PL47 PLUMSTEAD VESTRY. Annual Report OF THE Medical Officer of Health. 1895. H. Pryce & Son, Steam Pointers (Reg. L.S.O.), Woolwich. PL47 ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH, PLUMSTEAD, Year, Jan.-Dec., 1895. To the Plumstead Vestry. Gentlemen, I have the honour to present to you my fifth Annual Report on the health of Plumstead. A.— Vital Statistics. Population. 1. The estimated population, 61,494, supposes an increase at a lower rate than obtained in the ten years 1881-91; but it is probably more than the actual population. This is indicated (1) by the great decrease in the birth-rate; (2) by the number of houses. There were at Midsummer, 1895, 3098 houses assessed in West Plumstead, and 6356 in East Plumstead—total, 9454. This gives on the estimated population 6 5 per house, compared with 6.0 at the census, and 6.2 in each of the last two years. As another census will be taken in April, the question will soon be settled. I estimate the population of West Plumstead to be 18,187 and of East Plumstead 43,307. X 2 Births. (See Tables I., II. and VI.) 2. The birth-rate was the lowest since 1885, and for the first time was lower than the average for London. The actual number of births in the year was the lowest since 1889. There were 468 births in West Plumstead, and 1398 in East Plumstead. This gives birth-rates of 25 and 32 respectively. Deaths. (See Tables I., II., and VI.) 3. The death-rate, corrected for Public Institutions, was 15-1. With the exception of 1894, this is the lowest rate since 1889. TABLE A. Year 1889 1890 1891 1892 1893 1894 1895 Deaths from Influenza 0 9 41 27 35 7 17 ,, Bronchitis and Pneumonia 93 136 207 170 204 124 166 „ Phthisis 69 95 114 100 111 70 96 Total 162 240 365 303 350 201 279 Total Deaths—all causes (corrected) 759 923 920 849 994 736 930 Table A shows the effect that Influenza has had on the death-rate in recent years. The years when Influenza has been prevalent have been years of high death-rate, and vice versa. In the first quarter of last year, we experienced the fifth epidemic of Influenza, and it is this that was the chief cause of the increase of the death-rate over 1894. The warm summer and the resulting Diarrhœa, and the Typhoid epidemic, were the other special factors in last year's mortality. 3 The first quarter had the highest mortality, and the last quarter the lowest. Roughly estimated the death-rate in West Plumstead was 13 i and in East 15'8. Last year the numbers were 113 and 12 6 respectively. Infant Mortality. (See Tables I. and VI.) 4. The number of deaths of children under one year to 1000 births was 134. This is high for Plumstead. Since 1885 it has only twice been higher than this, viz:—in 1890, when it was 137, and in 1893 when it was 140. The largest number of deaths of infants occurred in the third or summer quarter, no doubt as a result of the unusually warm and dry weather. In West Plumstead the infantile death rate was only 91, whereas in East Plumstead it was more than half as much again, viz : 147. This difference is no doubt mainly due to West Plumstead containing a larger proportion of the well to do and educated, who have the knowledge and means to take better care of their children. It is a curious fact that the difference between West and East Plumstead in respect of the infantile death rate has increased rapidly in the past three years; the figures are West. East. 1893 132 143 1894 77 100 1895 91 147 x 2 4 Zymotic Death-rate. (See Tables I. and VI.) 5. The Zymotic death-rate was 2.42, as compared with 2.06 and 3 71 in the two preceding years. The number of deaths from Measles was below the average, and Whooping Cough only caused five deaths, the lowest number by far since 1885; Enteric Fever however and Diarrhæa brought up the death-rate. Diarrhæa. 6. Diarrhoea caused 48 deaths, giving a death-rate of .8 per 1000, the highest number since 1885; 46 of these were under five years of age, most of them under two years; 5 were in West Plumstead and 43 in East; 38 of these deaths occurred in the third or summer quarter, and 8 in the fourth quarter. No doubt the warm dry weather of the summer and autumn were mainly responsible for this high death-rate from Diarrhoea. The Diarrhoea death-rate was also very high throughout England. Phthisis. 7. Phthisis caused 96 deaths, compared with 111 and 70 in the two preceding years. This gives a death-rate of 1.5. There were 28 deaths in West Plumstead, and 68 in East Plumstead, giving rate per 1000 of l.53 and 1.58 respectively. This shows a larger proportional prevalence in East Plumstead, contrary to what has occurred in previous years. Uncertified Deaths. 8. There were 28 uncertified deaths, equal to 3.0 per cent of total deaths, compared with 30 and 3 6 in the two preceding years ; 14 of the cases were under five years, and 14 over five 5 years. It appears that in many of these cases a medical certificate might be obtained from the doctor who has attended the patient, but owing to the death having been sudden, or the doctor not having seen the patient recently, the matter is referred to the Coroner. That the case should be so referred to the Coroner is no doubt most desirable, but it seems to me it would be better for the sake of getting accurate registration of the causes of death, if, when the Coroner decides not to hold an inquest, he were to leave it to the medical man to give a certificate. I have heard nothing more of the very desirable proposal of the County Council to appoint medical investigators to assist the Coroners in their duties. Inquests. 9. There were 43 inquests held compared with 43 and 35 in the two preceding years; 11 were in West Plumstead, and 32 in East; 30 were from accident or violence, 13 from 'natural causes.' There was no verdict of murder, but in a case of suffocation of an illegitimate child the Coroner stated the circumstances to be very suspicious. There were 4 suicides, 1 by cutting the throat, 1 by throwing himself under a train, 1 by taking carbolic acid, and 1 by taking oxalic acid. A seafaring man died of starvation in Bostal Woods. A tramp was suffocated by carbon-monoxide while sleeping in a brick field. Two children were scalded in hot baths, and a third by pulling the kettle over. One case of taking an overdose of an opium sleeping draught. One fell from a cart. One man, a labourer, died of a surfeit of apples. One fell from a railway bridge, the death being in this case due to delirium tremens. A woman of 87 died from a scalp wound caused by falling downstairs. A woman of 52 burnt by a paraffin lamp upset. A man run 6 over by a horse and cart. A boy struck by falling roof of football pavilion in a gale. A child burnt by clothes igniting. Four children suffocated in bed. One child fell out of bed. A child was poisoned with carbolic acid, and an adult with ammonia. A child died from injudicious feeding. Other causes of Death. (See Table II.) 10. Twenty deaths under 5, and seven over 5 were due to Tuberculosis, besides those from Phthisis. There were 37 deaths from cancer compared with 33 and 31 in the two preceding years; 15 deaths were either attributed to alcoholism or to diseases like cirrhosis of the liver, which are almost invariably the result of alcoholism; 71 deaths were from premature birth and low vitality. East and West Plumstead Compared. 11. It is characteristic of the past year that as regards the general death-rate, the infantile death-rate, and the deaths from Phthisis, East Plumstead compared very unfavourably with West, both absolutely and relatively to the last two years. Plumstead compared with the other Sanitary Areas of the Metropolis. (See Table VII). 12. Five districts had a lower death-rate, viz:—Hampstead, Stoke Newington, Lee, Lewisham, and Wandsworth. Two only had a lower infantile death-rate, viz :—Stoke Newington and Wandsworth. It must be remembered that Plumstead is the only sanitary area whose death-rate does not need to be corrected for age distribution. If this correction were applied, Plumstead would take at least the third place, if not the second. 7 B.—Infectious Diseases. (See Tables IV. and V.) 1. A total of 762 notifications were received during the year, compared with 790, 886, and 713 in the three preceding years. 412 of these went to Hospital, or rather more than half. A larger proportion still would have gone to Hospital if there had been sufficient accommodation. But twice during the year the accommodation of the Asylums Board Managers failed—first during the Typhoid epidemic, and again in the autumn when Scarlet Fever and Diphtheria became unusually prevalent. 2. The Sanitary Committee directed, in the middle of the year, that the Arsenal authorities should be informed of the occurrence of infectious diseases in the house of any Arsenal employe. This practice renders it unnecessary for Arsenal employes to report personally at the Arsenal, and so diminishes the chances of infection being carried. The clerical work of the Sanitary Department has thus been considerably augmented. Small Pox. 3. There were 16 cases of Small Pox notified, compared with 51 and 22 in the two preceding years. All but one were removed to Hospital, and two died. All the cases were in adults. They mostly occurred in the autumn at a time whep there was a serious outbreak of Small Pox in certain parts of London. Seven of the cases occurred in the Workhouse and Infirmary. Most of the remaining cases were probably contracted from people living outside Plumstead. Owing to the neglect of vaccination, Small Pox has been endemic in West Ham for some years, and Plumstead suffers from the close connection with West Ham now prevailing by the Free Ferry. 8 A Local Government Board Inspector came down to enquire into the cases of Small Pox, and the efficacy with which vaccination was carried out. He consulted with the vaccination officer and myself, and impressed on the former the necessity of using all means to secure vaccination of friends and neighbours of those attacked with Small Pox. 4. With one exception all the cases were removed to the Small Pox ships. Besides the usual measures of disinfection, the rooms where the cases occurred were stripped, re-papered, and lime whited at the Vestry's expense. In most cases the other inmates of the houses were re-vaccinated. All the inmates of the workhouse and infirmary were re-vaccinated. In one case the friends refused vaccination; the sister went to the Hospital Ship to see the first patient and caught the disease. In no other case was there any spread of the disease locally, except in the workhouse. Two cases died, one of whom was unvaccinated. Scarlet Fever. 5. There were 323 cases notified, compared with 61, 584, 527, and 480 in the four years preceding. This shows a steady decline since the outbreak of 1892; 194 went to Hospital; this is nearly two-thirds of the whole; more would have gone but for the fact that owing to prevalence of the disease in other parts of London the Hospitals in the autumn were overful. There were 10 deaths, 4 at home, and 6 at Hospital, giving a death-rate of 3.0 both at home and in Hospital. The deathrate has declined each year in the past two years, and the Hospital rate which in 1893 was twice as high as the rate at home, has become the same as at home. 9 6. The disease was pretty equally distributed over the parish. In the early part of the autumn most of the cases were connected with Bloomfield Road School. Miss English, the head teacher, called my attention to a female pupil whom she had refused to admit to the school, suspecting her to have Scarlet Fever. I visited the house, where washing was taken in, and found the child to be peeling from Scarlet Fever. I have little doubt that the mother was aware of the existence of the disease, but here again as in the cases I mentioned last year there was no evidence to show that she was aware. 7. The 323 cases occurred in 283 houses; only 27 houses had two cases, and only 13 houses had three cases. This shows the great benefits obtained by isolation. In most of the instances of two or more cases occurring in one house, the infection has already spread before the disease is notified, owing either to wilfully or carelessly neglecting to obtain medical advice in good time. I believe that if the law not only compelled notification where the householders were aware of infectious diseases, but also laid on them the responsibility of making themselves aware, Scarlet Fever might become as rare as Small Pox. It is no doubt the concealing of mild cases, and allowing them to go about unnotified that keeps up the disease. 8. Return Gases.—In six cases the infection was apparently due to the return of a previous case from the Fever Hospital. I have examined carefully into these cases, and have formed the opinion that they are mostly due to the returned case carrying the infection in his throat. It appears cases may continue to be infectious for 8, 10, and even 12 weeks. In some of these cases the throats were obviously unhealthy when I saw them. I think it would be a wise precaution to recommend the use of an antiseptic gargle for some weeks after the patient is 10 apparently well. It would be impracticable and undesirable to isolate all patients for 12 weeks. Iu one of these cases the returning patient had been away from home 11 weeks, and in another 4 months. One patient who returned on July 2nd, after a stay of 11 weeks, apparently infected three others ; a brother notified on July 9th, a second brother notified on July 15th, and a friend visiting the family on September 11th. This supposes a duration of infection of 20 weeks. This patient had an unhealthy throat. Diphtheria. 9. There were 148 cases of Diphtheria and Membranous Group, compared with 179 and 118 in the two previous years. Of these 67 went to Hospital, or nearly one half. Last year only one-third went to Hospital; the year before only onesixth. Still more would have gone but for the pressure on the Hospitals in the autumn. 21 died at home and 13 at Hospital, giving death-rates of 25 per cent. and 19 per cent. respectively, compared with 32 and 35 last year, and 30 and 50 in 1893. The diminished death-rate, especially the greatly diminished Hospital death-rate is very satisfactory. There can be little doubt that the latter is largely due to the use of the newremedy Anti-toxin, which was used during 1895 in all the more serious cases taken into the Fever Hospital. 10. School Influence in the Spread of Diphtheria.— A good deal has been written lately on the effects of School Influence in promoting the spread of Diphtheria, and attempts have been made to shew that the increase of Diphtheria in towns, in recent years, is mainly due to the effects of the Education Act of 1870, which has led to aggregation of children in schools to a much greater extent than previously. 11 In order to see to what extent this factor prevails in Plumstead, I have, in the past year, gone to great pains in obtaining full information concerning the school attendance in all the cases of Diphtheria that occurred last year. 11. Out of the 148 cases of Diphtheria, 77 or just over onehalf attended School; 71 or just under one-half attended no School. In 45 cases no School was attended by other children in the family. In 85 cases School is stated not to have been attended within one week of the attack. If, as is generally supposed, the incubation period of Diphtheria is under a week, it follows that in more than a half of the cases in Plumstead last year School attendance was not the direct cause of the infection, and it also appears that in nearly a third of tne cases School attendance could not have been either the direct or indirect cause of the infection. 12. Fifty-nine of the patients were under 5 years of age ; of these 12 attended School, or 20 per cent, I find that of 185 consecutive notifications of all the infectious diseases, Scarlet Fever, Diphtheria, Enteric Fever, Erysipelas, &c., in children under 5 years, 42, or 22 per cent., attended School. Whence it appears that School attendance is less connected with the infection of Diphtheria than with that of the other infectious diseases. This is markedly the case with Scarlet Fever, as is shewn by the fact that in Scarlet Fever a much larger proportion of the patients were of School age than in Diphtheria. 13. As regards the Schools attended the cases were pretty well distributed. Ancona Eoad and Bloomfield Eoad had the largest number of cases; Eglinton Eoad the fewest, viz.: none. This immunity of Eglinton Eoad School has lasted since 1890, and is connected with a comparative immunity of All Saints' Parish. 12 14. As usual, St. James' Parish has had the highest number of cases per cent. of the population, namely, .38; St. Nicholas' comes next with a per centage of .30, St. Margaret's .28, All Saints' .21, and St. John's .19. These figures are calculated on the census population. 15. Thirty cases occurred in the first quarter of the year with 7 deaths, 26 cases in the second quarter with 4 deaths, 16 cases in the third quarter with 4 deaths, and 65 cases in the fourth quarter with 19 deaths. 16. Out of the 148 cases it was stated in 30 that other members of the family had suffered from throat illness (not Diphtheria) within a month previously. 17. In 34 cases of patients who attended school, it was stated that other pupils were absent from patients' class with some throat illness; in 24 cases one pupil was absent, and in the remaining 10 cases 2 or 3 pupils were absent for this reason. 18. So far as the above statistics go there appears no evidence that school attendance is the dominant factor in the receut prevalence of Diphtheria. On the other hand, it would appear that Diphtheria has less to do with school attendance than Scarlet Fever, and that it has more to do with local conditions. 19. The 148 cases occurred in 61 streets. Eight cases occurred in King's Highway, containing about 30 houses in all. These cases all occurred between 21st January and 20th February. A previous case occurred on 10th December, 1894, in this road—this was at the Cemetery Lodge, which is situated on a higher level than the other houses. All the houses in King's Highway drained into cesspools at that time. The road is situated at the bottom of a valley running down 13 hill from West to East, the Cemetery Lodge being situated at the westerly end of the houses. A stream which at that time received the overflow of cesspools 200 yards away runs down this valley, but disappears underground where the houses commence. The soil is a few feet of gravel with a layer of underlying clayey loam. Of the eight cases four attended school, three going to one, and the fourth to another. No local communication between the families could be traced. Two short streets run up from King's Highway at steep gradients, but no one in these streets was attacked. These cases appear to me to point to infection by infiltration of the soil, the infection being carried from the cesspool in the first case by the flow of the underground water. This was the only indication of a localized outbreak. 20. Six cases of Diphtheria having occurred consecutively in connection with the Infant School in Conway Eoad, I inspected this school and personally examined the throats of all the infants present, 166 in number. I found no throats suggestive of Diphtheria. No further cases occurred after my visit. I made one or two suggestions to the School Board for improving the drainage of this school. These were quickly carried out. Enteric Fever. 21. There were 214 cases of Enteric Fever notified during the year, with 30 deaths. This large number was due to a milk epidemic which occurred in May and June. I reported fully on this epidemic at the time. The following paragraphs, Nos. 22-44, are extracted from that report. 22. Previous to May 9th, only six cases of Enteric Fever had been notified during the year in Plumstead. These all occurred in East Plumstead, whereas the recent epidemic was 14 mainly confined to West Plumstead. The number of cases notified in the three preceding years respectively was 22, 29 and 26. The first case of the epidemic was notified on the 9th May, at a public house in Plumstead Common Eoad, and two more on the 11th. On this day I was informed by Dr. Clarke, of Plumstead Common Eoad, that he had several suspicious cases in his practice. I visited two of these, and had no hesitation in pronouncing them to be Enteric Fever. On the whole I had information on the 11th of six recent cases of Enteric, and five of them derived their milk supply from the same source, a dairy in Princes Road. (I found afterwards that the sixth case also had milk from the same source, though from a different dairy). I felt no doubt accordingly that I had an epidemic of Enteric Fever to deal with, and that in all probability it was conveyed by the milk supplied from the Princes Road dairy. I at once inspected this dairy. It contained thirteen cows, all apparently in good condition. The Kent Company's water was laid on. Although not kept in a very cleanly condition, the only thing which excited my suspicion was a tank about three feet square and two feet deep, situated under a tap, and used for watering the cows. Evidently this tank was seldom cleaned out, and in all probability was used for washing the cans into which the cows were milked, if not also the churns. 23. I waited till the 13th, on which day I knew of 16 cases, 15 of which were found to have had milk from the Princes Road dairy. The evidence now seemed sufficient to incriminate the dairy, and a special meeting of the Health Committee was summoned for the following day. This meeting decided, on my recommendation, to put in force Section 71 of the Public Health (London) Act, and gave notice to the dairyman to appear the next day before them and show cause why the dairy should not be c losed. 15 24. An order was made requiring the occupier not to supply any milk from the dairy within the Plumstead district. This was on May 15th, six days after the first case was notified, four days after the first indications of an epidemic, and two days after there was reasonable ground to attribute it to the milk supply. It might have been expected that there would have been no further trouble with the milk supply. But the event was far otherwise. I soon heard that the employes of the dairy were still selling milk. 25. In order to obtain evidence for a prosecution, they were watched by the chief inspector early in the morning, and seen to bring the churns out of the dairy and proceed straightway and sell it to several houses. For this the occupier was summoned to the police court on May 20th, and fined the full penalty, £5. I believe some milk was sold even after this, but probably not very much. It was, however, turned into butter, the sale of which is not interfered with by the Act. On the 28th the cows were sold. 26. Up to May 15th, 25 cases were reported; on the 29th the number had reached 92 ; in the following fortnight 47 fresh cases occurred ; in the fortnight ending June 26th, 10 cases, since when there has been a slow but steady diminution. (See Table A.) 27. The epidemic may be said to have declined rapidly from the 12th June, or about three weeks after the dairyman was summoned to the Police Court. In the cases that occurred after that date it was usually found that either the patient had been ill for two or more weeks before a diagnosis was made, or that there had been a previous case in the same house. 28. As a result of a house-to-house inspection in Barnfield and Princes Roads (the roads most affected by the epidemic), 16 I found that, of 49 houses which had had milk from the Princes Road dairy, only 20 escaped having a case of enteric fever. On the other hand, only two had the fever out of 150 houses which were stated not to have had this milk. Altogether, this dairy must have supplied a very large number of people, probably, at least, 250 houses. 29. In May and June, 33 cases of enteric fever occurred in Woolwich, nearly all of which, I understand, had milk from a Woolwich dairy which was supplied by the Princes Road dairy. 30. The house contained a cellar, where milk was put to stand for separating the cream. In the cellar was a cupboard full of old condensed-milk tins. 31. Water Supply.—The dairy was supplied by the Kent Water Company. There was one tap in the house, and one situated over the tank. This tank consisted of cemented brickwork. From it the cows were watered by means of pails. There was a green deposit on the sides and bottom, and the water was cloudy, as seen in a bottle. This water was analysed by Professor Smith, and pronounced unfit for drinking purposes on account of vegetable debris. Professor Smith also examined it bacteriologically, with a negative result, as regards the specific organism of enteric fever. The water from the tap was also analysed and found to be of the usual good quality of Kent Company's water. The water pipes supplying the dairy on both sides were carefully tested by Mr. Duck, chief Sanitary Inspector, but were found perfectly sound; the water stood in the pipes without leakage for two days. I was informed by the Company's Inspector that the water had not been shut off in this locality within the previous two months. There was no well or underground tank situated on the premises, 17 32. Sanitary Condition and Drainage.— The cow-house was not in a very cleanly condition. The roof was full of cobwebs, and the cow-dung not swept back on any of my visits. It was well-ventilated and properly drained. The water-closet of the house was satisfactory, as regarded the apparatus. The drains of the house were tested with the smoke machine, and found very defective, but the defects were all outside the buildings. there was, however, escape of smoke in an area outside the window of the cellar, where the milk was creamed, and where the condensed-milk tins were found. The rain-water pipes were in direct connection with the drains, and there was a defective gully outside the can-house. 33. Incidence of the Disease.—The disease attacked 74 males and 103 females : 28 were under 5 years of age, 41 from 5 to 10, 57 from 10 to 20, 45 from 20 to 40, and 6 over 40. One patient was 71 years old. He had a slight attack, and was at his occupation (Analyst's Inspector) within four weeks. (See table A.) 34. In my house-to-house inspection of the streets most affected I met with several cases of infants and young children who were out of sorts, and had diarrhoea. I think, probably, some of them were mild cases of Enteric, but they were not notified. The cases presented the ordinary symptoms, and usually had diarrhoea. 113 went to Hospital, and 64 were treated at home. Up to the end of July there were 13 deaths at Hospital and 10 at home. 35. Death-rate. — Thus the case death-rate was 11 per cent. at Hospital and 15 per cent at home. The case death-rate for Plumstead in the three years (1892, 1893, and 1894), was 22 per cent. This lower death-rate at Hospital is highly satisfactory, and is probably mainly due to the more careful feeding that Hospital patients have. Y 18 36. Hospital Accommodation.— Many of the cases were unable to be removed to Hospital for several days after notification, on account of want of accommodation. The accommodation at the South-Eastern Hospital was soon exhausted, and cases were taken to the more distant Fever Hospitals. Arrangements were also made with the London, Guy's, and other general Hospitals to receive patients. It is certainly undesirable to move an Enteric case, after the first week, so long a journey as was required to reach these Hospitals ; but the result does not appear to have been so unfavourable to recovery as I anticipated. It is hardly creditable that London should be so deficient in accommodation for fever cases, that, at a time when very little fever prevailed over the great bulk of the Metropolis, a small localized outbreak could not be satisfactorily dealt with. 37. District Nurses.—Great and valuable assistance was rendered by the nurses of the Woolwich District Nursing Association in nursing cases before they went to Hospital, as well as those who remained at home all through their illness. 38. Infectiousness.—The great importance of Hospital treatment for all who cannot afford to have a trained nurse in continued and exclusive attendance on the patient is shown by the number of cases which appeared to have been transmitted from the first patient to another in the same house, viz.:—six at least. A case attended by myself is instructive from this point of view. Mrs. R--, living with her husband (a carpenter) and baby in three very comfortable and wellfurnished rooms, in a well-drained and in every way sanitary house, caught the fever by drinking the Princes Road milk when calling at her mother's. Her own house had a different 19 milk supply. She was placed in a large well-ventilated room, the husband occupied a separate one, and nursed by the District Visiting Nurse, and an untrained nurse who remained in the house. The latter prepared the husband's food ; but she was given strict directions about rendering her hands aseptic. Nevertheless, the husband fell ill about a week after the wife got up. No other source of infection besides his wife could be tfaced. 39. Remarks.—The facts given above are, I consider, conclusive proof that this epidemic was caused by a particular milk supply. A. Source of Infection.—A considerable number of milk epidemics of Enteric Fever have been reported in recent years. Some of these have been clearly traced to the use (for washing the milk cans or diluting the milk) of water contaminated with the excreta of a previous case of the disease. But in other cases—as in the present epidemic—there appeared no probability of contamination by a previous ease. It has been suggested that, as is probably the case with Scarlet Fever, Enteric Fever may be communicated to man by the milk of diseased cattle. A third explanation is the contamination of the milk by sewer gas. Pre-existent Case of Enteric.—In the present case, it seems unlikely that anyone with Enteric Fever had had any connection with the dairy. I enquired carefully from their medical attendants as to the recent ailments of all connected with the dairy, and could find nothing suspicious about them. May, too, is the month when Enteric Fever is least prevalent. If there had been any case of the disease among the dairy people, the dirty and intemperate habits of these, and the existence of the tank of water, offered a likely means of the contamination Y 2 20 of the milk. A comparison of the bacteria found respectively in the tank water and the milk, shows that there was a close resemblance between them, and increases the probability that this water found its way into the milk. In the absence of any evidence of a pre-existing case of Enteric, it is impossible to say more than that this offers a not unlikely explanation. 40. The Beveridge Epidemic.— An almost parallel case reported by Dr. Beveridge, of Aberdeen, is referred to by Dr. Ernest Hart, in the British Medical Journal for July 13th, 1895. Here an epidemic affecting 322 people was traced to the milk from a farm:— "The cistern at the farm was situated at a corner of the cowshed, its contents being used for all dairy and byre purposes. Analysis showed the water to be pure prior to entry into the cistern, but to become highly polluted with organic matter while in the cistern. All the 322 cases of fever occurring in the month of April were in consumers of the milk from this dairy, and no condition of the milch cows could be discovered, after very careful examination, to account for the infectivity of the milk by the cattle. No one taking other milk was attacked, and persons whose cans were not washed in the cistern water escaped the fever." "The case is interesting as showing that despite the patent fact that the water was the vera causa of the epidemic, there is no knowing in what manner the water obtained its infective quality." In the case of the Plumstead dairy, the use of th3 tank water, even for washing the cans, was denied. But in all other respects the two epidemics are analogous, 21 41. Infection by Sewer Gas.—The possibility of the infectivity of the milk coining from sewer gas would be disregarded by many, but in spite of recent researches as to the absence of pathogenic germs in sewer gas, there is no getting away from the multitude of evidence that disease (especially Enteric Fever) is conveyed directly in this way, and indirectly through the pollution of food. In the number of the British Medical Journal above quoted, Dr. Hart refers to an outbreak in Cornwall, reported by Dr. Ballard of the Local Government Board : — Typhoid dejecta found their way into "a drain which had aerial connection with the room of a dairy farm in which the milk was stored on shelves, with extension of the disease as a result in the dairyman's family and an unknown number of his customers." At the Plumstead dairy the sewer gas only had connection with the room where milk was stored through the window of a cellar or by the door of a can house. There was also no evidence or probability of the drain or sewers containing Enteric dejecta, no case having been reported in the street for some years. So that on the whole I am inclined to regard sewer gas as a possible source of infection, though less probable than the tank water. 42. Cows as the Source of Infection.—Finally, could the infection have been in the milk as it came from the cows ? Two veterinary surgeons pronounced the cows healthy. But as one of them was suspected to have drunk water contaminated with sewage, while out at grass about a month previously, it was killed, and examined pathologically and bacteriologically at the Brown Institute, but with a negative result. If cow malady can be excluded, the tank water remains as the most probable explanation of the epidemic. 22 43. B. Dairy Regulations.—The question of the proper control of dairies and the milk traffic is a most important one, and will soon have to be taken in hand by the legislature. They are now under the dual control of the County Council and Local Sanitary Authority. It would be better to make one only of these bodies responsible, and probably the local authority would be most satisfactory—at any rate, for executive functions. The County Council might with advantage have extended powers of making regulations, and certainly further regulations are needed. It seems to me most undesirable that tanks of water such as existed in Princes Eoad should be allowed, but the dairy regulations do not forbid them. There is no law or regulation, I believe, to prevent the sale of milk from tuberculous cows, although I think this might be done by extending the term dangerous infectious disease to tubercle under Section 58 of Public Health (London) Act, after which Section 71 would apply. Milk should not be kept in such a cellar as it was at the Princes Road dairy, but probably this was unknown to the inspector. 44. Conclusion.—On the whole, I think it must be said that, under the existing law, nothing was left undone by the authorities which, if done, would have prevented this epidemic. I consider the lessons of the epidemic are; — 1. That under our present knowledge milk cannot be considered a safe food unless boiled or otherwise sterilized. 2. That legal powers are required for more effectively closing a dairy which is shown to be the source of infectious disease. 3. That more stringent regulations for, and more effective inspection of dairies, are required. 23 ENTERIC FEVER. A.—Cases Occurring Each Week of the Epidemic. Week ending 15th May 25 22nd 53 29th 39 ,, ,, 5th June 28 ,, ,, 12th „ 19 ,, ,, 19th ,, 7 ,, ,, 26th ,, 4 Four days ending 30th ,, 2 Total 177 B.—Sex and Age Distribution. Cases. Deaths. Male and Female. Deaths. Per cent. of cases. Male. Female. Under 5 17 11 2 7.0 5-10 15 26 4 10.0 10-20 23 34 5 9.0 20-40 16 29 9 20.0 Over 40 3 3 3 50.0 Totals 74 103 23 13.0 45. Consultations for Diagnosis. —In nineteen doubtful cases of infectious diseases I visited the patient in consultation with the medical attendant, my advice being sought in most cases for purposes of diagnosis. They included Small Pox, Enteric Fever, Scarlet Fever, &c. 24 Measles. 46. Owing to the prevalence of measles, some handbills were printed and distributed in January, 1895, warning those who had the care of children of the infectiousness and fatality of this disease. I believe that if this common affection of childhood were regarded more seriously, and medical advice sought and precautions taken many lives might be saved which are now lost. With the view of inducing the public to recognize the importance of this disease, I recommended that application should be made to the Local Government Board for leave to apply Sections 64, 68 and 70 of the Public Health Act to Measles. This would have the effect of making it penal to expose cases of Measles, without enforcing notification of such cases. The Committee did not however think it desirable that these Sections should be applied. Erysipelas. 47. Having found that cases of Erysipelas were usually moved to the Workhouse Infirmary in the ordinary vehicle which was used for non-infectious cases, I called the attention of the Guardians to the fact that this was a breach of the Public Health Act, and they now keep a special vehicle for use in such cases. 48. On my suggestion the Health Committee attempted to obtain from the Asylums Board weekly returns of the cases from Plumstead that had removed from, or died in the Board's Hospitals, but without success. The Asylums Board pointed out that their returns were sent to the Woolwich Guardians. This instance illustrates the anomalous condition under which the Sanitary Authority is quite out of touch with its own Fever Hospital Authority. The Clerk to the Health Committee now 25 goes fortnightly to the Workhouse, and obtains a copy of the returns of deaths of Plumstead cases in the Asylums Board Hospitals. C.—Sanitary Work. Sewers. 49. The new Wickham Valley Sewer was completed in the summer. This has enabled the greater part of the cesspools still remaining in the Parish to be abolished, thus putting an end to the great nuisance on the Heathfield Estate. On my recommendation a branch sewer was ordered to be made, to enable some houses in Wickham Lane to be drained. These houses had a cesspool going down into the chalk, which is a danger to the water supply. Early in the year I called attention to the nuisance arising from the cesspools in Bostal Lane. The Works Committee considered the question of making a Sewer up the Lane, but adjourned the matter for six months. 50. I discovered that the Plumstead Common Eoad Sewer was partially silted up. This sewer is the cause of frequent complaints of bad smells arising from the open manholes. I recommended thorough flushing and relaying where necessary to improve the fall. The flushing has been carried out, but no structural alteration has yet been made. Water Closets. 51. The Health Committee took the wise step of recommending an addition to the regulations of the Surveyor for new buildings, with the object of dispensing with the risers of water closets. This is a great improvement, securing greater cleanliness and dryness, and enabling defects to be more easily detected. The reform is being widely introduced. 26 Builders and contractors continue to put in very trumpery forms of Waste Preventers, which easily and continually get out of order. An improved pattern should be insisted on. 52. Long Hoppers are being gradually displaced by Short Hoppers or some other improved form of pan. But I find that long hoppers are still put in occasionally. It is a question whether even short hoppers fulfil the requirements of the County Council Bye-Laws. 53. I discovered that a Cesspool had been constructed for some new houses in Plumstead Common Road, contravening the County Council Bye-Law, which forbids a cesspool to be placed within 100 feet of a house—the cesspool was in this case within 10 feet. On the recommendation of the Health Committee, the sewer was continued so as to enable these houses to be drained into it. The Churchyard. 54. The Churchyard was inspected by me at various times. There were 358 interments during the year, compared with 318 in 1894. This is far more than is desirable. So far little or nothing has been done to improve the boundaries and general condition of this burying ground. I believe that the whole matter is receiving the close attention of the new Vicar, and it is to be hoped that he may be quickly able to put an end to the present discreditable state of things. The Cemeteey. 55. I have inspected the Cemetery and found its condition all that could be desired. 27 The Mortuary. 56. I visited the Mortuary on several occasions and found it always well kept. It was used for 35 bodies during the year, compared with 19 in 1894. I reported to the Committee that on one occasion at the end of the year I found five bodies in it. These figures indicate the urgent need for the new Mortuary, for which plans have already been prepared. Three bodies of cases dead of infectious disease were moved to the Mortuary by the Sanitary Inspectors. Dust Shoots. 57. I am pleased to be able to state that there has been less nuisance from Dust Shoots during the year than in previous years. I paid frequent visits to the various shoots, and reported to the Committee those that were within the 300 yards limit prescribed by the Bye-Laws. The principal shoot has been on land specially purchased for this and other objects, on the levels. This shoot came within the prescribed distance, but it was far enough away from houses not to cause any nuisance from smell. There was, however, a complaint from the nearest houses of a plague of flies, which was no doubt a result of the contiguity of this shoot. Special efforts were made to burn the worst of the refuse, and cover the surface with soil turned up in the field. I think, however, that the only satisfactory remedy is to provide a shoot much farther away, which can easily be procured on the levels. 58. I have inspected a new apparatus that has recently been tried by the West Ham Corporation, for desiccating house refuse, the resulting desiccated materials being found to be of commercial value for making bricks. This apparatus is 28 small and inexpensive, and there being no objectionable smoke no high chimney is required. So far, however, I understand that it has not been found to give complete satisfaction in working. Dust Collection. 59. Arrangements have been made with the Contractor for the dust to be collected weekly from every house, whether or not the occupiers place it in the forecourt. I had to report, however, that I found, that where people were careless about having their dust removed, the dustmen frequently neglected to call, and thus the dust was left at houses whence its frequent removal was most important. The only remedy for this seems to be more efficient inspection, and steps have been taken to obtain it. Health Refuge. 60. The Health Refuge was used on two occasions, by families comprising ten persons; in 1894 it was used on nine occasions by 20 persons. I examined those who used it before their removal to see that that they were free from infection. I inspected the Refuge on two occasions, and reported as to certain necessary repairs to render its condition more sanitary. Registration of Houses let in Lodgings, ok to more than One Family. 61. There are now four houses on the Register compared with three last year. Three houses were added, but three were taken off the Register on account of being no longer occupied by more than one family. The Committee has shewn a desire to register all houses where I consider it requisite. The reason why no more houses are registered, is that the Landlords show 29 so much unwillingness to have their houses registered, that they prefer to give notice to the tenants, and let the houses to one family occupying all the rooms. As this step would defeat one of the chief objects aimed at—viz.: the keeping under observation of families of dirty habits—I have frequently preferred to put such houses down on a special list for frequent inspection. One of the houses registered in the year was an Italian Ice-cream depot, which was found in a very dirty and overcrowded condition. The effects of the registration has been marked improvement in these respects. Bakehouses. 62. I made the usual half-yearly inspection of the Bakehouses. There are now no bakehouses in a decidedly bad sanitary condition, and most of them are very well kept. House Inspection. 63. On the whole I made 352 inspections of premises. This included a house to house inspection in Pendrell Street, Garland Street, Barnfield Road, Princes Road, and Palmerston Road. I found a good many defects but very few houses in a seriously bad condition. The most common structual defects were defective water closet apparatus, and damp walls and floors from absence of damp courses, defective roofs and damp basements. A great deal of work was done in Palmerston Road on account of dampness. The defects found have now I believe been all remedied. Arsenal Football Ground. 64. I inspected the sanitary conveniences at the Arsenal Football Ground, and found two of them defective, and drained into the adjoining ditch. These have been put into better condition and cesspools constructed. 30 Public House Urinals. 65. The Public House Urinals in the parish are now all cleansed systematically by the parish, with the result that they are much better kept than formerly. Overcrowding. 66. I visited seven houses with respect to Overcrowding. In most of these cases I found, that, by a little modification of sleeping arrangements, the overcrowding could be abated, but in others notices were served. I always prefer not serving notices in such cases as it means, probably, transferring the overcrowding from a known house to an unknown house. I prefer keeping such houses under observation. Police Court. 67. There were 15 prosecutions in the Police Court. I attended and gave evidence in two, one for not providing a sufficient water supply, and the other for selling milk after a closing order had been made. Convictions were obtained in 11 cases. One contractor was fined £10 for improper repair of a drain, and a workman £5 for a similar offence. F. S. Saunders was fined 40/- for exposing unsound Bananas for sale. 68. In addition to the above, R. B. Robinson was fined 20/for adulteration of milk 7 percent., Isaac Wells £2 for adulteration of milk 10 per cent., and W. Huggins 20/- for adulteration of milk 15 per cent. These were the only cases of adulteration discovered, but owing to the provisions of the Food and Drugs Act, it is not very easy to obtain specimens in a way to form a ground for legal proceedings. It is striking to notice the 31 different penalties inflicted for adulterating spirits and milk. If milk vendors were liable to the same penalties as those who tamper with spirits we should probably not have much watered milk. The Sanitary Inspector's Work. 69. Table X. shows the large amount of work done during the year by the Sanitary Inspectors. The House-to-house Inspection has not proceeded as fast as I should like. But a good deal more work has been done in the way of testing drains and getting them repaired, especially combined drains. House owners have found out the recently declared liabilities of the Vestry with respect to combined drains where no plans exist, and this has thrown much work on the Sanitary Inspectors. At the same time, I believe that the Vestry doing the work has caused it to be done more promptly and efficiently. There were also an unusually large number of inspections on account of infectious diseases, largely due to the Typhoid epidemic. On the whole, the work compares very favourably with last year. The third column shows the work done by the Chief Sanitary Inspector. In conclusion, I wish to acknowledge the excellent work performed by the Sanitary Inspectors and the Health Committee Clerk, and to thank the Health Committee for the kind way they have received my reports and recommendations. I am, Gentlemen, Your obedient Servant, SIDNEY DAVIES. April 14 th, 1896. 32 TABLE I. Summary of Statistics for 1895, compared with Registration London. Plumstead. London. 1. Area 3,388 acress 77,410 acres Inhabited houses 9,454 544,977 Number of persons to a house 6.5 7.7 2. Population, Census 1891— West Plumstead 15,867 East Plumstead 36,556 Total 52,436 4,221,452 Population estimated to June, 30th, 1895 61,494 4,392,346 Total Deaths—Corrected for Public Institutions 930 85,138 Total Births 1866 133,715 Natural increase of population 936 46,778 Estimated increase 2261 43,395 3. Birth rate 30.3 30.5 Death rate 15.1 19.4 Zymotic death rate 2.4 2.6 Deaths under 1 year to 1000 births 134 165 4. Uncertified deaths per cent. of total deaths 3.0 Deaths from violence 31 Inquest cases 43 5. Death rate, 1893 17.5 21.3 „ 1894 12.4 17.8 „ 1895 15.1 19.4 33 TABLE II. Births & Deaths, for each Quarter of the Year, corrected for Deaths in Union and Outlying Hospitals Date. Ages. Jan. Mar Apl-June July-Sep Oct.-Dec Total. Births Dths. Under 1 year 1 and under 5 5—15 15—25 25—65 Over 65 Under 5 Over 5 Under 5 Over 5 Under 5 Over 5 Under 5 Over 5 Under 5 Over 5 Jan.-Mar. 525 279 62 55 9 7 82 64 Small Pox .. .. .. .. .. 2 .. .. .. 2 Scarlet Fever 4 .. 2 1 1 .. 3 .. 10 .. Diphtheria 5 1 3 .. 1 2 9 9 18 13 Membranous Croup 1 .. .. .. 1 .. 1 .. 3 .. April-June 447 211 56 25 12 10 79 29 Enteric Fever .. 1 2 17 1 6 .. 3 3 27 Puerperal Fever .. .. .. 2 .. .. .. 2 .. 4 Cholera .. .. .. .. .. .. .. .. .. .. Erysipelas .. .. .. .. .. .. .. 1 .. 1 Measles 17 .. 1 .. 1 .. 4 .. 23 Whooping Cough .. .. 1 .. 4 5 .. Diarrhœa .. .. 2 ... 36 2 8 .. 46 2 RheumaticFever .. .. .. 2 .. 1 .. .. .. 3 Influenza .. 11 .. 6 .. .. .. .. .. 17 Phthisis 3 24 2 29 17 . 21 5 91 OtherTubercular Diseases Cancer and 9 1 5 2 4 •• 2 3 20 6 July-Sept. 471 216 80 29 8 11 49 39 Neoplasms .. 7 .. 9 .. 8 .. 13 .. 37 Alcohelic Diseases .. 2 .. 1 .. 4 .. 8 .. 15 Bronchitis, Pneumonia, Pleurisy 35 52 18 18 10 9 15 14 78 88 Heart Disease .. 17 2 15 .. 8 .. 15 2 55 Oct.-Dec. 423 224 52 34 17 8 77 36 Labour and Sequelæ .. .. .. 3 .. .. .. 2 .. 5 Premature Birth and LowVitality Injuries 21 .. 21 .. 13 .. 16 .. 71 .. 3 3 5 5 2 7 2 4 12 19 All other Diseases 19 43 17 25 35 41 26 43 97 152 Total 1866 930 250 143 46 36 287 168 Total 117 162 81 130 109 107 86 138 303 537 Not Certified 2 6 4 2 4 2 4 4 14 14 Inquests 7 5 7 7 3 7 3 4 20 23 (A) TABLE III. Table of DEATHS during t`he Year 1895, in Plumstead Parish, classified according to Diseases, Ages, and Localities Mortality from all causes, at subjoined ages. Mortality from subjoined causes, distinguishing Deaths of Children under Five Years of Age. Names of Localities adopted for the purpose of these Statistics; public institutions being shown as separate localities. At all Ages. Under year. 1 & under 5. 5 & under 15. 15 & under 25 25 & under 65 65 & upwards 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 fevers. Smallpox. Scarlatina. Diphtheria. Membranous Croup. Typhus. Enteric or Typhoid Continued Relapsing.l Puerperal. Cholera. Erysipelas. Measles Whooping Cough. Diarrhœa & Ovsenterv. Rheumatic Fever. Phthisis. Bronchitis, Pneumonia and Pleurisy Heart Disease. Injuries. Ail Other Diseases. Total. (a) (b) (C) (d) (e) (f) (g) (h) (i) WEST PLUMSTEAD 194 43 19 4 7 68 53 Under 5 0 0 4 0 0 0 0 0 0 0 0 1 0 5 0 1 8 1 5 37 62 5 upwds. 0 0 1 0 0 7 0 0 0 0 0 0 0 0 1 18 29 10 2 62 132 EAST PLUMSTEAD (Workhouse excluded) 557 200 103 22 17 136 79 Under 5 0 4 7 3 0 0 0 0 0 0 0 22 5 41 0 2 09 1 0 143 303 5 upwds. 0 0 6 0 0 4 0 0 2 0 1 0 0 1 2 48 43 30 10 107 254 WORKHOUSE & INFIRMARY 199 6 2 2 7 107 75 Under 5 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 6 8 5 upwds. 1 0 0 0 0 2 0 0 0 0 0 0 0 2 0 55 32 24 5 70 191 totals 950 249 124 28 31 311 207 Under 5 0 4 11 3 0 0 0 0 0 0 0 23 6 46 0 3 77 2 12 186 373 5 upwds. 1 0 7 0 0 13 0 0 4 0 1 0 0 3 3 121 104 61 17 239 577 The subjoined numbers have also to be taken into account in judging of the above records of mortality. Deaths occurring outside the district among persons belonging thereto. 98 5 20 18 8 43 4 Under 5 0 0 7 0 0 3 0 0 0 0 0 0 0 0 0 2 1 0 01 6 25 5 upwds. 1 0 6 0 0 14 0 0 0 0 0 0 0 0 0 5 5 5 5 32 73 Deaths occurring within the district among persons not belonging thereto. 118 1 0 0 67 43 Under 5 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 4 5 5 upwds 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 35 21 14 3 39 113 (35) Z 2 TABLE IV. Table of POPULATION, BIRTHS, AND OF NEW CASES OF INFECTIOUS SICKNESS, coming to the (B) knowledge of the Medical Officer of Health, during the year 1895, in the Parish of Plumstead; classified according to Diseases, Ages, and Localities. Names of Localities adopted for the purpose of these Statistics, public Institutions being shown as separate localities. Population at all Ages. Registered Births. Aged under 5 or over 5. New Cases of Sickness in each Locality, coming to the knowledge of the medical Officer of Health. Number of such Cases Removed from their Homes in the several Localities for treatment in isolation hospital. Census 1891. Estimated to middle of 1894. 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 Fevers. oj Fevers. Smallpox. Scarlatina. Diphtheria. Merabranous Croup. Typhus. Enteric or Typhoid. Continued. Relapsing. Puerperal. Cholera. Erysipelas. Total. Smallpox. Scarlatina. Diphtheria, Membranou Croup. Typhus. Enteric or Typhoid. Continued. Relapsing. Puerperal. Cholera. Erysipelas. Total. (a) (b) (c) (d) (e) ST. JAMES 4096 .. .. Under 5 .. 4 7 .. .. 3 .. .. .. .. .. .. .. 3 6 .. .. 1 .. .. .. .. .. .. 5 upwds. .. 24 11 .. .. 23 .. .. .. .. 2 .. .. 20 4 .. .. 13 .. .. .. .. .. .. ST. MARGARET 12550 .. .. Under 5 .. 27 8 1 .. 8 .. .. .. .. 1 .. .. 14 6 .. .. 8 .. .. .. .. .. .. 5 upwds. .. 65 27 .. .. 64 1 .. 1 .. 11 .. .. 41 13 .. .. 31 .. .. .. .. .. .. ALL SAINTS 5966 .. .. Under 5 .. 9 4 .. .. 14 .. .. .. .. 1 .. .. 4 1 .. .. 10 .. .. .. .. .. .. 5 upwds. .. 19 9 .. .. 78 .. .. 2 .. 4 .. .. 7 3 .. .. 56 .. .. .. .. .. .. CHRIST CHURCH 262 .. .. Under 5 .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 5 upwds. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. St. JOHN 5752 .. .. Under 5 .. 14 4 1 .. .. .. .. .. .. 2 .. .. .. 3 .. .. .. .. .. .. .. .. .. 5 upwds. .. 17 6 .. .. 4 .. .. 1 .. 8 .. 1 14 9 .. .. 4 .. .. .. .. .. .. ST. NICHOLAS 23207 ... .. Under 5 .. 36 28 .. .. 1 .. .. .. .. 1 .. .. 90 9 .. .. 1 .. .. .. .. .. .. 5 upwds. 8 105 34 1 .. 17 .. .. 3 .. 25 .. 7 61 20 .. .. 10 .. .. .. .. 1 .. WORKHOUSE .. .. .. Under 5 .. 1 .. .. .. .. .. .. .. .. .. .. .. 1 .. .. .. .. .. .. .. .. .. .. 5 upwards 3 2 .. .. .. .. .. .. .. .. .. .. 3 2 .. .. .. .. .. .. .. .. .. INFIRMARY .. .. .. Under 5 .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 5 upwards 4 .. .. .. .. 9 .. .. .. .. 3 .. 4 .. .. .. .. 1 .. .. .. .. .. .. TOTALS 52436 61494 1866 Under 5 .. 91 51 0 26 .. .. .. .. 5 189 .. 49 95 .. .. 20 .. .. .. .. .. 94 5 upwds. 16 232 87 1 188 1 .. 7 .. 48 580 15 145 42 .. .. 115 .. .. .. .. .. 1318 State here whetter "Notification of Infections Disease" is compulsory in the District—Yes. Since when?—Notification Act. State here the name of the Isolation Hospital used by the sick of the District. Murk (H) the Locality in which such Hospital is situated; and if not within the District, state where it is situated— South Eastern Fever Hospital, Deptford. TABLE V. Ages, Schools and other particulars of the cases of SCARLET FEVER AND DIPHTHERIA. Total Cases. ages. sex. Houses with 1 Case only. Houses with 2 Cases. Houses with 3 Cases. Houses No. with to 4 Cases. Hospital Under 1 1 to 5 5 to 10 10 to 20 Over 20 Males. Females SCARLET FEVER 323 13 80 145 75 11 159 164 228 27 11 2 194 DIPHTHERIA & MEMBRANOUS CROUP 148 2 57 55 24 10 83 65 91 17 5 2 67 Number of Patients Attending Each School. Aucona Road Earl Street. Vicarage Road Plumstead Road. Purrett Road. Bloomfield Road The Slade Burrage Grove. Church Terrace. Eglinton Road High Street. Conway Road. Knee Hill, Abbey Wood Plum Lane. Other Schools. On Roll On Roll On Roll On Roll On Roll On Roll On Roll Oil Roll Jll Roll On Roll On Roll On Roll 1350 1082 1156 1185 1178 1429 896 1114 183 1298 1153 430 151 188 SCARLET FEVER 21 11 16 22 19 33 26 15 7 5 9 3 0 0 8 DIPHTHERIA & MEMBRANOUS CROUP 15 10 3 6 3 14 4 1 0 0 7 8 0 0 8 TABLE VI. Summary of the Vital Statistics of the Parish of Plumstead, 1885-1895. Year. Estimated Population middle of year. Births. Deaths. Annual Rate per 1000 living. Deaths from Principal Zymotic Diseases Smallpox. Measles. Scarlet Fever. Diphtheria. Whooping Cough Typhus. Enteric Fever. Simple and Undefined Fever. Diarrhoea. Deaths of Children under year of age to 1000 births. Births. Deaths. Principal Zymotic Diseases. 1885 40,354 1390 607 34.5 15.1 1.71 69 3 14 2 4 27 •• 5 .. 14 120 1886 42,235 1609 735 38.2 17.5 2.64 111 .. 48 2 11 12 •• 3 1 34 124 1887 44,204 1667 714 37.8 16.2 2.36 104 2 22 2 11 32 •• 2 •• 30 116 1888 46,264 1703 689 36.9 14.9 1.58 73 .. .. 3 19 33 •• 2 •• 16 112 1889 48,420 1852 759 38.4 15.7 20.3 98 .. 43 5 13 14 •• 2 •• 21 115 1890 50,676 1933 923 37.5 17.9 24. 127 .. 33 11 14 44 •• 2 •• 22 137 1891 53,037 1867 920 35.3 17.4 1.57 83 .. 33 1 6 24 •• 4 •• 15 124 1892 55,009 1932 849 35.2 15.5 2.48 13 .. 19 25 38 29 •• 3 •• 22 108 1893 57,073 1914 994 33.6 17.5 3.71 211 2 47 31 65 23 •• 8 •• 35 140 1894 59,233 1910 736 32.2 12.4 20.6 123 2 20 21 34 30 •• 6 •• 10 94 1895 61,494 1866 930 30.3 15.1 2.4 153 2 24 10 34 5 •• 30 •• 48 134 TABLE VII. Analysis of the Vital and Mortal Statistics of the Sanitary Districts Institutions during SANITARY AREAS. Estimated Population middle of 1895. Births. Deaths. Annual Rate per 1,000 living. Deaths from Principal Zymotic Diseases Births. Deaths. Principal Zymotic Diseases. London 4,392,346 133,715 85,1.38 30.5 19.4 2.6 11,466 West Districts— Paddington 122,756 2,977 2,107 24.3 17.2 1.7 207 Kensington 167,671 3,621 2,759 21.7 16.5 1.9 322 Hammersmith 108,429 2,909 1,810 26.9 16.7 2.1 225 Fulham 117,745 3,930 2,195 33.5 18.7 2.9 342 Chelsea 99,930 2,734 1,913 27.4 19.2 2.2 221 St. George, Hanover Square 74,037 1,470 1,175 19.9 15.9 1.6 117 Westminster 54,003 1,284 1,146 23.8 21.3 2.1 111 St. James. Westminster 23,149 542 411 23.5 17.8 1.3 31 North Districts— Marylebone 137,392 4,400 2,843 32.1 20.3 1.7 239 Hampstead 77,592 1,453 931 18.8 12.0 1.0 78 St. Pan eras 233,543 7,118 4,778 30.5 20.5 3.2 741 Islington 335,929 9.879 5,753 29.5 17.2 2.0 686 Stoke Newington 35,234 813 471 23.1 13.4 1.1 39 Hackney 215,623 6,172 3,735 28.7 17.4 2.5 545 Central Distiicts— St. Giles 37,654 1.150 859 298 229 2.1 77 St, Martin-in-the-Fields 13,536 189 244 140 18.1 1.8 24 Strand 22,586 612 569 27.2 25.3 2.2 49 Holborn 32,188 821 810 25 .6 25.2 2.8 90 Clerkenwell 65,036 2,083 1,491 32.1 23.0 3.9 250 St. Luke 40,763 1,904 1,226 46.8 30.2 5.5 224 London City 33,824 553 720 16.4 21.4 1.6 55 Hast Districts— Shoreditch 122,932 4,352 2,856 355 23 3 3-8 460 Bethnal Green 180,061 4,771 2,769 36.8 21.4 3.4 441 Wbitchapel 75,820 3,130 1,824 41.4 24.1 3.3 250 St. George-in-the-East 45,227 1,972 1,330 43.7 29.5 5.5 246 Limehouse 56 8P5 2,035 1,547 35.9 27.3 4.6 261 Mile End Old Town 108,443 4,204 2,486 38.9 22.5 3.9 424 Poplar 171,230 6,071 3,865 356 22.6 4.0 677 South Distriits— St. Saviour, Southwark 26,570 830 677 31.3 25.5 2.9 76 St. George, Southwark 60,168 2,168 1,524 36.5 25.4 3.2 194 Newington 119,358 4,284 2,872 35.6 24.1 3.4 401 St. Olave, Southwark 13,065 428 314 32.9 24.1 2.4 31 Bermondsey 83,861 3,212 1,869 38.4 223 3.2 270 Rotherhithe 40,713 1,304 783 32.1 19.3 2.7 110 Lambeth 284,883 9,341 5,567 32.9 19.6 2.6 741 Battersea 165,130 5,264 2.872 32.0 17.4 2.7 442 Wandsworth 185,956 4,721 2,747 25.5 14.8 1.3 250 Camberwell 252,737 7,528 4,610 29.9 18.3 2.6 648 Greenwich 175,183 5,475 3,305 31.3 18.9 2.7 465 Lee 38,832 826 561 21.3 14.5 1.4 54 Lewisham 82,410 2,037 1,187 24.8 14.4 1.5 126 Woolwich 42,768 1,331 748 31.2 17 .5 1.7 73 Plumstead 61,494 1,877 929 30.6 15.2 2.5 153 TABLE VII.—(Continued). of the Metropolis, after Distribution of Deaths occurring in Public the Year 1895. Small Pox. Measles. Scarlet Fever. Diphtheria. Whooping Cough. Typhus. Enteric Fever. Simple and undefined Fever. Diarrhœa. Phthisis. Deaths of Children under 1 year of age to 1.000 births. 55 2,628 829 2,289 1,480 5 596 10 3,574 7,742 165 .. 19 14 47 20 .. 13 .. 94 163 164 .. 34 28 90 38 .. 15 1 116 253 172 1 27 17 44 43 .. 12 .. 81 160 166 .. 51 21 77 50 .. 12 1 130 154 187 1 11 25 57 35 .. 13 .. 79 185 168 1 10 10 24 26 .. 9 1 36 105 138 .. 25 6 21 15 .. 3 .. 41 125 185 .. 2 3 4 10 .. 6 .. 6 35 144 9 25 14 35 39 .. 23 l 93 299 138 .. 9 8 14 7 1 9 l 29 75 135 1 228 52 131 94 .. 30 .. 205 428 174 1 141 67 146 79 1 30 2 219 532 143 .. 7 1 5 5 .. 4 .. 17 37 116 1 120 41 83 65 1 45 .. 189 314 154 2 13 0 13 13 .. 2 .. 28 127 160 l 2 2 7 6 .. 1 .. 5 24 265 2 6 9 13 3 .. 5 .. 11 76 175 .. 45 6 7 8 .. .. .. 24 98 212 .. 93 17 34 41 .. 11 .. 53 159 192 .. 106 5 20 21 .. 6 .. 66 113 184 .. 15 4 8 3 .. 13 .. 12 51 157 2 106 30 58 87 .. 22 .. 155 283 199 4 116 30 101 34 .. 17 .. 139 245 162 4 82 23 58 19 .. 10 .. 54 219 157 .. 88 20 50 21 .. 7 .. 60 113 196 1 86 20 45 40 .. 10 .. 59 136 202 1 113 26 111 42 .. 17 .. 114 182 165 1 216 48 152 80 .. 33 .. 147 273 183 .. 17 6 13 13 .. 1 .. 26 84 205 .. 49 14 17 38 .. 7 .. 69 186 198 4 132 16 52 71 .. 15 .. 110 263 201 .. 3 .. 4 7 .. 2 .. 15 32 206 .. 114 16 29 20 .. 11 .. 80 190 162 1 19 8 31 10 .. 9 .. 32 76 148 2 150 53 112 132 .. 26 .. 264 511 152 1 98 30 92 53 .. 22 .. 145 247 177 2 30 16 46 24 .. 26 .. 106 213 132 7 111 46 179 68 .. 33 .. 204 394 164 3 49 36 184 55 .. 17 .. 121 268 150 .. 18 5 11 5 .. 3 .. 12 56 140 .. 12 9 14 32 .. 7 .. 52 76 135 .. 6 11 14 3 .. 9 .. 30 92 153 2 24 10 36 5 .... 30 .... 46 90 133 TABLE VIII. Abstract from Mortuary Register for 1895. Date. Age. Sex. Inquest or No. Post Mortem or No. Cause of Death. 1895 Jan. 13 th 3 years Male Yes Yes Inflammation of brain. „ 29th 29 years Male Yes Yes Hemorrhage from lungs. „ 29 th 61 years Female Yes Yes Failure of the heart's action. Feb. 7th 36 years Male Yes Yes Aneurism of the aorta. „ 11th — Female No No „ 23rd 3 9/12 years Male Yes Yes Convulsions. Mar. 10th 35 years Male Yes Yes Committed suicide by taking oxalic acid. „ 12th 7 months Female Yes Yes Congestion of Lungs. April 15th 10 months Female Yes Yes Convulsions. „ 26th 36 years Male Yes Yes Apoplexy. May 13th 6 weeks Female No No „ 20th 35 years Female Yes Yes Suffocated by the fumes from bricks. „ 20 th 61 years Male Yes No Committed suicide whilst temporarily insane. June 3rd 3 months Female Yes Yes Suffocation. „ 3rd 4 weeks Male Yes Yes Suffocation. „ 6th 56 years Female No No Typhoid fever. „ 6th 7 years Female No No Typhoid fever. July 13 th 6 weeks Male Yes Yes Suffocation. „ 13th — Male Yes Yes „ 15 th 29 years Male Yes Yes Asthenia from Purpura Hemorrhagica. Aug. 18th 20 years Male Yes — Committed suicide during temporary insanity. „ 18th 32 years Male Yes Yes Committed suicide by taking carbolic acid. Sept. 2nd 11 months Female Yes Yes Pneumonia and convulsions. „ 11th 52 years Male Yes Yes Heart disease. Oct. l6th 20 years Male Yes Yes Pressure upon the heart from over distention of the stomach, caused by the deceased having eaten about 2½-lbs. of raw apples which were found in stomach. Nov. 14th 61 years Male Yes No Accidental death. „ 15th 26 years Female Yes Yes Misadventure. Dec. 3rd 54 years Male Yes Yes Heart disease. „ 4th 31 years Female Yes Yes Puerperal Eclampsia: „ 23rd 59 years Male Yes Yes Pneumonia accelerated by alcoholism. „ 27th 66 years Male Yes No Suffocation. „ 27 th 65 years Female Yes No From burns, the origin of of which there was no evidence to show. „ 30 th 45 years Female Yes Yes Syncope. „ 30th 6 years Female No No Diphtheria. „ 30 th 12½ years Male Yes No Found drowned „ 31st 4 years Female No No Diphtheria. TABLE IX. Return respecting the Vaccination of Children born in the Woolwich Union Districts, in the year 1894. Sub-Districts. Number of Births Registered from Jan. 1st to Dec. 31st, 1894. Successfully Vaccinated. Insusceptable of Vaccination. Had Smallpox. Dead Unvaccinated. Postponed by Medical Certificate. Gone away, address not known. Other Causes. EAST PLUMSTEAD 1424 1263 7 .. 104 6 44 WEST PLUMSTEAD 494 443 1 .. 26 4 18 2 Fined 20/- and 2/- costs for refusal to obey the act WOOLWICH ARSENAL 763 656 6 .. 73 8 20 WOOLWICH DOCKYARD 470 399 3 .. 45 3 20 CHARLTON AND KIDBROOK 323 283 2 .. 26 1 11 TOTAL 3474 3044 19 .. 274 22 113 2 Dated February 7th, 1896, C. JOLLY, Vaccination Officer, Woolwich Union. 42 TABLE X. Summary of Nuisances abated, Notices served, and General Work of the Sanitary Department for 12 months, ended 31st December, 1895:— Inspections and Results. Special in both Districts. Total. West East PREMISES INSPECTED. No. of houses inspected, House to house 747 774 1021 „ „ re-inspected after service of notices .. 1795 1941 1315 5051 „ „ houses and premises specially inspected, re infectious diseases and complaints 1092 923 1216 3231 „ „ new buildings re certificates .. .. .. 203 203 „ „ where drains have been tested by smoke test 333 197 63 593 NUISANCES ABATED— Drains. Waste pipes from baths, lavatories, and wash-house sinks, repaired or nected from drains 42 56 36 134 Choked and defective drains remedied 127 163 132 422 Defective traps abolished 43 119 28 190 Defective and unventilated soil pipes remedied 20 59 14 93 Stables drained 4 4 2 10 Combined drains taken up and relaid . . .. 33 33 No. of houses re-drained by combined drains .. •• 240 240 W.C.'s W.C.'s repaired, new traps or pans provided, fittings repaired 168 214 85 467 Water supply apparatus repaired 271 250 199 720 Premises. Interiors cleansed, repaired, and defectivo roofs repaired 66 196 53 315 Damp walls remedied 48 82 18 148 Paving in yards and wash-houses repaired 175 156 . 36 367 Through ventilation provided 19 10 11 40 Wash-houses without sinks and outlets for waste water 13 21 13 47 Defective guttering and rain water pipes 95 109 27 231 Dustbins supplied 707 981 196 1944 43 TABLE X.—continued. Inspections and Results. Special in both Districts. Total. West East Animals. Accumulations of manure removed 15 16 22 53 Animals kept in such a state, as to be a nuisance 2 3 6 11 Water. Defective and foul rain water tanks remedied 22 3 6 31 Defective water pipes flooding premises remedied 71 46 47 164 Insufficient supply for domestic purposes 23 14 13 50 Miscellaneous Seizures of unsound food .. 1 4 5 Obstructions of footpaths .. .. 28 28 Summonses at the Police Court .. .. 15 15 Cases of overcrowding remedied 4 5 11 20 Ditches cleansed .. .. 16 16 Bakehouses cleansed 23 15 • • 38 Cowhouses and Slaughterhouses inspected 14 14 DISINFECTION. Total. No. of houses disinfectded after infectious disesae 615 „ cases disinfected for other parishes (Lee and Eltham) 53 CLERICAL WORK. Letters 833 „ written 845 Notifications received 815 Certificates issued after disinfection 1580 Certificates of infectious disease forwarded to schools 1065 Notices for sanitary defects 2482 Complaints of Sanitary defects, non-removal of dust, &c. 402 Woolwich: H. Pryce & Son, Steam Printers, powis street.