HAML 5 REPORT of the MEDICAL OFFICER OF HEALTH to THE VESTRY of Mile End Old Town. ANNUAL REPORT, JUNE, 1857. London: PRINTED BY F. S. NEWELL, ASSEMBLY ROW, MILE END ROAD. 1857. R E P O R T. In the month of June last, (1856,) the Vestry of this Hamlet caused to be printed and circulated, a Report presented to them by their Medical Officer of Health, purporting to be preliminary to others, to be rendered as necessity or the desire of the Vestry required. That first Report described the Hamlet, its population and sanitary condition. The present is intended to contain in its course any matter of importance omitted in the first communication, a Statement of the Mortality of the Hamlet since the Medical Officer has had the means of estimating it, a review of that which has been done in the way of sanitary improvement, and an enumeration of the principal causes which influence generally the public health, with an exposition of such existing conditions and relations as impede the removal of morbific agents in our particular district. I shall at once offer to you a statement of the mortality, and while, for the purposes of comparison, it will be at present useless, since it commences only from January last, when your Medical Officer of Health was first supplied with returns of the mortality of the Hamlet by the Registrar General, yet its value as a basis or starting point will be evident and cannot be over-rated.* * The Returns of the Registrar General were, previous to January last, made for the Stepney District, which comprised several parishes, and therefore would not represent the mortality of this Hamlet. 4 USES AND ADVANTAGES OF MORTALITY RETURNS. The proportion of deaths to the number of living persons in a town or district, may be considered a fair indication of its sanitary state. If the diseases which have caused death are particularized, the information becomes more valuable, and still more so if the age, residence, sex, and occupation of each deceased person is described. This is the nature of the information now furnished by the Registrar's Weekly Returns. The list of diseases enables us to estimate the number of deaths which have been occasioned by preventible causes, and which may be diminished by improvement of dwellings, the quick removal of refuse, and other matters, as far as possible, which have the character of directly or indirectly promoting the spread of disease. I do not think I am stating too much when I affirm that many mortal diseases depend, for their very existence, on certain conditions which are perfectly within our own control; and it may be reasonably expected, as well as desired, that before many years have passed, such a modification of those conditions will have been universally effected, that we shall hold Typhus Fever and Cholera in as little dread as we do now Small Pox, through the beneficent agency of vaccination. The parallel also holds good still further. When it was discovered that the artificial introduction of Cow Pox possessed the property of keeping off and preventing the graver disease, prejudice and want of knowledge were the opponents which obstructed its introduction. Real, comprehensive sanitary improvement has to contend with the same enemies to our collective and individual advantage and progress. The knowledge of the ages at which death has taken place is extremely useful in directing sanitary investigation. A great preponderance of deaths among aged persons and children of tender years, is prima facie evidence of a healthy condition of the locality, such deaths being closely connected with changes of temperature and weather, as well as with more evident natural causes of death. 5 A considerable excess of deaths of females over males, is also a point of importance. Men, for the most part, are less exposed to local influences than those of the opposite sex, who are engaged in domestic occupations, while their husbands are variously employed at a greater or less distance from home. If the place in which they reside be unhealthy, women, from being so much more constantly under local influences, are found to suffer most. I apprehend this is exemplified by the mortality of our West Ward. (See last column of Table No. 1.) Of no less importance is the knowledge of the residence, while living, of those whose deaths are recorded by the Registrar. To be able to distinguish the places which are especially the haunts of Fever and diseases of a kindred nature, is the first step towards their examination, and subsequent essential improvement. Occupations indicate mortality causes, both connected with, and distinct from, those of a zymotic character; or those which are occasioned or made worse, when otherwise produced, by fermentation, putrefaction, or decay. With such information we can distinguish healthy from unhealthy occupations, and infer the result which the exercise of certain occupations may produce on the public health. All these particulars, which may be regarded as so many finger-posts to direct us to places where our alteration is most required, are now furnished weekly by the Registrar General, viz.: the number of deaths in the Hamlet, the age, sex, previous residence, and occupation of each deceased person, and the disease which has caused death. When tabulated, and used by statistical method, they become most valuable sources of information. The health of one particular month, week, or other period, may be compared with the same month, or other period, in a preceding year, so as to be able to estimate our state and sanitary progress. 6 MORTALITY RETURNS, WITH BIRTHS. Births during the Quarter ending March 28th, 1857 736 Deaths „ „ 420 Excess of births over deaths 316 TABLE X. DEATHS. WARD. Population DEATHS During Quarter ending March 28, 1857. Number of Persons to Acre. Rate per 1000 per annum. ( estimated.) Males. Females. Total. North 12,188 40 38 78 75 25.6 East 7,262 20 23 43 37 23.7 West 11,712 44 52 96 150 32.1 Centre 16,775 36 53 89 124 21.2 South 13,511 34 43 77 119 22.8 Workhouse — 31 3 34 — — Hospitals (jews) — — 3 3 — — Total - - - 420 The calculations are made on the estimated population of last year. If the exact number of the Ward population could be procured, it is probable that a slight difference would be found in the last column; I think it would show a rather more favourable rate. But the comparative rate of death in the five Wards would remain nearly the same. The average rate per annum of the whole Hamlet, for the Quarter, is 25 deaths to 1000 living persons,—that for all London, in the same period, nearly 23 in the 1000 (22.920). 7 DISPROPORTION OF MORTALITY IN THE WARDS. I must confess that I was not prepared to find so great a difference in the mortality of the Wards. Although I was well aware that in the West Ward were more cases of disease and death than in the others, the excess has occasioned me some surprise. Figures, however, are hard things, and are not easy to be got over. While it must be borne in mind that the foregoing Table gives the mortality for one quarter only, and is not an average, yet it is right to endeavour to explain or account for that which appears to be an undue proportion of deaths in the East Ward, which one would have supposed to have been the healthiest of the five, and the West. The East Ward contains about 193 acres, as near as I can ascertain, and the number of persons to the acre is 37; as compared with the West Ward, the proportion is as 1 to 4¼. Here are two of the principal conditions for a state of sound public health,—open ground, and no over-crowding; yet we have it not. The solution is obtained by reference to the Registrar's Weekly Returns, and the Parochial Medical Officer's books, an examination of which will show that much sickness and a number of deaths take place in the new town which has sprung up in the last few years at the rear of the Edinburgh Castle Tavern, sometimes called the Rhodeswell Estate. These houses form a considerable proportion of the inhabited houses of the whole Ward, and have been constructed and remain in a notoriously bad condition. The houses have been built, and most of them inhabited several years; yet the roads are not made up, and the district is destitute of drainage. On account of the lowness of the level, up to the present time it has been a matter of considerable difficulty to accomplish the drainage of this part, while its want has been extensively felt. The difficulties have now been overcome, to a useful extent at least; sewers will soon be constructed, and the roads made up. Happily, the Building Act of 1855, and the Local Management Act, will effectively prevent any similar future attempt to secure individual gain at the expense of public health. The drainage of a new street is now made before the houses are built, instead of after. 8 The density of population, and the poverty of a great number of the inhabitants in the West Ward, are the only reasons which occur to me to account for its heavy mortality, beyond its sanitary defects. The Hamlet was divided into Wards a year and a half ago, without regard, of course, to the state of health in any place; so that, if disease be shown to exist in the West Ward, it can, by pursuing the same course, be traced to the most offending part of it. I find upon examination, that some parts of the Ward are as healthy as any portion of the Hamlet, and that the mortality is similar to that of its contiguous district in Whitechapel, which I think has been well looked after for some time by sanitary officers. I intend to try to turn the information afforded by the table to practical use. At the present moment I am impressed with the idea, that besides ordinary causes, the mortality is exalted through the existence of a greater amount of poverty and dissipation. TABLE II. DEATHS AT PARTICULAR AGES. AGES. DEATHS. Under 5 years 153 From 5 to 10 years 16 „ 10 „ 15 „ 4 „ 15 ,, 20 „ 3 „ 20 „ 30 „ 24 „ 30 „ 40 „ 34 „ 40 „ 50 „ 31 „ 50 „ 60 „ 47 „ 60 „ 70 „ 48 70 and upwards 60 Total 420 Here, as in all populous districts, the deaths of children appear to be in undue proportion. The value of life under five 9 years of age is considerably less than in places where children have the advantage of fresh air and freedom of exercise. TABLE III. CAUSES OF DEATH. DISEASES. DEATHS. Fever 10 Measles 2 Scarlatina and Cynanche Maligna 22 Diarrhoea and Dysentery 6 Hooping Cough 19 Croup 8 Erysipelas 3 Consumption 50 Inflammation of the Lungs 82 Diarrhoea, Bronchitis, and Pneumonia of Infants under 3 years 33 Water on the Brain, and Convulsions of Infauts 29 Dropsy 9 Cancer 2 Hernia 1 Diseased Heart and Large Vessels 11 Apoplexy, and Diseases of the Brain 7 Puerperal Fever 1 Premature Birth, & Debility from Birth 22 Violence, Poison, and Privation 12 Natural Decay 38 Other Diseases, chiefly Chronic 54 Total 420 10 to be low, lower in fact than in some of the districts we arc accustomed to think more favorably situated. The proportion is rather more than 1 to 7 of the whole number of deaths. Consumption, on the other hand, has destroyed a number nearly equal with the six diseases named in the note—1 to 8 of the whole number of deaths.* So much of this fatal disease, which destroys more lives in the Hamlet than any other, owes its development to over-crowding and want of ventilation and cleanliness, that while the Vestry are directing their atten'tion to the prevention of other diseases by the means placed at their disposal, such changes will be made in the fomenting causes of consumption, that it is fair to suppose our future records will show a reduction in the number of deaths. Scarcely less valuable than the mortality returns have been found to be, would be information of recent cases of acute and contagious disease coming under treatment by those gentlemen who are engaged in parochial or other public medical service. The report of the occurrence of deaths in a street may be received in time to create alarm, to be followed by examination and exertion to rectify that which is contrary to a satisfactory sanitary condition. But the evil will have become known too late for those who have fallen victims. The registration of a death from fever may be taken in itself as an announcement of the existence on the spot of many current cases; some of them, perhaps, equal in gravity with that which proved fatal, may be added to the list of the dead,—so paying a debt which can scarcely with strictness, at that time, be termed an inevitable debt of nature. This source of information has been considered by the Metropolitan Medical Officers of Health of sufficient importance to induce them to collect and publish weekly for their mutual information accounts of such diseases from each of their respective districts. Five of these publications have already been issued, and my own communications have only been withheld until the arrangements consequent on the recent separation of the Hamlet from the Stepney Union are completed. * The proportions of the deaths in all London for the Quarter is about 1 to 6 of this kind of disease, and of Consumption 1 to 8½ . 11 PAVING, DRAINAGE, AND SEWERAGE EFFECTED. The improvement which has been made in the drainage and sewerage of the Hamlet, as well as the paving, is so considerable that palpable results are to be expected. The surface water is now more rapidly and effectually removed by their united operation. When the extent to which the works have been carried, is considered, the fairness of the inference will be apparent. From Mr. Lemon, the Surveyor to the Vestry, I learn that, between June last and March 28th, 47,858 feet of new York paving have been laid down, and 16,440 feet of new kerb; and that 28,64.3 feet of old Paving have been taken up and relaid; 7,053 feet of Pipe have also been laid down, and 2,755 feet of Brick Sewer, and 142 Gullies, have been constructed. INSPECTOR OF NUISANCES' RETURNS. The Inspector of Nuisances has furnished me with the following return of Nuisances removed, from June 4th, 1856, the date of my Report last year, to March 28th, inst. Privies emptied 499 Drains cleansed 215 Cesspools emptied 20 Privies filled up, connected with sewer, and furnished with pan, trap, &c. 211 Drains connected with sewer, and trapped 211 Removals of dust 565 Houses cleansed, pursuant to Notice 7 Sundries, including removals of dung, swine, &c. 17 Besides which number, 42 places are at the present moment undergoing correction, either by alteration or the removal of offensive matter. 12 To effect these cleansings and alterations, 499 Notices have been served, and 211 Second Notices. Summonses have been issued in not more than half a dozen cases. HOUSE TO HOUSE VISITATION. If a complete house to house visitation were made throughout the Hamlet, even at the rate of two or three streets per week, to ascertain the state of drainage and repair, so far as is influential on health, and to enforce compliance with that part of the Act of Parliament which regulates the communication with the existing sewers, I feel assured that we should individually experience the benefit in pocket as well as in health. For in an unhealthy district, the full enjoyment of health is comparatively unknown within its limits. A freedom from prevalent disease is accepted and acknowledged as health; but there are many, from being possessed of constitutional strength and organization, who are able to resist for a time a certain amount of injury and poisonous influence, without exhibiting any specific form of disease, yet, are made conscious of defective health through deteriorated functional action, and although they may escape Typhus and its congeners, are suffering obscure and irreparable damage in vital organs, with a consequent shortening of their existence; then, if poor, they become an expense to the rate-payers, both in sickness and death; and if rich, cease, by the curtailment of life, to contribute their quota to the general expenses of the community. The value of life might possibly be computed in a moneyscale, which would show how much is actually lost to the public by permitting removable causes of human destruction. From two to three hundred lives, according to a fair computation, might be saved annually in Mile End by a thorough system of sanitary regulation and local improvement. True it is, that it could not be accomplished without some public expense and sacrifice of individual interests. Immunity from epidemic disease for a long period, such as we have recently experienced, and may even now almost be said to enjoy, is aptto create indifference to its dangers, and to induce us to 13 diminish our efforts for improvement, except where the offences are palpably evident to our nostrils or vision. But, it must never be forgotten, that here, as elsewhere, it behoves us " during peace to prepare for war." SLAUGHTER HOUSES AND LICENSES. In the month of September, pursuant to public notice, thirty-four persons applied to the Vestry to have their premises inspected, which were used for slaughtering cattle, previous to application for a license at Quarter Sessions. Many of the places were found commodious, but some persons who made application had no buildings at all, having been accustomed to kill sheep and calves in the open air in their back premises. Alterations were required in the premises of some, which were partially effected; and a few, refusing or neglecting to pay attention to the matter, were not allowed the license, in the absence of the recommendation by the Vestry. Twenty-eight licenses were granted, two were refused on the ground of the applicant having no proper premises, one for refusing to connect his slaughter-house with the sewer, and three because slaughtering was not considered a necessary portion of their business,—one of them being a drover, and the others cow-keepers on an extensive scale. It appears to me that in our district the act of parliament requiring the licensing of slaughter-houses, has been nullified by the indiscriminate permission to license granted by the magistrates at Quarter Sessions. In my opinion it was contemplated by the legislature, in the enactment alluded to, to provide for the better conduct of a necessarily offensive process, by restricting it to buildings and premises in every way appropriate to the purpose, and not to perpetuate and legalize the continuance of an occupation, in itself a nuisance, in places so manifestly unfit for the purpose as are many so-styled slaughter houses, which have received a license. 14 ADULTERATION. I have not been able to attend so much as I could wish to the subject of the adulteration of food. The proper examination of articles of diet involves sometimes chemical analysis, sometimes investigations scarcely less elaborate of other kinds. To do this in a manner at all to be depended on, requires the purchase of sundry instruments and appliances of which I am not possessed. The practice of using alum in making bread is very generally admitted ; the quantity used is small, but I am of opinion is sufficiently large to do harm. The possible amount of injury may perhaps be small, but there are many persons who, estimating it at a higher rate than others, would be glad to procure the staff of life without any admixture, if they knew how to do it. I think the remedy lies mainly with the purchasers, by supplying themselves from those who profess to make and sell the article perfectly pure, when their professions might be occasionally tested by competent chemists. I have examined many specimens of milk, as well as the means at my disposal would permit me, and I believe that none of them were adulterated with any pernicious or offensive substance. The specific gravity was found to be lower than it ought to have been according to the scales which have been published, showing that the milk had, from a forced diet, been either produced devoid of its richer and heavier elements, or that it had been diluted by a thinner fluid. If the specific gravity of water be supposed to be 1000, that of good milk should be 1031. The present high price of meat is likely to be the means of introducing to the markets frequented by the poor that which is inferior in quality, if not unwholesome. The Nuisances Removal Act, section 26, empowers the officer of local authority to seize any food found exposed for sale of unwholesome quality, or in an unwholesome condition. It has not yet occurred to your officers to make any such seizure, but 15 it is not at all unlikely that if the price should continue to increase, the oupidity of dealers and the difficulty of supplying the usual amount of animal food among poor classes may afford fresh employment for your officers. HIGH PRICE OF MEAT.—MURRAIN. The rise in the price of meat has, I believe, taken place in consequence of the prohibition of the importation of cattle from certain ports in the Baltic, from whence we have been accustomed to derive a supply, where a murrain,* attended with an alarming mortality, is said to be raging among cattle. I learn from very good authority that the murrain in question is that pulmonic disease with which we are here but too well acquainted, and although it is extremely severe in and about the Baltic ports, from whence the cattle have been used to be shipped to England, more alarm is created than would otherwise exist, in consequence of a much more terrible and fatal disease being prevalent in Russia, termed the "steppe murrain," which, I am told, resembles human cholera. The various governments are making great exertions to insulate districts which are affected, by surrounding them with military cordons. No such disease, I believe, has made its appearance here. COWS AND COW HOUSES. From this subject to that of cows and cow houses the transition is easy. I have visited and examined, I believe, every one in the Hamlet, to ascertain their cubical measurement, their general condition, and to endeavour to obtain intelligence respecting the subject of the last paragraph. There are in the Hamlet 39 establishments,—where 482 cows are supported. Some have the advantage of grazing in summer, and with the exception of some easily remediable defects of paving, draining, and removal of manure, I think ought not to * The term murrain is not confined to one particular disease. It is derived from a Greek word, meaning "to waste away," and has long been used to denote several kinds of Epizootic disease. 16 be pronounced generally detrimental to the public health. The greater number are kept in the East Ward, where there is sufficient space to allow the effluvium belonging to such places to be effectively diluted by the atmosphere. More offensive odour appears to proceed from the distillers' wash and brewers' grains, which are used for feeding the animals, than from the cows themselves. There is probably less effluvium proceeding from a cow than from any other animal of equal bulk and producing an equal quantity of manure and refuse litter. Sheep and horses, both of them herbivorous, have each a peculiar odour, that belonging to the former is especially unpleasant. That proceeding from cows is usually spoken of as agreeable, and giving an idea of sweetness and cleanness rather than of offensive filth. Notwithstanding, in close and densely-populated places I believe it impossible for cows to be kept so clean as to be quite consistent with the best state of public health. If it were not that the remark is so frequently made to me, that the smell of a cow-house and of cows is healthy, and even a good remedy for some complaints, especially consumption, I should not think it worth while to notice it; and I only now avail myself of this opportunity to state that such a supposition has no foundation whatever in fact, in consequence of the general belief in the error. Nearly all the causes which produce and aggravate disease,* arc to be found in full and combined operation in many * The following are the principal causes which produce and aggravate disease:— 1.—Want of drainage (surface and sewerage); 2.—Uncleanliness of houses; 3.—Dampness, and bad repair; 4.—Want of ventilation; 5.—Atmospheric pollution; 1, fermenting rubbish, 2, escape of gas from sewers, cesspools, &c. 3, emanations from noxious trades; 6.—The use of improper food and water; 7.—Over-crowding of dwellings; 8.—Deficient water supply. These are so evidently that which I have stated them to be, that I need do no more than enumerate them. 17 populous districts, in their courts and alleys, which are and always have been, here, and elsewhere, unhealthy places. Unfortunately, in our own district, such property, besides being heavily encumbered, belongs mostly to persons of very scanty means,—the collected rents barely paying the ground rents, and the owners deriving from their possession little or no advantage. They have really no money to spend on required improvements. To charge such property with the costs of thorough repair would leave the owners, in some instances, I am fully aware, destitute; but life is more sacred, and possesses higher rights, than property, and it cannot be just to inflict or continue a public injury, while endeavouring to spare and sympathize with the inconvenience of an individual. COURTS, ALLEYS, AND MODEL LODGING-HOUSES. The repair of courts, above all other places, requires to be comprehensive and complete. The houses should be kept carefully cleansed and limewashed, while the open space of the court itself should be, except in a few instances where the opening is spacious, well paved with York stone, set in cement, so as to admit of its being flushed or washed, when required to be done, almost as perfectly as if it were a vessel. By such thorough purification alone can we expect to realise the advantages offered to us by the Local Management Act. The state of several of our courts has been much improved, and the improvement has been felt by the extinction of disease in them, as in White Horse Court,—John's Court,—Edgar Place,—and others; but in no instance has a court been put, in sanitary particulars, in perfect order. So much of our mortality, I am confident, is dependant on this cause, that I feel it my duty to urge the Vestry to adopt some decisive and general plan for their purification. If it should be found that the property is not worth the cost of repair, it is worthy of consideration whether it would not be advisable to remove the defective cottages altogether, and to build, in their place, Lodging-houses for the poor. The Vestry is empowered by the statute 14 and 15 Victoria, cap. 34, sec. 18 31 and 32, to do so, and to borrow money for the purpose from the Public Works Loan Commissioners. Model Lodging-houses hare been found to be something more than self-supporting in other districts, and there can be no reason why similar success should not attend their introduction to Mile End. PUBLIC URINALS. I take the opportunity offered me in addressing this report to the Vestry, to suggest to them the advantage, in various points, which would accrue from the construction of public urinals. If proper places were provided, there would be some rational plea for preventing the commission of nuisance in improper places. The plan which appears to me to have the fewest objections, would be, to erect in the Mde End Road, single screens of cast iron, in the form of a scroll, at, and around every tenth or twelfth lamp-post, on alternate sides of the road; and a modification of the arrangement might afterwards be applied to some of the principal streets. The cost would not be excessive, and the two great objects of publicity and decency would be attained. It would be vastly superior to the plan adopted and much approved of in the French capital, where the screens are only such to foot passengers, and are exposed to equestrians and others who use the road. INTRAMURAL BURIAL. The subject of Intramural Burial is not likely to trouble us, for some long time at least. I have been in all the vaults which were formerly used for interments, and, with the exception of those beneath Brunswick Chapel, they contain too few coffins ever to be, under any circumstances, injurious to health; and even those few are built in with brick and cement. The vaults beneath Brunswick Chapel contain a great number of coffins, and as they now receive no addition the whole could easily' be sealed up, if it were considered desirable. 19 Upon review, I think it must be observed that the past year has not been idly spent; and if even the present rate of mortality be maintained, in the absence of epidemic disease, I think we shall have some cause for congratulation in the success of our attempts at sanitary improvement. I have the honor to be, Gentlemen, Your most obedient servant, J. H. FREEMAN, % Medical Officer of Health. Town House, Mile End Road. 20th May, 1857.