BARN66 THE ANNUAL REPORT For 1901 TO THE Urban District Council of Barnes, OF THE MEDICAL OFFICER OF HEALTH, F. GRAHAM CROOKSHANK, M.D. Lond., M.R.C.S., L.R.C.P. BARNES: R. W. SIMPSON AND CO., LIMITED, PRINTERS. 1902. Extract from the recent Memorandum of the Local Government Board as to Annual Reports of Medical Officers of Health. As subjects concerning which the Board desire to obtain, through Annual Reports of the Medical Officer of Health, not only definite general information, but record also of particular changes of condition that are occurring incidentally or by action of the local authority, the following deserve to be especially borne in mind:— Physical features and general character of the District. House accommodation, especially for the working class: its adequacy and fitness for habitation. Sufficiency of open space about houses and cleanliness of surroundings. Supervision over erection of new houses. Sewerage and drainage: its sufficiency in all parts of the District. Condition of sewers and house drains. Method or methods of disposal of sewage. Localities where improvements are needed. Excrement disposal: system in vogue ; defects, if any. Removal and disposal of house refuse—whether by public scavenger or occupiers : frequency and method. Water supply of the District or its several parts: its source (from public service or otherwise), nature (river water, well water, upland water, &c.), sufficiency, wholesomeness, and freedom (byspecial treatment or otherwise) from risks of pollution. 4 Places over which the Council have supervision, e.g., lodging houses, slaughterhouses, bakehouses, dairies, cowsheds, and milkshops, factories and workshops, and offensive trades. Nuisances: proceedings for their abatement—any remaining unabated. Methods of dealing with infectious diseases; notification; isolation hospital accommodation and its sufficiency; disinfection. The Medical Officer of Health, in reporting his proceedings and advice, should put on record whether he has made systematic inspections of his district. By "systematic inspections" are meant inspections independent of such inquiries as the Medical Officer of Health may have to make into particular outbreaks of disease, or into unwholesome conditions to which his attention has been especially called by complaints or otherwise, and such inspections will include house-to-house inspections which may be necessary in particular localities. The report should deal with the extent, distribution, and causes of disease, especially of epidemic and notifiable diseases, within the district; and should give an account of any noteworthy outbreaks of such diseases during the year under review, stating the result of his investigations into their origin and propagation, and the steps taken by him, or on his advice, with a view to check their spread. The Council Offices, High Street, Mortlake, January, 1902. THE Urban District Council of Barnes. Mr. Chairman and Gentlemen, In writing the subjoined Report I have been guided by the recent Memorandum of the Local Government Board as to Annual Reports of Medical Officers of Health. In this Memorandum it is laid down, inter alia, that such reports " are for the information of the Local Government Board and the County Council, as well as for the Council of the district, and that a statement of the local circumstances and history of local sanitary questions, which may seem superfluous for the latter, may often be needed by the former bodies." I am indebted to Dr. A. J. B. Adams, who acted as Medical Officer of Health during the first three months of last year, for statistical and other information ; and to Mr. Grylls, the Inspector of Nuisances, for the valuable assistance which, from his intimate knowledge of the district, he has been able to afford me. I am, Gentlemen, Your obedient Servant, F. GRAHAM CROOKSHANK, M.D. Lond., M.R.C.S., LR.C.P. 6 The Urban District Council of Barnes is in the greater part of its extent riverain, flat, low-lying, with an alluvial soil, and a gravelly subsoil of varying depth based upon the London Clay. The most southerly portions are the most elevated, and in them the clay, as a rule, is nearer to the surface. The incidence of disease is, in general terms, similar to that met with throughout the Thames Valley. The geographical position of the district is peculiar and not unimportant, for its component parishes, Barnes and Mortlake, are separated on the north and east by a long stretch of river, and on the south by a broad belt of wood and common land, from neighbouring suburbs. The greater part of Barnes proper is cut off from Putney on the east by Barnes Common, and market gardens still prevent the continuity of Mortlake with Richmond on the west. So long as this curiously insulated position is preserved, infectious disease will be found, as at present, to be introduced mainly from two sources:—from London by railroad, and from Hammersmith by local communication across Hammersmith Bridge. At the recent census of 1901, 3,403 inhabited houses were enumerated, and the average number of persons per house was estimated at. 5.23. Although there is some reason to doubt the accuracy of the population returns from the poorer localities, it must be admitted that there is no great numerical overcrowding. The number of houses of all grades that are empty shews that in one sense at least house accommodation is ample. In another sense it is not so ample, for the size of living and bedrooms in the cheaper houses recently erected is small, and in a sanitarian's opinion overcrowding exists whenever one person sleeps in an inadequately ventilated room of small size. 7 The class which has difficulty in finding accommodation in this district, as in others, is that to which belongs the working man earning 25/- or so a week, and who has a family of five or more beneath the wage-earning age. And, unless sisshilling houses are to be provided at four shillings a week, this class will continue to be inadequately housed. For, rightly or wrongly, the supposed objection of the working man to cottages without a "front room," a "front door," and a "hall," deters builders from erecting cottages with one living room, two or three bedrooms and no waste of space and material on " passages " and "porches." Roughly, houses in Barnes and Mortlake fall into three main groups:— (a) Detached "residences," old, or of recent construction, standing in grounds of adequate or even considerable extent. From all but one part—and that is being now encroached upon—the older houses have been for some years steadily disappearing; and, in consequence, the character of the district is becoming modified. (b) Detached, semi-detached, and terrace houses of recent construction, and rents varying from £30 to £100 or more, per annum. Many of these have been erected under the building bye-laws, and in almost all the drains and closets are well planned. But it is much to be desired that these houses, as well as those of the poorer classes, should be subjected by an Inspector of Nuisances to regular visitation. This, however, is not at present practicable. In some of the terrace houses recently built, the open space allotted is insufficient: and a common fault is the absence of proper forecourts. 8 In some, planned with a central kitchen, the house drains run beneath the house, and at least once last summer diphtheria appeared to be connected with this arrangement. (c) Houses inhabited by the working classes. Some very old cottages are found built without "passages," and "front rooms." These afford cheap and wholesome accommodation to those who are content with them, and it is seldom that their inmates suffer from infectious disease. Not a few of these old cottages are surrounded by a little ground, which is sometimes cultivated. Others, of more recent date, but built before the time of building bye-laws, are in "terraces," "rows," "places," and "squares," or "alleys," and are, perhaps, the most undesirable in the district. Dark and insufficiently ventilated, they are surrounded by no proper open space, and some are without forecourt, or backyard. They are occupied by the most uncleanly part of the population, and furnish a large proportion of the patients of the Isolation Hospital. They are, however, solidly built and, for technical reasons, it is but seldom that any can be pronounced "unfit for habitation" in the legal sense. It is to these houses that the working man with a large family is too often compelled to turn, or it is in them that poverty sometimes compels the introduction of lodgers, and, hence, legal overcrowding. There are in Barnes certain houses of an inferior class built largely of wood but there is reason to hope that the demolition of some of them will shortly be witnessed. 9 Small houses, such as many in the Westfields, Barnes, and in part of Mortlake, afford fair accommodation to many respectable artizans and labourers. But in too many instances weekly rents of seven, eight, nine, and ten shillings compel subletting with its attendant evils—insufficiency of closet accommodation and water supply amongst others. Houses for the working-classes that have been built under the bye-laws of the Council are few in number. "Double tenements" are being built with rapidity, it is true, and many more are proposed. These, however, do not become occupied by the working-classes, the overlying social strata providing to the landlord persons who are desirable tenants, and are yet content with such accommodation as they can procure at an inclusive rent of ten, eleven, or twelve shillings a week. "Double tenements" are erected under bye-laws devised at a time when the demand for those constructions was not anticipated. It may be doubted very seriously whether they afford proper cubic space and ventilation, and whether they will not in the long run prove most undesirable in a public health point of view. It is not a little curious to note that the demand for them, and the supply, has followed closely, for obvious reasons, the adoption by the lower middle classes of measures which artificially restrict the birth rate. During 1901 the workmen's dwellings erected under the auspices of the District Council were completed. All are now occupied, and the applications from would-be tenants have proved considerably in excess of the dwellings available. It is open to question, however, whether these buildings—excellent as they are—in any way solve the really urgent problem in the housing of the poor, inasmuch as the tenants are mostly persons with small families who are earning good wages. In Mortlake private enterprise has provided a street of workmen's dwellings, built on the "flat" principle, and let at 10 moderate rentals. The construction of these dwellings is interesting, as the floors are of concrete and the walls simply plastered. It is at present too soon to say how far these and other distinctive characteristics will prove attractive to tenants. But the size of the rooms is certainly ample, and the buildings themselves are wisely broken into blocks and not constructed in terraces. On the whole it may be said that in this district the working classes are comparatively well housed. Certain localities are unhealthy and the disappearance of not a few houses would be welcomed. But the causes for dissatisfaction with many houses are not such as can be easily removed under existing Acts. What is really needed by the working classes is more air, more light, and more water. In recent and projected buildings the chief deficiency is in the cubic space of living and bedrooms. At the present time cubic space is sacrificed to perfection of construction and low rentals. Another matter of sanitary interest to which legislative attention is required is the quality of plastering employed by competitive and speculative builders. The rapid increase of building operations has rendered the important work of the Building Inspector arduous and difficult of fulfilment. It is satisfactory therefore that additional assistance to the Surveyor in this department of his work is proposed. The water carriage system of excrement-removal is now general throughout the greater part of the district, although some cesspools are in use. The sewage is disposed of, with that of Richmond, at the works of the Richmond Main Sewerage Board at the confines of Mortlake and Kew. The present system of sewage treatment is chemical, but the idea of bacterial methods has been lately mooted. The 11 condition of the main sewers appears to be satisfactory, and the extension along the Lonsdale Road, now in progress, has been wisely planned on lines adequate for the inevitable development of the district in that direction. When the present system of excrement-removal was first adopted, the then existing house-drains were, in many cases, connected with the new sewers. Some of these old house-drains have been since replaced or improved; but some still give occasional trouble. During the past year, improperly connected or imperfect house drains have been found to cause ill-health and annoyance on several occasions, but they have been speedily made good. The repeated occurrence of cases of infectious sore throat in Charles, Thorne, and the north side of Archway Street, has been the subject of special investigation by the Surveyor, the Inspector of Nuisances, and myself, and a report to the Sanitary Committee on the matter has been called for. It may be remarked here that the cases of sore throat from Archway Street occurred on that side of the road the houses of which are drained by the same system of sewers as are Charles and Thorne Streets, and that more frequent flushing of this system has been followed by a remarkable diminution in the number of cases of sore throat notified. The removal of house refuse is at present carried out by the employes, in the carts, of the District Council, under the direction of the Surveyor. The refuse is carted to Small Profit Dock, and there emptied into barges which are, when full, removed under contract. The refuse is collected and removed regularly and with system; the cartage is efficiently performed without annoyance to the residents; but during last summer, strong and not infrequent complaints were made of effluvia from the partly-laden barges. Although everything possible was being 12 done to obviate any nuisance, the complaints were not without justification. A continuance of the present system will certainly lead to complaints, and very probably to disorders of health, amongst those who may dwell in the houses shortly to be erected in the vicinity of the dock. The erection of a dust destructor in some part of the district, as has been proposed and so freely discussed, will become a matter of sanitary necessity, if no other alternative to the present system can be devised. Places over which the Council has supervision:— (a) Lodging houses. There are no lodging houses in Barnes and Mortlake. (b) Slaughter houses. These, in actual use, are few, and fairly well kept. I have found the occupiers of the various premises willing, and indeed eager, to adopt any measures the desirability of which I have pointed out to them. But the slaughter houses themselves are mostly old and roughly constructed of wood. Under the present conditions of the meat trade, they are destined however, in all probability, to gradually fall into desuetude. The local butchers' shops are, as a rule, very well kept. The greater part of the meat sold locally is procured from the dead meat market, and therefore undergoes critical inspection by trained officials before being brought into the district. (c) Bakehouses. The condition of these important places is not always satisfactory, although the letter of the law 13 is usually complied with. But it mutt be confessed that the antiquated and imperfect state of some premises, and the cramped construction of others, hampers the efforts of the occupiers to maintain cleanliness and orderliness. There are five underground bakehouses in the district, and although they are, as such, undesirable, 1 have found them as a rule well kept. In fact, they compare favourably in some respects with others that are above ground. Bakehouses of recent construction are very few, and have not been favoured by the exigencies of the sites on which they have heen erected. (d) Dairies, Cowsheds, and Milk Shops. There are now in Barnes only two, and in Mortlake only one, registered cowkeepers. Of these only two have cowsheds in constant use. The sheds are frequently inspected, and their condition is usually as satisfactory as the construction of the buildings allows. The cowkeepers are themselves purveyors of milk, and the milk is in consequence distributed by them to the consumers very shortly after it is drawn. The condition of the milkshops, i.e., trade premises occupied by purveyors of milk who, as a rule, merely distribute to the consumer milk brought from a distance by middle-man companies, is less satisfactory. It is regrettable that beyond the power to enforce registration, the Sanitary Authority has so little effective control over them. It is not unusual for me to find milk standing in open shallow vessels within a few feet of the roadway or other source 14 of dust, on a stone or earthen floor. The usual explanation offered is that this course promotes cooling, and so retards fermentation; but it is not realized that milk so kept becomes laden with the germs of putrefaction, which rapidly become active when the milk is taken into the warm and stuffy kitchens of the poor. The importance of the bacteriological purity of milk can hardly be overestimated, and it is to the absence of precautions to avoid germ-contamination of milk brought from a distance that much infantile mortality and sickness is to be ascribed. Under the Dairies, Cowsheds, and Milkshops order, no "cowshed or dairy" may be occupied unless certain sanitary requirements are first complied with. It is regrettable that no similar enactment obtains in the case of "milk shops." For it is no infrequent occurrence to find a milkseller occupying premises with nowhere to keep his milk but in the scullery or a fowl house, and nowhere to wash his cans but in the family washtub. Under these circumstances the cost of any alteration or improvement found necessary falls on the tenant, whose resources are perhaps insufficient to supply what should have been provided before he commenced his tenancy. No offensive trades are carried on in Barnes and Mortlake. Such places as under the old Factories Acts required the occasional visitation of the Inspector of Nuisances have been usually found in a proper sanitary condition. Under the new Factories Act—which operates from January 1, 1902—a large number of workshops and workplaces are to be registered by the Sanitary Authority, and it will be the duty of the Medical Officer of Health to report annually to the Home Office on their condition. This will necessitate the inspection and supervision by him of about one hundred additional places of business or trade. 15 The domestic water supply of Barnes and Mortlake is derived from the Southwark and Vauxhall Water Company. One or two wells, it is true, still exist, and one at least is used for drinking purposes. In no part of the district is a constant water supply provided. In some places one small cistern contains the entire supply of two cottages during the hours that the water is " turned off," and in not a few streets two families living in one house are dependent on one cistern of 40 or 50 gallons. The question of inadequate cisterns has been laid before the District Council, but it does not appear that either the Council or the Water Company have power to enforce better provision. In a sanitarian's view a constant water supply is the best, if indeed it be not the only remedy for such a regrettable state of affairs. Such action as has been taken during 1901 for the abatement of nuisances is summarized in the report of the Inspector of Nuisances. It will be seen that the greater number of nuisance abated have been such as from time to time occur, or are discovered, in dwelling-houses, and that many of them are such as are injurious to health. That not a few of them were discovered when seeking the cause of disease is proof of the advisability of house to house inspections being made in all parts of the district. In the summer of 1901, the Inspector of Nuisances and myself gave evidence in support of a summons against the London & South Western Railway Company for failing to abate a nuisance arising from the presence, in the sidings on Barnes Common, of trucks loaded with offensive manure. The nuisance, and also injury to health, was proved, but the summons was dismissed, the Bench holding that it was not proved the defendants 16 kept the trucks on the sidings longer than was necessary for the purpose of their business. Since the hearing of the summons, however, the nuisance has been sensibly less. Certainly no complaints have been received from the persons who were formerly aggrieved. Complaints are frequently made of offensive smells perceptible in Barnes High Street and on the Terrace, which apparently are due to offensive deposits on the Middlesex side of the river. Representations have been made on more than one occasion to the contiguous Sanitary Authority, but the nuisance recurs from time to time. As soon as is possible, after the Sanitary Officers are made aware of the existence of notifiable disease, the infected house is visited by myself or the Inspector of Nuisances, all necessary inquiries are made, and the patient, if thought fit, is removed to the Isolation Hospital, at Mortlake. The usual statutory notices are now sent from the Council offices to the householder, and with them a paper of directions for preventing the spread of disease. Disinfectants are liberally supplied, when it is desirable so to do, and disinfection is performed by the Inspector in almost every case and at the appropriate time. The method employed is that of disinfection by Nitrous Acid Gas. Mattresses and textile substances are disinfected, when desired, in the Steam Disinfector at Mortlake, and the cleansing of infected houses by either landlord or tenant is frequently insisted on. These methods prove, in practice, perfectly satisfactory. In fact the public confidence in them is such that persons not infrequently request the disinfection of rooms, &c., by the Sanitary Officers after the occurrence of certain non-notifiable diseases. The high percentage (70.3 per cent.) of cases of Scarlet Fever and Diphtheria notified that were removed to the Isolation Hospital in 1901 sufficiently demonstrates the popularity of that institution. The present 17 accommodation at the Hospital for patients is, in point of ward space, ample. But the usefulness of the new Block would be greater than it now is if more convenient accommodation had been devised for the Nurses. During 1901 eighteen cases of Scarlet Fever were treated without loss of life, and of 56 cases of Diphtheria only one died. In one successful case Tracheotomy was performed on a child under three, and in this, as in other severe cases, Antitoxin was administered. Three cases of Typhoid Fever were admitted ; in two instances the patients were gravely ill when removed, and removal was necessary to prevent spread of the disease. The removal to Hospital of cases of Scarlet Fever and Diphtheria, is, as a rule, called for both by the interests of the patient and those of the public. But the removal to Hospital of cases of Typhoid Fever is a less simple matter. The process of removal itself is not always free from risk to the patients, who can often be successfully isolated in their own houses. But Typhoid is a disease of long and uncertain duration, calling for the constant care of skilled nurses. For this reason, cases from, not merely the poorest, but from the lower middle classes have for years past been admitted into the wards of General Hospitals. Such facilities, are, however, now less easily obtained than formerly, as there is a disposition on the part of those governing the great London Hospitals to exclude from their wards more than a certain percentage of typhoid cases. In consequence, when domestic resources are unable to provide the necessary skilled nursing, admission to local Isolation Hospitals is sought— 18 not for the purpose for which Isolation Hospitals were founded, but in the interests of the patient and the relief of domestic strain. The admission and treatment of such cases is a severe and sometimes sudden strain on the resources of a small Isolation Hospital. With a view, therefore, to meet these and other circumstances, as Medical Superintendent of the Hospital at Mortlake, I have been lately empowered to make provisional arrangements for the reception of certain patients at an adjustable weekly charge. It is not, however, the practice of the Council to recover the charges legally due in ordinary cases when removal is dictated by regard to the public health, though charges are made if persons other than ratepayers, or persons requiring private wards, are admitted. Typhoid Fever is certain to become more frequent as the district becomes more urban and means of communication are multiplied, and the question of hospital treatment, therefore, requires consideration. A few cases of Measles were admitted in the Spring from the Children's Home, Barnes, under special arrangement with the Guardians, at a time when the Hospital was almost empty. In the Autumn, the outbreak of Small Pox in London led to the consideration of what should be done in the event of the disease appearing in this district, as no means of isolation had been devised when the old Highgate Hospital (to which cases were formerly sent), became disused. Communications were made to the authorities of every Small Pox Hospital (including the Metropolitan Asylums Board) within reach, but in each case a reply was received that the admission of cases from Barnes could not, under the circumstances, be entertained. 19 The Urban District Council then, having regard to the proximity of Barnes to the Metropolis, proceeded to take steps to provide the district with the means of isolating cases that might occur. A very complete plan was devised for the reception of patients in a temporary building on Sheen Common, but this plan was successfully defeated by action which raised the question of the legal right of the Council to erect such a building on the Common. But appeals had been made, without any success, to every owner of land in any way suitable for the erection of such a building, and it appeared therefore, for some time, likely that the district would be withouc proper means of isolation in the event of an outbreak. Representations were then made to the Surrey County Council of the urgent need of some such means, and on almost the last day of the year it was announced that the Surrey County Council had concluded an arrangement with the Joint Small Pox Hospital Board for Croydon and Wimbledon, by which the latter body bound themselves to "admit into their Hospital at Cheam, at a weekly charge, cases of Small Pox occurring within the administrative County of Surrey generally. This arrangement is, for the present, satisfactory, but it is to be hoped that it will shortly give place to another on broader lines. In April, a medical man was prosecuted at the Court at Mortlake for having failed to notify, in compliance with the Act, the occurrence of a case of Typhoid Fever on which he was attendant. As a matter of fact, the case was only notified, and then irregularly, after the unfortunate termination by death of the patient's prolonged illness. 20 A formal summons was also taken out against the widow for having failed to notify the case, and further for having vacated the house in contravention of the Infectious Diseases (Prevention) Act, 1890. Sec. 7. A fine of 20s. was inflicted on the medical man, and the first summons against the widow was withdrawn, as it was only desired to draw attention to the duties imposed by the Act on the relatives of persons suffering from notifiable diseases. A fine of 5s. was imposed in respect of the second summons. In September, it was resolved by the Urban District Council to invite from medical men practising in the district the notification of cases of Phthisis, with the object of enabling the Sanitary Officers to disseminate information, to disinfect rooms, See., when necessary, and to investigate the domestic surroundings of such cases, with a view to taking any requisite action under the Sanitary Acts. It was also resolved to pay the fee of 2s. 6d. for any such notifications made in the course of private practice, and Is. for any made in an official capacity. These resolutions have already met with considerable success; the pithy memorandum of the Surrey County Council on the Prevention of Consumption has been distributed; and disinfection has been performed in nearly every case of death or removal. It should not be forgotten that the Guardians of the Poor are making at Richmond most excellent provision for the open-air treatment of consumptive persons. Already such have been with advantage removed there from this district, the phthisical poor of which will shortly enjoy the full advantages of voluntary notification, gratuitous disinfection, and "sanatorium" treatment. With respect to the notification of infectious diseases 21 generally, it may be observed that different qualities must be connoted with notifications from different sources. Medical opinion, on some matters, is at present in a state of flux, and while circumstances may sometimes require the notification of a case as diphtheria on grounds bacteriological rather than clinical, yet at other times notification may be called for rather by the obvious need for isolation than the ascertained presence of a specific organism. Naturally the former set of circumstances obtains most frequently amongst the upper classes, and the latter amongst the lower. With regard to vaccination, it may be said that the District Council, at the beginning of the present outbreak of Small Pox, took every possible step to promote the adoption of this necessary means of protection, and it is largely to the great measure of success that has followed these steps that 1 attribute the immunity of the district during 1901. The Richmond Guardians were officially communicated with, and they courteously and promptly acceded to a request that they would promulgate notices of the need and opportunities for re-vaccination. The School Board for Barnes, and the Managers of the National Schools at Mortlake, also responded to communications made to them by taking steps to promote, with all due deference to parental authority, vaccination and re-vaccination amongst their scholars. The general public have also submitted in great numbers to re-vaccination at the hands of private and public vaccinators. I am unable to publish this year, as my predecessor did in times past, any statistics of value in respect of infant vaccination, for, under the new Act vaccination is so generally postponed until the sixth month that any tabulated return would shew 22 almost every child born since July as unvaccinated. And it is owing to the curious anomaly that the most important of protective measures—vaccination—is not under the control of the Sanitary Authority that I am unable to give any numerical estimate of the official re-vaccinations performed during 1901. Such information would be of the greatest interest and value to the Aulhority on which the duty of dealing with Small Pox actually falls. Systematic inspections of the district have been made throughout the year, and much of the work thus done is summarized in the Inspector's Report. Five houses reported as unfit for habitation have been repaired, others have been cleansed and repaired under notice; others have been put in order on verbal request. The unwholesome condition of Barnes Pond was in the summer reported on by me, and its cleansing advised. A scheme for its purification and drainage into the main sewer has been agreed upon by the District Council, and the necessary consent of the Richmond Main Sewerage Board secured. The work will shortly be completed. Steps have been taken to improve the condition of Lodge Avenue, Mortlake, of Malthouse Cottages, and other places. A necessary alteration to the sewer draining St. Ann's Passage, Barnes, will also, it is hoped, be shortly carried out. The contemplated improvements in High Street, Barnes, in a sanitary sense are important, and will, it is hoped, lead to the disappearance of certain houses in the vicinity. In December I was required specially to report on the suitability, in a sanitary sense, of the land at East Sheen which it is proposed to acquire for burial purposes. I had no difficulty 23 in pronouncing the site in every way a proper one for the proposed purpose. The same, however, could not have been said of other sites that have been mentioned. In inspecting the district at various times I have noticed the practice of builders to erect rows of shops which are—in trade parlance—afterwards completed to satisfy the requirements of tenants. The practice is a bad one, and leads to the occupation by milksellers, butchers, and other persons, of premises which are not, sanitarily, suitable for the purpose to which they are put. It is to be desired that no shops should be erected which may be used for certain trades, unless the Sanitary Authority is first satisfied that the proposed structures will admit of the fulfilment of all sanitary requirements. Early in the year an outbreak of Diphtheria occurred in Barnes that was found by the acting Medical Officer of Health to be modified by School Influence. School closure was in consequence enforced with satisfactory results. Later, having occasion to inspect the Board Schools in Barnes, certain sanitary defects were found which, as soon as the Board were made acquainted with, were remedied. Since then no Diphtheria has occurred due to "School Influence." Three brief outbreaks have, however, since occurred in part of the Westfields, Barnes. These were promptly terminated by extra flushings of the drains. It was the occurrence of these cases which led to the report being called for that has already been referred to. It is hoped that the measures to be proposed will prove adequate in the coming year Most other cases of Diphtheria have been sporadic. Some have been imported; in others a connection has been traced with insanitary conditions of domestic origin. In the early part of the year cases of Scarlet Fever were few; but in the later months many more were notified. Not a few times the 24 disease was brought into Barnes by children residing in Lilian Road, or thereabouts, who were attending Board Schools in Hammersmith. It is to be hoped that the extended school accommodation proposed by the Barnes School Board will in future obviate this source of infection. During the spring many cases of measles and mumps occurred, and it was a frequent sight to see children playing in the streets with the obvious signs of these complaints present. It is forgotten, or ignored, that Measles is both indirectly and directly a more frequent cause of death than Scarlet Fever, if not than Scarlet Fever and Diphtheria together. The number of cases of Typhoid Fever that have been notified is greater than last year. In most instances, if not in all, the infection was contracted, so far as I know, outside the district, and it is gratifying that no secondary cases occurred. In more than one instance the infection was probably from soldiers returned from South Africa, and it is not perhaps generally realized that owing to rapid means of transit a person may be discharged convalescent from hospital abroad and yet reach England in an infective condition. One case of true Dysentery occurred in Barnes during the year. The patient had come from Aldershot, in which place I was subsequently made aware many similar cases were under observation. 25 Statistical Tables. The Tables appended to this Report are those now required by the Local Government Board, and differ from those employed in previous years. It will be noticed that the population of the district as enumerated at the census of 1901, is less than the population as estimated for 1899 and 1900. The calculated birth and death rates, therefore, for the last few years have been, so far as they depend on the estimated population, too low. That the birth rate for 1901 happens to be exactly the same as the average of the birth rates as calculated for a series of years, during which the population was over-estimated, tends to prove that the real birth rate is lower than in past years. The cause for the lower birth rate in this district, is probably the same as elsewhere:—a well-understood matter of national importance, the effects of which can only be counteracted by efforts to diminish infantile mortality. From Table I. Cols. 5 and 6, it will be gathered that the heavy mortality amongst children of less than one year does not in this district appreciably decrease, and it is in this fact, coupled with the slightly lowered birth rate, that we must seek some explanation of the disappointing census return, one meaning of which is that the natural increase of the population, as opposed to increase by immigration, is less than formerly. 1 n calculating the death rates for 1901, it has been necessary, from the arrangement of the new Tables, to take account of all 26 deaths registered in this district. Not a few of these deaths are those of persons whose bodies have been recovered from the river, and such deaths were in times past excluded from consideration. For purposes of comparison, therefore, 1 have re-calculated, from the figures at my disposal, the total deaths registered for the last seven years, and the death rates, on the basis now required. This inclusion of the deaths of non-residents is, perhaps, not so unfair as at first appears, for not a few persons from this district die in London Hospitals and elsewhere, their deaths, which should be credited to Barnes and Mortlake, being for statistical purposes lost count of. Particular pains, however, have been taken to make the figures for 1901 in Column 11 accurate, and it will be seen that 24 such deaths have been discovered as against only three in 1900. This fact should be borne in mind when observing the apparent increase of the death rate from 12.1 in 1900 to 13.2 in 1901. This figure (13.2) would be still higher if I were able to give the deaths that have occurred in Brookwood during 1901 of former residents in this district. Table II. affords some means of comparison between the vital statistics of Barnes and Mortlake. The absolute value of these figures is, of course, affected by the considerations already mentioned as affecting those for the whole district. It appears that in 1901 the infantile mortality was greater in Mortlake than in Barnes—and not only relatively to the lesser population, but absolutely. In previous years the absolute mortality has usually been higher in Barnes. 27 The loss of infant life in the district as a whole is a serious matter, and it should be not forgotten that from the report of the County Medical Officer of Health for 1900 it appears that the Urban District of Barnes occupies in this respect a position less creditable than 30 of the 34 districts into which the administrative County of Surrey is divided. The only districts with a less creditable record are Ham, Richmond, and Wimbledon. Ham is so small that its statistics are of no value; and the difference between the infantile mortality of Richmond and Barnes is a fractional percentage only. I am unable to agree with the opinion frequently expressed that this heavy mortality is due to neglect by mothers working in laundries and market gardens, for the simple reason that in none of the many cases that have come under my personal observation did this factor obtain. I attribute the heavy infantile mortality of Barnes and Mortlake very largely to the germ-laden condition of the milk offered to babies, much of which is supplied by "purveyors of milk"—some of them itinerant and from a distance—over whose proper cleanliness there is little real control. I am not aware of any milkshop in the district in which there is a proper place for the storage of milk during the summer nights, or from which milk in a fresh condition can be obtained after certain hours. Table III. gives the number of cases of infectious disease notified during the year. The number is greater than last year, the increase in the notifications of Diphtheria alone being 50. The cases of Scarlet Fever were 3 less and those of Typhoid 7 more than in 1900. 28 In spite of the relatively enormous increase in the number of cases of Diphtheria notified, there was only one death. The case mortality for the district is, therefore, only 1-3 per cent. 1 attribute part of the increase in the notifications of Diphtheria to local circumstances which have resulted in the notification of more cases than formerly on bacteriological grounds alone, and also to an increasing desire to obtain for cases of non-specific but infective sore throat the advantage of hospital treatment. One member of the Hospital Staff contracted Erysipelas in performance of her duties, and it is this case which is tabulated as "removed to Hospital." In Table IV. the cause of deaths during 1901 are set forth with the ages at which death occurred. It will be noticed that no deaths occurred from Measles, and only one from Whooping Cough. Fifteen fatal cases of Diarrhoea in infants are recorded, as against 5 in 1900, but there is reason to believe that this is due to increased accuracy of certification and classification. "Zymotic enteritis" is now more generally recognized as an entity than was the case a few years ago. Nineteen deaths were recorded as due to Phthisis. This number is twice as great as in 1900, and considerably greater than the average number of the last 6 years. This, alone (and there are corroborative facts), seems to shew that the disease is increasing, rather than diminishing, locally. It is interesting, therefore, to remember that my predecessor, Dr. Adams, was in the habit of pointing out how the Phthisis mortality of Barnes fell as the ground water sank; and that, in the opinion of Mr. Tomes, the Surveyor, the level of the ground water has lately risen appreciably. 49 But at the same time it must not be forgotten that the exceedingly small rooms now occupied by persons of the middle and lower classes are a potent cause of Phthisis; and that these rooms, cramped and small by reason of the demand for low rents and the high price of materials, are rendered more air-tight than is necessary by the general improvement in construction that is maintained. Twenty deaths from Cancer and malignant disease were reported. This number, 8.5 per cent, of the total deaths, confirms the general belief in the prevalence of Cancer in riverside districts, and the Thames Valley in particular. A large number of the total deaths are not classified, but referred to "other causes." Not a few of these are deaths, the causes of which are expressed on the death certificates in terms too vague to be of any statistical or scientific value. 31 TABLE I. Vital Statistics of whole District during 1901 and Previous Years. Year. Population estimated to Middle of each Year. Births. Totai. Deaths registered in the District. Total Deaths in Public Institutions in the District. Deaths of Nonresidents registered in Publie Institutions in the District. Deathe of Residents registered in Public Institutions beyond the District. Net Deaths at all Ages belonging to the District. Number. Rate* Under 1 Year of Age At all Ates. Number Rate per 1.000 Births registered Number Rate.* Number. Rate.* 1 2 3 4 5 6 7 8 9 10 11 12 13 1893. 15,600 412 26.4 56 135.9 246 15.7 11 … 29 275 17-6 1894. 16,000 367 22.79 44 119.3 166 10.3 2 … 1 167 10.4 1895. 16,200 397 26.5 51 128.4 218 13.45 7 … 6 224 13.8 1896. 16,800 404 24 61 140.9 191 11.36 4 … 7 198 11.7 1897. 16,950 370 21.8 54 145.9 196 11.56 2 … 5 201 12.4 1898. 17,300 351 20.28 64 182.3 203 11.7 5 … 3 207 11.9 1899. 18,000 458 25.4 58 126.6 225 12.2 5 ... 4 229 12.6 1900. 18,300 416 22.7 56 134.6 220 12.02 1 … 3 223 12.1 Averages for years 1893-1900. 16,893.7 396.6 23.49 55.6 139.6 208.1 12.3 4.62 … 7.37 215.5 128 1901. 17,900 420 23.49 56 133.3 214 11.9 3 … 24 238 13.2 * Rates in Columns 4, 8, and 13 calculated per 1,000 of estimated population. Area of District Exclusive of Area Covered by Water 2,400 acres. Total population of all ages 17,821 Number of inhabited houses 3,403 Average number persons per house 5.23 Census of 1901. Institutions within the district receiving sick and infirm persons from outside the district—none. Institutions outside the district receiving sick and infirm persons from the district:—Richmond Infirmary and Workhouse, Richmond General Hospital, Brookwood Asylum. Other institutions, the deaths in which have been distributed among the several localities of the district:—University College Hospital, and West London Hospital, Hammersmith. 32 TABLE II. Names of Localities 1. BARNES URBAN. 2. BARNES. 3. MORTLAKE. Year. Population estimated to middle of each Year. Births registered. Deaths at all Ages. Deaths under 1 Year. Population estimated to middle of each year. Births registered. Deaths at all Ages. Deaths under 1 Year. Population estimated to middle of each Year. Births registered. Deaths at all Ages. Deaths under 1 Year. a. b. c. d. a. b. c. d. a. b. c. d. 1893 15600 412 275 56 8740 219 138 27 6860 193 137 29 1894 16000 367 167 44 9000 202 85 19 7000 165 82 25 1895 16200 397 224 51 9100 226 107 25 7050 171 117 26 1896 16800 404 198 61 9500 217 104 30 7300 187 94 31 1897 16950 370 201 54 9600 218 101 26 7350 152 100 28 1898 17300 351 207 64 9800 193 126 42 7500 158 81 22 1899 18000 458 229 58 10200 286 123 36 7800 192 106 22 1900 18300 416 223 56 10300 230 107 26 8000 186 116 30 Averages) of Years 1893 to 1900. 16893.7 396.6 215.5 55.5 9536.2 221.3 111.2 28.6 7357.4 175.4 104.3 26.6 1901 17900 420 238 56 10100 258 127 26 7800 162 111 30 33 TABLE III. Cases of Infectious Disease notified, during the Year 1901. Notifiable Disease. Cases notified in Whole District. Total Cases notified in each Locality. No. of Cases removed to Hospital from each Loca ity. At all Ages. At Ages—Years. 1 Barnes. 2 Mortlake. 1 Barnes. 2 Mortlake. Under 1. 1 to 5. 5 to 16. 15 to 25 25 to 65. 65 and up'wrds Small-pox - - - - - - - - - - - Cholera - - - - - - - - - - - Diphtheria 76 1 17 43 9 6 - 60 16 49 7 Membranous croup - - - - - - - - - - - Erysipelas 10 - - 16 1 7 2 4 6 - 1 Scarlet fever 29 - 7 - 4 2 — 23 6 13 5 Typhus fever - - - - - - --- - - - - Enteric fever 12 - - - 2 10 - 6 6 2 1 Relapsing fever - - - - - - - - - - - Continued fever - - - - - - - - - - - Puerperal fever 2 - - - - 2 - - 2 - - Plague - - - - - - - - - - - Phthisis* 5 - - - 1 4 - 5 - - - Total 134 1 24 59 17 31 2 98 36 64 14 * Notifiable voluntarily only. 34 TABLE IV. Causes of, and Ages at, Death during Year 1901. Causes of Death. deaths in or belonging to whole district at subjoined ages. Deaths in or belonging to Localities (at all Ages). Total Deaths in Public Institutions in the District. All ages. Under 1 year. 1 and under 5. 5 and under 15. 15 and under 25. 25 and under 65. 65 and upwards. Barnes. Mortlake. Small-pox - - - - - - - - - - Measles - - - - - - - - - - Scarlet fever - - - - - - - - - - Whooping-cough 1 - 1 - - - - 1 - - Diphtheria and membranous croup 1 - - 1 - - - 1 - 1 Croup - - - - - - - - - - Fever Typhus - - - - - - - - - Enteric 5 - - - - 5 - 3 2 2 Other continued - - - - - - - - - - Epidemic influenza 4 - - - 1 2 1 3 1 — Cholera - - - - - - - - - - Plague - - - - - - - - - - Diarrhœa 15 15 - - - - - 7 8 - Enteritis 2 - - - - 1 1 1 1 — Puerperal fever 2 - - - - 2 - - 2 - 35 Erysipelas - - - - - - - - - - Other septic diseases - - - - - - - - - - Phthisis 19 - - 3 3 12 1 11 8 - Other tuberculardiseases 2 1 1 - - - - - 2 - Cancer, malignant „ 20 - - - - 18 2 11 9 - Bronchitis 16 1 - - - 8 7 6 10 - Pneumonia 3 2 - - - - 1 1 2 - Pleurisy - - - - - - - - - - Other diseases of Respiratory organs 8 6 2 - - - - 3 5 — Alcoholism ) Cirrhosis of liver 6 - - - - 6 - 4 2 - Venereal diseases - - - - - - - - - - Premature birth 12 12 - - - - - 8 4 - Diseases and accidents of parturition - - - - - - - - - - Heart diseases 23 - - 1 2 16 4 19 4 - Accidents 5 - - - 3 2 - 3 2 - Suicides 6 - - - - 5 1 4 2 - Wilful murder 1 1 - - - - - 1 - - All other causes 87 19 - 2 2 36 28 40 47 - All causes 238 57 4 7 11 113 46 127 111 3 36 REPORT OF Inspector of Nuisances For the Year ending December 31st, 1901. Notices have been served to abate 397 nuisances in the District for the year 1901, as against 316 for the preceding year. The total number of house to house inspections has been 2,391 as against 2,225. ABSTRACT OF NOTICES. Barnes. Mortlake. Total. Defective drains 11 19 30 Condemned closet pans and traps 9 12 21 Dilapidated closet fittings 2 5 7 Pipes insufficiently ventilated 6 9 15 Defective Hushing cisterns 61 55 116 No proper dust bins 39 46 85 Defects in cisterns 15 17 32 Houses in need of cleansing 11 11 22 Overcrowding 5 2 7 Houses unfit for habitation, but repaired 4 1 5 Animals so kept as to be a nuisance 3 3 Foul deposits 5 3 8 Defective roofs and gutterings 6 5 11 Yards in need of paving 18 17 35 Total 195 202 397 Number of Cowkeepers 2 1 3 Number of Purveyors of Milk 7 7 14 Number of Bake Houses 5 6 11 Number of Slaughter Houses 2 3 5 Number of persons licensed for Petroleum 2 1 3