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520 PUBLIC HEALTH AND POOR LAW.-VITAL STATISTIOS. done by private charity rather than by official outdoor relief, but possibly something approaching the Elberfeld system of relief, where the money is dispensed by unpaid visitors who are responsible for an economical and productive disposal of the poor-rate funds, might best meet the requirements of these cases. 24 per cent. of all the deaths in Manchester occur in its public institutions, and Dr. Niven thinks that possibly the maintenance of this high percentage represents a diminished aversion on the part of the poor to seek admission to the union hospitals. An increase in the prevalence of diphtheria is taking place in Manchester at the present time, and the medical officer of health is consequently devoting more attention to the subject of its causation and control. During the year a circular was addressed to the medical practitioners urging them, in dealing with suspicious cases, at once to inject antitoxin and not to wait until their suspicions are confirmed by the bacteriolo- gist ; both the syringes and the antitoxin are at the disposal of medical practitioners on application at the town hall. "If," says Dr. Niven, "we could by sufficient promptitude in treatment avert the fatal issue of diphtheria we should be fulfilling one of the aims of the Public Health Act" ; and he considers that it is difficult to see how a medical man can be relieved of responsibility if he fails to save a child under his care suffering from diphtheria, assuming that the fatal issue can be averted by injection of a sufficient amount of antitoxin within the first three days. So strongly does Dr. Niven feel upon this point that during recent months letters have been sent to practitioners when it has been doubtful whether antitoxin has been used. This attitude on the part of a medical officer of health raises some novel and interesting issues and we may add that we are far from antagonistic to the attitude adopted, though it indicates an indi- vidualistic tendency on the part of the public health authorities. It is pointed out in the report before us that diphtheria is largely spread by "carrier and unrecognised cases in schools and elsewhere, and the medical officer of health remarks, "All these are conditions which a sanitary inspector cannot be expected to ascertain or to deal with ; yet to discover them and prevent them from remaining sources of danger is the essence of the prevention of diphtheria " ; and he then pleads both with respect to diphtheria and scarlet fever for the services of a "medical investigator," who would be able to undertake the requisite investigation rapidly and to administer preventive doses of antitoxin when requisite. In Dr. Niven’s view " the power of isolation in hospital to limit the spread or fatality of scarlet fever and diphtheria is but limited and more pre- ventive value could be got, in my opinion, by increasing the staff off the medical officer of health." As regards diphtheria "contacts," he adds : "As for the wholesale isolation of contacts I do not believe it to be practicable here and I am not clear that it is desirable." Much work was done in 1905 on the investigation of enteric fever, a disease which, falling mainly on those Et ages from 10 to 45 years, is of considerable economic importance. The conclusions of the investigators are to the effect that the disease is spread in Manchester largely by failure to recognise the disease, especially in the case of children ; its infective power is "fairly high and this is also particularly obvious in children." In the prevention of the disease skilled inquiry by trained health officers is likely to produce the greatest results at a minimum cost, and Dr. Niven is careful to point out that the best results are not to be obtained by the ordinary routine methods of the sanitary inspectors, useful as they may be. Shell-fish have, we are told, a decided influence in maintaining the prevalence of enteric fever and diarrhoea, in Manchester, and in order that cases thus caused can be properly investigated further powers are necessary for procuring information with reference to the sources of the infected shell-fish. Mussels not properly cooked should not, in his opinion, be used as an article of food. He thinks, too, that probably flies play a part in the spread of enteric fever in August and September, and that therefore steps should be taken towards the destruction of the house-fly and its eggs. Dr. Niven has evidently, like others, found considerable difficulty in procuring from the wholesale shell-fish merchants the names of the "layings" from which supplies of shell-fish were furnished to retail dealers involved in the sale of suspected mussels. He has, however, obtained sufficient information to raise suspicion against certain layings on the Welsh and Irish coasts, and he adds that he will not be satisfied of their freedom from pollution without examination either by himself or by the Local Government Board. Curiously enough, Dr. Niven makes no reference to any Dutch mussels, but whether this is because none of these imported molluscs are consumed or because none have come under suspicion is not clear. Certainly a large number of mussels are imported into this country from Holland. We are quite in agreement with Dr. Niven that the local authority sbould be in a position to obtain the name of any laying or natural gathering ground from which any given mussels have been procured, and that shell-fish hawkers should be duly registered. Provisions such as these should be embodied in any fresh Public Health Bill unless in the meantime Manchester can secure such powers for herself by means of a local Act. Bat possibly the shortest way of bringing about amendment of the law as regards shell fish generally would be to urge the Local Government Board to promote legislation on the lines recommended by the Royal Commission on Sewage Disposal. Dr. Niven is clearly in need of further professional assistance to enable him to carry on the admirable investigations which he has in hand and in contemplation, and every medical officer of health who is at the same time an epidemiologist will agree that no sanitary inspector can bring to bear upon these etiological investiga- tions the knowledge necessary to enable their full value to be brought out. It is to be hoped that the future will see a very considerable increase in the number of assistant medical officers of health throughout the country. A capital summary of the measures taken in Manchester towards the better control of tuberculosis is furnished in the report, and with regard to the system of voluntary notifica. tion Dr. Niven makes the following somewhat significant remarks : "It has been believed by many that a scheme of notification would fail unless there were a hospital to which cases might be sent by the authority dealing with notification. This is not the case. But there is more in this view than I had at first supposed. Even supposing Bowdon Hospital and the Hardman- street out-patient department had not been in exist- ence it would still have been advisable to begin with a notification scheme so that the needs of the community might be ascertained and much useful work would have been done by way of instruction. But it has to be remembered that to sustain household visits month after month, perhaps for years, becomes rather trying and demands great tact and management from the visitor as well as judgment on the part of the person visited." But Dr. Niven is inclined to believe that the death-rate from pulmonary tuberculosis is beginning to show a result from the work which has been done in consequence of notification since 1899, and all who know Dr. Niven and his work will trust that his hopes may be realised, VITAL STATISTICS. HEALTH OF ENGLISH TOWNS. In 76 of the largest English towns 8877 births and 5157 deaths were registered during the week ending August 18th. The annual rate of mortality in these towns, which had steadily increased in the five preceding weeks from 11’7 to 14 - per 1000, further rose to 17’0 0 in the week under notice. During the first seven weeks of the current quarter the death-rate in these towns averaged 13’4 per 1000, the same rate having also prevailed in London. The lowest death-rates in the 76 towns last week were 6’5 5 in Handsworth, 6’6 6 in Hornsey, 7’2 2 in King’s Norton, and 7’3 3 in Devonport ; the rates in the other towns ranged upwards to 26 - 0 in Tynemouth, 26 - 1 in Middlesbrough, 26’ 8 in Wigan, and 28’ 9 in Birkenhead. The 5157 deaths in the 76 towns showed a further increase of 733 upon the numbers returned in recent weeks, and included 1623 which were referred to the principal epidemic diseases, against numbers increasing from 361 to 1105 in the five pre- ceding weeks; of these no fewer than 1385 resulted from diarrhoea, 103 from measles, 50 from diphtheria, 42 from whooping-cough, 25 from scarlet fever, 18 from "fever" (principally enteric) and not one from small-pox. The deaths from these principal epidemic diseases were equal to an annual rate of 5’3 per 1000 in the 76 towns and to 5’4 in London. No death from any of these epi- demic diseases was registered last week in Bournemouth, Reading, Halifax, or Stockton-on-Tees ; whereas they caused annual death-rates equal to 11’ 9 per 1000 in Norwich and Leyton, 15’ 0 in West Ham, and 16’ 0in Birkenhead. The deaths referred to diarrhoea, which had steadily increased
