SURBITON URBAN DISTRICT COUNCIL. Eighteenth Annual Report of the Medical Officer of Health, 1894. BULL AND RON, PRINTERS, VICTORIA ROAD, 8URBITON. Surbiton Urban District Council EIGHTEENTH ANNUAL REPORT of the Medical Officer of Health, 1894. Mr. Chairman and Gentlemen, I have now the honour of presenting to you for your consideration this my eighteenth annual report on the health and sanitary condition of the district under your care. Mortality. In order to arrive at the proper number of deaths to be credited to the district for statistical purposes, it is necessary to make various additions to and withdrawals from the number assigned by the local registrar. Firstly, with regard to deaths in public institutions within the district, it is required to exclude those of persons living elsewhere who are brought in for treatment, and to forward particulars of them for inclusion in the returns of their respective localities; and, secondly, to include those of 2 residents, as far as it is possible to trace them, who may have died elsewhere in similar institutions. The Cottage Hospital is the only place of this class within our boundaries, and applying this process I forwarded to the county Medical Officer particulars of seven deaths taking place there, to be by him remitted to the Health Officers of their respective sanitary districts, and through the same medium I received intimation of the number of deaths that occurred outside and that were to be added to those I already knew of. Made up in this way the total number of deaths for Surbiton during 1894 is 116, the constituent numbers being 105 registered within the district, 4 in the Cottage Hospital, 3 in the Isolation Hospital, and 4 from the County Lunatic Asylum at Brookwood. For 1893 they were 122. Death Rate. The estimate of the increase of the population to the middle of 1894 is 10,320, which may be taken as correct, for it has been furnished by the General Register Office, Somerset House, plus the county correction for institutions, and on this basis the death rate is 11.24 per thousand per annum. This compares with 11.87 of the year before. The death rate of London last year was 17.4 which is considerably lower than any year on record. For England and Wales during the same time the rate was 16.6, also the lowest on record. Zymotic Diseases Zymotic death rate is a term commonly applied, not to the mortality from all diseases classed as zymotic, but to that from the seven principal zymotic diseases, viz:— small-pox, measles, scarlet fever, diphtheria, whooping cough, fever (simple continued, typhus and enteric) and diarrhoea. To these seven principal diseases 10 deaths are referable, being four from enteric fever, three from diphtheria, one from whooping cough, and two from diarrhoea. This gives a zymotic death rate of 0.97 per thousand, that for England and Wales for the same period being 1.76. 8 Causes of Death. Of these 116 deaths 46 are males and 70 females, 27 were 70 years and upwards and 22 were under one year of age. There died of phthisis 5, including 1 in the County Asylum, of other lung diseases 15, of heart disease 12, of cancer 9, of violence 6 (including 4 suicides), of influenza 5. There were 10 inquests. Births. There is an increase in the number of births from 186 in 1893 to 210 in 1894, of whom 109 were boys and 101 girls. The birth rate is therefore 20.3 per thousand. The deaths of infants were in the ratio of 104.7 per thousand births registered. The following are some particulars respecting the various diseases of the zymotic group:— Small Pox. No cases of this disease were reported. Enteric Fever. There were twelve cases and four deaths. This is a larger number than has ever been recorded before, but an examination of the history of the cases will show that the majority have no possible local causation. Of the 12 cases notified, 3 were Kingston ones admitted into the Cottage Hospital and treated there, where one died, consequently that particular case is excluded from consideration altogether, as owing to its having occurred in a public institution it was referred to the district from whence it came, but the notification has to remain. The first case was that of a boy of seven years of age on Surbiton Hill, in February, the premises were duly inspected and the report by the Sanitary Inspector was "I do not find any serious sanitary defects, all the connections and arrangements are outside the house, but the sink waste requires more thoroughly disconnecting from drain." The patient however died. The second case did not happen until June, at the Cottage Hospital, it came from Canbury Park Road, Kingston, and was the fatal case alluded to above, the diagnosis not being made until after admission; the third 4 case was contracted at Greenhithe; the fourth at Ostend, also fatal; the fifth from Eagle Chambers, Kingston, admitted to the Cottage Hospital; the sixth, a young man from Chelsea Villas was sent to the Isolation Hospital and recovered ; an examination of the premises was made, but no circumstance was discovered to account for the disease and it was probable that the illness was contracted through some agency—food or drink—elsewhere; the seventh case was admitted to the Cottage Hospital from Mill Street, Kingston, having formerly been in service at Surbiton, but no defect was found in the sanitary arrangements of the house where the patient had been residing ; the eighth, was a page boy in a villa residence, enquiries were carefully made, but nothing was discoverable as a cause and there was no antecedent illness in the house; the ninth, was a gentleman of middle age, living in apartments and going to London daily, he was removed to the Isolation Hospital and ultimately got well, nothing was wrong in the house sanitation, but the cistern for domestic use was in a cupboard opening into the patient's bedroom, a most objectionable plan; there were grounds for suspecting that this illness was caught in London; the tenth case was that of a footman employed in a house near Hyde Park, he was taken ill there and sent home, and on arrival, was found to have typhoid; the eleventh, was a boy of eight, son of a caretaker, living in an empty house, the drains were possibly not very thoroughly flushed, but beyond that fact no material sanitary defects were found; the twelfth and last was a gentleman engaged in business in London. The medical attendant informs me that in all probability he was the victim of oysters, his companions on a certain occasion being also subsequently laid up with the same illness. The other two deaths took place in the Isolation Hospital and were remanets from the year before, being cases that were admitted in 1893, and were mentioned in the report for that year, one died on January 1st, and the other on the 5th. Of these twelve cases therefore it appears that three were admitted from Kingston 5 and three were known to have been contracted elsewhere, leaving six to be assumed as possibly due to local causes, and of these, two were almost certainly caught in London. In no case was any sanitary defect found that could be supposed to have anything to do with the disease; there were no secondary cases, and no other illnesses in any of the houses. Attention has been lately directed both in the general and medical press to the conveyance of disease by means of watercress and shell fish, and it is admitted that there is every reason to believe that these charges are based on good and sufficient grounds; the fact that both oysters and watercress are eaten uncooked lends support to the belief that they may possibly be carriers of the disease. Measles. But very few cases and no deaths. WhoopingCough This was not at all prevalent, only a few cases coming to my knowledge, but there was one death, the complication or secondary cause being Laryngismus Stridulus. Diphtheria. There were twenty cases in thirteen houses, with three deaths, as against twenty-three cases in nineteen houses and three deaths the year before. There was no outbreak, no cause common to the majority, and the cases were pretty evenly distributed throughout the year. With two exceptions there seems to have been no spread by personal contact or infection. One case in a lodginghouse was removed to the hospital, and inspection shewed a somewhat defective condition of sanitary arrangements which were subsequently rectified. The head of the house in another case referred the illness to a stagnant pool in adjoining premises at the foot of his garden, the house being stated to be sanitarily perfect. Quite early in January a case occurred in a house that had had considerable attention paid to it before occupation. The patient was a male aged 23, he recovered in due course, but on October 2nd another member of the family became ill, and on the 20th a third. No defects sufficient to 6 explain these illnesses were found. The third case most probably caught it from the second, and it is a question whether infection from the first case was or was not active from January to October. This supposition is not so unreasonable as may be supposed, for bacteriological examination is now revealing unsuspected sources of contagion, and for periods of time that a few months ago would not have been thought possible. The following extract from a letter written me by Dr. Armand Buffer, Director of the British Institute of Preventive Medicine, and which was embodied in a circular letter that I sent to all the medical men in the district by your direction in connection with the anti-toxin treatment, exactly illustrates to what I refer:—"a boy [H.] had diptheria in May last at school. He got perfectly well, went home and returned to the school in November. At that time another boy [S.] sitting at the same desk, and another boy [B.] in the form had diphtheria and recovered. As nothing could be found to account for this, I examined the first boy's [H.] throat and cultures at once revealed the presence of diphtheria bacilli in his throat. Now mark what follows. Three weeks after the boy [S.] was to all appearances perfectly well, bacilli were still present in his throat. His father, nevertheless, took him home with the result that his sister got diphtheria seven days after the boy's return. All three boys were then ordered antiseptic gargles and two of them are now free from diptheria organisms." As a further illustration of spreading by personal contact the following is an example, and accounts for no less than six out of the twenty cases notified. A servant had been ailing but had had no special treatment, a child of 3 years old was then found to have diphtheria, the maid's throat was examined and was found also to be infected; she was removed forthwith to the Isolation Hospital and all precautions I was assured by the medical attendant were taken, but nevertheless, personal contact evidently was responsible for a succession of cases, dating as notified, on the 9th, 10th, 13th, 14th, 17th and 19th 7 of the month, by which time the servant, three children, the mother and the aunt, all living in the same house were down with it. The anti-toxin treatment was here used in most if not all the cases, and there was fortunately only one death, but the incident points to the advantages attendant on complete and perfect isolation, and to the difficulties of carrying this out efficiently in an ordinary household. No sanitary defects were found. One death took place in the Isolation Hospital, that of a young woman who had been in attendance on her brother whose death was registered as from "septic tonsillitis," otherwise quinsy. In connection with this disease the anti-toxin treatment just newly brought into notice was used on a few cases during December, and early in the present year your Board sanctioned my making special arrangements for the supply of serum and for communicating all necessary particulars to every medical man known to be at any time practising in Surbiton. This will be referred to in detail in my next report. The following table records some of the facts in connection with the diphtheria cases of this and former years. Houses Invaded. Cases. Deaths. Average Age per case. Case Mortality, per cent. 1890 31 36* 3 19.5 8.3 1891 16 21 10 9.8 47.6 1892 14 16 l 18.1 6.2 1893 19 23 3 18.7 13.0 1894 13 20 3 17.3 15.0 * 27 of these cases were due to an infected milk supply. Scarlet Fever. The epidemic of this disease from which in point of numbers we suffered so heavily in 1893, in common with the whole country, had almost left us, there being but nine notifications compared with ninty-four of that year. Five of these were removed to the hospital, three children from one family and a domestic servant from another, there were no fatal cases. 8 Erysipelas. There was one fatal case, an adult, and twelve cases in all were notified, but several of these were, there is some reason to believe, very mild in type. Epidemic Influenza. There has again being a renewal of influenza, but it would hardly be correct to say that it had ever wholly gone, at least for long, because there seem to have been sporadic cases throughout the year. Two deaths were registered. Cholera. A circular dated July 16th from the Local Government Board headed "Cholera—Notifications of Diarrhoea" was sent on to me by your Clerk, in which after reciting that Cholera cases occurred in 1892 and 1893, it mentioned that in those localities where it got a footing an antecedent diarrhoea had prevailed, and reminding Sanitary Authorities of the necessity of vigilance, said the Board would give favourable consideration to applications for the notification of diarrhoea until the termination of the then current quarter. In reply, I reported to your Board that I had given careful consideration to this circular and did not propose to advise you to make this application, as the surroundings here especially in the important matters of drainage and water supply were not such as were likely to become sources of danger to the inhabitants, nor—as I had learnt from lengthy personal experience—was diarrhoea ever very prevalent here, and further that in my opinion it would possibly tend to create unnecessary alarm, and be productive of no compensating good. This advice was acted upon. Notification Act Extract from Notification Book. Scarlet Fever. Diphtheria & Memb. Croup. Enteric Fever. Pueperal Fever. Erysipelas. Contin. Fever. Smail pox. Totals. 1890 3 36 l 2 4 0 0 46 1891 3 21 l 0 10 0 0 35 1892 4 16 3 1 5 0 0 29 1893 94 23 5 2 15 2 1 142 1894 9 20 12 2 12 0 0 55 9 As compared with the previous year the total of returns is much less, but with that exception it is higher than any former year. The excess seems to be due to the scarlatina cases and to the abnormal amount of typhoid. This latter has been much in evidence the last few years throughout the country, and the notifications the last four years, 1, 3, 5, 12, are suggestively progressive, the more so that during the seventeen years from 1877 to 1893 inclusive, the total deaths were only twelve. The number of typhoid cases treated in this country, but contracted abroad must be enormous, and the risk in travelling is no small one. Owing to the long period of incubation—often three weeks —and the gradual feeling of malaise, travellers warned by their increasing indisposition have often time to return home before being laid up, and in this way, besides numerous cases from continental towns comparatively near by, I have had others from as far as "Vienna and Chicago. Now that we are becoming aware of the extended duration of infectivity in diphtheria, and have also increasing evidence of the numerous hitherto unsuspected sources of infection of typhoid, especially abroad, the incidence of disease as shown by notifications of these and other zymotic diseases cannot, without a lot of correcting be taken as more than a refex of the health, for the time being, of a more or less small aggregation of residents, and not nessarily idicative of the healthiness or otherwise of the locality itself, especially if the population is a migratory one, or where as in districts like this, it contains a large proportion who leave their homes yearly or oftener. In this respect, indeed, the value of notifications is somewhat on a par with that of a death-rate, and as the latter is more often than not taken by the generality of the public to indicate by itself the superior healthiness of one place over another, it is necessary to be on one's guard and to point out, that while by itself this is in the main a simple and accurate measure of the comparative prevalence of diseases as between places, it is apt to be misleading as regards healthiness when there is a wide difference in the character 10 of the populations as regards occupation, age, sex, &c., so now that there are not wanting signs that notifications may be viewed in the same light, it is equally necessary to remember that since apparently undue relative proportions of sickness may be taken to imply defective sanitary conditions, they may also be equally due to temporary or accidental causes such as climatic conditions (floods, &c.), importations, or extreme pollution of milk or water. In connection with this matter of notification the carrying out of the provisions of the Act for the benefit of the community is largely dependent for success on the tact and consideration of the officials and on the good will of those with whom they come in contact. I have again to gratefully acknowledge the assistance and courtesy which I have in nearly every instance received at the hands of my medical colleagues and the heads of families. Isolation Hospital. The resources of tnis institution have not been drawn upon so largely as in 1893, owing to the differences in numbers of the scarlet fever cases, yet the benefits have been very considerable in individual cases. There were thirteen cases admitted and one death, distinguished thus, Scarlet Fever. Diphtheria. Typhoid. Small Pox. Total. 1893 35 6 3 l 45 1894 5 6 2 0 13 Two cases in addition were admitted under observation, but neither of them were found eventually to be notifiable. On January 1st, 1894, there were in the hospital under treatment, seven cases of scarlet fever and two of enteric fever, both of these latter died, they were referred to in the 1893 report. Mortuary. The reasons which were to my thinking good and sufficient in 1892 when I first advocated the necessity of a mortuary, are still more so now when the district is enlarging its borders, so that I have no hesitation in recapitulating them. In the matter of accidents or deaths 11 necessitating an inquest the Coroner has tor some time past taken to ordering the removal of the body in nearly all instances to the mortuary at Kingston, and then holding the inquest in that town. This is a subject of very considerable importance to relatives, witnesses, jury, and medical men, as the distance—one to two miles or more— and the bringing back of the body in many cases, involves expense and much waste of time. But in addition to this the Infectious Disease [Prevention] Act, 1890, adopted by your Board requires the removal of bodies under certain circumstances to a mortuary. I do not know what right or powers, if any, we have of access to the Kingston mortuary for the purposes of the Act, i.e. those dying of infectious diseases, but I think the matter should be arranged for in some more suitable way than at present, and better and more convenient premises provided in our own district than those we have to put up with at present. Southborough has now been incorporated with Surbiton, and if Hook and Tolworth are added this subject certainly cannot be overlooked. General Sanitary Work. The sanitary inspector in his report has referred to most matters of interest under this heading, and I have only to add that the district has been well and carefully looked after. The amount of work done has largely increased, especially the visits and correspondence. The matter of all absorbing importance, however, has been of course the attempt of our venerable neighbour to deprive us of our independence and liberty of progress. The result of the Local Government Board Enquiry is not at the time of writing this yet known, and I am not going to produce figures or imagine facts by way of argument or appeal against the possible but improbable adverse verdict; but as a sanitarian, I maintain there are absolutely no advantages of any description whatever to be gained—in a sanitary sense—by amalgamation with Kingston. The possibilities of successful sanitary administration are mainly dependent on the more or less enlightened views 12 taken by the Sanitary Authority of the legislation provided, a large portion of which is at present permissive, and upon the judiciously liberal spending of money. From this point of view, absorption by Kingston would be a positive loss— a loss not only of our independence, but a blow at self. government in its best and healthiest aspect. Surbiton has hitherto been administered by an authority, every member of which was thoroughly conversant with every part of the district, and by reason of this intimate knowledge was well able to grasp all the details that were brought forward from time to time whenever sanitary business or affairs concerning the health of the inhabitants were under consideration. We have every reason to be well satisfied with our progress, with our sewers and with our roads, their construction and their maintenance, with our building byelaws and their administration, notwithstanding the enemy within our gates, and we may be well content and proud as inhabitants of Surbiton to place opposite the offer of a free library, and the dubious advantages of the public [Kingston] electric light, the positive and practical benefits of a well.constructed and well.administered Cottage hospital, and ample accommodation at the Isolation Hospital for our infected sick. It is a fact, and a noteworthy fact (but a fact that it is to be hoped is exceptional among towns of such a size), that the town that proposes to absorb us— a town of nearly 30,000 inhabitants with its large artisan population, has not and never has had a single hospital bed of its own for those of its people who are injured, are sick, or may be infected. Inspector's Report. The Sanitary Inspector,Mr.Mather,reports as follows:— "During the past year the sanitary condition of the district has been well maintained and the number of complaints received unusually small, being only eight as against twenty.nine during the previous year. In twenty.one cases the usual order for abatement of nuisances has been served and the directions therein named have been 13 promptly complied with. No legal proceedings have been necessary in any case dealt with, and it is exceedingly satisfactory to find the very ready and willing responses with which my instructions and demands are invariably met with. I have made 231 inspections during the twelve months without encountering the slightest obstruction or objection to my visits. The adoption of the more important system of sanitation is gradually increasing and forty.five houses have been re.drained during the year. The building bye.laws continue to be well observed, and houses of the speculative character which have recently been erected will, I am convinced, bear a most favourable comparison with similar erections in any neighbourhood within measurable distance of Surbiton. The amended regulations have been returned to the Local Government Board for the third time and it is anticipated that they will very shortly be returned to the Council fully confirmed, and that the Council will soon possess the advantage of enforcing the improved system of sanitation, viz.—the power to demand watertight drains and to prevent any house being occupied without a certificate from the Council. The sewers of the district have been regularly inspected and flushed with disinfectants during the year, and observations are made at regular intervals throughout their entire length, and reliable evidence obtained of their satisfactory condition and that their constant flow to the outfall is being well maintained, and it is very gratifying to state that during the floods of November when the river rose to nearly 10 feet above its summer level not a house in the district was inconvenienced, whilst many of the surrounding localities, particularly Kingston, had large numbers of their dwellings filled with the discharge from their sewers. 14 The weekly collection of the house refuse during the summer months continues to be much appreciated, and is no doubt highly beneficial to the health of the district. Year by year the complaints of inattention decrease, whilst the supervision and attention given to this important contract is never relaxed. During my own experience the annual cost of this work has increased by £815, it is an expenditure which contributes largely to the comfort, convenience and well being of the district." Inspector's Report of Sanitary Work completed, during 1894. No. of complaints received during the year 8 No. of inspections of houses, premises, &c. 101 No. of re.inspections of houses and premises, &c. 130 No. of cesspools abolished 1 No. of house.drains tested 19 No. of beddings destroyed 0 Results of Inspection. orders issued for sanitary amendments of houses and premises 21 Houses, &c., cleansed, repaired, white.washed 0 Houses disinfected after infectious illness 15 House Drains. Houses re.drained 45 House drains repaired, cleansed, trapped, &c. 16 Ventilated 8 Privies and W.C.'S. Repaired, &c 0 Supplied with water 3 New provided 4 Dust Bins. New provided 22 Repaired, covered, &c 1 15 Water Supply. Wells condemned nil Cisterns (new) erected 3 Cisterns cleansed, repaired and covered 2 Waste pipes connected with drains, &c., done away with 1 Miscellaneous. Dust removal—No. of communications received and attended to 90 Removal of accumulations of dung, stagnant water, animal and other refuse 3 Animals removed being improperly kept 1 Regularly Inspected. Bake.houses 12 Licensed cow.sheds 14 „ slaughter.houses 1 New Buildings, 1894. No. of plans passed 87 No. of houses completed 21 Legal proceedings, e.g., summonses nil I am, Gentlemen, Yours obediently, OWEN COLEMAN, M.D., D.P.H., Medical Officer of Health. February 28th, 1895. (A) TABLE OF DEATHS during the Year 1894, in the Surbiton Urban District, classified according to Diseases, Ages, and Localities. Names of Localities adopted for the purpose of these Statistics; public institutions being shown as separate localities. Mortality from all causes, at subjoined AGES. Mortality from subjoined causes, Distinguishing Deaths of Children under Five Years of Age. At all ages. Under 1 year. 1 and under 5. 5 and under 15. 15 and under 25. 25 and under 65. 65 and upwds Diphtheria. Typhus Enteric or Typhoid. Puerperal. Erysipelas Whooping Cough. Diarrhoea and Dysentery Phthisis. Bronchitis, Pneumonia and Pleurisy. Heart Diseases. Injuries. All Other Diseases. Total. surbiton 105 22 4 3 6 38 33 Under 5 1 1 7 17 26 5 upwds. 1 2 2 1 1 1 4 6 11 5 45 79 COTTAGE HOSPITAL 4 1 1 1 1 Under 5 1 1 5 upwds. 1 2 3 ISOLATION HOSPITAL. 3 3 Under 5 5 upwds. 1 2 3 COUNTY LUNATIC ASYLUM 4 4 Under 5 5 upwds. 1 3 4 Totals 116 22 5 4 6 46 33 Under 5 1 1 7 18 27 5 upwds. 2 4 2 1 1 1 6 6 12 5 50 89 Deaths occuring outside the district among person belonging thereto. 7 7 Under 5 5 upwds. 1 2 1 3 7 Deaths occuring within the district among persons not belonging thereto. 7 1 3 3 Under 5 1 1 5 upwds. 1 1 4 6 (B) TABLE OF POPULATION, BIRTHS, and of NEW CASES of INFECTIOUS SICKNESS, coming to the knowledge of the Medical Officer of Health, during the year 1894, in the Surbiton Urban District; classified according to Diseases, Ages, and Localities. Names or 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. Smallpox. Scarlatina. Diphtheria Enteric or Typhoid. Continued. Puerperal Erysipelas. Smallpox. Scarlatinia | Diphtheria Enteric or Typhoid. Continued. Puerperal Erysipelas. surbiton 10052 10320 210 Under 5 4 5 upwds. 9 16 9 2 12 5 6 2 COTTAGE HOSPITAL Under 5 5 upwds. 3 Totals Under 5 4 5 upwds. 9 16 12 2 12 5 6 2 Table I.—Summary of Births and Deaths and Mortality from certain Classes of Diseases for 13 years. 1882 1883 1884 1885 1886 1887 1888 1889 1890 1891 1892 1893 1894 Zymotic Diseases 18 4 15 4 8 6 10 2 6 12 4 7 10 Total Deaths 118 111 125 104 123 108 137 100 110 136 121 122 116 Death Rate 11.8 10.8 11.9 9.7 11.4 10.0 12.6 9.09 10.0 13.5 11.9 11.8 11.24 Mortality from Phthisis 5 12 10 12 7 5 14 8 7 6 10 4 5 „ „ other Lung Diseases 9 15 27 16 27 27 16 11 17 32 21 25 15 „ „ Heart Diseases 14 14 14 12 8 16 19 17 17 7 11 19 12 „ „ Cancer 5 2 1 2 3 4 2 9 5 2 6 7 9 „ „ Violence 1 1 1 1 4 3 8 1 5 4 3 6 6 Total Births 246 236 221 222 206 200 209 192 166 210 218 186 210 Birth Rate 24.6 23.0 21.0 20.7 19.2 18.5 19.3 17.4 1509 20.8 21.5 18.2 20.3 Table II.—Deaths from seven chief Zymotic Diseases for 13 years. 1882 1883 1884 1885 1886 1887 1888 1889 1890 1891 1892 1893 1894 Small Pox 0 0 0 0 0 0 0 0 0 0 0 0 0 Measles 7 0 0 0 1 3 2 1 1 0 1 0 0 Scarlet Fever 0 1 4 0 0 1 0 0 0 0 0 3 0 Whooping Cough 7 0 6 2 1 0 2 0 2 2 2 0 1 Diphtheria 1 0 4 2 0 2 4 1 3 10 1 3 3 Fever, Typhus 0 0 0 0 0 0 0 0 0 0 0 0 0 „ Enteric 2 1 0 0 1 0 2 0 0 0 0 1 4 Diarrhœa 1 2 1 0 5 0 2 0 0 0 0 0 2 Deaths from 7 chief Zymotic Diseases 18 4 15 4 8 6 12 2 6 12 4 7 10 Death Rate from 7 chief Zymotic Diseases 1.8 .3 1.4 .46 .74 0.5 0.92 0.18 0.54 1.1 0.3 0.6 0.97 Total Death Rate 11.8 10.8 11.9 9.7 11.4 10.0 12.6 9.09 10.0 13.5 11.94 11.87 11.24 „ „ „ England and Wales 19.6 19.5 19.6 19.0 19.3 188 17.8 17.9 20.2 19. 19.2 16.6 ,, „ „ Birth Rate 33.7 33.2 33.5 32.5 32.4 31.4 30.8