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diphtheria. 13
The use of certificates of " conscientious objection " shows a marked growth, dating from
1907, when the number of certificates issued was 97, more than twice the number issued in
1906 (41). In 1908, 201 certificates were taken out, and in the first half of 1909, 113, the total
for the whole year being 245. On the other hand, the proportion of children born who were
either successfully vaccinated or died before vaccination, has, with the exception of a very
triflng increase in 1906, steadily diminished.
DIPHTHERIA.
During the past year 180 persons were certified to be suffering with this disease, but 7
of them were subsequently reported by the Staff of the Metropolitan Asylums Board to have
scarlet fever. Such cases have been dealt with in this report as scarlet fever. The total of
173 cases thus obtained represent an increase of 31 above the total for 1908 (142), and of 19
above that of 1907 (154). In 1906 182 cases were reported. Two (2) cases of membranous
croup were also reported last year, such cases being regarded and dealt with as cases of
diphtheria. The morbidity rate from diphtheria, after including membranous croup, was 1.15
per 1,000 persons, an increase of 0'20 above the quinquennial mean (0.95). (See Table 4.)
The numbers of cases reported from the whole Borough in the first and third quarters of the
year, were below the averages for the five vears 1904-08. (See Table 12.) That table also
shows the variations from the averages for each quarter of the year in each Ward.
According to the Registrar-General (Table 5), the morbidity rate for the Borough was
1.21 per 1,000 last year, and the quinquennial mean rate, 0.99. Higher rates were recorded
in Westminster (1.33, mean 0.92) and Willesden (1.29, mean 1.93). The lowest rate was that
of Hampstead (0.49, mean 0.87).
The 175 cases included 27 cases erroneously diagnosed, in addition to the seven already
referred to. Neglecting the latter, the errors formed 15.4 per cent. of the total, more than 3
per cent. above the average for the preceding five vears (12.2). Six of the genuine cases
were reported from hospitals, in patients admitted for previous attacks of scarlet fever.
Deducting the 27 errors and the six cases contracted in hospital, there remain 142 cases, of
which 15 were apparently due to infection derived from sources outside the Borough, and one
to the recent discharge of a patient from hospital. The 142 cases comprised 127 primary and
15 (10.5 per cent. as compared with 10.3 in 1908) secondary.
The 175 notifications came from 160 houses, the incidence of multiple notifications
during the six years being given below.

If the cases erroneously diagnosed be eliminated, the distribution of multiple cases during
the past year was as follows:—
Houses with 2 cases, 7 ; with 3 cases, 1 ;
and was exactly the same as in 1908. In two instances two cases were reported on the same
day from the same house, and in three other instances the infection spread to a second family
in the house.