TOT 40 TOTTENHAM Urban District Council. REPORT on the Health of Tottenham, FOR THE YEAR 1902. by J. F. BUTLER-HOGAN, B.A., M.D., D.P.H., &c., Medical Officer of Health for Tottenham. Tottenham: W. Conquest & Co., Trade Union Printers, 99, High Road. REPORT. To the Chairman and Members of the Tottenham Urban District Council. Gentlemen, I have the honour to submit to you my Annual Report for the year 1902. It is gratifying to he able to record that (a) the genetal (b) the infantile, and (c) the zymotic death rates all show a marked diminution as compared with preceding years, and this, notwithstanding the prevalence of Small-pox in the Parish during the greater portion of the period in question; indeed, that disease alone contributed a quota of 74 to the total death roll of 1,438. On the other hand, the birth tate has risen, and is considerably above, as the death tate is even more considerably below the average rates of England and Wales. The large number of deaths (37) attributed to Whooping Cough, is doubtless chiefly due to the small importance so generally attached to the early stages of this disease by parents and others having the control of children, and the consequent failure to procure and follow proper medical advice. The above remarks apply with even greater force to the onset of Diphtheria; too much care cannot be taken to secure its early diagnosis and treatment; bacteriological examinations and anti-diphtheritic serum are now provided for this purpose by many sanitary authorities, through their Public Health Departments, and the results of such an enlightened policy are evidenced, not merely by the preservation of human life, but also by the markedly decreased hospital expenditure on this disease. The number of deaths from Phthisis is lower than that of last year, and were that disease brought under the operation of the Infectious Disease (Notification) Act, 1889,1 am convinced 3 that its spread would be materially lessened, for the Medical Officer of Health could then provide for the proper treatment of Phthisical Sputa, and the regular disinfection of the rooms and clothes used by consumptive patients. The incidence of Typhoid was greatest in St. Ann's Ward where the sanitary conditions are, generally, less satisfactory than in other portions of the district. The annual statistics show, on the whole, very considerable progress from a public health point of view, and the assiduous and systematic attention which has been bestowed during the year, on the inspection both of dwellings and food materials, must necessarily produce even more favorable results in the future. My thanks are due and hereby tendered to your Clerk and Engineer for much detailed information embodied in this Report. I am, Gentlemen, Faithfully yours, J. F. BUTLER-HOGAN. February 3rd, 1903. DISTRICT STATISTICS. The Rateable Value was £230,557 in 1891, it is now (1902) £453,247, the increase during the past year alone has been £38,688. The rates at the commencement of the year were: General District Rate, 2s. 6d.; Water Rate, 6d.; and are now 2s. 4d. and 7d. respectively. The Population of Tottenham in April, 1901, was 102,531. At the 1891 Census it was 71,343, showing an increase of 31,188 during the decade. The estimated population at the middle of 1902 was 107,003, the number of inhabited houses 17,341, giving an average of 6.17 per house. Area of District in acres 3.033 Total population at all ages 102,531 At Census of 1901. Number of Inhabited Houses 16,441 Average number of persons per house 6.2 4 It may be interesting to note the following particulars taken from Robinson's History and Antiquities of Tottenham. The Population of the Parish of Tottenham, as taken in the years 1801 and 1811. Houses. Families. Males. Females. Total Persons. 1801. High Cross Ward 197 260 519 612 1131 Middle „ 193 254 558 689 1247 Lower „ 193 196 447 503 950 Wood Green „ 64 71 154 140 294 Total 674 781 1678 1944 3622 1811. High Cross Ward 283 309 700 843 1543 Middle „ 269 317 728 884 1612 Lower „ 207 240 520 667 1187 Wood Green „ 72 81 202 227 429 Total 831 947 2150 2621 4771 The amount of population in 1801 3,622 Increase of population between the years 1801 and 1811 1,149 The comparative state of the population of the Parish of Tottenham from the reign of Queen Elizabeth. The Parish Register begins in the year 1558:— Baptisms. Average about. Burials. Average about. From 1559 to 1568 138 14 166 17 „ 1600 ,, 1610 309 31 347 35 „ 1700 „ 1710 345 34 469 47 ,, 1795 „ 1804 - 98 - 86 „ 1805 „ 1814 - 118 - 90 The Parish is more populous than the above averages denote, a great part of the inhabitants consisting of Quakers and other dissenters. In the year 1603, there were 79 burials in Tottenham, being about double the average of that period; 44 persons are said to have died of the Plague. In 1625 there were 54 burials. Births. 3,179 Births were registered in the year (1,775 males and 1,622 females), giving a birth rate of 31.74 against 30.06 in 1901. The natural increase of population, that is the increase of births over deaths, was 1,964, that of 1901 being 1,629. The birth rate for England and Wales for the year was 28.3, i.e. 3.44 below this district. 5 Deaths. The number of deaths was 1,438 (739 males and 699 females), against 1,550 in 1901. On the estimated population of 107,003 the 1,438 deaths give an annual mortality rate of 13.4 against 15.01 in 1901. The deaths were distributed according to age as follows:— Under 1 year 420 From 1 to 5 years 191 „ 5 to 15 „ 86 „ 15 to 25 „ 71 „ 25 to 65 „ 406 „ 65 and upwards 264 1,438 The death rate of England and Wales was 16.4, i.e. 2.4 above this district. Infantile Deaths. The number of deaths under 5 years of age was 610, and of these 420 were under 12 months old. The Infantile mortality was 123.6 per 1,000 births, last year it was 132.4. Deaths from Zymotic Diseases. The total number of deaths from Zymotic Diseases during the year was 237, equivalent to a death rate of 2.1 against 3.1 for 1901. These were distributed as follows:— Small-pox 74 Measles 23 Scarlet Fever 12 Diphtheria 35 Membranous Croup 3 Whooping Cough 37 Enteric Fever 15 Diarrhoea 30 Continued Fever - Puerperal Fever 1 Erysipelas 7 237 6 This includes deaths of residents occurring at Public Institutions in Tottenham. The total number of cases notified was as follows:— Small-pox 481 Diphtheria 235 Membranous Croup 7 Erysipelas 78 Scarlet Fever 484 Enteric Fever 118 Puerperal Fever 4 Chicken Pox 669 2,076 Small-pox. As I have already submitted a Special Report on the recent epidemic of this disease, I need only mention that we have had 5 cases removed to South Mimms, and treated there since the local hospital was closed. Scarlet Fever. There were 12 deaths from Scarlet Fever (against 6 in 1901 and 7 in 1900), the incidence and mortality being as follows:— Cases. Deaths. St. Ann's 118 4 Harringay 102 2 Middle 84 2 Lower 65 2 High Cross 62 1 West Green 53 1 Diphtheria and Membranous Croup. The deaths from Diphtheria and Membranous Croup numbered 35, against 89 in 1901 and 20 in 1900. The cases notified numbered 242, as against 264 in 1901. Incidence and mortality in Wards:— Cases. Deaths. Middle Ward 54 4 St. Ann's „ 48 12 High Cross „ 40 10 Harringay „ 40 6 West Green „ 37 2 Lower „ 16 1 7 Puerperal Fever. Four cases were notified, 1 of which had a fatal result. Typhoid Fever. Incidence and mortality in Wards:— Cases. Deaths. St. Ann's Ward 31 4 Lower „ 26 3 Middle 19 4 High Cross ,, 18 — Harringay ,, 14 3 West Green „ 10 1 Diarrhœa. The deaths from Diarrhoea were 30, against 100 in 1901 and 111 in 1900. Phthisis (Consumption). The deaths from Phthisis amounted to 87, against 90 in 1901 and 130 in 1900. 22 deaths occurred in St. Ann's Ward, 19 in High Cross, 17 in Harringay, 12 each in the Middle and Lower Wards, and 5 in West Green Ward. Other Tubercular diseases caused 58 deaths. Epidemic Influenza. 20 deaths were certified from this disease during the past year. Cancer. There were 42 deaths certified, as against 80 last year. Measles. The number of deaths from this disease amounted to 23, against 28 in 1901 and 40 in 1900. Of these, 6 occurred in children under one year, 16 from one to five years, and 1 from five to fifteen years. Whooping Cough. The deaths from this infantile disorder amounted to 37 against 20 in 1901 and 54 in 1900. 8 The deaths included:— 19 children under 1 year. 15 „ from 1 to 5 years. 2 „ „ 5 „ 15 „ 1 case over 15 years. Alcoholism. 18 deaths were notified as being directly due to Alcohol, of which 5 occurred in St. Ann's Ward, 3 in Middle Ward, 3 in Lower, 3 West Green, and 2 each in High Cross and Harringay Wards. Violent Deaths. Different forms of violence caused 44 deaths. Of these, 4 were referred to suffocation, 5 to fractures, 4 to drowning, 3 to hanging, 4 to poisoning, 10 to burns, 5 to falls, 5 to suicide, 3 were run over, and there was 1 case of homicide. Chicken Pox. As a consequence of the temporary adoption of Varicella as a notifiable disease, under the Infectious Disease (Notification) Act, 1889, 669 cases have been notified from 14th February to 31st December, 1902. Comparative Statement of areas, houses, population and death rate, in Wards. Ward. Area in Acres. Total No. Houses. Inhabited Houses. Empty Houses. Estimated Population. No per. Acre. Deaths. No. Rate. Harringay 266 2800 2520 280 16,005 60.16 190 11.87 West Green 471 2073 1828 245 11,650 24.73 128 10.98 St. Ann's 246 3739 3559 180 20,776 84.45 333 16.00 High Cross 460 3442 3204 238 19,908 43.27 266 13.36 Middle 640 3449 3285 164 20,404 31.88 284 13.91 Lower 950 3148 2945 203 18,260 19.22 237 12.98 Total 3033 18,651 17,341 1310 107,003 1438 Table I.— Table showing the Population, Birth Rate, and Death Rate from all causes, in Tottenham, during the last ten years. Year. Population estimated to Middle of each Year. Births. Deaths under One Year of Age. Deaths of all Ages Total. Deaths in Public Institutions. Deaths of NonResidents registered in District. Deaths of Residents registered beyond District. Deaths at all Ages. Nett Number. Rate.* Number. Rate per 1000 Births registered Number. Rate." Number. Rate.* 1 2 3 4 5 6 7 8 9 10 11 12 13 1892 73,590 2429 33.0 361 148.6 1237 16.8 106 79 ... 1158 15.7 1893 75,000 2580 34.4 379 146.8 1429 19.0 243 184 ... 1245 16.6 1894 75,000 2437 32.5 337 138.5 1176 15.6 203 164 ... 1012 13.4 1895 78,258 2602 33.3 371 137.5 1297 16.5 158 145 ... 1152 14.7 1896 83,790 2513 29.4 377 151.9 1227 14.6 103 99 ... 1128 13.4 1897 87,180 2643 30.3 430 162.8 1314 15.0 115 110 ... 1204 13.8 1898 91,692 2707 29.5 465 171.7 1209 14.2 90 83 ... 1126 12.2 1899 96,498 2925 30.3 478 163.4 1466 15.1 82 81 ... 1385 14.4 1900 98,268 2964 30.1 501 169.0 1527 15.5 116 82 ... 1445 14.7 1901 103,243 3179 30.0 431 135.5 1550 5.0 274 40 ... 1510 14.6 Averages for years 1892-1901. ... ... 31-\.2 ... 152.5 ... 15.7 ... ... ... 14.3 1902 107,003 3397 31.7 420 123.6 1656 15.5 318 223 5 1438 13.4 * Rates calculated per 1,000 of estimated population. 10 Note.—The Deaths included in Column 7 of this Table are the whole of those registered during the year as having actually occurred within the District. The Deaths included in column 12 are the number in column 7, corrected by the substraction of the number in column 10, and the addition of the figures in Column 11. By the term "Non-Residents," is meant persons brought into the district on account of illness, and dying there; and by the term " Residents" is meant persons who have been taken out of the District on account of illness, and have died elsewhere. 1. Institutions within the District receiving sick and infirm persons from outside the District. 2. Institutions outside the District receiving- sick and infirm oersons from the District. 3. Other Institutions, the deaths in which have been distributed among the several localities ill the District. Jewish Home for Incurables South Minims Smallpox Hospital Tottenham General Hospital Tottenham General Hospital Edmonton Union South Minims Smallpox Hospital M.A.B. Hospital (N.E.) M.A.B. Hospitals (other than N.E.) 11 Table II. Vital Statistics in 1902 and previous years. WHOLE DISTRICT. Year. Population estimated to middle of each year. Births registered. Deaths at all Ages. Deaths under one year. 1892 73,590 2429 1237 361 1893 75,090 2580 1429 379 1894 75,000 2437 1176 337 1895 78,256 2602 1297 371 1896 83,790 2513 1227 377 1897 87,180 2643 1314 430 1898 91,692 2707 1209 465 1899 96,498 2925 146 6 478 1900 98,268 2964 1445 498 1901 103,243 3179 1550 421 1902 107,003 3397 1438 408 Ward Statistics for the Year. Harringay (New District 1902), Ward 16,005 586 190 46 West Green Ward 11,650 305 128 31 St. Ann's ,, 20,776 824 333 104 High Cross „ 19,908 576 266 76 Middle „ 20,404 616 284 90 Lower „ 18,260 491 237 61 Table iv. TABLE OF DEATHS during the Year 1902 in the Tottenham Urban Sanitary District, classified according to Diseases, Ages, and Localities. Causes of Death. Deaths in or belonging to whole Districts at subjoined Ages. Deaths in or belonging to Localities (at all ages). Total Deaths in Public Institutions in the District All Ages. Under 1. 1 and under 5. 5 and under 15. 15 and under 25. 25 and under 65. 65 and upwards. Harringay W. Green. St. Ann's. H. Cross. Middle. Lower. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Small-pox 74 4 14 16 7 30 2 5 2 28 11 14 14 ... Measles 23 6 16 1 3 4 6 8 2 6 Scarlet-fever 12 7 4 1 ... ... 2 1 4 1 2 2 58 Whooping-cough 37 19 15 2 1 ... ... 7 4 6 8 6 6 ... Diphtheria and Membranous Croup 35 2 18 12 2 1 ... 6 2 12 10 4 1 73 Croup 3 1 2 ... ... ... ... ... ... 1 ... 1 1 ... Fever Typhus ... ... ... ... ... ... ... ... ... ... ... ... ... ... Enteric 15 1 ... 1 6 7 ... 3 1 4 ... 4 3 40 Other continued ... ... ... ... ... ... ... ... ... ... ... ... ... ... Epidemic Influenza 20 l ... 2 2 12 ... 6 1 8 1 2 2 1 Cholera ... ... ... ... ... ... ... ... ... ... ... ... ... ... Plague ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diarrhoea (see notes following) 30 25 2 ... ... 1 2 4 4 8 2 9 3 ... Enteritis 51 43 5 ... ... 2 1 9 1 11 7 7 16 2 Puerperal Fever 1 ... ... ... ... 1 ... ... ... ... ... 1 ... 2 Erysipelas 7 1 ... ... ... 4 2 1 1 ... 2 2 1 ... Other Septic Diseases 5 ... ... ... ... 4 1 1 ... ... ... 3 1 1 Phthisis 87 2 1 2 10 65 5 17 5 22 19 12 12 4 TABLE OF DEATHS—Continued. Causes of Death. Deaths in or belonging to whole Districts at subjoined Ages. Deaths in or belonging to Localities (at all Ages). Total Deaths in Public Institutions in the District All Ages. Under 1. 1 and under 5. 5 and under 15. 15 and under 25. 25 and under 65. 65 and upwards. Harringay W. Green. St. Ann's. H. Cross. Middle. Lower. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Other tubercular diseases 58 11 16 12 6 12 1 8 4 13 6 21 6 8 Cancer, malignant disease 42 ... ... ... 1 29 12 6 5 6 7 9 9 6 Bronchitis 121 39 15 1 1 18 47 17 10 33 28 17 16 6 Pneumonia 122 36 34 6 5 26 15 17 11 24 18 31 21 17 Pleurisy 3 ... ... ... ... 3 ... 2 ... 1 ... ... ... ... Other diseases of Respiratory organs 17 6 2 ... 1 3 5 ... ... 4 4 7 2 ... Alcoholism 18 ... ... ... ... 17 1 2 3 5 2 3 3 2 Cirrhosis of Liver Venereal diseases 3 2 ... ... ... 1 ... ... 2 1 ... ... ... 1 Premature birth 45 45 ... ... ... ... ... 9 4 5 10 9 8 2 Diseases and accidents of parturition 3 ... ... ... 1 2 ... 1 ... 1 ... ... 1 ... Heart diseases 126 8 1 8 6 61 42 17 14 19 22 26 28 12 Accidents 39 8 8 2 2 14 5 ... 4 12 15 4 4 19 Suicides 5 ... ... ... ... 4 1 1 ... ... 1 ... 3 1 All other causes 436 160 33 17 19 88 119 49 46 101 86 82 72 57 All causes 1438 421 191 86 71 405 264 190 128 333 266 284 237 318 14 Notes. (а) In this Table all deaths of "Residents" occurring in public institutions, whether within or without the district, are included with the other deaths in the columns for the several age groups (columns 2-8). They are also in columns 9-13, included among the deaths in their respective "Localities" according to the previous addresses of the deceased as given by the Registrars. Deaths of "Non-Residents" occurring in public institutions in the district are in like manner excluded from columns 2-8 and 9-13 of this Table. (б) All deaths occurring in public institutions situated within the district, whether of "Residents" or of "Non-Residents," are, in addition to being dealt with as in note (a), entered in the last column of this Table. The total number in this column equals the figures for the year in column 9, Table I. (c) Under the heading of "Diarrhœa" are included deaths certified as from diarrhoea, alone or in combination with some other cause of ill-defined nature; and also deaths certified as from Epidemic enteritis; Zymotic entiritis; Epidemic diarrhoea. Summer diarrhœa; Dysentery and dysenteric diarrhœa ; Choleraic diarrhoea, cholera nostras (in the absence of Asiatic cholera). Deaths from diarrhoea secondary to some other welldefined disease are included under the latter. Factory and Workshop Act, 1901. Number of Factories and Workshops 73 ,, Laundries .. 38 ,, Bakehouses 63 174 A Register of Factories and Workplaces, Laundries, and Bakehouses in the district is kept as required by the provisions of Sec. 131 of the Factory and Workshop Act, 1901. Such premises have been regularly visited, and any sanitary defect or nuisance found on inspection has been promptly remedied. The printed regulations of the Council referring to this Act, have been served upon the occupiers of all workplaces in the district. Outworkers— The number of outworkers reported during the year was 171, and Sec. 107 of the above-mentioned Act has been properly 15 enforced. Sec. 14 referring to the provision of means of escape in case of fire is being enforced by the Engineer and Chief Surveyor's Department Sec. 22, Public Health (Amendment) Act, 1890. Several improvements at various Workplaces have been effected under the above Section during the year. Particulars of Food Inspections. During the five months from July to December inclusive, 1491 inspections have been made, viz:—612 butchers, 282 fruiterers, and 597 fishmongers, and all the stalls in the streets have been inspected on Friday and Saturday nights. Large quantities of fruit (apples, bananas, cherries, plums, damsons, lemons, and pears); vegetables (peas, brussels sprouts, tomatoes); fish (haddocks, kippers, gurnets), and meat (beef, lungs, kidneys, &c.) have been condemned and destroyed. There has been a decided decrease in the quantity which it has been necessary to condemn during the past two months. The slaughterhouses, cowsheds, dairies and milkshops have been periodically visited, and notices in many cases served to abate nuisances. The required works have in nearly all cases been effected. All the Slaughterhouses throughout the district are placed in such close proximity to dwelling houses, and are in many cases so defective in construction, that it would be most desirable if the Council could see its way clear to erect a Public Abattoir the advantages of which, to the district in general, would be very considerable indeed. Dairies, Cowsheds and Milkshops. Forty-nine persons have been registered during the year under the Dairies, Cowsheds and Milkshops Order, 1885, as against 12 in 1901 and 27 in 1900. The number now on the register is as follows:— Cowsheds 19 Dairies 56 Milkshops 157 232 Gipsy Encampments. 252 encampments (as against 98 last year) have been removed by your Inspectors, exclusive of those dealt with by the Police. 16 Shooting of House Refuse and Slop within the District. There have been no serious complaints respecting this matter during the past year. Dust Collection. 11,268 loads (24,548 tons) of house refuse have been collected and removed by the contractors. There have been far fewer complaints during the later than there was in the earlier part of the year with regard to the method of collection. Refuse Destructor. I am glad to be able to report that the sanction of the Local Government Board to the loan of £27,300 for this work, has this day (3rd February) been received, and that preparations are consequently being made to carry out the work immediately. There can be no doubt, that when completed, it will be a great advantage to the public health of the district. Private Roads. Many of these roads, particularly those in the poorer portions of the district, are in a disgraceful condition, and undoubtedly exercise a prejudicial influence on the health of those dwelling in their immediate vicinity. Waste Land, corner of Woodlands Park Road. The nuisance which existed at this spot has at length been removed, and a proper fence provided round the laud. Spitting in Public. This habit, which prevails largely in Tottenham, is at once both disagreeable and dangerous, and should be discouraged by everyone who takes an interest in the health of the district. Public Institutions. The North Eastern Fever Hospital (M.A.B.) at the close of the year contained 461 inmates and 312 officials, the Tottenham General Hospital 47 inmates and 43 officials, and the Jewish Home for Incurables 54 inmates and 24 officials. Houses and Population. The number of Houses and Shops actually erected in Tottenham in the year 1902 was 712, as against 972 for year 1901. The number of Buildings for which plans were passed by the Council was as follows:— Year 1900 1901 1902 Dwelling-houses and Shops 1183 971 808 Other Buildings 107 50 36 Alterations and Additions 76 52 53 1366 1073 897 17 Plans passed for houses in Tottenham during the past ten years:— 1893 206 1894 334 1895 408 1896 963 1897 349 1898 907 1899 1216 1900 1366 1901 1073 1902 897 Water Supply. To carry the Water Supply to new premises and to improve defective supplies where necessary, 2,320 yards of new water mains have been laid, and 46 hydrants fixed. During the past year the water fittings in 12,300 houses have been inspected and the necessary notices to remedy defects served. Hale Waterworks. The old pump has been taken out, and a new one fixed in the well to a depth of 250 feet, being 100 feet lower than the old pump. This work, which was carried out under contract by Messrs. Gimson & Co., of Leicester, includes alterations to the two beam engines, and pumps under same. Deepening Well at Park Pumping Station. Messrs. Docwra's contract has now been completed. Drainage. Since the work of examining all Sewers in the District was commenced in March, 1896, the following works have been carried out:— 46½ miles of Soil Sewers plotted and examined. 32¾ „ Surface Water Sewers do. The relaying of all defective Sewers in No. 2 District has been completed. The total length of soil and surface water Sewers to be kept clear and in working order is 250 miles. During the year the following work was carried out:— Defective Mains repaired 25 New Manholes built 130 Blind Manholes build up 32 Ventilating Shafts erected 9 Stoppages cleared 300 Connections made 206 Drains examined and passed 1424 18 List of Principal Streets and other Improvements carried out during the past twelve months. 1. Fire Station and General Depot, Conway Road. 2. Widening Ferry Lane, near Station, East side of Broad Lane. 3. Widening West Green Road, opposite Stanmore Road. 4. 18-in. Relief Surface Water Sewer has been laid in Russell Rd. 5. 18-in. Relief Soil Sewer in Forster Road. 6. The Concrete Surface Water Culvert in Chesnut Road and High Road has been completed. Improvements of Footways. 1. Paving path, North side Chesnut Road. 2. ,, North and South side Ferry Lane. 3. ,, East side Broad Lane. 4. ,, Front of London and Provincial Bank, junction of High Road and Broad Lane. 5. „ Junction of West Green Road and Green Lanes. Works under the consideration of the Council. Of other important schemes engaging the attention of the Council, and which are shortly expected to be carried out, the following may be mentioned, viz.:— Refuse Destructor. Municipal Buildings and Baths. Stables and General Depot Buildings. Electrification of North Metro. Tramway System. Light Railway Schemes. Paving Main Roads with Wood. Swimming Baths. Scheme for housing the Working Classes. Recreation Ground, Downhills Estate. ,, ,, Down Lane. Parliamentary Plan for North-east London Railway. General Improvements to the Main Roads and Highways.—Plans, Estimates, &c. for the improvement of Soil and Surface Water Sewers, No. 3 District. Private Street Works. During the year 1902, 29 Private Roads were made up under the Tottenham Local Board Act, 1890, at a cost of £34,000, and declared Public Highways. Contracts have been entered into for making-up the following Private Roads, and the works are now in hand :— Chester Road. Belton Road. Gladesmore Road (part of). Gourley Street. Collingwood Road. Nelson Road (No. 1). Nelson Road (No. 2). Shelborne Road. Fairview Road (part of). Paxton Road. Fladbury Road. Eve Road. Waldeck Road. 19 Tenders have been accepted for the making-up of the following Private Roads, and the Works will shortly be commenced :— Crowland Road Ferndale ,, Langham ,, (West) Harefield Road Vernon „ Lealand ,, Plans for the making-up of 5 Private Roads have been submitted, and the notices for same have been served. Electric Lighting. The Council have appointed W. C. C. Hawtayne, Esq., to be their Consulting Electrical Engineer, in order to carry out in conjunction with Mr. Prescott, the Electric Lighting of Tottenham under their Provisional Order. Fire Brigade. The Council are purchasing a Motor Escape and Chemical Engine, and a Motor Fire Engine. New Steam Road Roller. A new 12-ton Steam Roller, with Scarifier has been purchased. New Boiler at Disinfecting Station. In consequence of the giving out of the Lancashire Boiler at the Disinfecting Station, a new Vertical Boiler has been purchased and fixed. Factory and Workshop Act. The various Factories and Workshops in the Districts are being inspected with a view to the granting of certificates that efficient means of exit are provided for escape in case of fire, in accordance with the provisions of the above Act. Repairs of Tools. The repair of tools is now being effected by the Council's own workmen at the forge situated at the Outfall Works. Greenhouses. A greenhouse has been erected at "Bruce Castle," and also one at the "Chestnuts." London County Council new Estate, Lordship Lane. The London County Council have commenced laying out one portion of their estate for the erection of Working Men's Dwellings. Collection of Slop and Trade Refuse. 13575 loads of slop and other refuse have been collected and removed during the year. 20 House to House Inspection, 1902. Name of Road. No. of Houses Name of Road. No. of Houses Alexandria Cottages 5 Brought forward 1394 Alexandria Road 5 Markfield Road 140 Arthur Road 22 Moreton Road 63 Albany Road 9 Moselle Street 40 Bloomfield Street 7 Malvern Road 1 Bræmar Road 67 North Grove 45 Bruce Grove Road 17 Nassau Road 23 Brunswick Road 81 Newton Road 36 Bernard Road 21 Norman Road 12 Baileys Lane 3 Netherton Road 43 Brunswick Court 16 Orchard Place 9 „ Cottages 32 Old Lane 4 Charles Street 16 Osman Road 55 Clarence Road 3 Penrith Road 23 Clinton Road 65 Princes Street 3 Compton Road 23 Park Road 33 Cornwall Road 88 Plevna Road 28 Culross Road 38 Poynton Road 12 Catherine Road 36 Park Lane 17 Cape Road 13 Queen Street 20 Church Road 28 Rosslyn Road 44 Derby Road 27 Richmond Road 94 Dawlish Road 1 Rose and Crown Yard 5 Elizabeth Road 23 Rangemoor Road 71 Eckington Road 49 Station Road 19 Fountain Square 9 Seaford Road 147 Fairview Road 10 Shrubbery Road 56 Fairfax Road 29 South Grove 7 Fladbury Road 16 Spratt's Row 33 Gourley Street 18 St. Loy's Road 93 Herbert Road 30 Stanley Road 46 Henrietta Road 36 Sperling Road 24 Henry Road 35 Shaftesbury Street 40 Highweek Road 41 St. Ann's Road 35 Hendricks Terrace 7 Suffield Road 38 High Cross Road 105 Sutton Road 11 Hale, The 18 Suffolk Road 28 Harold Road 5 Scales Road 74 High Road 30 Selwyn Road 8 Hampden Road 6 St. John's Road 4 Harefield Road 33 Templeton Road 72 Ida Road 26 Tewkesbury Road 211 Ipplepen Road 40 Tiverton Road 71 James Place 10 Union Row 26 Junction Road 24 Vine Cottages 6 Kent Road 20 Whitehall Street 42 „ Terrace 9 William Street 12 Langhedge Road 35 Willow Walk 57 Love Lane 71 Westerfield Road 61 Laura Road 13 Waggon Lane 28 Lealand Road 18 West Green Road 4 Lincoln Road 15 Welbourne Road 2 Carried forward 1394 Total 3470 Mortuary Table for the Year 1902. Bodies Admitted. No. of Post Mortems. No. of Inquests. No. of Funerals. No. of Drowning Cases. Month. Males. F'm'les Total. Males. F'm'les Total. January 7 6 13 2 3 5 13 10 1 February 6 6 12 3 2 5 11 13 0 March 5 5 10 0 3 3 10 10 0 April 13 1 14 10 0 10 14 12 0 May 6 3 9 3 2 5 8 11 1 June 5 5 10 0 1 1 7 7 2 July 9 5 14 8 3 11 15 15 0 August 8 2 10 6 2 8 9 11 2 September 9 11 20 9 7 16 20 18 0 October 7 2 9 4 2 6 10 11 0 November 7 5 12 5 5 10 11 11 1 December 12 11 23 6 6 12 23 24 1 Total 94 62 156 56 36 92 151 153 8 Comparative Statement of work executed, during the years 1900, 1901, and 1902. 1900. 1901. 1902. Complaints Received 787 857 756 Dust Applications 1097 632 660 Cases of Infectious Disease Notified 832 1204 2181 Houses Inspected—from House to House 1183 889 3470 Total No of Houses Inspected 3113 2246 5253 „ „ Re-Inspections 11227 9974 21850 ,, „ Inspections and Re-Inspections 17942 12720 30929 Letters Written 1933 2420 3500 Notices Served 3690 3469 4166 Houses aud Premises Cleansed or Repaired 560 442 781 Movable Dwellings and Tents Removed 593 98 252 Registered Lodging Houses, No. of Inspections 392 350 620 Workshops „ „ 200 174 407 Laundries „ „ 96 86 157 Bakehouses „ „ 280 140 240 Slaughter-houses „ „ 397 287 428 Dairies,Cow Sheds, Milk Shops „ „ 1010 850 593 Bodies in Mortuary 176 176 156 Cisterns Cleansed or Repaired 124 97 198 Flush Cisterns to W.C.'s Provided 41 10 8 W.C.'s Cleansed and Repaired or Water Supply 411 363 459 Rendered Efficient Drains Examined, Tested, etc. 2400 1800 3400 „ Reconstructed 1095 818 379 „ Unstopped, Trapped, etc. 183 157 126 R.W. Pipes and Sink Wastes Disconnected 230 87 45 Soil Pipes and Drains Ventilated 299 163 209 Rooms Fumigated 645 981 1422 Dustbins Repaired 198 115 223 New Dustbins Provided Yards Paved or Drained 195 98 235 Smoke Nuisances Abated 8 6 12 Offensive Accumulations Removed 53 46 77 Animals kept improperly 20 22 16 Articles Disinfected or Destroyed 3959 6997 31683 Cases Removed to Hospital (M.A.B.) 383 509 929 „ „ S.P. Hospital, S. Mimms ... 46 48 „ „ Isolation Hospital, Downs Lane ... ... 405 TOTTENHAM URBAN DISTRICT. COUNTY OF MIDDLESEX.—SANITARY WORK, 1902. Inspections. Notices. Dwelling Houses. Houses let in separate Dwellings or Lodgings. Common Lodging Houses. Canal Boats used as Dwellings. Movable Dwellings, Caravans, Tents, &c. Complaints received. Cases of Infectious Diseases notified. Number of Premises periodically Inspected. Houses Inspected from House-to-House. Total Number of Houses Premises, &c., Inspected. Total Number of Re-inspections after Order or Notice. Total Number of Inspections and Re-inspections. Letters Written. Cautionary Notices Given. Statutory Orders Issued. Summonses Served. Convictions Obtained. Houses. Premises, &c., Cleansed, Repaired, &c. Closed as Unfit for Habitation. Re-opened after Repairs, Alterations, &c. Demolished. Illegal Underground Dwellings Vacated. Number Registered under Bye-Laws. Periodical Frequency or Number of Inspections Number of Contraventions. Number Registered under Bye-laws. Periodical Frequency or Number of Inspections! Number of Contraventions. Number Registered under the Acts. Periodical Frequency or | Number of Inspections Number of Contraventions of Regulations. Number observed during the year. Number of Nuisances therefrom abated. | Number Removed from District. 786 2181 3826 3470 5253 21850 30929 3500 3091 975 - - 781 - — - - — — — 6 620 - — — — 286 — 252 SANITARY WORK, 1902.—Continued. Workshops and Workplaces. Laundries. Bakehouses. Slaughterhouses. Cowsheds. Dairies and Milkshops. Uns'nd Food. Mortuaries. Number in District. Periodical Frequency or Number of Inspections Contraventions of Factory Acts. Number in District. Periodical Frequency or Number of Inspections Contraventions of Factory Acts. Number in District. Periodical Frequency or Number of Inspections Contraventions of Factory Acts. Number on Register. Periodical Frequency or Number of Inspections Contraventions of Bye-laws. Number on Register. Periodical Frequency or Number of Inspections Contraventions of Bye-laws. | Number on Register. l Periodical Frequency or Number of Inspections Contraventions of Bye-laws Animals seized. Articles or Parcels seized. Accommodation. Number of Bodies received. 73 407 - 38 157 - 63 240 - 17 428 - 19 264 - 211 329 - - - 5 156 • Large and miscellaneous lot SANITARY WORK, 1902.—Continued. Water Supply and Water Service. Privy and Ash Pits, Ash & Earth Closets. Drainage and Sewerage. Wells. Houses, Water laid on to. Percentage of Houses Supplied | from Mains. Cisterns. Flush Cisterns providedjto W.C.'s- i Draw Taps removed from Cisterns to Mains. Percentage of Houses Supplied on Constant System. Above Ground Receptacles substituted for Pits. Movable Receptacles substituted for Fixed. Water Closets substituted for Dry keceptacles. Water Closets. Percentage of Houses Provided with Water Closets. Drains. Percentage of Houses Draining) into Sewers. Sewers. New, Sunk Cleansed, Repaired,etc. Closed as Polluted. New, Provided. Cleansed, Repaired, Covered, etc. Overflow Pipes Disconnected from Drains. New, Constructed. NewApparatus provided. Repaired, Cleansed, etc. Supplied with Water, or Supply Rendered Efficient. Ventilated. Examined, Tested. Exposed, etc. Unstopped, Repaired, Trapped, etc. Waste Pipes, Rain Water Pipes, etc., disconnected. Soil Pipes and Drains Ventilated. Disconnecting Traps or Chambers Inserted. Reconstructed. New Laid. Soil. Yards of New Surface Sewers Land Water. Soil. Yards of Sewers Surface Reconstructed. Water. - — - — 100 p.c. — 198 - 8 — 50 p.c. — — — - 20 83 356 - 100 p.c. 3400 126 45 209 - 379 - 100 p.c. 990 1240 1801 760 SANITARY WORK.—Continued. Disinfection. Dust. Dampness. Sundry Nuisances Abated. Rooms Fumigated. Rooms Stripped and Cleaned. Articles Disinfected or Destroyed. Dust Bins Repaired and New Bins Provided. Movable Receptacles substituted for Fixed. Periodical Frequency of Dust Removal. Number of Complaints of Non-removal Received. Roofs Repaired, etc. Guttering and Rain Pipes Repaired. Gardens, Areas, etc. Levelled and Drained. Yards Paved & Drained. Surface adjoining Houses Paved. Dry Areas Provided. Ventilation below Floor | Provided. Basements rendered Impervious. Overcrowding. Smoke. Accumulations of Refuse. Foul Ditches, Ponds, etc., and Stagnant Water. Foul Pigs and other Animals. Other Nuisances. 1422 866 31683 223 - Weekly 660 356 335 - 235 - 129 22 - 13 12 77 10 16 50 Table ITI.— Table of cases of infectious disease coming to the knowledge of the Medical Officer of Health during the year 1902, in the Tottenham Urban Sanitary District, classified according to diseases, ages, and Localities. Notifiable Disease. Cases notified in Whole District. Total Cases notified in each Locality. No. of Cases removed to Hospital from bach Locality. At all Ages. At Ages—Years. 65 and upwards. 1 2 3 4 6 6 1 2 3 4 5 6 7 Under 1. 1 to 5. 5 to 15. 15 to 25. 25 to 65. Harrin - gray. West Green. St. Ann's. High Cross. Middle. Lower. Harrin- gay. West Green. St. Ann's. High Cross. Middle. Lower. Total. Small-pox 481 19 49 104 108 197 4 24 30 176 78 110 63 24 27 161 78 103 60 453 Cholera ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diphtheria 235 3 76 122 24 10 ... 40 37 48 40 54 16 28 13 21 15 30 12 119 Membranous Croup 7 ... 4 2 1 ... ... ... ... 2 3 1 1 ... ... ... ... ... ... ... Erysipelas 78 5 3 1 6 53 10 11 5 17 18 16 11 ... ... ... ... ... ... ... Scarlet Fever 484 3 127 264 70 20 ... 102 53 118 62 84 65 65 33 99 27 48 32 304 Typhus Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Enteric Fever 118 ... 7 33 36 42 ... 14 10 31 18 19 26 9 4 17 7 7 9 53 Relapsing Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Continued Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Puerperal Fever 4 ... ... ... ... 4 ... 1 1 ... 1 1 ... ... ... ... ... ... ... ... Chicken Pox 669 61 294 302 8 4 ... 100 70 126 113 147 113 ... ... ... ... ... ... ... Totals 2076 91 560 828 253 330 14 292 206 518 333 432 295 126 77 298 127 188 113 929 Cottenham Urban District Council. SALUS POPULI SUPREMA LEX EST. Report ON THE 1901-2 EPIDEMIC OF Small pox at Cottenham. BY J. F. BUILER-HOGAN, B.A., M.D., D.P.H., &c. (MEDICAL OFFICER OK HEALTH.) TOTTENHAM: CRUSH A & SON, PRINTERS. Cottenham Urban District Council. Public Health Department, The Green, Totteham, September 29th, 1902. To the Members of the Tottenham Urban District Council. Mr. Chairman and Gentlemen, I beg to submit to you my Report on the Epidemic of Small Pox which has prevailed in your District during the past 13 months, incorporating therewith some statistical and general information on the subject of vaccination, not ordinarily available to the general public in a concise form, and which I trust may prove useful to Councillors in "spreading the light.":— Small Pox in Tottenham from August 28th, 1901, to September 29th, 1902. The Epidemic began with a gravely instructive case, the particulars of which I may therefore be pardoned for quoting briefly. On August 28th, 1901, George Howard, living at Culvert Road, but working in the City (where Small Pox was already rampant), feeling ill at his work went to King's College Hospital, where his case was diagnosed as one of Small Pox, and removed to one of the Hospital Ships. Unfortunately, however, his wife was subsequently allowed to visit him by the Asylums Board Authorities, and she not only contracted the disease herself, but brought home the infection to her daughter. This is a practical example of the manner in which the disease spreads, and of the danger of allowing visitors to cases of Small Pox. The disease having once entered Tottenham spread rapidly, its progress being facilitated by the large number of unvaccinated individuals and insanitary houses in the district. The following table gives the monthly number of cases and deaths during the epidemic:— Table 1a — 1901. Aug. Sept. Oct. Nov. Dec Cases 1 11 13 10 Deaths 0 2 2 2 4 Table 1a (contd.):— 1902. Jan. Feb. Mar. April May June July Aug. Sept. Cases 40 44 115 81 129 39 15 7 2 Deaths 3 5 9 12 24 11 3 0 0 This makes a total of 525 cases of Small Pox that have occurred from the 28th August, 1901, to the present time. The total number of deaths during the same period was 74, giving a percentage mortality of 14.009. the greatest number of deaths occurring in May, and no deaths at all in August or September. Cases and Deaths from Small Pox at Different Ages during Table 1b. Tottenham Epidemic. Under 1. 1 to 5. 5 to 10. 10 to 30. 30 and upwards. Cases 24 58 62 227 154 Deaths 6 13 13 20 22 It will be seen from the above that the mortality from Small Pox in Tottenham, though rather h gh, has not been excessive, and, indeed, compares favourably with that of one epidemic of which I have had previous personal experience (Gloucester 1895—6), in which the death rate was nearly 25 per cent., though not so favourably with that of another in which I also took a practical part (the London Epidemic cf 1892—3), when the death rate did not amount to 10 per cent. ****** With regard to the important question of the spread of infection from the Small Pox Hospital to neighbouring houses, I am pleased to be able to inform you that in only one instance was their question of any such air borne infection from the Down Lane Hospital, and I have satisfied myself by careful personal enquiries that the infection reached the house in question not from the Local Small Pox Hospital, but through the contact of one of its inmates with a fellow-workman in the City. ****** The Cost of the Epidemic. The approximate cost of the epidemic was £10,071, of which the patients at South Mimms cost about £1000, and the building, tents, etc., £6,000, leaving a balance of rather more than £3000 spent on themaintenance of the Small Pox Hospital and the salaries of its staff. 5 As 437 patients were treated at the Down Lane Hospital and 88 at South Minims, the above figures show that the average cost at your own Hospital was less than £7, and at South Minims more than £ll per patient, and considering that so large a pioportion of the cases treated in your own district were of the malignant type, while the cases sent to South Mimms were as far as possible, those not likely to be injured by transport for 14 miles in an ambulance, that is to say milder cases, the balance on the score of economy certainly lies with the Local Hospital; moreover, at the latter institution full salary was invariably paid to members of the staff during illness, and quarantine allowed on the termination of their engagements The average duration of patients' detention in Hospital was 33.2 days, the number of cases isolated was 13, and of those whom it was found necessary, owing to false diagnosis, to return to their homes (after due disinfection) on the day of admission was 7. * * * * * * I can well believe that with all the conflicting and inaccurate statements which are made about Vaccination, you must find it difficult to arrive at any sound conclusion on the subject. I take this opportunity of putting before you some of the evidence, which has been sufficient at any rate to convince myself, that of all the weapons which have been devised for fighting Small Pox, Vaccination is not only the most efficient and the least harmful, but there is absolutely no known substitute. It has been maintained that other means, such as Sanitation and Quarantine, are more effectual safeguards against the disease than Vaccination, and that to them is due the diminution of the death rate from Small Pox which has taken place during the last century. As I shall showyou, the diminution in the fatality from Small Pox is, in this country, mainly in the early years of life. It it were due to Sanitation, the same beneficient results ought to be shown in the death rate from other diseases which are righty considered as infantile disorders. But this is not the case; on the contrary, although the share of Small Pox mortality borne by children under 5 years of age diminished greatly between 1851 and 1880 (during which years vaccination was made compulsory), there is no corresponding diminution in the share of the death rate in children of the same age from other infantile disorders, such as Measles, Scarlet Fever, Diphtheria, etc. The actual figures are given in the following table, quoting from McVail, which shows how the contributions—made by children under 5 years of age to the total mortality from each disease—have altered - 6 Table 2.— Showing that if the Death Rate as given at all Ages be taken at Unity, then the Death Rate fur Children under 5 Years of Age will be as fallows*:— 1851-60. 1861-70. 1871-80. From all Causes 3.0 3.0 2.9 „ Small Pox 4.7 4.0 2.2 „ Measles 6.8 6.8 6.8 „ Scarlatina 4.7 4.7 4.8 „ Diphtheria 4.0 4.1 3.9 „ Whooping Cough 7.2 7.2 7.1 „ Fevers (including Typhus, Typhoid, and Ill-defined) 1.5 1.4 1.3 „ Diarrhœa. 4.9 5.6 6.1 * Calculated from pp. 112-114 of the Registrar-General's Supplement to the Forty-Fifth Annual Report. It will be seen that whilst the proportion of deaths from Small Pox contributed by infants has so greatly diminished, there is no corresponding diminution in the other infantile disorders mentioned, and in two the proportion is actually greater. It will therefore seem that there must be some other agency than Sanitation at work to account for the diminution in the infantile death rate from Small Pox. It has been suggested that Quarantine and the Isolation of all those who have been exposed to the infection of Small Pox would suffice to stay a local outbreak; but in any large community such means are impossible and hopelessly inadequate, and must bleak down as they did under the very limited strain of the local outbreak at Leicester in 1890; and even if they were adequate, it is difficult to see why the protection should be exerted especially on the children and not on the adults, since Small Pox was, and now is, amongst the unvaccinated, a disease falling with special severity on the earlier years of life. There must be some other factor at work. I will endeavour to lay before you some of the evidence there is to show that this factor is Vaccination. You will hear all kinds of bad things said about Vaccination, of which I will tell you a few, 1st, it is said that, as Vaccinia and Small Pox are totally distinct diseases, it is impossible for Vaccination to protect against Small Pox. 2nd, that Vaccinia is nothing but Small Pox artificially transmitted through the cow, and that statistics show that not only does Vaccination not protect against Small Pox, but that it actual y causes the disease 7 Now I think you will admit that these statements, being diametrically opposed to each other, cannot both be true; I will only, therefore, add a few words of practical criticism on each of them. As to the 1st statement, "that Vaccination cannot protect against Small Pox because it is a totally distinct disease," every one who thinks at all will allow that, if it can be shown that Vaccination does in fact afford protection, the objection falls to the ground As to the 2nd point, "that Vaccination does not protect against Small Pox, but actually causes the disease," Dr. Acland, who was for 7 years Medical Officer to the Royal Commission on Vaccination and was engaged in making enquiries into Vaccinal Injuries throughout the length and breadth of the kingdom, informs us that during that period many millions of Vaccinations were performed, and that he had never seen or heard of an authentic case of Small Pox resulting from Vaccination in this country. There is still a 3rd objection which is frequently urged against Vaccination, viz, that the harm done by it and the risk which it involves are so great, that there is no justification for the practice, as it is productive only of evil, and powerless for good. If you will have patience with roe, I shall endeavour to show you how very far from the truth both these statements are. Before doing so, however, I should like to say that we know, even if all goes well, that a vaccinated child suffers something and is an increased care or anxiety to an often overworked mother. No one can sympathize more than I do with the trouble and distress which may thus come to mother and child through the 2nd week of even a normal vaccination. Sometimes, when all does not go well—when there is inflammation of the arm, or ulceration of the pocks—the burden thus imposed on the mother is heavier, and the suffering to the child is greater, and in some few instances the injury may be severe. It cannot be denied that in the case of a working man, such trouble in the house may be a serious one, and it must be looked upon as a sacrifice which he is asked to make for the good of the State, as well as for the good of his child. To return to the consideration of Vaccinal Injuries. Calculating from the cases which were brought under the notice of the Royal Commission on Vaccination during the years 1889 to 1896, and from the cases enquired into during 1888—1891 by the Local Government Board, it would appear that there was death or serious injury in one case in about 14,000 (in England 1 in 14,159, in Scotland 1 in 38,872) primary Vaccinations You may say that even this amount of harm ought not to be, and the fact that it does occur is a powerful argument against Vaccination, Before accepting this conclusion, you must take into consideration that more than half (57.6 per cent.) of these cases 8 result from preventable causes, that is from one or other of the various forms of inflammatiou. Further, when we consider the ease with which the Vaccine Pocks may be injured, rubbed, or fouled, and when you consider the terrible conditions under which, unfortunately, thousands of our fellow working men have to live, it is hardly to be wondered at that an open wound like vaccination does sometimes go wrong. All things occasionally go wrong in this imperfect world, and wherever you turn you will find that a certain amount of penalty has to be paid for anything we have, however valuable and beneficent it may be. Gas explosions, railway accidents, ship wrecks, fires, all contribute something to the sorrow and suffering of the world, yet no one in his senses would give up gas, or railways, or ships, or houses because some injury is caused and some lives are lost by their use. Surely it is a question of degree It is no use, in the presence of an enemy, discarding a weapon (because you fear it may not be absolutely free from danger to yourself), until you have something better. In the case of Small Pox there is no substitute, and if you discard Vaccination, you are left defenceless and without any protection but flight in the presence of a relentless foe. It cannot even be pretended that the practice of Vaccination hinders the adoption of every other useful means of combating Small I'm When first I began to consider these questions seriously, I oast about for something with which the risk caused by Vaccination (infinitesimally small though it really is) might fairly be compared, and I came to the conclusion that the use of Anaesthetics (Chloroform and Ether) was on the whole the greatest blessing which my Profession had ever been able to confer on suffering mankind. Now, as you are well aware, a certain number of deaths occur every year through the use of Anaesthetics. The percentage number of deaths from Chloroform is about seven times as great as that from the complications or accidents of Vaccination. The deaths from Ether are considerably fewer than from Chloroform, but even so, the total directly traceable to Anaesthetics is considerably greater than that resulting from Vaccination. It is interesting to compare the number of Vaccinal Injuries with fatality from Small Pox (even in a mild epidemic) where the practice of Vaccination has been allowed to lapse. In Leicester, during the outbreak of 1891-2, 100 unvaccinated children were attacked, of whom 12 died. Thus in this community (with an unvaccinated child population), with all the boasted safeguards of Isolation and Sanitation, as many children died from Small Pox as, according to the calculation given above might be estimated to die or to suffer from serious injury amongst a like number of children (100) in 1,680 years, or in about 169,908 Vaccinations. During the same epidemic only 2 vaccinated children under 10 years of age were attacked by Small Pox, wither of whom died. 9 In a severe epidemic, such as that at Gloucester (1895-6), no fewer than 279 unvaccinated children under 10 years of age died out of 680 attacked (14 per cent.) Such fatality would not occur in less than 3,000,000 primary Vaccinations, and a very little calculation will show that the risk of a fatal issue amongst those attacked was just 6,000 times as great as from Vaccination. Comment is unnecessary, but the facts are deserving of serious study. They seem to me to show quite clearly that, although there is a certain amount of risk in Vaccination, the risk is so small that it is one which should be readily faced if it can be shown that Vaccination is for the good of the individual and for the benefit of the State. A great deal has been written and said about the serious nature of the risks, but they are in fact very small, and are such as the members of my own Profession readily incur for themselves, their wives, and their children, for though they know them better than anyone else can know them, they judge them to be, as they are, insignificant as compared with the risks of Small Pox. It is the duty of every one of us, as far as in us lies, to prevent ourselves from becoming a centre of infection. Every one will, I think, allow that if they want a good pair of boots, they should go to a good bootmaker, and if they want a good loaf of bread, they should go to a good baker; and similarly it might be expected that those who wish to learn about Small Pox and its prevention would be wise to go to those likely to possess the most accurate knowledge of the disease, namely, those who have spent their lives in the practical study of Small Pox. You will find that the unanimity of opinion expressed by those (who have so spent their lives) as to the effect of Vaccination is very striking, and that those who are opposed to Vaccination are either those who have no very practical acquaintance with Small Pox, or whose eyes have been so completely blinded by preconceived prejudice as to be incapable of seeing aright. There are, unfortunately, armchair generals even in medicine, who prefer to sit at home and deal out what they consider destructive criticism to those who are in the midst of the fight, rather than to be up and doing something for the good of the individual and the welfare of the community. Means which might be Adopted for Deciding the Question as to Whether, and if so, to What Extent Vaccination Protects Against Small Pox. The question as to whether or not Vaccination protects against Small Pox, and if so, to what degree, may be approached in various ways; 1st.—By vaccinating first, and inoculating with Small Pox after, a test which cannot, of course, be made in the present day, but I shall refer to this again. 10 2nd.—By observing the effect of Vaccination of particular groups of persons exposed to the contagion of Small Pox under more or less similar conditions. 3rd.—By observing the comparative frequency with which Small Pox attacks the vaccinated and unvaccinated in large communities, the degree of the severity of the attack in each of these classes, and the resulting death rate. 4th—By observing the effect of Vaccination upon the age at which Small Pox is most prevalent amongst those who have been vaccinated in infancy and amongst those who have not. May I here parenthetically explain what I mean by "vaccinated"? I mean efficiently vaccinated. It is well known that Vaccination in infancy gives its most effective protection only for a certain number of years. It is necessary to bear this in mind, since there are many fallacies based on statements made to the effect that in adult life more vaccinated than unvaccinated persons suffer from Small Pox. This statement is one of those falsehoods masquerading in the guise of truth, which, as I shall show later on, has but little justification, since a child vaccinated in infancy, although in fact vaccinated, does not continue to benefit to any large extent from the Vaccination after from 7 to 10 years; and as regards liability to attack from Small Pox gradually approximates to the condition of those who have not been vaccinated. 1.—The method of testing the efficacy of Vaccination by the subsequent inoculation of Small Pox is now out of the question, since inoculation is forbidden by law; but it was frequently adopted by Jenner, who, in 1801, wrote "that upwards of 6,000 persons had been inoculated with the virus of cow pox, and that the far greater part of them has since been inoculated with that of Small Pox, and exposed to its infection in every rational way that could be devised, but without effect." This was, at any rate, an experiment on a sufficiently large scale, and, even if the problem was not capable of being finally solved in this manner, was sufficient to convince his contemporaries of the efficacy of Vaccination. 2.—The second method of attempting to estimate the utility or the reverse of Vaccination is to study its effect upon limited communities living under approximately the same conditions. There cannot be any better illustration than the experience of the staffs of the various Small Pox Hospitals. In Highgate Small Pox Hospital, from 1836 to 1896—a period of no less than 60 years—one case of Small Pox, and one only, occurred among the Hospital Staff, and he was the gardener, least exposed to infection, but not revaccinated. During the years 1883—1896 there were 137 nurses and 11 attendants employed; 30 of these had previously had Small Pox, but none of the others suffered from the disease. At the Sheffield Hospitals the staffs numbered 143; of 80 who were re-vuceinated ax adults not one contracted Small Pox, whilst of (12 who had not been re-vaccinated 5 suffered from the disease, as did one other who was not successfully re-vaccinated until he was sickening from the disease. At Warrington, Homerton, Fulham, and your own Hospital at Tottenham, the experience has been similar. I will not weary you with the details of these since they merely confirm the conclusion that even the nurses—who are exposed to a concentrated form of infection for longer periods than the Medical Officers—can be, and are protected against Small Pox by the simple expedient of re-vaccination. To come down to a striking and quite recent experience; during the third week in February of this year, a statement appeared in the Daily Press to the effect that out of a staff of 43 nurses employed at the Mile End 'Infirmary, 35 were re-vaccinated and had not suffered from Small Pox, while of the other 8 who were not re-vaccinated, 7 had already contracted the disease. Such a statement was not likely to be accepted without criticism and challenge, and thinking it would be a good test case from a practical and common sense point of view, Dr. Acland enquired into the facts, which were found to be as follows:—Early in January, 1902, there were 40 nurses and 2 matrons on the staff of the Mile End Infirmary, and one nurse on sick leave, a total of 43. Not one of them had had Small Pox previously; of these 31 had been re-vaccinated at various dates up to 2 years before the outbreak. Four were re-vaccinated on January 28th and 29th (2 of them unsuccessfully). None of these 35 contracted Small Pox. Of the remaining 8, one was away on sick leave, leaving 7, who all suffered from Small Pax. Of these, 3 were not re-vaccinated, and the remaining 4 all sickened with Small Pox in 2 days (2 cases), 3 days, and 6 days respectively after vaccination. Thus these 4 cases were incubating Small Pox at the time they were re-vaccinated, and though it may not be strictly correct to say that none of the vaccinated cases suffered from Small Pox, it is certain that none of the cases who were re-vaccinated before infection, contracted the disease, and all the cases who suffered from Small Pox were either unvaccinated or re-vaccinated only during the incubation period of the disease I may here remark that vaccination within a short time after exposure to the infection of Small Pox may be of some use in mitigating the attack, but that if delayed until the incubation period is advanced, it may be expected to exercise little or no influence on the result. A similar and very striking object lesson may be learnt from the records of the Small Pox Hospitals of the Metropolitan Asylums 12 Board. During the year 1901, amongst the patients admitted to these Hospitals were 21 persons who had been employed in disinfecting work; not one of these had been re-vaccinated since infancy; and Dr. Acland, who made careful enquiries, was informed that not a single person who had been properly re-vaccinated, engaged in work similar to that of the 21 persons mentioned above, is known to have been admitted during this period (1901); further, no official of the Board, (all of whom are re-vaccinated when they commence their work) had suffered from Small Pox during the year 1901. Nine other cases were admitted to the Board's Hospitals suffering from Small Pox, contracted in the discharge of their duties as Sanitary Inspectors, Dustmen, and Undertakers; of these, 5 had not been re-vaccinated, one was said to have been re-vaccinated 40 and one 19 years ago, and one without success 4 years previously. Further, during the 16 years, 1884—1900, more than 2,000 persons have been employed in the Small Pox Hospitals of the Metropolitan Asylums Board; of this large number— some few of whom no doubt were protected by a previous attack—only 17 contracted Small Pox, though constantly exposed to the infection. Of these, 4 are known to have escaped re-vaccination, and the remaining 13 are known to have been re-vaccinated after having been exposed to infection. From the dates at which the eruption appealed in these cases, it is practically certain that every one of them had contracted Small Pox before their re-vaccination could possibly have taken effect. Lastly, not one of the staffs of the Hospital Ships has ever died of Small Pox, and not one has even suffered from the disease for the last 8 years (1893-1901) During 20 years, 1881-1901, the Board's Ambulance Service has employed over 1250 persons; of these, 4 have contracted Small Pox, one was unvaccinated and died, one had been unsuccessfully vaccinated and died, two only had been re-vaccinated— they both recovered. In the Tottenham epidemic, 1901-2, there have been 4 instances in which the one unvaccinated member of a family was the only one to catch Small Pox, and there has not been a single case amongst clergymen, doctors, postmen, or policemen, the classes amongst whom vaccination and re-vaccination generally obtain. In this connection I might mention that not a single member of the Hospital Staff contracted the disease, although the Resident Medical Officers and several of the Nurses suffered from sore throats, which latter fact can, however, be easily accounted for by the enforced isolation, and the marshy nature of the ground on which the Temporary Hospital had perforce to be erected. These are remarkable facts, and do not seem to me to justify any other conclusion than that these persons—constantly exposed to infection in a virulent form (in the Tottenham Hospital 41 per cent. of 13 the cases suffered from Hemorrhagic Small Pox)—were protected from the disease, not by sanitation, not by isolation, not by any of the various remedies which have been suggested, but solely by efficient Vaccination and Re-vaccination, such as is open to everyone to obtain. Before leaving this branch of the subject, I should like to call your attention to 4 tables which show the relative liability to contract Small Pox, to suffer severely, and to die from it, amongst the Vaccinated and Unvaccinated respectively. N.B.—In all the following tables, under "vaccinated" are included all cases vaccinated in infancy, although after the. age of from 7 to 10 years they ought rather to be classed as "unvaccinated," because the protective influence of vaccination very rapidly diminishes. Table 3.—Showing Numbers of Attacks and Deaths amongst those Exposed to Small Pox in certain Outbreaks. Vaccinated. Unvaccinated. Exposed. Attacked. Died. Exposed Attacked. Died. Under 1 year: Tottenham 12 0 0 51 24 6 Dewsbury 16 1 0 59 24 16 Leicester 1 0 0 32 7 2 Gloucester 14 0 0 153 80 56 1 to 10 years: Tottenham 209 20 1* 267 100 26 Dewsbury 400 48 1 254 133 31 Leicester 77 2 0 251 93 10 Gloucester 258 24 1 1178 537 192 10 to 30 years: Tottenham 1975 188 5 107 39 15 Dewsbury 1125 641 5 224 141 19 Leicester 438 104 0 96 47 3 Gloucester 1649 539 30 102 55 18 30 years & over: Tottenham 889 127 10 92 27 12 Dewsbury 833 187 7 68 15 4 Leicester 321 64 1 9 3 1 Gloucester 1465 465 64 42 17 9 Age uncertain: Tottenham — — — — — — Dewsbury 21 — — — — — Leicester 9 — — — — — Gloucester — — — — — — All ages. Total 9712 2420 125 2985 1342 420 * This child had not been efficiently vaccinated, possessing only one small scar, and was moreover very delicate before admission. 14 This table shows that in 4 separate towns, children who had been Vaccinated were far less liable to attack from Small Pox, and if attacked to death from it, than those who were unvaccinated. After 10 years of age, as I have said, the protection becomes less, and re-vaccination is necessary. It will be seen that of the Vaccinated children under 10 years of age, exposed to infection in the 4 Towns, about 10 per cent. only were attacked, and of those attacked less than 3 per cent. died; whilst amongst the unvaccinated more than 45 per cent. of those exposed to infection were attacked by the disease, and of those attacked, more than 38 per cent died; that is proportionately about 4 times as many unvaccinated as Vaccinated were attacked, and 60 times as many died. The next table shows the same thing in less detail, but in each case with an enormous advantage on the side of the Vaccinated, as its figures prove that under 10 years of age, when the Vaccinated were more fully protected, the unvaccinated were about 7½ times more liable to attack by Small Pox than the Vaccinated. Table 4.— Small Pox Attack rate of Vaccinated and Unvaccinated Persons, under and. over 10 Years of Age, in Five Towns in which Small Pox Epidemics have recently occurred.* Towns. Date of Epidemic. Attack-rate under 10. Attack-rate over to. Vaccinated. Unvaccinated. Vaccinated. Unvaccinated. Sheffield 1887-88 7.9 67.6 28.3 53.6 Warrington 1892-93 4.4 54.5 29.9 57.6 Dewsbury 1891-92 10.2 50.8 27.7 53.4 Leicester 1892-93 2.5 35.3 22.2 47.6 Gloucester 1895-96 8.8 46.3 32.2 50.0 * Final Report of the Royal Commission on Vaccination, p. 65. In the following table as well as in diagram 2 appended to this report, the relative severity of attack amongst the Vaccinated and Unvaccinated is shown. The table (apart from the Tottenham figures) is taken from the report of the Royal Commission on Vaccination, the diagram being from A Study of 972 Cases of Small Pox by Dr. G. B. Russell, late Medical Officer of Health for Glasgow. 15 Tablk 5.—The Incidence of Mild and Severe Canes of Smalt Pox on each Hundred of Vaccinated and Unvaccinated Persons attacked duringSix recent Small Pox Epidemics* Local Epidemics. Mild. Severe. London Vaccinated 89.0 11.0 Unvaccinated 35.2 64.8 Sheffield Vaccinated 82.8 17.2 Unvaccinated 18.5 81.5 Dewsbury Vaccinated 82.0 18.0 Unvaccinated 23.1 76.9 Leicester Vaccinated 81.4 18.6 Unvaccinated 27.2 72.8 Warrington Vaccinated 78.2 21.8 Unvaccinated 29.4 70.6 Tottenham Vaccinated 83.0 17.0 Unvaccinated 19.1 80.9 * Final Report of the Royal Commission on Vaccination, pp. 69.70. There is, unfortunately, in this country, no obligation on the part of an adult to be re-vaccinated; consequently, as might be expected, the maximum evidence of the protective influence of Vaccination is shown in the earlier years of life. Small Pox used to be a disease of childhood, and is so now where there is a neglect of infantile Vaccination, as is shown by the next table, where it will be seen that the number of deaths in every 100 children under 10 years of age increased in direct proportion to the neglect of infantile Vaccination. Table 6.—Child Mortality from Small Pox in Relation to the. Neglect of Vaccination in Seven Towns which have recently suffered from. Small Pox Epidemics.* Town. Date of Epidemic. Total of Small Pox Deaths. Percentage of Total Deaths from Small Pox borne by Children under 10 Years of Age. Vaccination Default. Warrington 1892-93 62 22.5 Very slight. Sheffield 1887-88 589 25.6 Very slight. London 1892-93 182 36.8 In 1883-91, 10 percent. Tottenham 1901-2 74 43.2 Considerable. Dewsbury 1891-92 110 51.8 In 1882-92, 32.3 per cent. Gloucester 1895-96 443 64.5 In 1885-94,10.6to85.l percent. Leicester 1892-93 21 71.4‡ In 1883-92,43.8 to 80.1 per cent. * Final Report of the Royal Commission on Vaccination, pp. 50 and 176. ‡ Excluding the deaths of 3 patients in a scarlet fever ward in close proximity to the Small Pox Hospital, this proportion would bereducedto66.6. 16 The same facts are shown in a graphic form in Diagram 3 (Dr. Newsholme's Method). The importance of Vaccination in infancy is well shown by what happened in London last year. During the year 1901 there were admitted into the Hospitals of the Metropolitan Asylums Board 113 children under the age of 10 years. Of these, 12 had been vaccinated, and not one of them died; 95 were unvaccinated, and of these 52 died ; whilst there were 6 doubtful cases, all of whom died. Table 7.—Showing the Number of Completed Cases of Small Pox amongst the Vaccinated" and "Unvaccinated," and "Doubtful," Treated in the Hospitals of the Metropolitan Asylumns Board during the Year 1901.* - Ages. Vaccinated. Unvaccinated. Doubtful. Cases. Deaths. Cases. Deaths. Cases. Deaths. London, 1901 under 5 1 0 61 39 2 2 5 to 10 11 0 34 13 4 4 Total under 10 12 0 95 52 6 6 * Report of Statistical Committee, Metropolitan Asylums Board, January 10th; 1902. The same relative immunity amongst the vaccinated as compared with the unvaccinated, is shown in Table 8, which gives the number of children under 10 years of age who were attacked and died in the epidemics at Gloucester (1896), and Middlesborough (1898). Table 8. - Vaccinated in Infancy. Unvaccinated. Attack. Deaths. Fatality. Attacks. Deaths. Fatality. Middlesborough 43 0 0 62 29 46.7 Gloucester 26 1 3.8 513 215 41.9 69 1 1.44 575 244 42.4 The number of attacks and deaths from Small Pox in children under 10 in London, Gloucester, Middlesborough, and Tottenham will 17 be found in the accompanying Tables, and it is shown that the proportion of deaths amongst the unvaccinated is enormously greater than amongst the vaccinated. It will also be seen that whereas at Gloucester the number of cases amongst the unvaccinated was about 20 times as great (513—26) as amongst the vaccinated; in London the proportion was about 8 times (95—12); and in Middlesborough it was only 1½ times (62—43) as great If the London cases under 20 are taken it will be seen that the numbers are by some curious coincidence equal (161). Table 9.—Showing the Cases of Small Pox under 20 Years of Age Admitted, and Treated either to Recovery or Death in the Hospitals of the Metropolitan Asylumtis Board during the Year 1901.* Ages. Vaccinated. Doubtful. Unvaccinated. Cases. Deaths. Mortality per Cent. Cases. Deaths. Mortality per Cent. Cases. Deaths. Mortality per Cent. Under 1 — — — — — — 17 15 88.24 1—5 1 — — 2 2 100.00 44 24 54.55 5—10 11 — 4 4 100.00 34 13 38.24 10—15 42 1 2.38 3 1 33.33 41 14 34.15 15—20 107 2 1.87 3 — — 25 13 52.00 Under 20 161 3 1.86 12 7 58.33 161 79 49.07 Again, if reference is made to Table 3 it will be seen that, as is generally found, if the cases at all ages are taken together, the number under the head of "vaccinated" is considerably greater than under "unvaccinated." This fact has not escaped the notice of those opposed to vaccination, and has been used as an argument to show that vaccination is useless, thougn it really only shows that vaccination in infancy does not give (as is well known) life long immunity from Small Pox. The following considerations deserve attention:—(1) After the age of 10, the immunity afforded by vaccination in infancy has become materially lessened, consequently after that age an individual who has not been re-vaccinated is only very imperfectly protected. (2) The better a community is vaccinated, the more nearly will the numbers of attacks in each case "vaccinated" and "unvaccinated" approximate to one another. A little reflection will show the probability of this if, in fact, any protection is afforded by the operation. For instance, if any given Town, there are 1,000 children, of whom 900 are vaccinated 18 and 100 are not—a vaccination default found in the London District for years—and in each class there were 20 cases of Small Pox, this number would represent 20 per cent. of the unvaccinated and rather more than 2 per cent. of the vaccinated; so that, although the actual number of cases of Small Pox in the two classes were the same, the fact would be that, proportionately, about 10 times as many of the unvaccinated would be attacked as of the vaccinated Again, supposing the conditions were altered, and that the community was badly vaccinated, so that there were equal numbers of unvaccinated and vaccinated; if the ratio of attack were the same as before, there would be about 100 cases amongst the unvaccinated and 10 amongst the vaccinated. This is the clue to the solution of the difficulty. In Gloucester the vaccination default between 1885 and 1894 varied from 10 to 85.1 per cent. Middlesborough was well vaccinated. In the former town there were 680 eases of Small Pox with 279 deaths amongst the unvaccinated, and 26 attacks and 1 death amongst the vaccinated ; in the latter town there were 62 attacks and 29 deaths amongst the unvaccinated, and 43 without one death amongst the vaccinated. In London, where the default of vaccination was intermediate between the two, there were 95 attacks and 52 deaths amongst the unvaccinated, to 12 attacks with no deaths amongst the vaccinated The frightful mortality amongst the unvaccinated children attacked—(namely in round numbers 46, 41, and 58 per cent.)—shows that in these outbreaks amongst the infected children, at any rate, Small Pox had lost none of its virulence; the mortality amongst children which occurred in pre-vaccination times may be gathered from the two diagrams 4 and 5 at the end of this book, which I have expressly given for the purpose of the comparison. They show the total number of deaths from Small Pox at each age up to 10; at Pudsey, from 1776 to 1810 (Hunter), and at Kilmarnock, from 1728 to 1763 (McVail). The tables which have been quoted all tell the same tale in different ways. They show (1) that the vaccinated are less liable to attack on exposure to Small Pox; (2) that they are less liable to suffer severely or to die if attacked; and (3) where the ages are specified they show that the maximum protection amongst the vaccinated is found in the early years of life, and that the maximum incidence of Small Pox amongst the unvaccinated is in childhood. If, in fact, the diminution in the mortality from Small Pox amongst children is due to the effect of vaccination, it should be possible to show that it is coincident with and proportionate to the efficient performance of the operation. This is comparatively easy. Diagram 6 gives the 19 incidence of the deaths from Small Pox at different ages from 1848 to 1894 inclusive. It does not indicate the actual number of cases of Small Pox, but only the proportion out of every 1,000 cases which would fall on each age period. It will be seen at a glance that in proportion as vaccination was efficiently carried out, so did the maximum stress of Small Pox cease to fall on the early years of life, and was being transferred to the later years, when the protection afforded by infant vaccination would, in most instances hare been lost. Diagram 6 does not give the gross mortality from Small Pox, which is shown for the years indicated in the chart. The facts on which the seventh diagram is founded have never been disputed; they have, indeed, been used in the attempt to prove that "vaccination is a delusion." If the whole of the facts, or even the essential facts, are represented in the diagram, it would at first sight appear that there is ground for the contention, since in the years of the great pandemic (1870-1), the total deaths from Small Pox rose to a higher point than at any period during the last half of the 19th century, notwithstanding that vaccination was in 1853 made compulsory—without, however, the provision of any sufficient machinery for enforcing it—and that in 1867 the Guardians were authorised—not compelled—to appoint vaccination officers. It required the severe lesson of 1870-1 to force on the Executive the necessity for making the appointment of vaccination officers compulsory. Thus, at first sight it would seem as though vaccination had done nothing to check the epidemic. Now as to the facts :— (1) The mortality in 1870-71, which was higher than at any period during the last 50 years, was exceeded in no fewer than 9-3 years during the 18th century (McVail); so that for some reason or other there lias been a greed diminution in the gross mortality frem Small Pox. (2) The diagram does not give any indication as to the incidence of the disease; it does not show whether the mortality was greatest amongst infants or adults, amongst the vaccinated or unvaccinated. (3) It has been shown that during the 18th century and at the present day amongst the unvaccinated, Small Pox is a disease falling with special severity on children (see diagrams 4, 5, and 6, and tables 7, 8, and 9). (4) Unless for some reason or other the age incidence of Small Pox has altered, it should be found that, as was the case previous to the introduction of vaccination, the proportion of deaths amongst children in 1870-1, exceeded that amongst adults. (5) A glance at the sixth diagram shows that this is not the case; on the contrary, there is a steady diminution in the ratio 20 per 1,000 of deaths borne by the early years of life, and a steady proportionate increase in the death borne by adults. This diminution continued as vaccination became more and more efficiently performed, and ceased again with the neglect of vaccination. More remarkable still is the fact that the proportion of adults deaths in the period 1870-4 (including the years of the pandemic), was greatest, and the proportion of infant deaths less, than at any previous period included in the diagram. The chart (Diagram 7) in reality shows nothing more than that there was during the years 1870-1 an enormous increass in the total deaths from Small Pox; it gives no indication of the fact that the stress of the disease did not, as formerly, fall chiefly upon the children, of whom a considerable portion had been vaccinated, but that it fell on adults, most of whom were either unmeditated or had outlived the immunity which had been conferred by vaccination in infancy. * * * * * * The foregoing statement and the facts and figures which I have laid before you show with great clearness that both in small and large communities, in Hospitals and out of them, those who are protected by vaccination not only resist infection from Small Pox more easily, but suffer less severely when attacked, and more often recover than those who neglect this means of defence which is offered freely to all It has incidentally been shown that the so-called risks of vaccination are infinitesimally small, and that vaccination and re-vaccination (about the 10th and 20th years of life) should be universally practised if the nation is to be effectively protected. I have taken all the above evidence, not from foreign lands and from those who live under conditions different from our own, but from the every day life of our own country and from the experience of those who are in charge of our own Hospitals. I now wish to make a few observations as to the relative frequency of Small Pox in some European countries, and the influence of Vaccination thereon:— General Observations as to the Relative Frequency of Small Pox in some European Countries. The following information may be useful to those Councillors who have not had an opportunity elsewhere of studying the comparative mortality from Small Pox, and the causes that influence the same. In countries where there is much vaccination and re-vaccination, relatively to the population there is little Small Pox. In Prussia, both 21 vaccination and re-vaccination are compulsory, and Small Pox mortality in practically abolished. Beginning with the year 1816, it is found that in that country, previous to the law of 1874, the annual death rate from Small Pox was 390 per million of the population, from 1874 to 1892 it has been 15, and in the last 10 years of the period was only 7; moreover the compulsory vaccination age is the 2nd year of life, and investigation showed that, in 1886—90, more than two-fifths of the few deaths that occurred from Small Pox were under 2 years of age. In Austria, where vaccination is not compulsory, the rate, instead of being 7 per million as in Prussia, was 458 in the same period. In Belgium also vaccination is not compulsory, and in 1875 — 84 it had a rate of 441 per million as compared with Prussia's 22 in the same period. In Italy, since 1888, vaccination of infants has been compulsory, as has re-vaccination of children attending Public Schools. Already a great improvement is indicated. In 1881—i)0 the Small Pox death rate was 455 per million yearly, and in 1891—4 it was only 65. At the time of the European epidemic of 1870—5, Scotland, England, Sweden, and Bavaria passed a compulsory vaccination law, and their Small Pox rates: per million in the worst years were 1470, 1830, 1660, and 1661 respectively. Prussia, Holland, and Austria had no general compulsive vaccination, and their rates in the worst years were 5060, 5490, and 6180. Coming to 1877—1886 with vaccination not compulsory in Austria, with only infantile vaccination compulsory in England, and with vaccination and re-vaccination compulsory in Prussia, the average rate per million from Small Pox in the Capitals of these 3 countries was, in Vienna 670, London 250, Berlin 10. In London the rate would have been less but for the disease spreading from the Small Pox Hospital it then contained. I have very few words to add, but they are worthy of your serious consideration. Firstly, that it is of the utmost importance that if you or anyone in whom you are interested is vaccinated, the operation should be performed efficiently, that i3 with a sufficient area of vesicles. It is sometimes pretended that it does not matter whether there may be 1, 2, 3, or 4 marks. It matters a great deal. The amount of protection afforded by Vaccination is closely related to the area of the vesicles, and the making of 1, 2, or 3 small pocks is not sufficient to give lasting protection; it is merely trifling with the operation, and many certificates of so-called successful Vaccination are nothing better than an official sanction of what is known to be of very little value, and ought, to be illegal. Secondly, the lymph used should be pure and effective; it can hardiy be credited that a Nation which is so very careful that the margarine tub should not be labelled "Butter," can be so indifferent and careless as to the source, manufacture, and sale of the lymph 22 which Vaccinations are carried out by others than the Public Vaccinators. We should unite in demanding the establishment of StateLaboratories adequate to supply all who require it, with the lymph prepared in the best possible way, by the most accomplished experts, and that inspection and enquiry into the source and manufacture of all lymph, whether imported or made in this Country, should be made. It is much to be desired that the Nation should take up this matter, and urge the Central Authority to make arrangements for an adequate supply of lymph. We are told by Mr. Long that the Government does not intend to supply lymph from the National Vaccine Establishment to all who require it. He says that an ample supply can be obtained from private makers. Much of this lymph may be very good, but in a matter of this kind, which is of National importance, it is desirable that the preparation, quality, and efficiency of the lymph should be under the strict supervision of that Department of the Government which exists for the preservation of the health of the people. ****** Had the conclusions above drawn and the principles above promulgated been universally accepted and adopted in the past, there would to-day be no epidemics of Small Pox, were they so received and put into practice now, I can confidently assure the Council we should have no epidemics of Small Pox in the future, and many valuable lives, much agony of mind and body, and very considerable expense would be spared the country at large. Unfortunately the fight against ignorance and prejudice in these matters is not yet over, and the practical assistance of the Members of Local Sanitary Authorities is urgently needed to guide the people aright I feel confident that in Tottenham they will be found not merely on the right side, but in the battle's van. * * * * * * * In conclusion, I should like to thank the Members of the Council, and even more particularly the Members of the Sanitary Committee for th^ir continued and cordial co-operation with the Public Health Staff in combating this fell disease. Very few Sanitary Authorities have acted so wisely, promptly, and thorcughly in this respect as has the Sanitary Authority of Tottenham. I am, Mr. Chairman and Gentlemen, Faithfully yours, J. F. BUTLER-HOGAN. this and the three Charts immediately succeeding it illustrate the irregular periodicity of Small Pox Epidemics Fig. 1.—Annual Death Rate per Million of Population in London from Small Pox, 1780—1902. Fig. 2.—Annual Death Rate in Glasgow from Small Pox per Million Inhabitants, 1714—1812, 1835 — 30, and 1855—1900, (No statistics are available for 1840—54.,) Diagram 1.— Showing in regard of Persons residing in the Houses of Sheffield reported by the Enumerators to have been invaded by Small Pox, the Incidence of Small Pox Attack and of Small Pox Death, up to the Date of Enumeration, upon each hundred of A11 Classes, and upon each hundred Viccmated and Unvaccinated respectively, at each of several Age-periods. Diagram 2.—From Dr. J. B. Russell's" A Study of 972 Cases of Small Pox,"showing the severity of the eruption of Small Pox among patients with good vaccination marks, among patients with bad vaccination marks, and among unvaccinated patients, at each of the ages 0-9 years, 10-19 years, 20-29, and 30-39 years. Date of Epidemic 1898-3 1887-8 1892-3 1891-2 1895-6 1892-3 1001-2. Dimensions 661 4677 5353 l012 1978 357 525. of Epidemic Cases Deaths 62 496 182 110 434 21 74. Diagram .3 Showing that the Percentage of Cases and of Deaths occurring in Children under 10 Years of Age varied in the Towns named directly i proportion to the Neglect of Vaccination. Diagram 4.—(Hunter.) Diagram 5.—(McVail.) Diagrams 4 & 5 show the enormous proportion of deaths which occurred from Small Pox in the earlier years of life in communities unprotected bv vaccination. Diagram G.—Prepared by Dr. Newsholme from Data given in the Final Report of the Royal Commission on Vaccination, p. 47. It shows that in proportion as infant vaccination became more general, so did the deaths from Small Pox decrease during the earlier years, and proportionately increase durine adult life. The increased ratio of deaths in children corresponding to the increased vaccination default 1885-94 is well shown. The average vaccination default in London was as follows: 1875-1879, 7.8; 1810 1884, 6.5; 1885-1889,9.0; 1890-1894,17.5. These numbers are taken from the Report of the Medical Officer of the London County Council, 1900, p. 17. Diagram 7,—Shotting Gross Mortality from Small Pox at all apes—from the time when the Official Registration of Mortality commenced (1838) —in proportion to every 10,000 persons living at the time. During the four years 1843-7, for some unexplained reason, the causes of death, including, of course, Small Fox, were nut published by the RegistrarGeneral. Quoted in "The Effects of Vaccination in Infancy etc., Jenner Society, Gloucester, from Newsholme's "Vital Statistice," 1889 (p. 210.)