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Public Health.
567 of Ruthven to provide for its patients under private care. Another Commissioner describes interesting cases of improvement in the mental state of patients in private houses arising from circumstances which could only occur under that mode of care. It is interesting to note that the lunatic wards of poorhouses are inspected by the Board, and on the whole the impression derived from the report thereon is a favourable one. __
Public Health. ANNUAL REPORTS OF MEDICAL OFFICERS OF HEALTH.
The City of London.-Dr. William Collingridge begins his ninth annual report in a retrospective and comparative vein, and he takes us back 60 years, to a time when Sir John Simon, the first medical officer of the City, was calling attention in his graphic and forcible style to the need for a better water-supply in these words : " In the City of London the supply of water is a fraction of what it should be. Thousands of the population have no supply of it to the houses where they dwell. For their possession of the first necessity of social life such persons wholly depend on their power of attending at some fixed hour of the day, pail in hand, beside the nearest stop-cock, where, with their neighbours, they wait their turn--sometimes not without a struggle-during the tedious dribbling of a single small pipe." And Dr. Collingridge might, if he wished to do so, describe the gradual sweeping away of the shallow wells, the progress and disestablishment of the old water companies, the creation of the Metropolitan Water Board, and, curiously enough, the sinking of private wells right down into the chalk of the London basin, for no other reason than that it was found cheaper to do this than pay the charges of the Water Board. Dr. Collingridge states that a considerable number of artesian wells have recently been sunk in the City, and that more are in contemplation ; the water yields on analysis excellent results. Sir John Simon’s description of the housing conditions in the City only 60 years ago 11 seems to us in these days little short of appalling. It ,is no uncommon thing in a room 12 feet square or less to find three or four families styed together (perhaps with infectious diseases among them), filling the same space night and day-men, women, and children in the promiscuous intimacy of cattle." The night population of the City in 1901 was 26,923, but there was no day census taken at that time, and Dr. Collingridge is hoping that there will not be a similar omission in 1911, since he rightly regards it as essential that the number of persons for whose well-being during their working hours the Corporation takes such an active interest should be officially ascertained. It may be added that the cost of taking the last day census was
deeply as to make it hard to eradicate." At the instance of the Corporation, in conjunction with the Chamber of Commerce, an investigation into tinned meats was made by three bacteriologists-Dr. W. Bulloch, Professor R. T. Hewlett, and Dr. Klein-the samples being taken by Dr. Collingridge and sent to each of the bacteriologists. The results in many cases were unsatisfactory, as all three of the investigators, two of whom were appointed by the Chamber of Commerce, reported that a considerable proportion of the samples were not sterile. In connexion with this question of tinned foods Dr. Collingridge made praiseworthy efforts to bring about the marking of New Zealand tinned foods in such a manner as to indicate when and where they were packed, and it is much to be hoped that he will be as successful in his efforts as he has been in dealing with the soda-water industry in the City. In this case he has succeeded in inducing the trade to accept regulations and to obtain certificates as to the sanitation of their premises and the bacteriological purity of their products. Much useful information will be found in this report as to meat-supplies during 1908. The City of -B:?’M!M/m.—The general death-rate of this city, with its estimated population of 558,357, was for 1908 only 15-9 per 1000, which is the lowest death-rate ever recorded, the corresponding rates for Glasgow being 17’7, Liverpool 19’2, and Manchester 18-2. Dr. John Robertson gives, however, reasons for concluding that the methods adopted by the Registrar-General in estimation of populations over-estimates the people of Birmingham by some 25,000 to 30,000. The central portion of the city is decreasing steadily in population, a large number of people seeking the suburbs beyond the city boundaries as being more wholesome and generally pleasanter ; perhaps, too, it is cheaper. But one result of this wholesome change is that a large number of people, who during the day earn their livelihood under the protection of Birmingham corporation reside in districts beyond its operations, and Dr. Robertson foresees, if the present drift continues, as it assuredly will, a condition of affairs not unlike that of London, where there is, he says, much overlapping of authorities. He trusts that some means will be found to prevent a similar occurrence in
Birmingham. a
town such as
In his opinion there is a well-defined area for Birmingham, and he suggests that a radius of
five miles from the centre of the town might, now that the means of communication have so greatly improved, be taken as a convenient limit. Possibly Dr. Robertson is contemplating a scheme which would extend the city limits to this limit, and if so, and if this extension is allowed, there will soon be a very great increase of the population of what will then be called Birmingham. But Parliament seems somewhat shy of these great extensions, as was shown in the case of Liverpool when she sought to swallow up Bootle. But Parliament and ideas are apt to change. To turn, however, to less debateable points, there is much of interest in the report before us, and the figures relative to the isolation hospital are instructive. Of the cases admitted into the hospital with a certificate of scarlet fever 145, or 7 per cent., were eventually found not to be suffering from this disease, and it seems that of these 145 cases no fewer than 45 contracted the disease, of whom 18 per cent. died. This is a sufficiently serious matter, and it raises questions as to whether there should not be diagnosis at home before The large number of removal by a recognised expert. erroneous diagnoses in 1908 seems to have been in great In the case measure due to an epidemic of German measles. of diphtheria 44 out of 510 admissions were wrongly diagnosed, but fortunately none of them contracted diphtheria in hospital-a fact which may be partly explained by the lower infectivity of the disease and partly by the fact that each patient certified to be suffering from diphtheria is placed in a separate ward until the diagnosis is confirmed or negatived. Apparently this is not so with patients certified to be suffering from scarlet fever, and such isolation accommodation would have to be upon a very large scale. But omission to provide a large number of small wards is certainly the strongest criticism which can be directed against isolation hospitals generally, although the cost of their provision in adequate numbers would be almost prohibitive. However, there is a reasonable mean in all these cases. As regards the antitoxin treatment of diphtheria, it appears that it is not resorted to as much in the poorer better circumstanced districts in spite of as in the the fact that the University provides supplies of antitoxin.
568
enough
to enable it to be insured for a considerable sum The incidence of enteric fever was lower in 1908 than in any in the early morning hours. Of the number of infants previous year, but the disease amongst the cases which were notified was of a distinctly severe type with a fatality-rate of born in 1907, 80-6 per cent. were insured, as against, 25 - 4 per cent. The death-rate from this disease was 0’ 09 per 72’ 1 per cent. of those born in 1908. 1000 as compared with a death-rate from "fever " in England Metropolitan Borough of Woolwich.-The Plum stead well and Wales of 0 07 per 1000. Norwich yielded a death-rate of of the Metropolitan Water Board appears to be yielding 0 - 29 and Wigan of 030 per 1000. The greater part of enteric a water unduly high in chlorine and of considerable hard. fever in Birmingham is attributed by the medical officer of ness, but it is found that by reducing the rate of pumping health to filth nuisances in connexion with the pan-closets, the chlorine has been reduced from 10 to 6 parts per which were at one time found in every back-yard and which 100,000. The water examination committee does not regard were for the first time vigorously attacked in 1903, an attack either the chlorine or the hardness as prejudicial to health, which has been carried on incessantly ever since. Each and the water is, in its opinion, satisfactory both from a year has shown a marked diminution in the number of these chemical and bacteriological standpoint. Question has, howreceptacles, and a coincident decrease in the amount of ever, arisen, as in the case of other wells in estuary valleys enteric fever in the city, in the same fashion as has been the or near the coast, whether excess of chlorine may not be due case in certain other towns where a similar substitution of to insuction of polluted Thames water. Dr. Sidney Davies the water-carriage for the conservancy system of sewage thinks that the Water Board should not be content until it disposal has taken place. In so far as Birmingham is con- has reduced the chlorine in the Plumstead well to the level of cerned, it is an interesting fact that it was not until the the Kent waters, as a well about half a mile from this contains conversion was seriously commenced that a substantial fall only 3. 1 grains per 100,000 of chlorine. Dr. Davies expresses in enteric fever took place. There are still 8000 pan-closets the opinion that the well should be closed until both the left in Birmingham. It has also been found in this city that hardness and the chlorine are reduced to the Kent water a considerable proportion of those who suffer from enteric standard. The council of this borough has for several years fever at certain times of the year have eaten uncooked shell- past sent patients suffering from pulmonary tuberculosis to a, fish shortly before attack, but, of course, the etiological sanatorium near Reading, and Dr. Davies has presented the importance of this fact cannot be gauged until we know after-results in the only fashion which brings out the actual what proportion of the poor population in any given town facts-i. e., he keeps the cases for each year separate from In the case those of others, so that the cases discharged in, say, 1904 are in the habit of consuming these shell-fish. of Birmingham it is thought that uncooked mussels have can be followed up and their condition in January, 1909, probably been an important factor in producing enteric fever, stated. Of 12 cases discharged in 1904 there were in since in the last quarter of 1908 19 cases out of 74 had con1909, seven dead, three working, and two lost sight sumed mussels shortly before attack. The new Birmingham of ; of 16 discharged in 1900, nine were dead, two were sanatorium for pulmonary tuberculosis was opened in working, two alive but not working, and three lost sight of. October, 1908, and an examining physician has been Of those recorded at work a few are employed at the sanaappointed in order to ensure that only favourable cases torium in various capacities, receiving board and a small will be selected, and the medical officer of health entertains wage. Of those lost sight of some are believed to be well hopes that the after-results will compare favourably with and working. those secured elsewhere. VITAL STATISTICS. Connty Boron[Jh of Nort3eampton.-Dr. J. Doig McCrindle of tuberculosis for that 32 cases applied reports pulmonary HEALTH OF ENGLISH TOWNS. sanatorium treatment during the year, and 11 were rejected as unsuitable. As regards the remainder, one went to a IN 76 of the largest English towns 8285 births and 3632 private sanatorium, one or two others refused to accept a deaths were registered during the week ending August 14th. bed, and 11 others were rejected by the medical referee. The annual rate of mortality in these towns, which had Thus only nine survived the tests of one or another kind, been 10 6, 10’ 8, and 10’ 5 per 1000 in the three preceding and of these one obtained a letter of admission through weeks, rose again last week to 11 . 5 per 1000. During the another source, while another was eventually refused by the first six weeks of the current quarter the annual death-rate in sanatorium as too advanced. This is rather a harrowing these towns has averaged only 11.per 1000, the rate in tale of rejection. Seven cases completed treatment London during the same period being as low as 10’7 per during 1908. Dr. McCrindle thinks that sanatorium 1000. The lowest rates of mortality recorded in the 76 towns treatment alone, unaccompanied by rigorous after-care, is last week were 2 ’88 in Leyton, 4’6 in Walthamstow, 5’77 in somewhat disappointing among the poorer classes, and King’s Norton and in Preston, and 5’8 in Barrow-inthis was apparently the opinion of his predecessor, Furness ; the highest rates were 15’7 in Walsall, 15’8in who inaugurated the system and who wrote in 1906 : ’’ The Halifax, 16 - 4 in Swansea, 17-3 in Rhondda, 19 .2 in West results are decidedly disappointing to those who pin their Bromwich, and 23-3 in Newport (Mon.).. In London the refaith to sanatorium treatment, but they illustrate the correct- corded death-rate last week was 11-.3 per 1000, being 1’2per ness of this view put before the sanitary committee, that 1000 above the rate for the previous week. The 3632 deaths amongst the poor sanatorium treatment, unless followed up by in the 76 towns last week showed an increase of 321 over home treatment with sufficient food and outdoor work of not the exceptionally low number in the preceding week, and too severe a character, is likely to prove unsuccessful." Dr. included 413 which were referred to the principal epidemic McCrindle furnishes the after-history of the patients sent to diseases, against 313, 315, and 336 in the three preceding sanatoriums during previous years. At periods varying from weeks ; of these 413 deaths 208 resulted from diarrhoea, 87 13 months to 2 years four months after discharge 11 out from measles, 37 from whooping-cough, 33 from diphtheria, of 23 patients were at work (barely 48 per cent.). Over 32 from scarlet fever, and 16 from"fever"(principally 26 per cent. were dead and the same proportion quite in- enteric), but not one from small-pox. The 413 deaths from capacitated for work. But provision is also made in the these epidemic diseases last week were equal to an annual local isolation hospital for ten advanced cases, the idea rate of 1’3per 1000, against 11 in the preceding week. No being that of segregation. But under the rest and diet death from any of these epidemic diseases was registered obtained at the hospital the patients improve so much that last week in Bradford, Willesden, East Ham, Brighton, or in 14 other smaller towns ; the annual death-rates therefrom they desire to return home. in the J. J. -flele22s.-Dr. St. Buchan, ranged upwards, however, .to 3-2 in West Ham and in 6’oMK!’
even
January,
Public Health. ANNUAL REPORTS OF MEDICAL OFFICERS OF HEALTH.
The City of London.-Dr. William Collingridge begins his ninth annual report in a retrospective and comparative vein, and he takes us back 60 years, to a time when Sir John Simon, the first medical officer of the City, was calling attention in his graphic and forcible style to the need for a better water-supply in these words : " In the City of London the supply of water is a fraction of what it should be. Thousands of the population have no supply of it to the houses where they dwell. For their possession of the first necessity of social life such persons wholly depend on their power of attending at some fixed hour of the day, pail in hand, beside the nearest stop-cock, where, with their neighbours, they wait their turn--sometimes not without a struggle-during the tedious dribbling of a single small pipe." And Dr. Collingridge might, if he wished to do so, describe the gradual sweeping away of the shallow wells, the progress and disestablishment of the old water companies, the creation of the Metropolitan Water Board, and, curiously enough, the sinking of private wells right down into the chalk of the London basin, for no other reason than that it was found cheaper to do this than pay the charges of the Water Board. Dr. Collingridge states that a considerable number of artesian wells have recently been sunk in the City, and that more are in contemplation ; the water yields on analysis excellent results. Sir John Simon’s description of the housing conditions in the City only 60 years ago 11 seems to us in these days little short of appalling. It ,is no uncommon thing in a room 12 feet square or less to find three or four families styed together (perhaps with infectious diseases among them), filling the same space night and day-men, women, and children in the promiscuous intimacy of cattle." The night population of the City in 1901 was 26,923, but there was no day census taken at that time, and Dr. Collingridge is hoping that there will not be a similar omission in 1911, since he rightly regards it as essential that the number of persons for whose well-being during their working hours the Corporation takes such an active interest should be officially ascertained. It may be added that the cost of taking the last day census was
deeply as to make it hard to eradicate." At the instance of the Corporation, in conjunction with the Chamber of Commerce, an investigation into tinned meats was made by three bacteriologists-Dr. W. Bulloch, Professor R. T. Hewlett, and Dr. Klein-the samples being taken by Dr. Collingridge and sent to each of the bacteriologists. The results in many cases were unsatisfactory, as all three of the investigators, two of whom were appointed by the Chamber of Commerce, reported that a considerable proportion of the samples were not sterile. In connexion with this question of tinned foods Dr. Collingridge made praiseworthy efforts to bring about the marking of New Zealand tinned foods in such a manner as to indicate when and where they were packed, and it is much to be hoped that he will be as successful in his efforts as he has been in dealing with the soda-water industry in the City. In this case he has succeeded in inducing the trade to accept regulations and to obtain certificates as to the sanitation of their premises and the bacteriological purity of their products. Much useful information will be found in this report as to meat-supplies during 1908. The City of -B:?’M!M/m.—The general death-rate of this city, with its estimated population of 558,357, was for 1908 only 15-9 per 1000, which is the lowest death-rate ever recorded, the corresponding rates for Glasgow being 17’7, Liverpool 19’2, and Manchester 18-2. Dr. John Robertson gives, however, reasons for concluding that the methods adopted by the Registrar-General in estimation of populations over-estimates the people of Birmingham by some 25,000 to 30,000. The central portion of the city is decreasing steadily in population, a large number of people seeking the suburbs beyond the city boundaries as being more wholesome and generally pleasanter ; perhaps, too, it is cheaper. But one result of this wholesome change is that a large number of people, who during the day earn their livelihood under the protection of Birmingham corporation reside in districts beyond its operations, and Dr. Robertson foresees, if the present drift continues, as it assuredly will, a condition of affairs not unlike that of London, where there is, he says, much overlapping of authorities. He trusts that some means will be found to prevent a similar occurrence in
Birmingham. a
town such as
In his opinion there is a well-defined area for Birmingham, and he suggests that a radius of
five miles from the centre of the town might, now that the means of communication have so greatly improved, be taken as a convenient limit. Possibly Dr. Robertson is contemplating a scheme which would extend the city limits to this limit, and if so, and if this extension is allowed, there will soon be a very great increase of the population of what will then be called Birmingham. But Parliament seems somewhat shy of these great extensions, as was shown in the case of Liverpool when she sought to swallow up Bootle. But Parliament and ideas are apt to change. To turn, however, to less debateable points, there is much of interest in the report before us, and the figures relative to the isolation hospital are instructive. Of the cases admitted into the hospital with a certificate of scarlet fever 145, or 7 per cent., were eventually found not to be suffering from this disease, and it seems that of these 145 cases no fewer than 45 contracted the disease, of whom 18 per cent. died. This is a sufficiently serious matter, and it raises questions as to whether there should not be diagnosis at home before The large number of removal by a recognised expert. erroneous diagnoses in 1908 seems to have been in great In the case measure due to an epidemic of German measles. of diphtheria 44 out of 510 admissions were wrongly diagnosed, but fortunately none of them contracted diphtheria in hospital-a fact which may be partly explained by the lower infectivity of the disease and partly by the fact that each patient certified to be suffering from diphtheria is placed in a separate ward until the diagnosis is confirmed or negatived. Apparently this is not so with patients certified to be suffering from scarlet fever, and such isolation accommodation would have to be upon a very large scale. But omission to provide a large number of small wards is certainly the strongest criticism which can be directed against isolation hospitals generally, although the cost of their provision in adequate numbers would be almost prohibitive. However, there is a reasonable mean in all these cases. As regards the antitoxin treatment of diphtheria, it appears that it is not resorted to as much in the poorer better circumstanced districts in spite of as in the the fact that the University provides supplies of antitoxin.
568
enough
to enable it to be insured for a considerable sum The incidence of enteric fever was lower in 1908 than in any in the early morning hours. Of the number of infants previous year, but the disease amongst the cases which were notified was of a distinctly severe type with a fatality-rate of born in 1907, 80-6 per cent. were insured, as against, 25 - 4 per cent. The death-rate from this disease was 0’ 09 per 72’ 1 per cent. of those born in 1908. 1000 as compared with a death-rate from "fever " in England Metropolitan Borough of Woolwich.-The Plum stead well and Wales of 0 07 per 1000. Norwich yielded a death-rate of of the Metropolitan Water Board appears to be yielding 0 - 29 and Wigan of 030 per 1000. The greater part of enteric a water unduly high in chlorine and of considerable hard. fever in Birmingham is attributed by the medical officer of ness, but it is found that by reducing the rate of pumping health to filth nuisances in connexion with the pan-closets, the chlorine has been reduced from 10 to 6 parts per which were at one time found in every back-yard and which 100,000. The water examination committee does not regard were for the first time vigorously attacked in 1903, an attack either the chlorine or the hardness as prejudicial to health, which has been carried on incessantly ever since. Each and the water is, in its opinion, satisfactory both from a year has shown a marked diminution in the number of these chemical and bacteriological standpoint. Question has, howreceptacles, and a coincident decrease in the amount of ever, arisen, as in the case of other wells in estuary valleys enteric fever in the city, in the same fashion as has been the or near the coast, whether excess of chlorine may not be due case in certain other towns where a similar substitution of to insuction of polluted Thames water. Dr. Sidney Davies the water-carriage for the conservancy system of sewage thinks that the Water Board should not be content until it disposal has taken place. In so far as Birmingham is con- has reduced the chlorine in the Plumstead well to the level of cerned, it is an interesting fact that it was not until the the Kent waters, as a well about half a mile from this contains conversion was seriously commenced that a substantial fall only 3. 1 grains per 100,000 of chlorine. Dr. Davies expresses in enteric fever took place. There are still 8000 pan-closets the opinion that the well should be closed until both the left in Birmingham. It has also been found in this city that hardness and the chlorine are reduced to the Kent water a considerable proportion of those who suffer from enteric standard. The council of this borough has for several years fever at certain times of the year have eaten uncooked shell- past sent patients suffering from pulmonary tuberculosis to a, fish shortly before attack, but, of course, the etiological sanatorium near Reading, and Dr. Davies has presented the importance of this fact cannot be gauged until we know after-results in the only fashion which brings out the actual what proportion of the poor population in any given town facts-i. e., he keeps the cases for each year separate from In the case those of others, so that the cases discharged in, say, 1904 are in the habit of consuming these shell-fish. of Birmingham it is thought that uncooked mussels have can be followed up and their condition in January, 1909, probably been an important factor in producing enteric fever, stated. Of 12 cases discharged in 1904 there were in since in the last quarter of 1908 19 cases out of 74 had con1909, seven dead, three working, and two lost sight sumed mussels shortly before attack. The new Birmingham of ; of 16 discharged in 1900, nine were dead, two were sanatorium for pulmonary tuberculosis was opened in working, two alive but not working, and three lost sight of. October, 1908, and an examining physician has been Of those recorded at work a few are employed at the sanaappointed in order to ensure that only favourable cases torium in various capacities, receiving board and a small will be selected, and the medical officer of health entertains wage. Of those lost sight of some are believed to be well hopes that the after-results will compare favourably with and working. those secured elsewhere. VITAL STATISTICS. Connty Boron[Jh of Nort3eampton.-Dr. J. Doig McCrindle of tuberculosis for that 32 cases applied reports pulmonary HEALTH OF ENGLISH TOWNS. sanatorium treatment during the year, and 11 were rejected as unsuitable. As regards the remainder, one went to a IN 76 of the largest English towns 8285 births and 3632 private sanatorium, one or two others refused to accept a deaths were registered during the week ending August 14th. bed, and 11 others were rejected by the medical referee. The annual rate of mortality in these towns, which had Thus only nine survived the tests of one or another kind, been 10 6, 10’ 8, and 10’ 5 per 1000 in the three preceding and of these one obtained a letter of admission through weeks, rose again last week to 11 . 5 per 1000. During the another source, while another was eventually refused by the first six weeks of the current quarter the annual death-rate in sanatorium as too advanced. This is rather a harrowing these towns has averaged only 11.per 1000, the rate in tale of rejection. Seven cases completed treatment London during the same period being as low as 10’7 per during 1908. Dr. McCrindle thinks that sanatorium 1000. The lowest rates of mortality recorded in the 76 towns treatment alone, unaccompanied by rigorous after-care, is last week were 2 ’88 in Leyton, 4’6 in Walthamstow, 5’77 in somewhat disappointing among the poorer classes, and King’s Norton and in Preston, and 5’8 in Barrow-inthis was apparently the opinion of his predecessor, Furness ; the highest rates were 15’7 in Walsall, 15’8in who inaugurated the system and who wrote in 1906 : ’’ The Halifax, 16 - 4 in Swansea, 17-3 in Rhondda, 19 .2 in West results are decidedly disappointing to those who pin their Bromwich, and 23-3 in Newport (Mon.).. In London the refaith to sanatorium treatment, but they illustrate the correct- corded death-rate last week was 11-.3 per 1000, being 1’2per ness of this view put before the sanitary committee, that 1000 above the rate for the previous week. The 3632 deaths amongst the poor sanatorium treatment, unless followed up by in the 76 towns last week showed an increase of 321 over home treatment with sufficient food and outdoor work of not the exceptionally low number in the preceding week, and too severe a character, is likely to prove unsuccessful." Dr. included 413 which were referred to the principal epidemic McCrindle furnishes the after-history of the patients sent to diseases, against 313, 315, and 336 in the three preceding sanatoriums during previous years. At periods varying from weeks ; of these 413 deaths 208 resulted from diarrhoea, 87 13 months to 2 years four months after discharge 11 out from measles, 37 from whooping-cough, 33 from diphtheria, of 23 patients were at work (barely 48 per cent.). Over 32 from scarlet fever, and 16 from"fever"(principally 26 per cent. were dead and the same proportion quite in- enteric), but not one from small-pox. The 413 deaths from capacitated for work. But provision is also made in the these epidemic diseases last week were equal to an annual local isolation hospital for ten advanced cases, the idea rate of 1’3per 1000, against 11 in the preceding week. No being that of segregation. But under the rest and diet death from any of these epidemic diseases was registered obtained at the hospital the patients improve so much that last week in Bradford, Willesden, East Ham, Brighton, or in 14 other smaller towns ; the annual death-rates therefrom they desire to return home. in the J. J. -flele22s.-Dr. St. Buchan, ranged upwards, however, .to 3-2 in West Ham and in 6’oMK!’
even
January,