation, the temperature attained in some portion, of the interior of the fish during frying must be much lower than is popularly supposed.
c8c90a92-d09b-4507-97f6-5e2998bbf57e	The report is important as drawing attention to an additional source of typhoid infection, and as indicating the need for further supervision over the source and the gutting and over the details of preparation of fried fish, for food. 30 Several of the cases had eaten the kind of plaice which is under suspicion. They are sold in shops under the name of dabs. Six cases occurred in the same house, but live of the cases were probably infected by the primary case, which remained for over three weeks undetected. SCARLET FEVER. Two hundred and thirty four cases of Scarlet Fever were notified, and 6 deaths occurred.
7414ff3c-a41b-43a5-9b5a-bbaf057b0d21	There is an increase in the number of notifications of Scarlet Fever received, as compared with 1910, when 109 notifications were received, The number received each month during the year was as 'ollows:— January 8 July 17 February 10 August 10 March 8 September 15 April 35 October 43 May 12 November 35 June 3 December 38 The increase in the number of cases notified in April was due to an outbreak which occurred in Bedford Park. Up to April 22nd there had been no undue incidence of Scarlet Fever in the district. Between April 1st and April 22nd six cases of Scarlet Fever were notified. On April 22nd eight notifications were received, on April 24th 7 and on April 25th 5. On investigation of the cases notified on April 22nd it was found that all the cases had the same milk supply.
6e9e6b9d-a28c-4903-ab8e-0a7c65c59258	This dairy was situated outside the district, and on inquiry on April 24th 31 it was found that cases had also occurred in Chiswick amongst customers of the same dairy. I accompanied the Sanitary Inspector of Chiswick to the dairy for the purpose of making inquiries. It was found that, though a case of Scarlet Fever had occurred in the family of one the employees of the dairy, it was improbable, if not impossible, for the infection to have arisen in the dairy. When the dairy was visited it was found that the milk was being pasteurised, and the manager was advised to continue to pasteurize until further inquiries had been made.
df6be318-6fc0-41f2-88f0-38c1f9720b2e	Under Section 15 of the Acton Improvement Act, if the Medical Officer of Health shall have reasonable cause to believe that any person in the district is suffering from infectious disease attributable to milk supplied within the district, he may, by notice in writing, require every person supplying milk to the person so suffering, or to the house of which he is an inmate, to furnish him with a list of all farms, dairies or places from which such person derives his supply of milk, or from which he has derived his supply during the last six weeks. The list of farms was readily given. All the farms were situated in Berkshire, and I immediately communicated with Dr. Taylor, the Medical Officer of Health for the County. Before mid-day on April 25th Dr. Taylor had found on one of the farms a person suffering from Scarlet Fever. The patient was sent home, and the dairy refused to receive the milk from that farm pending further inquiries.
3e4e0fe9-7d16-4c3b-bf6b-e76f9cbd393e	Only two primary cases were notified amongst customers of this particular dairy after April 25th, and one of these had sickened on April 22nd. Briefly, these were the circumstances in which the outbreak occurred, and the action that was taken, and in the following report the connection between the cases and the milk supply is set forth. 32 As stated above, the outbreak was sudden in its onset, and there was no connection between the cases notified on April 22nd and subsequently with those which had previously been notified in the district. The schools could have had no part in the spread of the disease, as they had broken up for the Easter holidays on or before April 12th. Moreover, the distribution was not a school nor a class distribution.
71843a01-ecfa-4b42-822a-e676b7fd43ba	Between April 22nd and April 28th, 25 cases were notified the notifications being as follows:— April 22nd 8 cases „ 24th 7 „ „ 25th 6 „ „ 27th 1 case „ 28th 4 cases With two exceptions, all these cases occurred in houses supplied with milk from the same dairy. Subsequently to April 28th, no primary cases occurred amongst the customers of this dairy, but four cases occurred on May 1st and May 2nd in a house from which two previous cases had been removed to the hospital; in another bouse, where a case was being nursed at home, a second case was notified on May 6th. There are two other cases which were probably secondary cases. One of these was notified on April 29th, and had sickened on April 27th. She was a maid in the house, and on the previous day another maid had been removed to the hospital.
1f46ee7c-ae68-4d3a-9939-e40a50d5ae8e	The primaty case had been ill since April 22nd. The other probable secondary case was notified on April 24th, and had sickened on April 23rd. His two brothers had been removed to the hospital on April 22nd, and had sickened on April 21st, and his sister had been notified on April 22nd, and had sickened on April 20th. 33 This leaves 20 primary cases which had occurred in families supplied with milk by the same dairy, and this report deals with these 20 cases. Dealing with the question as to the evidence that the cases were Scarlet Fever, there is no doubt on that point. Eleven of the cases were admitted to the hospital, and all the patients presented the characteristic signs and symptoms of Scarlet Fever. The rash was indistinguishable from the ordinary rash of Scarlet Fever, and the appearance of the throat and tongue was typical of Scarlet Fever. Moreover, secondary cases occurred in several houses.
a9d3215a-2fa9-4501-aaa0-bf7773024ab5	In one house six cases occurred. The type of the disease was mild, but the age distribution of the disease was unusual. The proportion of adults was high, and this circumstance in itself might have affected the type of the disease. The 20 cases occurred in 18 houses, three of the cases having occurred in one house. The total number of inhabitants in the 18 houses was 95, and of these 54 were stated not to have had a previous attack of Scarlet Fever. In one instance the information obtained was indefinite. In one instance the patient had not taken unboiled milk. In seven instances the person attacked was the only one in the house who had partaken of unboiled milk. In two instances the maids of the house were attacked. When inquiries were made at the house, the heads of the family declared that no one in the house drank raw milk, but when the maids were questioned they admitted that they had taken uncooked milk.
2179ec8b-aa9b-4d36-8d70-6f87ca3e572a	In one of the houses, the maid was the only person attacked. In the other house, the maid was the primary case, but subsequently five other cases occurred in the house. In one instance, the person attacked and a sister were the only ones in the house who drank unboiled milk. The sister 34 subsequently developed Scarlet Fever, but it may have been a secondary case. The first case sickened on April 21st, and the second on April 25th. In two instances the person attacked and one other member of the family were the only ones who drank raw milk. In six instances all the members of the household drank unboiled milk, but in these families only one child under 10 years of age escaped. The age incidence of the persons attacked was as follows:— Under 5 years. 5 to 10. 10 to 15. 15 to 25. Over 25 years.
f12cd937-1da1-4b53-a253-270dbfe99ead	2 7 5 3 3 The dates of notification have already been given, but of more importance is the date of the onset of symptoms. Of the 20 cases we find the date of sickening as follows:— Five cases sickened on April 20th, eleven cases on April 21st, three on April 22nd, and one on April 26th. The estimation of an incubation is always a difficult matter. It may be asserted with some confidence that the latent stage of Scarlet Fever is invariably a short one. The vast majority of patients take from two to three days to develop their first symptoms. It has been stated that an incubation of only a few hours is possible. Murchison had, in his wide medical experience, found only 13 cases that allowed him to draw any certain conclusions as to the true incubation.
c72b4ea1-0423-4cd8-b8d4-da0d768fc871	Among these it was Less than 24 hours 2 24-48 3 Between 2-3 days 1 3-4 „ 2 4-5 „ 3 5-6 „ 2 35 Cases have been reported in which the disease is supposed to have taken two to four weeks to devolop, but most authorities refuse to accept these long incubation periods as authentic. We may take it that the incubation period does not exceed seven days, and that it is very seldom longer than four. It is stated that in milk epidemics the incubation period is shortened,' but usually the vast majority of patients take from two to three days to develop their symptoms. I think it may be fairly assumed that all the primary cases could have been infected on the same day, but in that case the date must have been either April 19th or April 20th.
efdaa91c-713f-42d0-9f30-9151178d0126	On the other hand, if the infection had been a continuous or an intermittent, and not a transient one, the contamination may have occurred on any dates between April 13th and April 26th. Apart from the dates on which these cases had occurred, an incident had occurred at the dairy which would have made it highly improbable for the milk to have been the means of spreading infection after April 21st. On April 20th, the child of the foreman at the dairy was notified as suffering from Scarlet Fever. Every possible precaution was taken at the house and at the dairy to prevent the contamination of the milk. The child was immediately removed to the hospital, the premises were disinfected and the father was not allowed to resume work until April 24th. In addition, all the milk was pasteurized on and after April 21st. When the dairy was visited on April 24th the milk was still being pasteurized.
2895e15e-3a85-4dee-8ea7-3be22af0c58b	There was no evidence by which the infection of the milk could be traced to the child of the foreman. It may be stated, though, that the Scarlet Fever patient, even [in the beginning 36 of the attack, is capable of transmitting the infection. Vogl goes much further, and closes the description of his experience in a Munich garrison with the statement that the contagion, as a rule, occurs through direct contact during the period of incubation. Although the dates of the illness of the foreman's child would not, under the above conditions, render it impossible for the milk to be contaminated from this source, there were circumstances which would render contamination from such a source extremely improbable. Although cases have been described in which the infection has been conveyed through the medium of a third person, who has carried it in his clothes, very few instances of such indirect transmission will bear critical examination, and there has been no authenticated case where an article of food could be thus affected.
24218f28-c7ca-4e1d-9a50-536d149f5bb7	The foreman had hardly been in contact with the child, and there was no evidence that he had personally handled all the milk. He supervised the distribution of the milk amongst the various employees. The cases which were notified on Saturday, April 22nd, occurred on five different rounds. 9 Inquiries were then made at the farm from which the milk was supplied. The dairy in question is one of several branches controlled by a large firm. The firm obtains its milk from several farms, but it was possible to trace the source of the milk supply to each of the branches. The Dairy obtained its milk from three farms in Berkshire. At two of the farms there were no suspicious circumstances, and the districts in which they were situated had been free of Scarlet Fever for a considerable time. 37 In the neighbourhood of the third farm Scarlet Fever had been prevalent for some time. This farm (G. M.)
fde0579f-ebf8-4ada-aa9f-2feb2457f508	comprises an area of about 350 acres of pasture land, and on it, in addition to other stock, are kept 55 milch cows. The whole of the milk was sent under contract to the above-mentioned firm. The milk was detrained at Ealing, and delivered direct to the branch depot. Connected with the farm are three cottages, in which most of the milkers reside. One of the milkers (D. F.), though, resides in a village (W. H.), situated about three miles away. A groom (G. R.), who occasionally assists in the milking, resides in the farmhouse, but obtained all his meals with the milkers. At the village (W. H.) Scarlet Fever has been prevalent for some time. In January, 1909, there were three cases of Scarlet Fever in D. F.
d5c15dd0-f33f-4d32-86c4-c99b86782d10	's house at W. H., but D. F. himself did not suffer from Scarlet Fever. Last December Scarlet Fever again made its appearance in W. H., but not in D. F.'s house. On March 25th, 1911, D. F. met with an accident, and was sent away from work until April 15th. On April 16th, 17th, and morning of the 18th he milked the cows. On the latter date he again went off duty with a bad cold, and had not resumed his work on April 25th. On April 25th he was examined by the County Medical Officer of Health, who found him suffering from inflamed tonsils, but there were no symptoms char???teristic of Scarlet Fever. D. F. was also examined by bis own doctor, And both doctors are of opinion that D. F. was not suffering from Scarlet Fever.
e7cb4b45-76ca-4939-850e-b4e6178d74ea	All the employees were examined on April 25th, and on that date the groom G. R. was and had been for some days suffering from Scarlet Fever. His throat and tongue were typical of Scarlet Fever, and desquamation of the skin was commencing. His family resided at a village some distance away. 38 He had visited his family since the commencement of his illness, and two further cases of Scarlet Fever subsequently occurred in his home. As far as can be gathered, the history of G, R.'s illness was as follows :— He was away on Easter Sunday, and returned to work on Easter Monday, April 17th. When he returned on Easter Monday he was suffering from a swollen face, which be attributed to "toothache.'' He continued at his work, and as one of the milkers (D. F.) had gone away indisposed on the Tuesday, he took D. F.
0e912daa-efd7-46a4-884d-c2bc75bebfe7	's smock and milked the cows on Tuesday, Wednesday and Thursday. On Wednesday afternoon G. R. undoubtedly was suffering from Scarlet Fever, the words he used himself being "that his throat was very bad." He continued at his work, though, until Friday, when he told his employer that he could go on no longer. He remained away from the farm until April 25th; on that date he returned to work, but as a result of his medical examination he did not remain at work, but was sent to his parents' home. It will be observed that G. R. milked the cows on April 18th, 19th and 20th, and on the 19th and 20th, at any rate, he was suffering from Scarlet Fever, From further inquiries, it was found that G. R. only milked the cows in the afternoon, and that he did not assist in the morning milking.
a53e3b1c-003f-4ce5-a3f4-3c434ea69408	Assuming that G. R. was not in an infectious state until April 19th, the only two days upon which he could infect the milk would be April 19th and 20th. The milk handled by G. R. on April 19th and April 20th would not in the ordinary course of events be delivered to the customers until the early morning of April 20th and 21st respectively. The afternoon milk was forwarded to the Dairy Company on the same day as it was drawn, but it would not reach its destination in time for the evening delivery of that day. It would consequently be delivered to the customers on the following day. 39 If G. R. was the source of the infection, the milk consumed on April 20th and April 21st would be the ones most liable to be contaminated. The dates correspond very closely to the probable dates upon which the cases that occurred in this district were infected.
dc1f8946-4d1b-4ff7-b05a-4f44ddd564fe	There was one other mode by which this milk supply might have been infected. It is possible for the Scarlet Fever germs to be implanted upon the udder and teats of the cows, if there be present an ulceration of the teats or an inflammation of the udder. The cow may thus be the source of Scarlet Fever in man, not because it is constitutionally infective, but because it is acting as a carrier of human infective organisms. It has been stated that another milker (D. F.) had suffered from sore throat, and that he lived in a village where Scarlet Fever was prevalent. As a rule, even a sore throat that occurs during a Scarlet Fever outbreak is looked upon with suspicion, and some authorities regard these cases of sore throat without a rash as an abortive form of Scarlet Fever.
44706c01-4817-46d9-93a0-f2bfdc320542	The possibility that D. F. had implanted the infective germs upon the teats of the cows was borne in mind, but all the evidence pointed against this indirect manner of infection. The cows were examined by a veterinary surgeon, who reported that there was no evidence of recent mastitis or ulceration of the teats. Moreover, the sudden outbreak of short duration pointed to a purely human source of infection. The bulk of the evidence goes to show that G. R. probably infected the milk when acting as milker. Although the specific germ of Scarlet Fever has not with certainty been isolated, there is reason to believe that the germ finds in milk a favourable medium for growth. From the time the milk was handled by G. R. to its delivery at the customers' houses there would be ample and favourable opportunity for the multiplication of the germs. 40 Briefly summarized, the reasons we had for assuming that the outbreak was connected with the particular milk supply were as follows:— 1.
a3e64037-96a8-4f2c-b58f-449c119fa799	The outbreak appeared suddenly, and the subsidence was equally prompt. 2. The cases were almost entirely limited to those families who used the milk of a certain dairy. 3. Those members of the family who drank uncooked milk were mostly infected. 4. The houses invaded were quite distant from each other, and not restricted to a particular part of the district. 5. The only condition common to all the houses affected was the milk supply. 6. The proportion of adults among the affected was high. 7. The outbreak was preceded by the occurrence of Scarlet Fever among one of the milkers. The present outbreak differs from most milk outbreaks in its limited character. This may be explained in many ways. The dairy supplies about 300 families in Acton, but this particular supply is obtained from three farms. The milk from these farms is not mixed, so that only about 100 families would be supplied with the suspected milk. This would tend to limit its extent.
a33e525d-d1b2-4a92-868d-da6ca29f0ff7	The period during which it could remain infected was also limited. The milk was pasteurized on April 21st; G. R. had been examined by Dr. Taylor, and the milk had been refused by the firm on April 25th, before G. R. had resumed milking. These circumstances would tend to limit the extent of the outbreak. 41 From the administrative side it deserves to be noted how it was possible for early localisation of the source of the mischief to be effected. I have to acknowledge the cordial assistance given by the proprietors and the manager of the dairy. As soon as the proprietors became aware that any suspicion attached to the milk, every step was taken by them to prevent the distribution of the milk from the suspected farm amongst their customers. To Dr. Taylor, the County Medical Officer of Health for Berkshire, the district is indebted to an extent that is not easily appreciated.
645c75a4-3c9f-4bb5-b080-f2b564031486	His system of recording the incidence of the Infectious Disease in the County enabled him to localise the mischief immediately. If I record the steps taken, the value of his services can be partly gauged. On Saturday, April 22nd, eight cases of Scarlet Fever were notified. As a result of inquiries, a milk supply was suspected. Monday, April 24th, the dairy was visited, and late on the same evening the names of the particular farms that supplied the dairy were obtained. By mid-day, April 25th, a case of Scarlet Fever had been detected on one of the farms and the milk supply stopped. Another increase occurred in the autumn. On the reopening of the schools after the summer holidays a few cases occurred, but it was not until the first week in October that the number of notifications assumed serious proportions.
d307dd33-3d26-44d6-8c1c-7be0305d0288	A large number of the children attacked were in attendance in the South Acton School, and, as is usual in these circumstances, some "missed" cases were found. The age distribution of the cases notified, together with the number removed to hospital, will be found on Table II 42 INFANTILE MORTALITY. 176 deaths under one year of age were registered in the district, and 29 infants under one year of age died in public institutions beyond the district, making a total of 205. Thiscorresponds to an infantile mortality of 138 per 1,000 births. The infantile mortality in England and Wales last year was 130; in 77 large towns it amounted to 140, and in the 136 smaller towns it was 133 per 1,000 births.
7f1bf215-85f8-45d0-a72a-605b2d6c757e	The deaths were distributed as follows:— North-East Ward 32 North-West Ward 25 South-East Ward 47 South-West Ward 101 The infantile mortality in each ward was :— North-East Ward 108 per 1,000 births. North-West Ward 119 „ „ South-East Ward 126 „ „ South-West Ward 173 „ „ The infantile mortality was 36 per 1,000' births higher than in 1910. Compared with 1910, the infantile mortality was higher in all the wards. The diseases which showed the greatest increase in the number of deaths were Diarrhœeal Diseases and Measles. Therewas a slight increase also in the number of deaths from Prematurity and Congenital Debility. There were 37 deaths from Prematurity and 23 from Atrophy,. Debility and Marasmus. These are the two groups of cases which are usually supposed to be affected by antenaital causes.
cbff8a29-bdcf-44fe-b4d8-ed4a2f65b8cc	A few 43 years ago it was frequently stated and believed that the industrial employment of married women was one of the most important direct factors in the causation of infantile mortality in large towns Owing to investigations carried out in certain large towns, it is now possible to approach this portion of the subject with greater accuracy than formerly. Although the number of cases investigated are not so large as could be desired, certain results have been obtained which cast some doubt upon the direct influence exerted by the industrial employment of women in producing excessive infantile mortality. Section 61 of the Factory and Workshop Act, 1901, makes it an offence for the occupier of a factory or workshop knowingly to allow a woman or girl to be employed therein within four weeks after she has given birth to a child. At the Conference on Infantile Mortality held in London in 1906, a resolution was adopted that this period should be extended from one month to three.
5856c165-977c-4fcd-b951-35d22738aa2d	In 1907 the Home Secretary addressed a letter to certain Medical Officers of Health, asking for certain information, as he was considering the question of the further regulation of the industrial employment of women before and after child-birth. Some of the results of these inquiries have now been published, and so far no case has been made out for the further restrictive legislation in the prohibition of employment of married women. In Blackburn, amongst 314 mothers industrially employed, 135 per cent, of the infants died in the first year of life. Amongst 175 mothers not industrially employed, 12.2 per cent, of the infants died in their first year. In Birmingham it was found that, if the children who have been weighed are divided into two classes, namely, those whose mothers were industrially employed and those whose mothers were not industrially employed, there is scarcely any difference in the average weight in the two classes.
49e5195b-70f0-4d4b-b3ca-bcf9e6850c40	44 If, however, the same children be divided into those whose fathers earned less than £1 per week and those whose fathers earned £1 per week or more, then a very material difference was apparent. It was seen that in the homes where acute poverty exists there is a marked falling off in the average weight of the baby, whether the mother is industrially employed or not. If industrial employment has a bad effect on infantile mortality, it is principally because it interferes with breast feeding, and for this reason employment in a factory is more harmful than employment at home. But it was apparent that the influence of industrial employment was small when compared with the influence of acute poverty. In the South-West Ward, where married female labour mostly prevails, the death rate from these diseases is not markedly higher than in the other wards. 39 per cent, of the births occurred in the South-West Ward; 45 per cent, of the deaths from these diseases occurred in this ward.
8b6d405c-16fa-4afd-877c-228dc2e99086	This is slightly higher than that of the other wards, but nearly 50 per cent, of the deaths of infants under 12 months occurred in this ward. Until the results of the Census are known it is difficult to estimate what percentage of the married women in the SouthWest Ward are employed in duties other than domestic work. 26 deaths from Prematurity were inquired into, and 11 of the mothers were employed in some occupation, but in one instance she had not been working for three months and in another for six weeks. The other 15 were not occupied except in domestic work. Although, compared with the immediately preceding years, there is a higher infantile mortality, if the infantile mortality of last year be compared with that of former years in which the meteorological conditions approximated to those of last year, the results are very gratifying.
d6c1853e-b687-4390-b27d-29a78105e694	45 It has been explained that the "outside" deaths were not included prior to 1905, but, excluding outside deaths, on two occasions only before 1903 did the infantile mortality fall below 150 per 1,000 births. In 1891 it was 146, and in 1887 it was 147 per 1,000 births. (Last year the deaths of infants registered in the district corresponded to an infantile mortality of 120 per 1,000 births registered in the district.) For the years 1897, 1898 and 1899 the figures were 198, 182. and 187 per 1,000 births respectively. Dry, hot, dusty summers and increased atmospheric and earth temperatures will always cause an increase in the deathsfrom infantile diarrhoea, and the summer of 1911 proved an exceptionally unfavourable one as regards the number of deaths from Diarrhoeal diseases.
5a3bd2e5-48c5-4736-86f9-3c509c363f0e	But the experiences of a few years ago„ when in dry, hot years about 200 or more children died during the first year of life for every 1,000 children born, will probably not be repeated. The educational measures, together with the improved steps in sanitary administration which have been adopted and carried out, are producing beneficial effects which will overcome the ill effects of adverse climatic conditions. There is no doubt that educational methods in preventing infantile mortality, such as are associated with the work of health visitors, midlives, &c., are of very great value, and should be continued and encouraged in every possible way. But unlessthese inquiries are assisted vigorously by efficient sanitary measures, these educational measures will probably be of small avail. Last year at all ages 98 deaths occurred from Diarrhoea and Enteritis, as compared with 29 from Diarrhoea, Enteritis and Gastritis in 1910.
af8d7026-4355-49d7-ab82-e876af9cc552	It is rather difficult to institute a comparison between this year's figures and those of earlier years, as considerable alterations have been made in the Tables issued by the Local Government Board. Up to the end of 1910 the 46 Diarrhceal diseases were included in three separate columns— Epidemic Diarrhoea, Enteritis and Gastritis. Last year, following on the adoption of the International List of Causes of Death, the heading was altered to Diarrhoea and Enteritis. The age periods were also altered last year. Formerly, the tables were divided into the columns under 1 year and 1—5 years; last year the columns were under 1 year, 1—2 years and 2— 5 years.
0cb80ce9-0646-4aa4-a28b-3e0731dbfd3d	Throughout the kingdom it is necessary to go back to 1899 to find a year with a higher total number of deaths from Diarrhoea and Enteritis, but in Acton 80 deaths of infants under one year occurred in 1906 from Diarrhceal diseases. Last year, out of the total number of deaths from Diarrhoea and Enteritis, 68 were of children under 12 months. Summer Diarrhoea is now believed by many authorities to be an infectious disease capable of spreading from the sick to the healthy. Undoubtedly, multiple cases do occur in houses and families. Last year in Acton there was no multiple death in any houses, but it was found that the fatal case investigated had been preceded or followed by the occurrence of Diarrhoea in other members of the family. Multiple attacks were known to have occurred in 64 houses.
30a899f9-7fd6-4f7e-a644-8bbfed8d2d6f	Whether summer Diarrhoea is produced by one definite micro-organism, or is an illness conditioned by several allied bacilli is doubtful; if the latter theory be true, then all these organisms are capable of exciting acute Diarrhoea in infants and of causing a disease which pursues a very definite cause. A few years ago it was considered to be due to a microorganism which resided in the superficial layers of the earth. The micro-organism was supposed to have the power of leaving the soil, to be carried in by the air, gain access to food and to be introduced into the human body. 47 According to Dr. Ballard's report to the Local Government Board on the subject, "from food, the micro-organism can manufacture a substance which is a virulent chemical poison, and this chemical substance is in the human body the material cause of epidemic summer Diarrhoea."
ebfff8de-c2f0-401e-a4e2-0de7c43308b8	The development and multiplication of the micro-organism depended on a high temperature, not in the air itself, but in the superficial layers of the soil. The rise in the Diarrhoea death rate does not begin until the average weekly temperature of the thermometer (suspended in an iron tube 4ft. deep in the earth) has reached 56°F. This takes place about a week later than in the air. Taking this into consideration, and that death occurs usually in a week or a fortnight after the onset of the disease, it will be observed that the relationship of the commencement of summer Diarrhoea with the temperature recorded at a point 4ft. below the surface of the earth, is corroborated by the following table, although the opinion is not now held that this is due to the growth of a micro-organism in the soil as described by Dr. Ballard.
3693a82b-e973-4969-9c11-ea823dc9a698	Deaths of Deaths Week Mean reading Rain- infants under from Diarrhoea ended, of Thermometer, fall. 1 year in London. in Acton. July „ „ „ „ Aug „ 1st 8th 15th 22nd 29th 5th 12th 57.5°F. (-4) 65.6°F. (x3.5°) 65.2°F. (2-3°) 69.5°F. (x6.2°) 71°F (x8.4°.) 68°F. (x5°) 72.5°F. (10.1°) .50in. nil nil nil .26in. .06in. nil 149 144 159 150 173 304 462 nil nil 1 1 3 6 4 48 Week ended. Mean reading of Thermometer. Rainfall.
9a237c52-1410-43f6-963a-8b99db316f80	Deaths of infants under 1 year in London. Deaths from Diarrhoea in Acton. Aug. 19th „ 26th Sept. 2nd „ 9th „ 16th „ 23rd 69.4°F. (x7.2°) 63.9°F ( ) 65.3°F. (x5.2°) 66.9°F. (x7.7°) 60 3°F. (x2.4) 54.3°F. (_1.9°) .58in. 636 .29in. 705 .41in. 712 .0lin. 622 .41in. 555 .48in. 442 14 14 11 10 6 2 With regard to the mean temperature, it is compared with the week's average in the 65 years ended 1905. X means above the average; — means below the average.
d7d60495-2033-471c-9e76-266a1fc9484d	Although it is generally accepted that summer Diarrhoea is in the large majority of cases due to bacterial infection, there is no certainty as to the sources of infection. The most important vehicle of infection undoubtedly is milk. Infants artificially fed are much more exposed to infection than breast-fed infants, partly on account of the greater opportunity whereby milk, other than from the breast, can be contaminated. Of the 68 deaths that occurred, 4 were breast fed and 64 were artificially fed. Professor Delapine adduces evidence showing that-milk, as it arrives from a distance in towns, may have much to do with the spread of the disease. This is very doubtful, and the evidence in this district does not suggest the theory.
5b91dca7-58f8-4656-a8c2-ef135c2b43e4	The source of the milk supply in the South West Ward is not very different to that in the other wards, but out of the .68 deaths from Diarrhoea and Enteritis 33 were in the South-West Ward, 13 in the North-East, 12 in the South-East and 10 in the North-West Ward. 49 Dr. Newsholme, on the other hand, from the observed facts in connection with breast-fed children, with infants fed on condensed milk, and from a comparison of the fatality experienced by infants fed on milk produced near the town, came to the conclusion that the infection was domestic. In support of the latter view, it may be pointed out that diarrhceal mortality does not rise in June and early in July, notwithstanding the exposure of outside milks to high temperature.
d83bc080-abf0-4a13-8c16-ef91314bba32	Of the 64 artificially-fed infants who died in Acton last year, 27 had cows' milk, 23 had condensed milk, 4 had patent foods, and 10 had cows' and condensed milk. In connection with domestic infection, a good deal of attention has recently been paid to the possibility of conveyance of infection by the common housefly. Many observers maintain that flies are important factors in causing summer Diarrhoea, and in support of their argument state that:— 1. Houseflies are present in great numbers in houses prior to primary attacks of Diarrhoea in infants, although not in all. 2. Houseflies have been shown, by means of bacteriological examination, to convey infection. 23 illegitimate children died under the age of 12 months. This corresponds to an infantile mortality of 535 per 1,000 illegitimate births. NOTIFICATION OF BIRTHS ACT, 1907.
895a6e4c-cb2c-45ec-92ee-14b834955f5a	One thousand four hundred and sixty nine births and 28 still births were notified during the year 515 were notified by doctors, 782 by midwives and 200 by one of the parents. 50 In 30 instances a birth was notified by both the doctor and the father, and in 25 instances by the doctor and the midwife. 74 births were registered that had not been notified within the statutory period. 71 per cent, of the births notified were visited. Of the infants visited, 96 died within twelve months of their birth TUBERCULAR DISEASES. There were 51 deaths from Phthisis or Consumption of the Lung, 6 from Tuberculous Meningitis and 7 from other Tuberculous diseases. 44 of the deaths were registered in the district, and the remaining deaths occurred in Public Institutions outside the district. Of the deaths from Pulmonary Tuberculosis, 22 were of males and 29 of females.
89bc41be-1eda-423b-8c11-db9f7a99f929	46 of the patients who died of Phthisis were over 15 years of age, and prior to their attack of illness were employed as follows:— Males. General Labourer Laundryman Carpenter Furniture Remover Clockmaker Draper's Porter Quartermaster Merchant Service Bricklayer Clerk Females. 3 Household 16 3 No occupation 3 1 Cookery Teacher 1 1 Dyer's Presser 1 1 Cook 1 1 Domestic Service 1 Confectioner's Assistant 1 1 1 Draper's Assistant 1 1 Laundress 1 51 Males. Commercial Traveller 1 Music Engraver 1 Cook 1 Electrical Engineer 1 Builder 1 Bootmaker 1 Draper 1 It was pointed out in previous reports that one of the chief obstacles in dealing with Pulmonary Tuberculosis is the difficulty of obtaining information of the early cases.
1bc930c0-e3c0-4bd6-a26d-d3e061692bc0	An important step has been taken in this direction by the adoption of compulsory notification of all cases of Pulmonary Tuberculosis. In 1908 the Local Government Board issued regulations for the notification of cases of Pulmonary Tuberculosis occurring amongst the inmates of Poor Law institutions or amongst persons under the care of district medical officers. In March, 1911, 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 contributions of the patients and otherwise than from the rates and taxes. In November, 1911, the Board issued regulations for the general notification of Pulmonary Tuberculosis, and after January 1st, 1912, it will be the duty of every medical practitioner to notify every case of Pulmonary Tuberculosis occurring in the course either of his public or his private practice.
f148ee8a-fa07-4c20-96a3-fd346bf8817e	A system of voluntary notification has been in force in the district since 1904, and 8 cases were notified last year by doctors under this system; 35 cases were notified under the Tuberculosis Regulations, 1908, and 41 under the Tuberculosis Regulations of March, 1911. 52 52 Seven persons were treated in the Council's beds at Northwood Sanatorium. COUNCIL LABORATORY. 607 examinations were made during the year, and the follow ing table gives a statement of the work done:— ]Disease. Nature of Specimen. Result. Positive. Negative. Total Diphtheria Swabs from nose and throat 207 380 587 Tuberculosis Sputum 2 2 Ringworm Hair of Scalp 9 9 18 216 391 607 CANCER. 52 deaths occurred from Cancer or Malignant Disease.
c765b494-5789-493e-9574-58eb0d0b4f63	This is exactly the same number as occurred in the years 1910 and 1909. The ward distribution of the disease was as follows :— North-East Ward 14 North-West Ward 16 South-East Ward 10 South-West Ward 12 INQUESTS. 40 Inquests were held, the causes of death being:— Heart Disease 7 Cerebral Haemorrhage — 4 Pneumonia 5 Convulsions 3 Tuberculosis 1 Spasm of bowel 1 Meningitis 2 Enteritis 2 Distention of the stomach 1 Overlaying 4 Suicide 3 Accidental burns 3 Wound in throat 1 Fractured neck 1 Fractured ribs 1 Run over by a taxi-cab 1 53 MORTUARY. 42 bodies were removed to the Mortuary; in 40 of these an inquest was held. The other bodies were removed to the Mortuary on account of insufficient accommodation in the house where the death occurred.
1e4c0598-6282-42e1-9671-6132c7d87d8f	31 post-mortem examinations were made. OFFENSIVE TRADE. There is only one offensive trade carried on in the district, viz., fat extraction. SLAUGHTER HOUSES. There are two licensed and one registered slaughter houses in the district. In the latter, slaughtering is very rarely carried on. In one of the slaughter houses, only pigs are slaughtered. In the other, sheep, and occasionally oxen, are slaughtered there. Complaints were received in respect of one of the slaughter houses, but as the complaints had reference mainly to the position of the slaughter house, the Council renewed the license. Both the slaughter houses have been regularly visited during the times of slaughter, and the following were surrendered:— 19 pigs' plucks. 14 ,, heads. 2 ,, spleens. UNSOUND FOOD.
7b6fe2dd-7275-4e37-b811-3ec2111e2fc0	In addition to the meat surrendered in the slaughter houses, the following articles were also destroyed as unfit for human consumption:— 54 1 boar's head 1 case of fresh herrings 1 bushel of pears 1 bag of winkles 10 boxes of kippers 9 bags of walnuts 3 pigs' heads 1 pig's pluck and spleen 1 pork pie DAIRIES AND COWSHEDS. There are two cowkeepers and 80 purveyors of milk in the district. There were 17 changes of occupation and 2 new premises were registered. All these premises are regularly visited, and every endeavour is made to induce the purveyors of milk to adopt precautions for the prevention of contamination. In some instances it is very difficult to keep the milk clean, especially in those shops where paraffin, wood, &c., are also sold. ISOLATION HOSPITAL. During the year 275 patients were admitted.
dbb01bd3-a66e-463f-b7dd-80be27915c57	On January 1st, 1911, there were 21 patients under treatment, and on January 1st, 1912, 54. Two of the nurses contracted Scarlet Fever, and one Diphtheria. Diphtheria. 86 cases of Diphtheria were admitted, and there were 9 deaths. 55 Scarlet Feveb. 185 cases of Scarlet Fever were admitted, and there were 5 deaths. Enteric Feveb. 4 cases of Enteric Fever were admitted, and there was no death. It will at once be seen to what an extent the accommodation at a fever hospital must differ from that of an ordinary hospital, when it is stated that over 57 per cent, of the cases were admitted during the four months September to December, and over 46 per cent, of the cases admitted during the three months October to December.
10c5bcf9-49ff-4dd3-a54d-e2577377d217	The average number of beds in occupation throughout the year was 33-6, but it varied from 14 in June to 72 in November. It is usual to find the number of fever cases increasing in the autumn. In September the average number of beds occupied was 30, in October it rose to 47, in November to 72 and in December the average number was 60, During the earlier three-quarters of the year, in only two months did the average number of beds in occupation rise above 30, viz., in May with 31 and in March 33. The new pavilion was opened for the reception of patients last October, and there is now accommodation at the Hospital for 73 patients. The new pavilion has accommodation for 36 patients, and it is divided into two wards of 18 and 16 beds respectively, and two separation wards each with accommodation for one patient.
d5447eaa-d00d-4cb7-b8b8-76836b34ca50	Leading out of each ward in the centre of the building is a bathroom, and at the extreme end of each ward are the annexes containing the water-closets, sinks, &c. Between the two wards and overlooking them and the separation ward is the nurse's kitchen, 56 The walls of the building are formed with 4in. clinker concrete of slabs rendered outside with cement and washed sand, and the floors are formed with 9in. clinker cement concrete and covered with Newoleum Patent composition Flooring fin. thick. The walls are ceiled at the level of the wall plates with fibrous plaster set in Keen's cement, and the inside of the wall is rendered in Serapite. The cost of the building itself was £4,159, or 4-66 pence per cubic foot. The building is heated with hot water on the low-pressure system, and the steam for heating the water in a calorifier is conveyed from the refuse destructor.
3a87aa66-2117-42db-b3fb-ffc53f3eb44d	In each ward there are also Shorlands ward-ventilating stoves, but these are only used when it is inconvenient to heat with steam. The cost of the heating apparatus was £668. COMMON LODGING HOUSE. There is only one common lodging house in the district. REFUSE COLLECTION AND DISPOSAL. The whole of the refuse of the district is collected by direct labour once a week, including trade refuse up to half a load from each building. The house refuse is destroyed in the Council's Refuse Destructor. Last year, 11,600 tons of house refuse and 1,300 loads of laundry clinker were collected and destroyed. SEWAGE DISPOSAL. A description of the Sewage Works has been given in previous reports. The whole of the sewage is removed into the London 57 sewers. The flood water, after proper treatment, is discharged into the Thames. CERTIFICATE FOR EXEMPTION FROM INHABITED HOUSE DUTY.
23517f3e-72a5-4a45-a87c-9ed0f0b745cf	Applications were received under the Customs Inland Revenue Acts in respect of 77 houses. Certificates of exemption were signed for 53 houses and refused for 24. HOUSING. Under Section 17 of the Housing, Town Planning, &c., Act, 1909, it is the duty of every Local Authority within the meaning of Part II of the Housing of the Working Classes Act, 1890, to cause to be made from time to time inspection of their district, with a view to ascertain whether any dwelling house is in such a state so dangerous or injurious to health as to be unfit for human habitation, and for that purpose to comply with such regulations and to keep such records as may be prescribed by the Board.
7b390f4c-4275-4124-b464-698ee0e8c370	The Local Government Board have issued an Order making Regulations with respect to the manner in which this section shall be carried out, and with respect to the records to be kept of such inspection,' During the year the Sanitary Staff has made a big effort to cope with the Housing Regulations of 1910, and 800 houseto-house inspections were made. These, of course, are in addition to the inspections which were made as a result of complaints, in the investigation of infectious disease, &c. A full list of all the inspections is given on tbe tables prepared for the County Medical Officer of Health. The following table gives a list of the streets, together with the number of houses inspected, and the principal defects found on inspection :— 58 HOUSE-TO-HOUSE INSPECTIONS, 1911. (wire made in following streets.) Nature of Sanitary Defect.
99d69f87-a42e-47a4-bfae-91c444418618	Antrobus Road Acton Lane (Basement Houses only) Burlington Mews Berrymede Road (Basement Houses only) 1 Beaconsfield Road isoiio nriage Koad (East End) Cheltenham Place (West Side^ Cunnington Street Clovelly Road (South Side) Chiswick Road Friars Place Lane Gloucester Road Gladstone Road Horn Lane Junction Road Ley the Road (North) Meon Road Nelson Place. No. of Houses Inspected 6 4 12 6 55 49 9 40 30 30 6 31 48 19 13 23 20 16 No.
df901849-1e58-4dad-8b73-7ab14b837fb9	of Tenements 11 8 12 13 56 54 9 49 32 31 6 44 48 22 73 46 40 24 Cases of Overcrowding — — — — — — — 1 4 — — — — — 7 — — 6 Defects of Drainage System 12 4 3 3 39 28 3 19 13 7 13 8 37 36 1 20 19 12 Defective or want of Yard Paving 6 4 — 2 32 12 9 18 14 15 3 14 18 2 4 3 7 16 Defective w.c.'s (including appliances) 2 2 6 5 7 6 8 9 1 11 3 7 7 3 2 2 22 6 Untrapped R.W.
325b704f-aa45-402d-9f0d-99de7c6020e3	Pipes 6 1 — — — 6 — — — 5 2 — — 4 — 11 — Dampness — 4 8 3 16 — 9 y 2 1 — 14 7 3 — 2 16 10 Dirty Walls and Ceilings of Rooms 3 6 26 11 29 6 7 9 51 13 — 24 15 9 11 8 20 29 Defects of Drinking Water Storage — 2 5 4 — 9 2 4 4 — 2 2 2 13 1 13 6 — Defective Sinks and Waste Pipes 6 2 2 3 21 5 8 29 3 24 8 22 14 30 8 19 8 26 Miscellaneous Defects (Sites, Floors, Roofs, Plastering, R.W.
26cf90bc-4446-428b-855e-42075f7498d7	Pipes, Gutter, &c. 5 6 11 14 13 4 13 22 48 14 5 11 16 20 4 13 16 34 59 HOUSE-TO-HOUSE INSPECTION, 1911—continutd. Nature of Sanitary Defect. N'emoure Road (North Side). Old Oak Lane Petersfield Road (East Side) Priory Road (Basement Houses only) Park Road North Richards Cottages Stanley Gardens Steyne Road Saville Road (Basement Houses only) Silver Crescent (West Side) South Parade (Sussex- Cottages) Shaftesbury Road (Tenement Houses) Strafford Road St. Margaret's Road Thorneyhedge Road Wolesley Terrace Willesden Lane TOTALS. No.
6a5770f0-4318-4cf1-8b2b-38263e130b0e	of Houses Inspected 10 14 46 7 36 25 61 10 5 33 4 6 60 16 27 18 5 800 No. of Tenements 11 14 47 21 46 25 83 18 11 33 4 18 84 48 27 31 6 1104 Cases of Overcrowding — — 5 — — 1 9 2 2 — 1 2 — — — — — 40 Defects of Drainage System 22 10 43 1 28 1 31 10 — 2 — 3 27 11 4 2 13 485 Defective or want of Yard Paving 6 0 27 6 IS 5 39 7 — 5 4 — 28 13 4 9 — 353 Defective w.c.
8644d641-485e-4f2f-9c01-087695285735	's (including appliances) 12 s 23 7 6 12 47 3 — 5 — 4 14 10 1 — 1 255 Untrapped R.W.
099338c3-a1b9-4fd3-a759-f535752199af	Pipes 3 — — 1 6 — — — — 1 2 — 7 — — — 1 56 Dampness 7 3 7 3 — 13 30 4 3 — 4 6 9 7 — — — 200 Dirty Walls and Ceilings of Rooms 8 6 122 48 6 17 102 6 2 — 4 16 34 23 — 6 — 675 Defects of Drinking Water Storage 4 1 3 3 9 3 39 1 — 4 4 2 10 12 5 4 — 173 Defective Sinks and Waste Pipes 16 9 47 16 5 32 32 8 1 1 4 3 33 13 3 1 7 469 Miscellaneous Defects (Sites, Floors, Roofs, Plastering, R W. Pipes,Gutter.
5d497b65-9924-403a-b72e-fab35ad28b52	&c. 13 17 79 37 4 39 78 21 5 1 25 31 22 9 2 6 9 667 60 The following houses were represented as unfit for human habitation during the year:— Nos. 71, 72, 73 and 74, South Parade. These houses consisted of two rooms and a scullery each. The houses were old and in a generally dilapidated condition. The houses were closed and demolished by the owner. Nos. 7, 9, 13, 15 and 17, Priory Road. The basements of these houses were let in separate tenements. The basements were all in a bad state of repair, the woodwork being defective and the walls damp. Extensive work was carried out, and the basements were rendered fit for human habitation. Talbot Cottage, Mill Hill Road.
d041564c-9a98-44cd-80a9-891d2788fa5d	This house was not originally intended for a dwelling house but a portion of some outhouses had been converted. The house was closed by the owner. Nos. 17 and 19, Gunnersbury Lane. These two houses were old and showed signs of decay. Structural work is being carried out by the owner, so as to render the houses fit for human habitation. Nos. 7, 8 and 9, Narrow Street, Steyne. These houses are also old and dilapidated, and the owners are carrying out extensive structural work for the purpose of Tendering the houses fit for human habitation. FACTORIES AND WORKSHOPS. The Factory and Workshop Acts places upon the local authority the following duties relating to— 61 A. Factories. 1. Provision of means of escape in case of fire. 2. Enforcing the provision of suitable and sufficient sanitary accommodation. B. Workshops and Workplaces. 1.
dad54553-9b38-4c0e-bb7c-d3389abceaf5	Sanitary condition, including (a) cleanliness, (b) air space, (c) ventilation, (d) drainage of floors and (e) sanitary accommodation. 2. Provision of means of escape from fire in workshops. 3. Special sanitary regulations of bakehouses. 4. Home work. The provision of means of escape in case of fire is dealt with by the Surveyor's Department. The number of workshops on the register at the end of 1911 was 333. This is a reduction of 84 on the number on the register in 1910. This reduction is due to the smaller number of workshop laundries on the register. During the inspections made in the year, inquiries were made as to the provision of any mechanical power, and wherever any mechanical power of any kind was used the premises were deleted from the workshop register. Since the registration of the premises as workshops a large number of laundries had installed mechanical power.
99b4361b-9e41-4746-a958-f0ae9900f665	592 inspections were made during the year, and 352 notices were served. In conclusion I have to thank the Staff of the Health Department for their co-operation during the year, and for their assistance in the compilation of the different Tables. As in former years, the County Council Tables have been compiled entirely by Mr. Kinch. The accuracy of the County 62 Council and Home Offices Tables depends upon the excellent system upon which the records are being kept in the Sanitary Inspector's Office. I remain, Your obedient Servant, D. J. THOMAS. 63 TABLE 1. VITAL STATISTICS OF WHOLE DISTRICT DURING 1911 AND PREVIOUS YEARS. Year. Population estimated to Middle of each Year. Births. Total Deaths Registered in the District. Transferable Deaths. Nett Deaths belonging to the District Under 1 Year of Age. At all Ages Uncorrected Number. Nett. Number. Rate.
0c000bd3-af06-4b2e-b9ab-9075bd440b72	of Non - residents registered in the District. of Residents not registered in the District. Number. Kate per 1.000 Nett Births. Number, Rate. Number. Rate. 1 2 3 4 5 6 7 8 9 10 11 12 13 1906 52,000 1,533 . 29.4 597 11.5 7 97 201 131 687 13.2 1907 53,000 1.535 . 29 605 11.4 8 140 200 130 737 13.9 1908 55,000 1,568 . 28.5 592 10.7 1 133 188 120 724 13.1 1909 56,000 1,480 . 26.4 575 10 3 1 137 158 106 708 12.
f44ca7bd-1105-4781-993c-e7f0c3ae3e66	6 1910 57,000 1,475 . 25 9 509 8.8 2 116 151 102 623 10.9 1911 58,048 1,458 1,486 25 6 602 10.3 3 178 205 138 777 13 3 Area of District in Acres (exclusive of area covered by water), 2,304. Total population at all ages, 57.523: 64 TABLE 2. CASES OF INFECTIOUS DISEASE NOTIFIED DURING THE YEAR 1911. Notifiable Disease Cases notified in whole District. Total cases notified in each ward. Total cases removed to Hospital. At all Ages. At Ages—Years. North-East' North.West South-East \| South-West Under I. 1 to 5.
e3718df8-b91f-4186-b2c1-9b8151229c30	5 to 15 15 to 25 25 to 45 45 to 65 65 & upwards Small-pox . . . . . . . . . . . . . Cholera . . . . . . . . . . . . . Diphtheria (including Membranous croup) 115 3 30 67 6 8 1 . 20 25 38 32 85 Erysipelas 37 2 1 3 2 10 13 . 8 6 9 14 Scarlet Fever 234 2 61 131 24 15 1 . 38 27 66 103 183 Typhus Fever . . . . . . 2 . . . . . . Enteric Fever 17 . . 10 . . 2 . . 3 . 14 12 Relapsing Fever . . . . . . . . . . . . . Continued Fever . . . . . .
fa4e81a4-f438-4f97-bbc2-d749b0789c55	. . . . . . . Puerperal Fever 3 . . . . 3 . . 1 . . 2 . Plague . . . . . . . . . . . . . Phthisis Under Tuberculosis ReguI lations, 1908 35 1 . 3 1 17 13 . 6 3 6 20 20 Under 1 uberculosisRegulations, 1911 41 . . 3 11 23 4 . 7 6 15 13 19 OTHERS 8 . . 1 2 5 . . 2 2 4 5 Totals 490 8 92 218 48 84 34 6 82 72 134 202 321 Isolation Hospital Name and Situation Friar's Place. Total available beds, 73. NMmber of Diseases that can be concurrently trpnted, 3. 65 TABLE 3.
e1a068d2-c0f3-42dc-a085-36b43582a7e5	CAUSES OF. AND AGES AT. DEATH DURING YEAR, 1911. Causes of Deaths Nett Deaths at the subjoined ages of " Residents," whether occurring within or without the District. Total Deaths whether of "Residents" or " NonResi dents" in Institutions in the District. All Ages. Under 1 year. 1 and under 2. 2 and under 5 5 and under 15 15 and under 25 23 and under 45 45 and under 65 65 and upwards Enteric 4 — — — 1 — 3 — — Small-pox — — — — — — — — — — Measles 44 12 14 16 2 — — — — — Scarlet fever 6 — 1 3 2 — — — — 5 Whooping-cough 16 5 3 1 1 — — — 1 Diphtheria and Croup 9 — —
70ca145a-c81e-488a-b996-6a4aa8d42275	6 3 — — — — 9 Influenza 5 — — — 1 — 1 2 1 — Erysipelas 2 — — — — — — I 1 — Cerebro-Spinal Fever — — — — — — — — — — Phthisis (Pulmonary Tuberculosis) 51 2 — 1 2 12 21 12 1 — Tuberculous Meningitis 6 1 9 2 1 — — — — 1 Other Tuberculous diseases 7 4 1 — — — — — — — Rheumatic Fever 5 — — — 1 1 2 1 — — Cancer, maglignant disease 52 — 1 — — 3 22 L'6 3 Bronchitis 58 12 — — — 3 17 26 — Broncho-Pneumonia 22 8 5 3 1 1 2 1 1
24822eb9-c1e4-4287-87c5-66372f07e8c9	1 Pneumonia (all other forms) 31 6 4 2 3 — 3 10 3 1 Other diseases of Respiratory Organs 6 — 2 1 — — 2 1 — — Diarrhoea and Enteritis 98 68 21 4 — — — 1 4 — Appendicitis and Typhlitis 5 1 — — 2 1 1 — — — Alcoholism — — — — — — — — — — Cirrhosis of Liver 8 — — — 1 7 — — Nephritis and Bright's Disease 15 — — 1 1 1 2 5 5 1 Puerperal Fever — — — — — — — — — Other accidents and Diseases of Pregnancy and Parturition 3 — — — — — — — — — Congenital Debility and Malformat'on,
72ee6445-3271-4d42-b647-4af751d4a872	including Premature birth 62 60 2 — — — — — — — Violent Deaths, excluding Suicide 22 5 1 4 3 2 3 2 2 4 Suicides 3 — 2 1 — — Other defined diseases 236 19 9 2 8 9 29 60 100 7 Diseases, ill-defined or unknown 1 1 — — — — — — — — All causes 777 205 67 49 34 28 81 143 170 33 66 TABLE 4. INFANTILE MORTALITY DURING THE YEAR, 1911. Deaths from stated causes in Week and Months under One Year of age. Cause of Death. 1' nder 1 weekl 1-2 weeks. weeks. 3-4 weeks. Total under 1 month. 1-3 months. 3-6 moathS. 6-9 months.

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