WAL 89 Malthamstom Arban District Council. REPORT BY THE MEDICAL OFFICER OF HEALTH on the SANITARY CONDITION AND VITAL STATISTICS, and REPORT OF THE SANITARY INSPECTOR, FOR THE YEAR 1902. Waltbamstow: Printed by Phelp Brothers, 62-64, Bedlam Road. To the Chairman and Members of the Walthamstow Urban District Council. Gentlemen, I beg to present to you my Annual Report for 1902. The year was a very favourable one. We have experienced unusual freedom from Summer Diarrhoea, which was mainly attributable to the heavy falls of rain, occurring during the months of July and August, cooling the atmosphere, lowering the earth surface temperature and preventing putrefactive changes. In other respects the year was chiefly remarkable for the severe epidemic of Small Pox which took its rise in London in the latter months of 1901, and spread rapidly to the various suburbs. The full force of the epidemic was experienced in your district in the first seven months of the year under review, and one hundred and forty-four cases occurred during that period followed by two in August, after which your district became quite free. With this exception, the year has been exceptionally free from illness of all kinds, and, whether judged by the general death rate, Infantile Mortality rate, Zymotic death rate, Infectious Sickness rate, or by any of the standards usually adopted, one of the healthiest on record. The Birth rate for the year was above the average for the preceding ten years, and 33'81 per 1,000 of the population. The Death rate was the extremely low one of 11'38, or 2'7 per 1,000 below the average for the previous ten years, and the lowest recorded for 23 years, and 5 per 1,000 lower than England and Wales, 1902. We have had a birth rate of 5 per 1,000 greater and a death rate of 5 per 1,000 less than the country generally, a condition that must be looked on as highly satisfactory, considering the locality and character of the population. 4 The Infantile Mortality rate has fallen from 147 in 1901 to 115 for 1902, and the Infectious Sickness rate, or the proportion of persons suffering from Infectious disease to 1,000 of the population, was 10.68 compared with 11.2 for the preceding ten years. During the year Mr. Brown, one of the Sanitary Inspectors, resigned, and his place was filled by the appointment of Mr. Pointon. In January the Sanitary Committee resolved that power be given to the Chairman, Medical Officer and Mr. West to engage temporarily an additional Assistant Sanitary Inspector should it become necessary through the prevalence of Small Pox. This was not done, and in consequence an extra amount of work was thrown on Mr. West and those under him, and I cannot speak too highly of the efficient and satisfactory manner in which the work was performed, nor of the uncomplaining spirit in which the extra work was undertaken and extra time put in. I respectfully suggest that these extra labours deserve some special recognition, similar service having been recognised by neighbouring authorities. Most cordial relations have existed between myself and the various officials under your control, and to Mr. Holmes, Mr. Morley, and Mr. Berry I am indebted for much of the details in this report. To Mr. Jones, of the School Board, and those gentlemen I return my thanks. Complete details of the work done throughout the year will be found in the body of the Report. Dr. Cameron's report on the work at the Sanatorium will be found on page 32 and the report of Mr. West is appended. I remain, Gentlemen, Your obedient Servant, J. J. CLARKE. 5 SANITARY AREA. POSITION AND LOCALITY. Walthamstow is divided into five wards for administrative purposes, and has been described as a town which " stands upon a hill of gravel, which rises gently from the marsh level of the Valley of the Lea to a height of 133 feet above ordnance datum." It lies between the River and Epping Forest from the west to east, extending from Leyton on its south to Chingford on the north. The sub-soil is mainly gravel, the London clay showing itself in various parts on the surface, notably at Church Hill and portions of the Hoe Street and Northern Wards adjoining. St. James Street Ward is the lowest portion of the district and the Northern (semi-rural in character) is the highest. High Street and portions of Wood Street (lying between the Old Church and Prospect Hill on the west and the Forest on the east) come next in point of elevation to St. James Street, while Hoe Street is intermediate between these and the Northern Wards. St. James Street Ward contains the largest population, 23,000, with a density of 92 persons per acre; Hoe Street contains 22,000, with a density of 63'5 per acre; High Street, 20,000, with 86 per acre; Northern, 20,000, with 8'3 per acre; and Wood Street, 16,000, with 32 persons per acre. The whole district has a duplicate system of sewers, and practically every house has water-closet accommodation and water supplied by the East London Waterworks Company. St. James Street Ward varies from 18 to 54 feet above sea level; High Street, 21 to 60 feet; Hoe Street, 50 to 140 feet; Wood Street, 50 to 170 feet; and the Northern Ward, 25 to 220 feet. The Sewage Farm, about 240 acres in extent, the precipitating tanks and sewage works are situate in St. James Street Ward, and the reservoirs of the East London Waterworks Company, about 330 acres in extent, are in the High Street Ward. POPULATION. In 1901 at the last Census the enumerated population was 95,125 in 1891 it was 46,346; and 10 years previously it was 21,697. G In 1901 the population was thus distributed, as given by the Registrar General:— TABLE I. Wards. Houses. Population. Inhabited. Uninhabited. Building Male. Female. Total. In occupation. Not in occupation. St. James Street 3,748 41 148 10 11,391 11,373 22,764 High Street 3,086 38 96 40 9,811 9,687 19,498 Hoe Street 3,808 34 242 59 9,975 11,124 21,099 Wood Street 2,540 29 147 62 7,381 7,827 15,208 Northern 2,901 10 466 254 8,274 8,278 16,552 Totals 16,083 152 1,099 425 46,832 48,289 95,121 During the year under review, 1902, plans for houses to the following extent were passed, necessitating the laying out of 22 new streets :— St. James St. High St. Hoe St. Wood St. Northern Ward Total. 66 38 252 124 706 1,186 Assuming that half of these houses were completed at the mid-year, we form the following Table II. :— TABLE II. Ward. Houses fit for Occupation. Uninhabited (Census 1901.) Occupied Mid-Year. Average Number per house. Population. James Street 3,980 1 in 21 3,790 60 22,740 High Street 3,279 1 in 24 3,142 63 19,794 Hoe Street 4,269 1 in 15 3.985 5'5 21,917 Wood Street 2,840 1 in 15 2,652 6.0 15,912 Northern 3,984 1 in 7 3,652 5.7 20.816 assumed 1 in 12 18,352 1 in 17'4 17,221 5.9 101,179 The number of houses occupied is arrived at by assuming the same proportion is empty in the various wards, as at the Census of 1901, excepting the Northern Ward, which I assume to have 1 empty in 12 ; whereas at the Census, 1 in 7 was empty. 7 The population of 101,179 comes very near to the estimated population of the Registrar-General, namely 101,318, arrived at by a different method, namely, by assuming that the population keeps growing at the same rate as in the intercensal period 1891-1901. A correct estimate of the population is very necessary if we are to place any value on the various birth, death, and infectious sickness rates of the district and its constituent parts, and as the population of the various wards are impossible to get at accurately, I will assume that the populations of the different wards are as follows :—• St. James St. High St. Hoe St. Wood St. Northern. Total. 23,000 20,000 22,000 16,000 20,000 101,000 This will give a fairly accurate estimate to base the various rates upon for the different wards. The St. James Street and High Street Wards have increased but little during the year, while Hoe Street, Wood Street, and the Northern Ward especially, have increased very greatly. In one year it is assumed that the Northern Ward has increased by 4,000, while Wood Street and Hoe Street districts have increased by nearly 1,000 each. From the following table the population may be assumed to be made up according to age, taking as a basis the age distribution as given in the censes of 1881 and 1891 :— TABLE III. Number of Houses fit for occupation. Total number of houses occupied. Number in Course of Erection. Assumed Population. Under 5 years of age. Over 5 and under 10. Over 10 under and 15. Over 15 and under 20. Over 20 and under 25. Over 25 and under 35. Over 35 and under 45. Over 45 and under 55. Over 55 and under 65. Over 65 and under 75. |75 years and upwards. 18,352 17.221 1,186 101,000 12,892 11,923 10,978 10,020 9,868 14,891 11,425 8,511 5,817 3,358 1,310 Average death rates. England and Wales. 56.82 5.29 3.02 4.35 5.61 7.53 11.42 17.06 31.33 64.65 153.67 Walthamstow. 40.3 ' 8 It is a matter of great regret that I have been unable to get the population as regards age and sex distribution, for the purpose of more accurately computing the death-rate for this district compared with that of England and Wales as a whole. We have a large infant population which, no doubt, is a large factor in the production of our death-rates. The following summary of the chief items of sanitary importance in your district may be given thus:— Area of Sanitary District in acres 4,355 Population, 1881 Census 21,697 „ 1891 „ 46,346 1901 95,125 „ 1902 Assumed Registrar General 101,318 No. of Persons per house (assumed) 5.8 No. of Persons per acre (exclusive of Sewage Farm and Reservoirs) 27.5 Total Births registered 3,426 „ Deaths „ 1,154 No. of Deaths of Persons not belonging to this District 8 Natural increase of Population 2,272 Birth-rate per 1,000 of estimated population 33.81 Death-rate , „ „ 1138 Zymotic Death-rate 1.3 Infantile Mortality Rate (or proportion which deaths under 1 year bear to 1,000 births) 115 0 Infectious Sickness Rate 10.68 BIRTHS.—BIRTH-RATE. The total number of births registered during the year was 3,426 ; males, 1,716; females, 1,710. Ten of these (males, 5; females, 5), were born at the Union Workhouse. In 1901 there were 3,210 births; in 1900, 3,037 ; and in 1899, 2,835. The birth-rate for 1902 is 33.81, compared with 33.1 for the previous year, and 32 95 for the ten preceding years. The number of births over deaths, or the natural increase of the population was 2,272, compared with 1,923 in 1901, 1,783 in 1900, and 1,553 in 1899. The birth-rate for England and Wales for 1902 was 28.6, or 5.21 below that for this district; and compared with the previous ten years the birth-rate is higher by nearly 1 per 1,000, while that of England and Wales as a whole has decreased by 1 per 1,000. The ratio of male to female births was as 100 to 99.65. Distributing the births as supplied by the Registrar over the various wards of the district, we had in the four quarters :— 9 TABLE IV.  St. James Street. High Street. Hoe Street. Wood Street. Northern. Workhouse. Totals. M. F. M. F. M. F. M. F. M. F. M. F. M. F. 1st quarter 94 91 94 87 71 88 58 51 84 108 3 2 404 427 2nd quarter 100 95 94 94 85 85 66 52 95 109 0 1 440 436 3rd quarter 96 98 92 94 84 74 67 62 95 79 2 2 436 409 4th quarter 93 97 96 82 77 84 53 71 117 104 0 0 436 438 383 381 376 357 317 331 244 236 391 400 5 5 1716 1710 Totals 764 733 648 480 791 10 3426 Population 23,000 20,000 22,000 16,000 20,000 — 101,000 Birth.rate 33.22 36.65 29.45 300 39.55 — 33.81 Do. 1901 33.03 35.7 27.9 28.43 39.86 — 3310 10 St. James Street and the Northern Wards have practically the same rates as last year, while the other Wards have higher rates. The difference in the Hoe Street Ward of 1-55 per 1,000 may be accounted for by the population assuming more the character of its neighbours— High Street, Wood Street and Northern Wards. DEATHS AND DEATH-RATE, WHOLE DISTRICT. During the year 1,009 deaths were registered as occurring in this district. Eight were of non-residents and eliminated in reckoning the death-rate, while 117 deaths occurring at the Workhouse, 19 deaths at the Small-Pox Hospital, Dagenham, 16 deaths at the Sanatorium, and 1 at Sheffield of a resident of this district, are added. The total number of deaths belonging to this district was 1,154 (males, 610 ; females, 544). Four deaths were registered without a Coroner's or a Medical Practitioner's Certificate of the cause of death. That no death should be registered without a certificate stating the cause by a doctor or the coroner is quite apparent to safeguard the public interest. In fact, no certificate of death registration should be issued without an inspection of the body post mortem. However conscientious and able a Registrar may be, such power should not be placed in his hands to dispense with a certificate. The corrected general death-rate for the district is 11.38 per 1,000, or 2.72 per 1,000 below the average (14.10) for the previous ten years, and is the lowest recorded death-rate for the past 23 years. The death-rate for England and Wales for 1902 was 16.3, or 5 per 1,000 above that of Walthamstow, and for the " 76 great towns," more justly comparable to your district, the death-rate was 17.4, or 6 per 1,000 greater than that for Walthamstow. One death was registered for every 87.8 persons of the population compared with 1 in 75 for 1901. ACCORDING TO WARDS. The deaths registered during the year and death-rates for the Wards were as follows. The birth-rates are also given as well as those for last year:— 11  St. James Street. High Street. Hoe Street. Wood Street. Northern. Total. No. of Deaths, 1902... 293 228 224 183 234 1162 Rate per 1,000 of es. 12.74 11.4 10.2 11.31 11.7 11.38 timated population Birth.rate, 1902 33.22 36.65 29.45 30.0 39.55 33.81 No. of Deaths, 1901 . 349 255 247 187 258 12.96 Rate per 1,000 of es. 15.03 12.82 11.5 12.05 15.27 13.35 timated population Birth.rate, 1901 3303 35.7 27.9 28.43 39.86 33.1 It will be seen that St. James Street and Wood Street Wards' death rates are considerably lower than last year, although they have practically the same birth rates as before. High birth rate is a considerable factor in a death rate, and the low death rate in these wards is mainly due to the wet summer and absence of Diarrhoea. In every Ward there is a considerable improvement in the death rates recorded compared with last year, when such rates were made out for the first time. That the improvement in the death rate for St. James Street Ward is actual and not due to over estimation of the population, can readily be seen when we remember that compared with 1901, when the census returns were issued, the population is assumed to have increased only 236 to the middle of 1902. It is evident this vastly improved rate has actually occurred and is not due to overestimation of population. INQUESTS. There were 86 inquests held during the year as compared with 105 held in 1901, 90 in 1900, 83 in 1899, and 62 in 1898. The deaths requiring investigation by the Coroner were 7.4 per cent. of the total deaths, and the results were as follows :— 34 died from Natural causes. 5 „ Suffocation through overlying. 1 ,, Accidental suffocation. 1 ,, Suffocating spasm of larynx. 1 „ Accidental suffocation in bed. 12 INQUESTS —continued. 1 died from Suffocation by strangulation by some person or persons unknown. 1 „ Suffocation (murder). 3 „ Suffocation by hanging (sijicide). 8 ,, Convulsions. 1 ,, Strangulated hernia. 4 ,, Poisoning (oxalic and carbolic acids), self-administered. 2 „ Suicide whilst temporarily insane. 1 „ Drowning (suicide). 1 „ Want of proper attention at birth. 1 „ Tetanus following accidental injury. 1 „ Broncho-pneumonia following Erysipelas (gnat bite). 1 ,, Pneumonia following blood poisoning. 1 ,, Blood poisoning following accidental wound. 1 „ Septic Pneumonia. 1 ,, Septicemia following injury. 4 „ Accidental burns. 1 ,, Bronchitis following accidental burns. 1 ,, Shock of strangulation of intestines. 1 „ Fracture of Femur followed by hypostatic congestion of lungs. 1 „ Rupture of aneurism of aorta. 1 „ Concussion of the brain, result of fall. 1 „ Accidental fracture of skull. 1 ,, Hemorrhage on brain following accident on the G.E R. 1 „ Injuries by being run over. 1 „ Shock of accidental fall. 1 „ Malnutrition, improper feeding. I ,, Obstruction of heart due to dilatation of stomach 1 „ Heart disease from drink 86 Total. The following Table gives the number of births and deaths, their rates, the zymotic death-rate, infantile mortality rate, and natural increase of population for the past ten years compared with 1902 :— 13 TABLE V. Year. Births. Deaths. B. Rate. D. Rate. Zymotic D. R. Infantile Mortality Rate. Natural Increase of Population. '91 1756 694 37 3 14.7 1.9 120.0 1062 '92 1717 915 34.75 18.0 3.9 145.6 802 '93 1809 809 34.78 15'55 243 133.2 1000 '94 1813 717 32.0 12.6 1.8 129.6 1096 '95 2021 965 33.2 15.8 3.5 153.3 1056 '96 2101 817 32.3 12.5 2.4 127.5 1284 '97 2246 832 32.08 11.88 2.8 132.0 1414 '98 2294 1034 29.8 13.4 3.67 169.5 1215 '99 2835 1282 34.14 15.44 2.94 170.0 1553 '00 3037 1254 33.37 13.78 2.8 158.7 1783 '01 3210 1296 331 13.35 2.82 147.6 1914 Average for . 10 years J '02 2307 3426 991 1154 3295 33.81 14.33 11.38 2.90 1.3 146.6 115 1235 2272 Total natural increase of population since 1891, 15,389. Total increase as shown by census, 1901, 48,779. Total increase as estimated to middle of the year 1902, 54,972. Total increase per cent., 118. INFANTILE MORTALITY RATE. There were 394 deaths of children under 1 year of age registered during the year, compared with 481 in 1901 and 482 in 1899 and 1900. The infantile mortality rate, or the proportion which deaths under 1 year bear to 1,000 births is 115, the lowest rate since 1890, and 18 lower than that for England and Wales as a whole for 1902, and 30 per 1,000 lower than the " 76 great towns." 14 By referring to the preceding table it will be seen that the births have steadily increased since 1890, from 1,544 in that year to 3,426 in 1902. During the years 1891-1895, the Infantile Mortality Rate fluctuated between 120 and 153, reached 170 in 1899 and steadily declining in 1900 to 158; 1901 to 147, until this year the rate is the lowest recorded. This favourable rate is no doubt due to the very wet summer we had, and the consequent absence of Diarrhoea in hand-fed children. That the infantile mortality rate is excessive in all the large Urban Districts of Essex is admitted when compared with the Rural Districts of the county. Dr. Thresh, the County Medical Officer of Health for Essex has interested himself greatly in this question, and a conference was called in November to discuss the causes of the excessive mortality, and men occupying public positions in the county, doctors and clergymen, as well as the Medical Officers of Health and the Chief Sanitary Inspectors of the county attended, presided over by T. F. Victor Buxton, Esq., J P. The points suggested for discussion by Dr. Thresh were (1) The relative importance of the following factors in causing an excessive infantile mortality, (a) Insanitary condition, (b) Season, (c) Ignorance of parents, (d) Artificial feeding. (2) Can any uniform action be taken to prevent this excessive mortality, and (3) is it desirable to establish depots for supplying fresh sterilized milk for infant feeding. No doubt Dr. Thresh enumerated the four main factors (a, b, cand d) in the causation of infantile mortality, but there is another which adds to it considerably in large Urban Districts—the early marriage of immature boys and girls and the consequent ignorance of the latter in dealing with children, as well as the number of premature children, the outcome of such unions. In your district one tenth of the deaths under one year of age are due to prematurity. The question is of such vast importance and the prevention of such mortality appeals to every humane person, that I cannot do better than quote Dr. Thresh's remarks at the conference, and to say that in pursuance of his action a subsequent conference has been held in London, and the deputation of the M.O.H.'s and those interested visited Battersea where humanized milk is prepared under the supervision of the M.O.H. for the Borough. There is every hope that your authority will receive material help in this direction from some of the gentlemen who are engaged in the milk industry in your district, and that before August is with us humanized milk will be procurable for infant feeding and the prevention of Infantile Diarrhoea. 15 At the Conference at Leytonstone, Dr. Thresh remarked that he had thought medical officers often paid too much attention to drains and stinks, and too little to the cause of diseases generally. This was perhaps due to the fact that nuisances could be easily remedied; and the more common infections were fairly well understood. In the south-western portion of the county, including West Ham, Barking, Walthamstow, and Leyton, infantile mortality was very great. The figures showed that for some reason infants under five years of age died from two or three times as fast in our large centres of population as in rural districts and small towns. In other words, over 1,000 infants died annually whose lives ought to be and could be saved. Not only, however, could these lives be saved, but the measures taken to strengthen the weak would tend to make others stronger. They would become from the outset better able to fight the battles of life, and increased physical strength would tend to a corresponding increase in mental and moral strength and to a general all-round improvement. At present we provided infirmaries, hospitals, and workhouses for the physically weak and diseased, asylums for the weakminded, and penitentiaries and gaols for the degenerate with a tendency to crime. All this was very good, but would it not be better to commence at an earlier stage and try and prevent rather than to palliate or cure? The unfortunate tendency of the birth-rate to decrease rendered the subject of infantile mortality of increasingly great national importance. If England is to assist in the populating of its Colonies, if it is to continue to maintain its present proud pre-eminence, it must produce a virile and increasing population. The following table shews the birth and infantile mortality rates according to wards:— TABLE VI. Whole Area. St. James Street. High Street. Hoe Street. Wood Street. Northern Ward. Births 3,426 766 735 650 482 793 Birth.rate 338 332 36.6 29.4 300 39.5 Deaths 1,162 293 223 224 183 234 Infantile mortality rate 115 116.8 110.2 84.6 132.7 132.4 16 Hoe Street with its lowest birth rate has the lowest Infantile Mortality rate; Wood Street with a very slightly increased birth rate has the largest death rate, larger than the Northern Ward with its birth rate of nearly 40 per 1,000. These rates may be looked on as a fair index of the character of the populations concerned and the localities, with the exception of the Northern Ward, whose high infantile mortality rate is mainly accounted for by its high birth-rate. SENILE MORTALITY. Of the 1,162 deaths recorded, 201—or 17.8 per cent. were of 65 years and upwards, as compared with 15 per cent, in 1901. In the St. James' Street Wards 24 were 75 or upwards. „ High Street Wards 20 „ ,, ,, Hoe Street „ 29 „ „ „ Wood Street Ward 28 „ „ „ Northern Ward 12 „ „ The following table shews the number and causes of death for the whole district, and the sub-divisions or wards. This table is a combination of Schedule B (form of the Medical Officers of Health Society), and Table IV. (Local Government Board form). ZYMOTIC MORTALITY. The " Seven Principal Zymotic Diseases," viz. :—Small-PoXj Measles, Scarlatina, Diphtheria, Fever (Typhus, Enteric and Continued), Whooping Cough and Diarrhoea caused 125 deaths. If Enteritis be included, the deaths were 186. As deaths due to Enteritis, Gastro-Enteritis, Muco-Enteritis and Gastric Catarrh are not included in the Zymotic Mortality rate, it follows that any deaths omitted from these causes (that rightly belong to Diarrhoea) lower the Zymotic rate and vice versa. To obviate the lowering of the Zymotic rate I have included all deaths certified as Enteritis under 1 year as belonging to the Zymotic group, and consequently reckon 86 instead of 28, making a total of 188 deaths. These deaths represent an annual rate of 1.81 compared with 2.82 in 1901; 2.72 in 1900; 2.81 in 1899; and an average of 2.86 for the preceding 10 years. Schedule B. Table of Deaths during the year 1902, in the Urban Sanitary District of Walthamstow, classified according to Diseases, Ages, and Wards. No. Causes of Deaths All Ages Under 1 1 to 5 5 to 15 15 to 25 25 to 65 65 and upwards St. James Street High Street Hoe Street Wood Street Northern Total Deaths in Public Institutions in the District l Small-Pox 20 1 3 4 4 8 4 3 6 5 2 20 2 Measles 14 6 8 — — — — 3 5 2 — 4 2 3 Scarlet Fever 6 — 2 2 — 2 — 3 1 — 1 1 6 4 Typhus Fever — - - - - - - - - - - - - 5 Epidemic Influenza 13 — — — — 10 3 7 2 3 — 1 — 6 Whooping Cough 23 15 8 — — — - 5 5 4 3 6 — 7 Diphtheria, Membranous Croup 17 3 8 5 — 1 — 6 — 5 4 2 10 8 Croup 4 2 1 1 — — — 1 — — 3 — — 9 Enteric Fever 13 — — 4 3 6 — — 2 5 3 3 2 10 Asiatic Cholera — — — — — — — — — — — — — 11 Diarrhoea, Dysentery 23 18 3 — — — 2 5 10 1 1 6 — 12 Epidemic or Zymotic Enteritis 5 3 1 — — — 1 — 2 1 1 1 — 13 Enteritis 11 8 2 — — 1 — 4 1 2 2 2 — 14 Other continued Fevers — — — — — — — — — — — — 15 Erysipelas 3 — 1 — — 1 1 — — — 1 2 1 16 Puerperal Fever - - - - - - - - - - - - — 17 Other Septic diseases 8 1 2 — 1 4 — 3 2 2 1 — 5 18 Intermittent Fever and Malarial Cachexia - - - - - - - - - - - - — 19 Tuberculosis of Meninges 13 4 6 2 1 — — 2 4 3 — 4 2 20 Tuberculosis of Lungs 87 6 — 2 9 68 2 21 22 17 14 13 16 21 Other forms of Tuberculosis 24 10 4 3 2 5 — 6 5 6 2 5 2 22 Alcoholism — — — — — — — — — — — — — 23 Cancer 52 — — — 1 31 20 17 9 12 4 10 7 24 Premature Birth 68 68 — — — — — 12 15 9 10 22 — 25 Developmental Diseases 100 92 8 — — — — 22 16 15 18 29 8 26 Old Age 66 — — — — 1 65 13 17 11 13 12 31 27 Meningitis 28 14 10 2 1 1 — 6 4 8 4 6 4 28 Inflammation and Softening of Brain 7 — — — — 5 2 1 — 4 1 1 5 29 Organic Diseases of Heart 21 — — — 3 13 5 4 4 6 4 3 1 30 Acute Bronchitis 78 41 15 3 1 11 7 21 28 10 7 12 3 31 Chronic Bronchitis 47 — — — 23 24 12 7 14 7 7 7 32 Lobar (Croupous) Pneumonia 52 7 3 4 1 29 8 16 4 6 17 9 7 33 Lobular (Broncho) Pneumoni 53 31 21 — — 1 — 17 8 8 9 11 — 34 Diseases of Stomach 10 5 1 2 — 2 - 2 1 3 1 3 — 35 Obstruction of Intestines 9 1 1 1 — 4 2 2 — 2 2 3 1 36 Cirrhosis of Liver 10 — — — — 9 1 3 — 3 2 2 ] 37 Nephritis and Bright's Disease 16 1 — 2 — 13 — 3 5 4 — 4 2 38 Tumours and other Affections of Female Genital Organs - - - - - - - - - - - - - 39 Accidents and Diseases of Parturition 10 — — — 2 8 — 1 4 1 2 2 — 40 Deaths by Accident or Negligence 21 9 3 3 — 4 2 3 6 3 6 3 7 41 Deaths by Suicide 11 — — — 2 8 1 2 3 2 1 3 — 42 Deaths from Ill-defined Causes 1 — — — 1 — — 1 — — — — — 43 All other Causes 218 48 15 11 11 78 55 65 33 46 34 40 31 All Causes 1,162 394 126 51 43 347 201 293 228 224 183 234 181 17 The following tabular statement shows the mortality in the last 5 years from Zymotic diseases :— TABLE VII. Small-Pox. Scarlatina. Diphtheria. Croup. Typhoid. Measles. Whooping Cough. Diarrhcea. Zymotic Enteritis. Total. 1902 20 6 17 4 13 14 23 23 5 125 1901 1 13 38 12 43 26 131 10 274 Gastro- Enteritis. 1900 — 5 71 7 6 3 54 110 27 283 ' 1899 — 6 64 9 19 33 34 144 309 1898 — 3 40 6 9 39 24 162 283 With the exception of Small Pox, every disease in the group shews a marked decline in the death-rates, while Typhoid Fever is only one case in excess of the previous year. The total deaths from this group of diseases is less than half the number of any of the preceding four years. The following Table gives the deaths from the seven principal Zymotic diseases in the four quarters of the year. TABLE VIII. Small-Pox. Scarlet Fever. Diphtheria and Membranous Croup. Croup. Measles. Whooping Cough. Enteric Fever. Diarrhoea and Zymotic Enteritis. Enteritis. Totals. Totals for 1900. Totals for 1901. 1st Quarter 7 3 5 1 2 6 4 1 2 31 44 44 2nd „ 9 1 4 0 1 9 1 2 2 29 45 51 3rd „ 3 1 2 2 2 5 5 19 3 42 142 171 4th „ 1 1 6 1 9 3 3 6 4 34 52 34 Total 20 6 17 4 14 23 13 28 11 136 283 300 18 The following Table shows graphically the death-rate from these diseases for the past ten years, with the rate for 1902: — table of zymotic mortality, j 1891 to 1902. TABLE IX. 19 DEATHS FROM NOTIFIABLE INFECTIOUS DISEASES. The diseases under this heading are :—Chicken Pox, Small Pox, Scarlet Fever, Diphtheria and Membranous Croup, Fever (Typhus, Typhoid and Continued), Erysipelas, Puerperal Fever, Cholera and Plague. There were 73 deaths registered from the above causes during the year, compared with 74 in 1901, 103 in 1900, and 104 in 1899. TABLE X. Names ok Diseases. Whole District. Wards, 1902. Deaths, 1902. Deaths, 1901. Increase + Decrease - St. James Street. High Street. Hoe Street. Wood Street. Northern. Small-Pox 20 1 + 19 4 3 6 5 2 Scarlatina 6 13 - 7 3 1 — 1 1 Diphtheria 17 38 -21 6 — 5 4 2 Membranous Croup 4 — + 4 1 — — 3 — Typhoid 13 12 + 1 2 5 3 3 Erysipelas 3 5 - 2 — — — 1 2 Puerperal Fever 10 5 + 5 1 4 1 2 2 Cholera 0 0 Plague 0 0 There is a considerable falling off in the deaths from Diphtheria, but James' Street Ward still has a majority in the number of cases and the number of deaths. This fact has been adverted to previously, and fully dealt with in 1900. 20 ZYMOTIC DISEASES NOTIFIED DURING THE YEAR 1902. Owing to the prevalence of Small Pox in London and the " Outer Ring," I advised that Chicken Pox should be made notifiable under the Act of 1889 for the period of one year. In consequence, the total number of cases notified during the year under this Statute was 1,860, an excess of 722 cases on the previous year, but eliminating the 777 cases of Chicken Pox, we had 1,083 cases of the usual diseases notified, compared with 1,138, or a decrease of 55 as compared with 1901. The following Table shows the number of cases notified each month during the year:— 21 TABLE XI.—Cases of Infectious Disease notified during the Year 1902. Notifications. Jan. Feb. Mar Apl May June July Aug. Sept Oct. Nov Dec Total. Deaths Small-Pox Under 5 years 1 1 1 1 2 0 4 0 0 0 0 0 10 4 Over „ 15 13 33 18 24 18 13 2 0 0 0 0 136 16 Scarlet Fever Under 5 years 32 14 11 19 12 18 20 10 9 21 10 11 187 2 Over „ 46 31 21 25 34 31 34 24 35 44 24 24 373 4 Diphtheria Under 5 years 3 7 8 7 4 4 3 3 5 6 3 3 56 11 Over „ 7 2 7 7 8 2 16 5 12 7 8 5 86 6 Membranous Croup Under 5 years 1 2 0 0 1 1 0 1 0 1 0 0 7 3 Over „ 0 0 0 0 0 0 0 0 0 0 0 1 1 1 Enteric Fever Under 5 years 0 0 0 0 1 1 0 0 0 0 0 0 2 0 Over „ 3 1 3 2 7 7 12 10 12 15 8 7 87 13 Puerperal Fever Under 5 years 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Over „ 0 1 1 0 1 0 1 0 0 0 1 2 7 0 Erysipelas Under 5 years 0 1 1 1 2 0 0 2 0 2 0 2 11 1 Over „ 12 7 9 7 7 7 9 8 7 10 18 19 120 2 Chicken Pox Under 5 years 81 27 25 31 57 103 52 14 7 5 16 29 447 0 Over „ 48 17 11 30 44 63 31 5 4 4 38 35 330 0 Totals 249 124 131 148 204 255 192 84 91 115 126 138 1860 63 1 he following Table shows the distribution of Infectious cases according to Wards, and the increase or decrease as compared with 1901:— 22 TABLE XII.—Distribution of Infectious Diseases according to Wards WARDS. Estimated Population. Small Pox. Scarlet Fever. Diphtheria. Croup. Erysipelas. Typhoid. Puerperal. Chicken Pox. Totals. Increase + or Decrease - on last year. Increase + or Decrease — excluding Chicken Pox. St. James Street 23,000 46 130 43 4 33 17 2 201 476 + 54 -129 High Street 20,000 27 121 26 — 23 20 3 157 377 + 79 -63 Hoe Street 22,000 31 117 25 1 25 23 1 109 332 + 124 + 26 Wood Street 16,000 16 54 25 — 19 13 1 157 285 + 156 + 2 Northern 20,000 26 138 23 3 31 16 — 153 390 + 256 + 109 1902 101,000 146 560 142 8 131 89 7 777 1,860 + 669 -55 1901 97,000 3 608 322 11 111 73 10 53 1,191 + 135 + 82 1900 95,383 — 347 516 11 87 Con. 1 1 86 8 — 1,056 — — 23 The following Table shows Infectious disease according to Wards, and the number removed to Hospital:— TABLE XIII. Cases of Infectious Disease notified during the Year 1902. Notifiable Disease. Cases Notified in Whole District. Total Cases Notified in Each Locality. No. of Cases Removed to Hospital from Each Locality. At all Ages. At Ages—Years. St. James Street. High Street. Hoe Street. Wood Street. Northern. St. James Street. High Street. Hoe Street. Wood Street. Northern. Under 1 1 to 5 5 to 15 15 to 25 25 to 65 65 and upwards Small Pox 146 2 8 22 48 65 1 46 27 31 16 26 45 27 31 16 26 — — — — — — — — — — — — — — — — — Diphtheria 142 6 50 55 19 12 — 43 26 25 25 23 28 18 10 12 13 Membranous croup 8 2 5 1 — — — 4 — 1 — 3 — — — — 1 Erysipelas 131 3 8 14 22 79 5 33 23 25 19 31 1 — — — — Scarlet Fever 560 9 178 308 38 26 1 130 121 117 54 138 24 23 41 8 41 Typhus Fever — — — — — — — — — — — — — — — — — Enteric Fever 89 — 2 23 26 38 — 17 20 23 13 16 6 11 7 3 5 Relapsing Fever - - — — - — — — — — - - - - - - - Continued Fever - — - - - - - - - - - - - - - - - Puerperal Fever 7 — — — 3 4 — 2 3 1 1 — - — — — — Plague — — — — — — — — — — — — - — — — — Chicken Pox 777 51 396 302 26 2 — 201 15/ 109 157 153 - - 1 - - Totals 1860 73 647 725 182 226 7 476 377 332 285 390 104 79 90 39 86 24 The following Table XIV. is of interest to show the estimated population, number of cases of Infectious Diseases notified, with Infectious Sickness rate and the mean for the years since the Notification Act came into operation :— TABLE XIV.—Estimated Population, Number of Infectious Diseases notified, with "Infectious Sickness Rate," and the Mean for the Years under consideration. Years. Population. Scarlet Fever. Small Pox. Diphtheria. Croup. Typhus Fever. Typhoid Fever. Continued Fever. Erysipelas. Puerperal Fever Totals. Infectious Sickness Rate. 1890 46,500 129 0 160 3 1 117 3 31 0 444 9.5 1891 47,000 125 0 153 9 0 59 4 44 3 397 8.4 1892 49,400 399 6 137 17 0 28 0 94 3 684 13.8 1893 52,000 597 8 142 11 0 60 4 134 5 961 18.5 1894 57,000 247 11 129 15 0 66 0 75 3 546 9.5 1895 61,000 263 1 198 10 0 95 6 85 4 664 10.8 1896 65,000 315 0 124 6 0 193 2 122 5 767 11.8 1897 70,000 492 0 152 6 0 88 0 78 7 823 11.7 1898 77,000 293 0 225 9 0 75 0 82 3 688 8.9 1899 83,000 332 0 338 7 0 118 1 112 5 913 11.0 1900 91,000 347 0 516 11 0 86 1 87 8 1056 11.6 1901 97,000 608 3 322 11 0 73 0 111 10 1138 11.7 1902 101,318 560 146 142 8 0 89 0 131 7 1083 10.68 Mean 69,017 362 134 211 9.5 0 88 1.6 91 4.85 782 11.4 25 INFECTIOUS DISEASES, AND MEASURES TAKEN TO PREVENT THEIR SPREAD. Owing to the Small Pox epidemic, special precautions had to be taken during the year. A new up-to-date ambulance was provided for Scarlet Fever and Diphtheria patients, and the ambulance previously in use was used solely for Small Pox. Upon receipt of the notifications of cases of Small Pox and Chicken Pox in persons over 12 years, I immediately paid a visit to the sufferer, and satisfied myself that the case was one for removal or otherwise. In three cases, notification of Chicken Pox enabled me, in consultation with the medical attendant, to diagnose Small Pox, and subsequent developments proved the correctness of this opinion, only in one case was an urticaerial rash diagnosed as Small Pox, Every case of Small Pox was removed to Dagenham or South Mimms, excepting one who died within 24 hours from Hsemorrhage. The following routine was adopted in every case where possible: Notification to Vaccination Officer, to School Board, managers of Voluntary Schools, to Medical Officer of Health, where contacts resided or worked, with daily observation of same where possible for 14 days, distribution of leaflets to the inhabitants of the same road in which a case had occurred advising them to be vaccinated or re-vaccinated. In all cases one of the Sanitary Inspectors makes a visit to the house invaded by infectious illness, and he carefully examines the sanitary condition existing and makes enquiries into the milk and water supply, noting the number of inmates and how employed. Printed instructions are left as to the precautions necessary to be taken and how best effected. Any clothing made on the premises is carefully disinfected before removal, the Medical Officer for the district whither the work is to be sent is notified, and no further work is taken in until the house has been disinfected. When children are attending school from an infected house, notification is sent to the Head Teachers, and such children are excluded. Upon the recovery or removal of the patient, the house is disinfected and, in cases of Scarlet Fever, three weeks must elapse, and in Diphtheria two weeks, before any of the children resume attendance at school. 26 What I said in last year's report is true as applied to 1902: "The inadequate accommodation for Scarlet Fever cases at the Sanatorium hampered the work of the prevention of the spread of this disease very much, and many of the cases could have been prevented if first cases were isolated. Especially was this the case where houses were occupied by two families, and, strange to say, practically every person in charge of a Scarlet Fever case was anxious to have it removed to the Sanatorium, whereas there were many who refused or did not care to allow the cases of Diphtheria to be removed. The long isolation, and consequent inconvenience in small households, was accountable for this, though, from a public health point of view, Diphtheria is much more necessary to be properly isolated, its death-rate being very high, while that of Scarlatina is very small. Eight hundred and thirteen houses were disinfected by your authority, or by the householders to the satisfaction of their medical attendants. In all cases we have tried to have the work done under skilled supervision, feeling that under your authority it is done much more efficiently and thoroughly than in private hands. In all cases bedding and other infected articles capable of removal were taken to the disinfecting station and disinfected by means of a Washington Lyon Disinfector." SMALL POX. In my Annual Report for 1901 I gave the origin of the outbreak of this disease in your district, and carried its history down to the 27th February, 1902. Owing to the extreme pressure put on the Authorities providing for small pox accommodation, many unvaccinated workmen were allowed to work at the erection of temporary small pox hospitals, with the result of taking the disease and bringing it to their homes, many of them being located in your district. Owing to this fact many cases occurred in your district which were preventable. The action taken by your Authority with reference to the patients in Hospital need only be referred to, and you have already expressed to the West Ham Authority your thanks for taking in every case sent to Dagenham. During the year 146 cases of small pox were notified and removed to Hospital. Of these 20 died from the disease, showing a case rate of 137 per cent., or in other words 3 in every 22 persons attacked died from the disease. The death rate per 1,000 of the population from small pox was -194. Contrary to expectation so far, March, 1903, no recrudescence of the 27 disease has occurred in London or its suburbs, and owing to the free use of vaccination and revaccination, an epidemic of such dimensions as that of 1902 is not likely to occur for some years. That some permanent provision should be made for small pox patients is very patent, and if your arrangement with West Ham Corporation cannot be renewed, some day a serious difficulty will be found in providing accommodation when possible sites will be farther and farther removed from your district, and the value of land enhanced. Until the Legislature makes vaccination in infancy, re-vaccination during school life and adult life compulsory, we may expect periodical recurrences of an ever-increasing expenditure. When the inmates of an attacked house availed themselves in time of re-vaccination not one took the disease, but where they refused, one or more were stricken down, and in many instances where a second or third person caught the disease, the remainder were glad to avail themselves of vaccination or revaccination, with benefit to themselves by immunity from the disease. The 146 cases occurred in 100 houses, and were scattered throughout the district. I made a personal examination of every case, which entailed a very large amount of time and labour, but I felt that these visits were necessary in the public interest In no case was there any difficulty with the doctor in attendance on the patients, and many medical men invited my opinion in doubtful cases. Printed lists were issued weekly to every medical practitioner in the district, showing where the sufferers resided, and thus keeping those gentlemen on the qui vive, a proceeding that must have been very helpful to them in their practice. By prompt removal of the patients, the distribution of the leaflets, and by the efficient way in which Mr. West and those under him carried out their duties, your Authority did all in its power to check the spread of the disease. During the year Dr. Dharra Mair had an interview with your Chairman, the Chairman of the Sanitary Committee, Mr. West, and myself, and I believe that he too felt satisfied that you were doing everything in your power to check the disease and taking every precaution that was known to be feasible or useful. The 146 cases of small pox cost your authority £2,289 12s. 2d. SCARLATINA OR SCARLET FEVER. The number of cases notified during the year was 560, compared with 008 the previous year. 28 On page 24 will be seen the number of cases notified each year since 1889, when notification became compulsory. The numbers varied from 597 in 1893 to 125 in 1891. The Scarlet Fever sickness rate per 1,000 of the population has varied from 2 in 1890 to 11 in 1893. The years following 1893 till 1902 varied between 4 and 7 per 1.000 or a mean of 4'8. Assuming four to be the normal rate, we may expect to have yearly, for some time, 450 cases to deal with. Six deaths resulted from the disease compared with 13 deaths in 1901. Generally the cases were of a very mild character, and those of greatest severity went to the Sanatorium. A number of the cases were complicated with Diphtheria, and in the Report of the Sanatorium will be found further details. The death-rate from Scarlet Fever was "06, nearly, or half what it was in 1901, and less than half of what it was in England and Wales. The case rate was 1.07 persons dying in every 100 attacked, or half what it was in the previous year. Four per 1,000 is a "permissible" mortality, seven times greater than this district. Of the six deaths, two were under five years and 187 of the 560 cases notified were of persons under five years of age. The plans prepared and submitted to the Local Government Board for a further 24 bed Block, with additions to the Administrative Block, a Discharge Block, Ambulance Station and Cottages for the Engineer and Gasmaker, were sent back for further consideration, and are still the subject of anxious thought with your Council. I feel sure the increased accommodation is urgently needed and that the difficulty of economy of construction will be got over. The incidence of Scarlatina in the various wards will be seen on page 23, Table XIII. DIPHTHERIA AND MEMBRANOUS CROUP. One hundred and forty-two cases of Diphtheria and eight cases of Membranous Croup were notified during the year; compared with the previous year, we have had 180 fewer cases of Diphtheria and three cases fewer of Membranous Croup. The sickness rate for these diseases for the year was 1.4 per 1,000 of the population compared with 3.4 in 1901, 5.6 in 1900 and the mean of 3.25 for the years 1890-1901 inclusive. Of the 150 cases notified, 17 deaths resulted from Diphtheria and four from Croup, ten of the 17 deaths from Diphtheria occurred at the Sanatorium. 29 These deaths represent a mortality rate of .2 per 1,000, and a case rate of 14 per 100 attacked. As in last year, two in every 17 attacked from Diphtheria, and half those attacked by Croup, died. The death.rate from Diphtheria is below that for England and Wales as a whole. A steady and marked decline in the sickness and death.rate of these diseases has occured since 1900, which is very gratifying. How much of it is due to natural conditions, and how much to the Isolation Hospital provision, would be difficult to determine. The following table shows the estimated population, the number of cases of Diphtheria and Membranous Croup, the attack rate since 1890, and the death.rate since 1898:- TABLE XV. Years. Population. Number of Diphtheria cases. Rate per l,ooo. Membranous Croup cases. Death.rate. 1890 46,500 129 2.5 3 - 1891 47,000 153 3.22 9 - 1892 49,400 137 2.77 17 - 1893 52,000 142 2.73 11 - 1894 57,000 129 2.26 15 - 1895 61,000 198 3.24 10 - 1896 65,000 124 1.9 6 - 1897 70,000 152 2.17 6 - 1898 77,000 225 2.9 9 59 1899 83,000 338 4.0 7 88 1900 91,000 516 5.6 11 .86 1901 97,000 322 34 11 .39 1902 101,318 142 1.40 8 .20 The Local Government Board form, on page 23, shows the distribution of the cases of Diphtheria according to wards. 30 The following table shows the distribution of cases of Diphtheria in the various wards, since I have been your Medical Officer of Health :— TABLE XVI. Diphtheria prevalence in Wards for the Years 1898 to 1902. Year. St. James Street. High Street. Hoe Street. Wood Street. Northern. Population. No. of Cases. Rate per l,ooo. Population. No. of Cases. Rate per i,ooo. Population. No. of Cases. Rate per 1,000. Population. No. of Cases. Rate per 1,000. Population. No. of Cases. Rate per 1,000. 1898 17,620 37 2 15,320 54 35 22,019 67 30 13,140 65 5 0 11,900 11 10 1899 21,942 112 5 19,452 79 43 21,523 81 30 13,888 45 32 10,478 28 2.6 1900 23,133 203 9 19,936 107 5.0 23,039 64 3 0 14,767 104 6.9 14,508 49 32 1901 23,218 144 6 19,886 74 37 21,508 53 2.5 15,512 41 2.6 16,884 21 1.3 1902 23,000 43 1.87 20,000 26 1.3 22,000 25 114 16,000 25 1.56 20,000 23 1.15 31 As pointed out in previous reports, the St. James' Street Ward has the greatest number of cases, a number in excess of the other Wards, taking population as a base, Wood Street comes next, Hoe Street and High Street practically the same rate and the Northern Ward the lowest. The decline in rate is most marked in St. James' Street and High Street Wards, the former falling from 6 to 2 per 1,000, the latter from 3.7 to T3 per 1,000. ISOLATION ACCOMMODATION. During the year every case of Diphtheria and Membranous Croup willing to go to the Sanatorium was admitted. Owing to the fewer cases occurring during the year, compared with 1901, the Sanitary Committee decided to reserve one pavilion only for Diphtheria, and C Block was consequently thoroughly disinfected and cleansed for the reception of Scarlet Fever cases. Up to the time of writing this report, this provision was found ample, but 16 beds for Diphtheria can in no sense be considered adequate, and possibly even before the projected additions are completed, your Authority may have to revert to the original conditions. To provide adequate accommodation for Diphtheria is an expensive proceeding, and how this can be done without having many empty beds at times I fail to see, knowing how the incidence of the disease varies monthly, rising from 6 in June to 19 in July, 17 in September, and falling to 8 in December in a very favourable year. What applies to Diphtheria applies with more force to Scarlet Fever Taking roughly the items of expenditure at the Sanatorium for the year ending March, 1902, you paid £1,024 in salaries and wages, £174 in rates and taxes, £52 for water, £294 for fuel, £20 insurance, interest on loans £797, instalments on loans £968, or a total of £3,329, equal to £64 per bed when empty, or over 24s. per week per bed. The actual cost for food was less than £9 per bed, or 4s. 6d. per week, but when horse hire for ambulance, medical and surgical sundries, clothing and drapery are added, the cost becomes a little over £20 per patient, or more than double. This expenditure includes £158 for horse hire for ambulance, £155 for medical and surgical sundries, and £302 for clothing. It will be readily seen that no just conclusion can be arrived at as regards costliness of isolation provision, according to cases treated, except the circumstances are known, but in my judgment, although 32 the amount of money spent seems excessive; in "the administration" of the Hospital, it has been spent judiciously, and the public have had value for their money; and if Diphtheria can be kept within reasonable limits and its death rate of 1 in 8 reduced, your Authority need have no regrets. I have received the following Report from Dr. Cameron, the Resident Medical Officer at the Sanatorium: - There were 226 patients admitted during the year 1902. Of these, 139 were sent in as Scarlet Fever, 85 as Diphtheria, and 2 as Scarlet Fever and Diphtheria. The following table gives the number each month: - Scarlet Fever. Diphtheria. Scarlet Fever and Diphtheria. Total. January 7 7 - 14 February 7 3 - 10 March 4 9 1 14 April 9 6 - 15 May 6 8 - 14 June 11 5 - 16 July 23 13 - 36 August 15 6 - 21 Sept. 16 7 - 23 October 9 7 1 17 Nov. 20 9 - 29 Dec. 12 5 - 17 139 85 2 226 The average number of patients in Hospital for the year 1902 was as follows: - January 24 February 20 March 22 April 21 May 21 June 24 July 28 August 39 September 39 October 39 November 39 December 37 83 There were 16 fatal cases during the year. Of these, 9 were Diphtheria, 6 Scarlet Fever, and 1 Scarlet Fever and Diphtheria. The operation of Tracheotomy was performed in two cases: one died from syncope thirty-six hours after the operation. There were several cases of Post-Diphtheritic Paralysis, 3 of which were of a severe type. One convalescent Diphtheria patient developed a well-marked Herpes of the leg. Among the Scarlet Fever patients, there were 3 who suffered from Nephritis, 4 from Bronchitis, 5 from Abscesses in the neck, and 1 from Facial Paralysis. One patient was admitted with burns of head and neck. One patient developed Chicken Pox shortly after admission, while another had Erysipelas. As there is with the present arrangement an inevitable delay in hearing the result of Bacteriological examinations, it is suggested that it would be desirable to have facilities for such examinations provided in the Hospital. J. D. CAMERON. TYPHOID FEVER. Eighty-nine cases of Enteric Fever were notified during the year, as compared with 73 in 1901, 86 in 1900, 119 in 1899, 76 in 1898, 78 in 1897, and 193 in 1896. On page 21 will be seen the number of cases occurring in each month during the year. In February we had only one case, but in October they had risen to 15, the greatest number notified in any month. Of the 89 cases notified, 32 were removed to various hospitals, the remainder were treated at their homes. The 89 cases occurred in 81 different houses, and caused 13 deaths, 4 being between 5 and 15 years of age, 3 between 15 and 25 years, and 6 between 25 and 65 years. The cases were distributed all over the district, and could not be traced to water or milk contamination, careful enquiries being made in each case. The following diagram shows at a glance the number of cases for 12 months:— c 34 The distribution of the cases according to Wards, and the number of deaths are represented in the following diagram:— Wards. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Population St James St 23.000 High St 20.000 Hoe St 22.000 Wood St 16.000 Northern 20.000 35 The cases were distributed as follows:— St. James St. High St. Hoe St. Wood St. Northern. Total. 17. 20. 23. 13. 16. 89. No death occurred in the St. James Street Ward, two occurred in High Street, 5 in Hoe Street, 3 in Wood Street, and 3 in the Northern Ward. The death rate for Typhoid in your district was .12 per 1,000 compared with T3 for England and Wales, and .15 for the "76 great towns." One person in every 1,150 of the population contracted Typhoid, and one person in every seven attacked died. The provision of Isolation Hospital accommodation for Typhoid cases seems to me to be worthy of serious consideration now that many general hospitals are refusing admission to such patients. SUMMER DIARRHCEA—EPIDEMIC OR ZYMOTIC ENTERITIS. Under this heading 28 deaths occurred during the year, 21 being under one year and four between 1 and 5 years. This number represents the smallest fatality occurring from this disease at any time in your district. To the very wet summer we experienced this low mortality is mainly attributable. Under the heading Infantile Mortality Rate, page 14, the history of Dr. Thresh's efforts with the co-operation of Mr. Buxton and the various Authorities, will be found what action has been and is proposed to be taken in the checking of Diarrhœa in children under one year of age. The special efforts of former years by the distribution of leaflets on Infant Feeding and the prevention of Summer Diarrhoea, and object lessons by the lady teachers of our numerous schools on milk as a food, were repeated in the early summer. What good these effect is difficult to measure, but that they are steps in the right direction I have no doubt. 36 The following Table shows the death rate in the various wards from this disease:. TABLE XVII. St. James Street. High Street. Hoe Street. Wood Street. Northern Ward. Number of Births 764 733 648 480 791 Birth.Rate 33.22 36.65 29.45 30 39.55 Number of Deaths 5 12 2 2 7 Death.Rate .21 .6 .09 13 .35 The deaths from Diarrhoea for the whole district was .27 per 1.000. The similar rate for England and Wales was .38 and for the "76 great towns " .54, or exactly double the rate in this district MEASLES AND WHOOPING COUGH. During the year Measles caused 14 deaths and Whooping Cough 23 deaths, compared with 43 deaths from Measles and 26 deaths from Whooping Cough in 1901. Twenty.one of the 37 deaths occurred in children under 1 year. Compared with Scarlatina and Diphtheria, Measles and Whooping Cough caused 14 deaths more than those diseases whose prevention costs your Authority over £5,000 per annum. "The fear, which Scarlatina and Diphtheria engenders in most people, contrasts strangely with the utter disregard shown towards complaints that are far more fatal and equally infectious—familiarity breeds contempt." The death rate for Measles was .13 as compared with .5 for England and Wales. The death rate for Whooping Cough was .22 as compared with .29 for England and Wales. Both rates are very satisfactory—the country generally having a rate three times greater than that of your district. 37 The following figures supplied by Mr. Jones, the School Board Officers' Superintendent, will show the number of children away from school during the year from these alleged causes:— TABLE XVIII. Months. Measles. Whooping Cough. Weeks. January 30 127 4 February 44 216 4 March 164 360 4 April 94 295 3 May 142 430 5 June 140 181 4 July 143 273 3 August 28 63 1 September 203 238 4 October 296 233 5 November 738 205 4 December 1,187 174 3 Total 3,209 2,795 44 INFLUENZA. Thirteen deaths were registered during the year as due to this disease, all being in persons over 25 years, as compared with 6 deaths in 1901. Ten of the deaths occurred in the first quarter, two in the second quarter, and one in the fourth quarter of the year. 38 In no sense was the disease epidemic, and was usually attended by some other condition, such as Bronchitis and Pneumonia. Since 1889 the following are the number of deaths directly ascribed to Influenza:— Years—1890 1891 1892 1893 1894 1895 1896 1897 1898 1899 1900 1901 1902 Deaths 3 21 25 10 9 23 10 7 19 30 20 6 13 PUERPERAL FEVER—LYING-IN FEVER. Seven cases of Puerperal Fever were notified during the year and 10 deaths were certified as due to "Accidents and Diseases of Parturition," compared with ten notifications in 1901, and five deaths. Under the heading Puerperal Fever are included "Septicfemia, Pyaemia, Septic Peritonitis, Septic Metritis, and other septic inflammations in the pelvis, occurring as the direct result of childbirth." The infectivity of Lying-in Fever is so marked, and its fatality so great, that in every case careful enquiries are made as to the sanitary conditions of the house and the likely source of infection. The nurse in attendance is instructed how to act and advised to abstain from attendance on others for four weeks and until she has had her clothing disinfected by boiling and washing, or at the Council's disinfecting station. In no cases could the nurse in attendance be held liable for infection. The death rate from "Accidents and Diseases of Parturition" was .09 per 1,000, or about the average for England and Wales. PHTHISIS OR CONSUMPTION Eighty-seven deaths were registered from this disease as compared with 86 the previous year. Including Tuberculosis of Meninges and other forms of Tuberculosis, the deaths due to this preventable disease were 124, equal to a rate of l.2 per 1,000 of the population Two in every 19 persons dying died from Tuberculosis. The death-rate from Tuberculosis of the lungs, or consumption, was 85 per 1,000, or about half what it was for England and Wales during the period of 1886-1890. The deaths from Tuberculosis in England and Wales during the period 1881-90 was 2.4, or three times greater than your district for the year under review. Of the total deaths in the district 7 in every 13.4 were from Consumption, compared with 1 in 15 for 1901. 39 Looking over Schedule B, page 53, it will be seen that Consumption causes more deaths than Small Pox, Scarlet Fever, Diphtheria, Croup, Typhoid and Measles, and at a time of life when man's capacity for work and his value to the country is greatest. Small Pox, Scarlet Fever and Diphtheria prevention have cost your authority £7,500, during the past year, while practically nothing has been done in the way of prevention of Phthisis except the disinfection of rooms when deaths took place. In last year's report I pointed out that at present we have no means of knowing who is suffering from Consumption, and although disinfection is offered whenever a case proves fatal, that is not enough. Before death, infectivity is constant and active; and I would suggest that every practitioner should be permitted to send the sputum of any suspicious or doubtful case to Dr. Thresh for bacteriological diagnosis, and the expenses paid by your Authority If a positive diagnosis is made, the case should be immediately notified and a fee paid as under the Act of 1889. The disease is a typical preventive one, and the loss and misery produced by it incalculable. As many of the sufferers are neither paupers nor persons able to afford to pay for the usual Open-air Sanatorium treatment, which is so effective, and the preventable and curative nature of the disease is so well established that Authorities like Sheffield and Brighton are either contemplating building Sanatoria or maintaining beds at some of the existing ones. "The provision of Sanatoria for Consumption is above all a case for philanthropy, and the philanthropist would have the satisfaction of knowing that by this means he was giving a fresh lease of life to many whose continuance as wage earners is essential for the welfare of the families of the poor. I feel sure that much can be done by way of voluntary notification and education of the public with very little expense."—N ewsholme. OTHER DISEASES. Other diseases of the Respiratory Organs—not Consumption—caused 230 deaths, compared with 189 in 1901. Cancer caused 52, practically the same as last year, and Cirrhosis of the Liver 10 deaths, as compared with 16 in 1901. 40 No cause was certified as due to Alcoholism. This fact may be accounted for by the prejudice naturally felt in certifying Alcoholism if any other cause was probable. Cirrhosis of Liver is a euphonious way of saying died from drink. If all the deaths indirectly due to alcohol were recorded the figures would be hundreds instead of tens. Here again we can only rely upon the education of the people. WATER SUPPLY. During the year the supply of water was good and constant, and entirely derived from the East London Water Company. In July and August there were 22 cases of Typhoid notified, and I had analyses, chemical and bacteriological, made by Dr. Thresh and Mr. Leo Taylor of the water supplied; the results were quite satisfactory. I have carefully noted the monthly analyses at the Government Laboratory of the waters of the several Water Companies, and felt that further analyses by your Authority were unnecessary. The School Board have continued to make use of the Public Baths to teach swimming to the children in the Elementary Schools, a form of education that tends to habits of cleanliness and physical well being. COW SHEDS, MILK SHOPS AND DAIRIES. The Model Bye-laws of the Local Government Board governing dairies are in operation. Repeated visits to the various Cow Sheds and Dairies have been made throughout the year and no serious complaints have been made, nor was interference called for by your Authority. No disease could be attributed as the direct result of milk or due to those employed in its supply or distribution. In the coming year it is to be hoped that Humanised Milk for Infant Feeding will be produced by some public spirited dairyman. OFFENSIVE TRADES. No complaints have been made during the year, nor was any difficulty experienced in dealing with the fat-boiling premises situated in the Northern Ward, the only offensive trade carried on in the district 41 REMOVAL OF HOUSE REFUSE. Systematic removal of house refuse takes place twice a week directly by the Council's workmen, under the supervision of a foreman, who is responsible to the Surveyor. No complaints have been made, and the work generally has been efficiently done. In previous reports I referred to the inadequate and dirty receptacles used for storing house refuse on premises, and suggested to the Sanitary Committee, in November, 1901, the necessity of compelling householders to provide proper dust-bins, under Section 36 of the Public Health Act, 1875, and Section 11 Public Health Acts Amendment Act, 1890. In January, 1902, the Clerk and Medical Officer were ordered to prepare draft of new Bye-laws for the collection of house refuse. After consultation with the Local Government Board and adopting amendments suggested by that body, the Council, on February 24th, 1903, resolved that the Bye-laws be printed and the usual advertisements be inserted, and that the Seal of the Council be affixed thereto, and a copy forwarded to the Local Government Board for confirmation. The Bye-laws provide that— The occupier of any premises on which any house refuse may from time to time accumulate, shall, on such days and at such hour of the day as the Council shall fix, and shall notify by public announcement in the district, deposit in a conveniently accessible position on the premises a removable receptacle or receptacles, properly constructed of galvanised iron or other suitable metal, and of such capacity not exceeding three cubic feet each, as may be sufficient in the aggregate to contain the house refuse which may accumulate on such premises during a period not exceeding one week, and in which such house refuse shall be placed for the purposes of removal by or on behalf of the Council. Owing to the increasing population and consequent difficulty of finding a suitable shoot for house refuse, the sooner your Authority erects a Destructor the better on sanitary and economical grounds. SEWAGE DISPOSAL. In 1900 power to borrow £33,250 for the purpose of laying down septic tanks, bacterial beds and the necessary plant for sewage precipitation, was sanctioned 42 Since then the disposal of the sewage and the production of a satisfactory effluent have been sources of anxiety to the Council, but nothing of a permanent or satisfactory nature has been accomplished. The treatment of the sewage by precipitation by the aid of lime and "black ash" and iron sulphate, followed by irrigation over the Sewage Farm, has been attended with varying results. With the ever-increasing population of the district and consequent increased amount of sewage to be dealt with, the question becomes pressing if your Authority is to avoid trouble with the neighbouring Authorities. During the year a deputation visited Barrhead and other Sewage Works, owing to a resolution of the Council in 1901—"That the time has arrived when the Council should make arrangements for either carrying out the system of Septic Tanks, or make vast improvements at our Sewage Works, so as to be able to treat successfully the enormous increase of sewage owing to the increase of inhabitants the last ten years," and made a valuable report with suggestions, and concluded by reporting that " the removal of the sewage out of the district would be preferable" to any system that could be devised, and that it would be preferable to continue our present system, with amendments, rather than rush into heavy expenditure in the laying down of an entirely new system of treatment. Practically since that report was issued in March, 1902, little has been accomplished, with the exception of some underdiaining on portions of the Farm. In July the Lea Conservancy Board issued a notice to discontinue the alleged pollution of the Dagenham Brook, and a letter was received from the M.O.H. of the Borough of Hackney, inviting this Council to form a deputation to the Lea Conservancy Board as to the carrying out of their scheme for the drainage of the Lea Valley. On October 8th, the Lea Conservancy Board asked for an interview with the Council as to their proposed schemes for the drainage of the Lea Valley. On October 27th, your Council in Committee met the deputation and recommended that a meeting should be held at an early date to consider the matter, and on November 14th it was agreed, " That the Council looks upon Scheme B with favour, and that this Council hopes that all the other authorities along the Lea Valley will also favour Scheme B, and that those authorities will respectively do what lies in their power to agree upon some method of carrying out this scheme, and that the Lea Conservancy Board be asked to call a meeting of representatives of the various authorities concerned as early as possible." 43 It is to be hoped that strong representation will be made to push on this scheme, and that the Council should not only favour the scheme, but warmly support it. A combined drainage scheme, carrying away the sewage from your district, would be the best solution of our difficulties and those of our neighbours, besides releasing a large quantity of land for other more useful purposes. There were no complaints of smells arising from the sewers in the streets. The Surveyor has erected ten ventilating shafts, 30 feet high, at points where sewer gases were most likely to accumulate, and there are now throughout the district fifty-one of these shafts. HOUSING OF THE WORKING CLASSES. Ample and sufficient accommodation is provided in your district, and practically there is no overcrowding. The rents prevailing for accommodation near the railway stations are in excess of what the average workman can pay, although within the means of the thrifty artisan, and much still might be done under Part 3, Housing of the Working Classes Act, by judicious municipal enterprise in the erection of cheap selfcontained workmen's cottages, when the proposed scheme of Electric Tramways is completed, and if the City and N.E. Suburban Electric Railway scheme become an accomplished fact, very large tracts of unoccupied land will be available for buildings of this description. All new buildings have to conform to the bye-laws (Model Bye-laws of the L.G.B.), and are supervised by the Surveyor, and two Building Inspectors are constantly employed under his supervision. That .this latter precaution is absolutely necessary is apparent, considering the number of new houses built yearly. MORTUARY This building, erected in 1901, and fitted up for the reception of infectious and non-infectious bodies, with post-mortem room attached, is of the most modern type, and has been a great acquisition to the district. During the year under review, a commodious building, suitable for the holding of inquests, and fitted up for that purpose, has been erected, and in future there will be no need to hold inquests at publichouses. The Coroner and his jury, as well as the public and press who have to attend, will appreciate the new order of things. 44 FACTORY AND WORKSHOPS ACT, 1901. Under this Act, which came into operation on January 1st, 1902, important and increased duties have been imposed on Sanitary Authorities, and the Medical Officer of Health is required to report on the administration of the Act, so far as the administration is in the hands of the District Council. The duties imposed by the Act, relate to Factories, Workshops and Workplaces. Laundries do not come within the definitions of Factory and Workshop, but under Section 108 of the Act, they are so far as sanitation and means of escape from fire are concerned, to be treated as Factories if mechanical power is used; if mechanical power is not used, as Workshops. Factories and Workshops are defined in the Act, but not Workplaces, but the latter are supposed to include such places as kitchens of restaurants and livery stable yards. In the case of Factories the Council is charged with the duty of seeing that every "factory" in its district is provided with the means of escape in the case of fire. This matter I have brought before the Sanitary Committee, and that duty was imposed on the Surveyor, and I believe carried out In company with Mr. West, I have visited the Factories in your district, and saw that the requirements of Section 22 of the Public Health Amendment Act were carried out, and suitable sanitary conveniences were provided. Workshops and Workplaces.-—The number of these premises on the register under the Act, at the close of the year, was 348 domestic workshops, 47 laundries, 51 retail bakehouses, and 55 other premises. The duties imposed in regard to these are classified under four headings, viz.:— 1. Sanitary condition of workshops and workplaces generally. 2. Provision of means of escape from fire. 3. Special sanitary regulations for bakehouses. 4. Homework. No. 1. Sanitary conditions include—(a) the cleanliness, (b) the air space, (c) ventilation, and (d) drainage of floors of workshops and workplaces where women are employed. 45 Systematic inspections were made during the course of the year by one or other of the Sanitary Inspectors, and cards, with the number of workers allowed for accommodation provided, were hung up in the workrooms. One workshop was found to be overcrowded and two required improved means of ventilation, while one laundry needed improved drainage for the floor. In each case the defects were remedied. Nearly all the workshops in your district are “Domestic Workshops,” that is, "premises where the only persons employed are members of the same family dwelling there," and as there is practically no overcrowding in your district, the sanitary conditions are good. The chief workshop industries of this parish are blouse making, collar and shirt making, tie making, and tailoring, No. 2. Safety from Fire.—This provision has been already referred to under Factories, but I might point out to your authority that under Section 15 of the Act a new and important power is given to your Council to make bye-laws providing for means of escape from fire in the case of any factory or workshop. That more and more Factories are being removed from London and coming into districts like yours, makes it an important consideration, and necessary precaution to safeguard the workers. No. 3. Bakehouses.—There are 51 retail bakehouses in your district and systematic inspection has been made throughout the year, and the bye-laws enforced, which are practically the same as the General Statutory Requirements laid down in the Acts. The Act defines an underground bakehouse as one, if any room used for baking or for any process incidental thereto, is so situated that the surface of the floor is more than three feet below the surface of the footway of the adjoining street. There are at present six such bakehouses in your district. Under Section 101, after the 1st of January, 1904, it will not be lawful to use any underground bakehouse (whenever established) unless the Council are satisfied that it is suitable for the purpose in regard to construction, light, ventilation, and in all other respects, and have given it a certificate of suitability. This provision will apply to all underground bakehouses whether wholesale or retail. This section places great responsibility on your Authority, and the duty you will be called upon to perform is of very great importance in the interests of Public Health. 46 To carry out the provisions of the Act without apparent hardship to some individual is impossible, but the intentions of the Act are quite evident. A Special Committee of the Incorporated Society of Medical Officers of Health in November, 1901, carefully considered and discussed a memorandum on Underground Bakehouses, drawn up at the special request of the Committee, by Dr. Niven, M.O.H. of Manchester, and the Society agreed that certain requirements as to light, construction and ventilation, &c., were indispensable before a certificate was given under Section 101. (a) As to construction the provisions among others demand that no underground bakehouse should be less than 8 feet in height, and if the floor area exceeds 300 square feet the height shall be at least 8 feet 6 inches, and no underground bakehouse shall have a cubic capacity clear of the oven of less than 1500 cubic feet. The other provisions required deal with walls and ceilings and staircases. (b) Light—The underground bakehouse should be adequately lighted with day-light so that an Official Copy of the Abstract of Factory and Workshops Act may be ordinarily read in all parts of such bakehouse between 11 a.m. and 3 p.m. (c) Ventilation.—This shall be so arranged that the circulation of air is confined to the underground bakehouse and the ventilation must be adequate, that is, provision must be made for 3000 cubic feet of air per hour per person employed, must be provided in such a manner as to avoid the occurrence of draught. Arrangements for ventilation shall be such that the temperature of the underground bakehouse from October 1st to May 31st shall not exceed 800 Fah. except within half-an-hour after a batch of bread has been drawn. (d) All other respects:— Proper provision shall be made for the storage of flour elsewhere than in the underground bakehouse itself. Convenience for personal ablution shall be provided in a suitable position, and shall include a water-tap and a sink or lavatory basin of an approved character. The conveniences should be outside the underground bakehouse. Proper provision shall be, made for the despositing of wearing apparel outside the underground bakehouse. 47 Besides the foregoing the Act lays down general statutory requirements similar to what are already in existence for all bakehouses as given in the bye-laws. Applying the foregoing conditions to the underground bakehouses in your district, not one of them is 8 feet high—their height varies from 6 feet 2 inches to 7 feet 9 inches—two only have 1500 feet or more, and in all of these the flour is stored in the bakehouse. To comply with the other requirements laid down, extensive and expensive alterations would be required, and to obviate any apparent hardship the proprietors of the bakehouses should know at an early date the decision of your Authority. A special report on this very important question will be presented whenever required and before any action is taken. On the owners of three bakehouses special notices were served for cleansing ; all the others were done in the usual way twice a year. In one the gully was broken and replaced, in another the drains were reconstructed, and in one the ventilation was defective and rectified. In two instances the closets were found defective and repaired. The roof was defective in one and replaced. In all these instances notices were served, and in consequence the work done. No. 4. Home Work.—Under this heading, important powers are given to your authority for the controlling of the conditions under which certain classes of work are done in the homes of the worker. In Section 107-115, powers are given for the prevention of home work being done in (a) unhealthy dwellings (b) in premises where there is dangerous infectious disease. This power only applies to certain classes of home work, and the only kind carried on in your district is in connection with clothing and the repair of furniture and upholstery work. Under unwholesome dwellings, that is, from insanitary conditions, want of ventilation, or overcrowding, action was taken as previously recorded in three instances. Infectious Dwellings.—Under this heading, the mosr important work in connection with the Act was performed owing to the large number of domestic factories in this district. In order to carry out this work an ever-changing register has to be kept, which entails an enormous amount of clerical work, and the Act provides that every person employing out-workers shall forward to the 48 Local Authority, twice yearly (on or before 1st February and 1st August) a list of those so employed. Sixty-nine such lists were received during the year, representing 64 employers, nine contractors or middlemen and 288 out-workers. In every case where dangerous infectious disease showed itself in any premises where home work was carried on, the employer was notified immediately, no further work was taken in until the premises were disinfected, and any articles of clothing already made up or about to be made were disinfected. Fifteen cases of infectious illness occurred in domestic workshops during the year. In one factory, clothing that was supposed to have been in contact with a Small-Pox patient, was disinfected before removal. One notice was received from H. M. Inspector of Factories of the dirty condition of a workshop, and this was cleaned. Separate W.C. accommodation for the sexes was provided for, in one instance where it did not already exist. The following requirements are needed for the sanitary equipment of your district:— 1. Further Isolation Hospital accommodation. 2. Separate ambulances for Scarlatina and Diphtheria patients. 3. Separate vans for the removal of infected and disinfected articles- 4. More adequate provision for the disposal of sewage. 5. Refuse Destructor. 6. More public conveniences as in James' Street and Selborne Road. A Coroner's court and the public convenience in James Street were provided during the year. APPENDIX. Local Government Board Forms:— Table I. Table II. Table III. Table IV. Chart showing Birth, Death and Zymotic Death Rates. Local Government Board Form.] TABLE I.—For Whole District. Year. Population estimated to Middle of each Year. Births. Deaths under One Year of Age. Deaths at all Ages. Total. Deaths in Public Institutions W'stow General Hospital Deaths of NonResidents registered in District. Deaths of Residents registered beyond District. Deaths at all Ages. Nett. Number. Rate * Number. Rate per 1,000 Births registered. N umber. Rate.* Number. Rate.* 1 2 3 4 5 6 7 8 9 10 11 12 13 1892. 49,400 1717 34.75 250 145.6 880 17-81 35 915 18.0 1893. 52 000 1809 34.78 238 133.2 783 15.05 26 809 15.55 1894. 57,000 1813 32.00 240 129.6 670 11.75 47 717 12.6 1895. 61,000 2021 33.20 311 153.3 937 15.36 28 965 15.8 1896. 65,000 2101 32.30 270 127.5 772 11.87 45 817 12.5 1897. 70,000 2246 32.08 306 132.0 795 11.41 28 4 37 832 11.88 1898. 77,000 2294 29.80 390 169.5 974 12.65 16 15 60 1034 13.4 1899. 83,000 2835 34.14 482 170.0 1220 14.70 28 8 62 1282 15.44 1900. 91,000 3037 33.37 482 158.7 1166 12.80 23 13 88 1254 13.78 1901. 97,000 3210 33.10 473 147.6 1191 12.27 42 4 114 1296 13.35 Averages for years 1892-1901. 70,240 2307 32.95 344 1491 938 13.35 30 9 54 991 14.10 1902. 101,318 3426 33.81 394 115 1009 995 28 8 153 1154 11.38 * Rates calculated per 1,000 of estimated population. Area of district in acres (exclusive of area covered by water), 4,025, Total population at all ages, 95,125. Number of inhabited houses, 16,083. Average number of persons per house, 5.8.—At Census of 1901, 50 I. Institutions within the District receiving sick and infirm persons from outside the District. Walthamstow, Leyton, and Wanstead Children's and General Hospital. II. Institutions outside the District receiving sick and infirm persons from the District. Sanatorium, Chingford. III. Other Institutions, the deaths in which have been distributed among the several localities in the District Small-Pox Hospital, Dagenham. Small-Pox Hospital, South Minims. 51 Local Government Board Form.] TABLE II. Year. Population estimated to middle of each Year. Births registered. Deaths at all Ages. Deaths under 1 year. 1892 49,400 1717 915 250 1893 52,000 1809 809 241 1894 57,000 1813 717 240 1895 61,000 2021 965 311 1896 65,000 2101 817 270 1897 70,000 2246 832 306 1898 77,000 2294 1079 390 1899 83,000 2835 1282 482 1900 91,000 3037 1254 482 1901 97,000 3210 1296 481 Averages of Years 1891 to 1900. 70,240 2307 991 345 1902 101,318 3426 1154 394 Wards. DISTRIBUTION IN 1902. St. James Street 23,000 766 293 89 High Street 20,000 735 228 81 Hoe Street 22,000 650 224 55 Wood Street 16 000 482 183 64 Northern 20,000 793 234 105 52 The following Table shows Infectious disease according to Wards, and the number removed to Hospital:— Local Government Board Form.] TABLE III. Cases of Infectious Disease notified during the Year 1902. Notifiable Disease. Cases Notified in Whole District. Total Cases Notified in Each Locality. No. of Cases Removed to Hospital from Each Locality. At all Ages. At Ages—Years. St. James Street. High Street. Hoe Street. Wood Street. Northern. St. James Street. High Street. Hoe Street. Wood Street. Northern. Under 1 1 to 5 5 to 15 15 to 25 25 to 65 65 and upwards Small Pox 146 2 8 22 48 65 1 46 27 31 16 26 45 27 31 16 26 Cholera — — — — — — — — — — — — — — — — — Diphtheria 142 6 50 55 19 12 — 43 26 25 25 23 28 18 10 12 13 Membranous croup 8 2 5 1 — — — 4 — 1 — 3 — — — — 1 Erysipelas 131 3 8 14 22 79 5 33 23 25 19 31 1 — — — — Scarlet Fever 560 9 178 308 38 26 1 130 121 117 54 138 24 23 41 8 41 Typhus Fever — — — — — — — — — — — — — — — — — Enteric Fever 89 — 2 23 26 38 — 17 20 23 13 16 6 11 7 3 5 Relapsing Fever — — — — — — — — — — — — — — — — — Continued Fever — — — — — — — — — — — — — — — — — Puerperal Fever 7 — — — 3 4 — 2 3 1 1 — — — — — — Plague — — — — — — — — — — — — — — — — — Chicken Pox 777 51 396 302 26 2 — 201 157 109 157 153 — — 1 — — Totals 1860 73 647 725 182 226 7 476 377 332 285 390 104 79 90 39 86 Local Government Board Form.] TABLE IV. Schedule B. Table of Deaths during the year 1902, in the Urban Sanitary District of Walthamstow, classified according to Diseases, Ages, and Wards. No. Causes of Deaths All Ages Under 1 1 to 5 5 to 15 15 to 25 25 to 65 65 and upwards St. James Street High Street Hoe Street Wood Street Northern Total Deaths in Public Institutions in the District 1 Small-Pox 20 1 3 4 4 8 4 3 6 5 2 20 2 Measles 14 6 8 — — — — 3 5 2 — 4 2 3 Scarlet Fever 6 — 2 2 — 2 — 3 1 — 1 1 6 4 Typhus Fever — — — — — — — — — — — — — 5 Epidemic Influenza 13 — — — — 10 3 7 2 3 — 1 — 6 Whooping Cough 23 15 8 — — — — 5 5 4 3 6 — 7 Diphtheria, Membranous Croup 17 3 8 5 — 1 — 6 — 5 4 2 10 8 Croup 4 2 1 1 — — — 1 — — 3 — — 9 Enteric Fever 13 — — 4 3 6 — — 2 5 3 3 2 10 Asiatic Cholera — — — — — — — — — — — — — 11 Diarrhoea, Dysentery 23 18 3 — — — 2 5 10 1 1 6 — 12 Epidemic or Zymotic Enteritis 5 3 1 — — — 1 — 2 1 1 1 — 13 Enteritis 11 8 2 — — 1 — 4 1 2 2 2 — 14 Other continued Fevers — — — — — — — — — — — — — 15 Erysipelas 3 — 1 — — 1 1 — — — 1 2 1 16 Puerperal Fever — — — — — — — — — — — — — 17 Other Septic diseases 8 1 2 — 1 4 — 3 2 2 1 — 5 18 Intermittent Fever and Malarial Cachexia — — — — — — — — — — — — — 19 Tuberculosis of Meninges 13 4 6 2 1 — — 2 4 3 — 4 2 20 Tuberculosis of Lungs 87 6 — 2 9 68 2 21 22 17 14 13 16 21 Other forms of Tuberculosis 24 10 4 3 2 5 — 6 5 6 2 5 2 22 Alcoholism — — — — — — — — — — — — 23 Cancer 52 — — — 1 31 20 17 9 12 4 10 7 24 Premature Birth 68 68 — — — — — 12 15 9 10 22 — 25 Developmental Diseases 100 92 8 — — — — 22 16 15 18 29 8 26 Old Age 66 — — — — 1 65 13 17 11 13 12 31 27 Meningitis 28 14 10 2 1 1 — 6 4 8 4 6 4 28 Inflammation and Softening of Brain 7 — — — — 5 2 1 — 4 1 1 5 29 Organic Diseases of Heart 21 — — — 3 13 5 4 4 6 4 3 1 30 Acute Bronchitis 78 41 15 3 1 11 7 21 28 10 7 12 3 31 Chronic Bronchitis 47 — — — — 23 24 12 7 14 7 7 7 32 Lobar (Croupous) Pneumonia 52 7 3 4 1 29 8 16 4 6 17 9 7 33 Lobular (Broncho) Pneumonia 53 31 21 — — 1 — 17 8 8 9 11 — 34 Diseases of Stomach 10 5 1 2 — 2 — 2 1 3 1 3 — 35 Obstruction of Intestines 9 1 1 1 — 4 2 2 — 2 2 3 1 36 Cirrhosis of Liver 10 — — — — 9 1 3 — 3 2 2 1 37 Nephritis and Bright's Disease 16 1 — 2 — 13 — 3 5 4 — 4 2 38 Tumours and other Affections of Female Genital Organs — — — — — — — — — — — — — 39 Accidents and Diseases of Parturition 10 — — — 2 8 — 1 4 1 2 2 — 40 Deaths by Accident or Negligence 21 9 3 3 — 4 2 3 6 3 6 3 7 41 Deaths by Suicide 11 — — — 2 8 1 2 3 2 1 3 — 42 Deaths from Ill-defined Causes 1 — — — 1 — — 1 — — — — — 43 All other Causes 218 48 15 11 11 78 55 65 33 46 34 40 31 All Causes 1,162 394 126 51 43 347 201 293 228 224 183 234 181 53 Chart shewing the Birth, Death and Zymotic Death-rates, for the years 1880 to 1902 Birth-Rate. General Death-rate. Zymotic Death-rate 54 TO THE CHAIRMAN AND MEMBERS of the Walthamstow Urban District Council. Gentlemen, I have the honour to submit to you the report of work done through my department during the year 1902. Inspection has been made of 3,444 houses, and in 1,877 of them works of sanitary improvement have been effected under my supervision. House to house inspection has been made in the following roads, viz.—Fulbourn, Spencer, Chaucer, Macdonald, Garner, Hazlewood, Glenthorne, Haroldstone, Brunner, Lennox, Boston, Longfellow, Chelmsford, Stafford and Colchester Roads, Lennox Avenue and South Grove. In these roads, some being in the newer and most in the older parts of the district, the results of the inspections may be summarised as follows:—Insanitary conditions that could be described as at all serious, were discovered in slightly over 3 per cent, of them; overcrowding was discovered in four instances. The number of families averaged T58 per house, with an average of 3.5 rooms per family of 4 persons, and 6.4 persons per house as compared with the census returns of 5,8 persons per house for the whole district. Drainage.—The reconstruction and repair of house drains number, of the former, 212, and of the latter, 71, including the following blocks of premises:— 6, 8 and 10, Albert Road. 16 and 18, Arkley Road. 21, 23 and 25, Arkley Road. 68 and 70, Albert Road. 68 and 70, Beaconsfield Road. 47 and 49, Buxton Road. 4 to 20, College Place. 2 to 12, Church Terrace. 77 to 87, Collard Road. 7 to 11, Clarkson Road. 4 and 6, Cottenham Road. 10, 12 and 14, Essex Grove. 69, 71 and 73, Eden Road. 56 and 58, Forest Road. 2 to 32, Fairlight Road. 3 and 4, Gamuel Road. 27 and 29, Gladstone Road. 53 and 55, Granville Road. 38 to 42, Harvey Park Road. 42 and 44, Hazlewood Road. 55 50 and 52, Haroldstone Road. 42 and 44, High Street. 47 and 49, Higham Street. 21 to 81, Linford Road. 8 to 15, Lennox Avenue. 1 to 6, Linden Road. 24 to 30, Mayfield Road. 49 to 53, Myrtle Road. 91 and 93, Oakfield Road. 79 to 83, Oakfield Road. 19 and 21, Pretoria Avenue. 76 St. Mary's Road. 1 to 7, Stainforth Road. 75 to 81, Spruce Hills Road. 77 to 83, St. Andrew's Road. 4 to 14, Tower Hamlets Road. 60 to 66, Vallentin Road. 22 and 24, Westbury Road. 32 to 86, Westbury Road. 49 to 53, Woodville Road. 2, 3 and 4, Western Road. Infectious Disease.— The work in connection with Infectious Disease this year, owing to the epidemic of Small Pox, has been of unusually onerous character, and temporarily affected to some extent other branches of our work. Arrangements were made for the appointment of a temporary Assistant, but before he could get to work, the advantages of his appointment were discounted by the resignation of one of the permanent staff, and whose post was subsequently filled by the Assistant temporarily engaged, namely. Mr. Pointon. However, by some re-arrangement of the work and increased exertions, we were able to deal with the subsequent cases. The urgent necessity for dealing with each case immediately was appreciated by all my assistants, and they ungrudgingly devoted themselves to whatever work and time was required of them. In connection with the 146 cases which occurred in the district, the immediate "contacts" of course were numbered by hundreds—inmates, visitors and school children, and the whole of them were kept under observation for a fortnight after the removal of the patient from the house, and we have had the satisfaction of knowing that absolutely no spread of the disease occurred. Work Carried On.—In accordance with the requirements of the Factory Acts, in cases where needlework is done at home, the introduction of further work has been prohibited, and that which was already on the premises disinfected before being sent away. In fifteen cases this has been done. Library Books.—In 48 cases, books have been found in infected houses, from various libraries, and have been removed and disinfected, and notice given to the librarian of the particulars. Disinfection.—After removal or recovery of the patient, the bedding, &c., are removed from the room to the Council's Washington Lyon Disinfector, and the room is fumigated, stripped, limewashed, 56 cleansed, and thoroughly aired, and it is satisfactory to note that in no case has there been a recurrence of a disease after the usual incubatory period has expired. Seven thousand six hundred and fifteen articles of bedding, clothing, &c., have been disinfected in the Council's apparatus as follows:— Beds 896 Bolsters 748 Pillows 1,703 Blankets 1,846 Miscellaneous 2,422 Removal to Hospital.—The number of cases removed to hospital has risen from 30 in 1900, to 222 in 1901, to 409 in 1902. Of these, 228 have gone to Chingford, and 146 to Dagenham Small-Pox Hospital, 21 to the Walthamstow General Hospital, and the remainder, 17, to various London Hospitals. Factory and Workshop Act.—The number of premises registered under the Factory and Workshop Act has increased from 216 to 501, in consequence of the obligation cast upon authorities to communicate to each other semi-annually the names and addresses of any "Outworkers" residing in their respective districts. The work of inspection of these premises is most complicated by the constant changes in the lists, half of each succeeding list consisting of new names in place of the old ones who have ceased to be employed. Many of the outworkers being married women working at home, anxious to add to the family income, work under fair sanitary conditions, and it is rare to find any cause for complaint. The various matters dealt with have been supplied to, and are dealt with in the report of, the Medical Officer of Health. The special premises periodically visited, besides Factories and Workshops, include:— Slaughterhouses 12 Dairies, Cowsheds and Milk Sellers 99 Fishmongers 39 Offensive Trades 3 Only minor causes of complaint were discovered in any of these, which were readily attended to by occupiers when pointed out. The two premises situate in the Northern Ward, on which pig-keeping and wash-boiling are carried on, have been under constant supervision. With a desire to further improving the conditions, I visited another district where, I had heard, a satisfactory arrangement had been adopted 57 to avoid the escape of smells arising during fat-melting, but I found that though quite adapted for the conditions existing there, where the apparatus could be closed up and left, it was quite unsuitable for a place where men had to remain at the work. However, considerable improvements have been made during the year in each place by improved paving and reconstruction of boilers and exhaust flues, with a view of minimising the unpleasantness which arises in the course of the work. Food Suppxy.—The outbreak of disease at Derby from eating pork pies which were poisonous, has called renewed attention to the condition of premises used for the preparation of food. It was shown in that case that even where reasonable care was taken to maintain the place in a wholesome, sanitary condition, it was possible for very serious results to obtain. While we endeavour to secure in Walthamstow that any insanitary conditions removable by law or suasion shall not exist, yet we have frequent evidence that breaches of the sanitary laws might at any time provoke dire results. To see a man perched tailor-fashion on the pastry-board in the semi-darkness of an underground bakehouse, beating with his hand in a dish, a rich concoction for the best Christmas cakes, or to see a batch of confections laid in trays to air on the damp straw from the adjoining stable, are not without suggestiveness of evil, and are indications of what ignorance and carelessness may do. The constant observation of food exposed for sale has been maintained, and the market places regularly visited on Fridays and Saturdays. No legal proceedings have been found necessary during the year, but the following articles have been destroyed with the consent of the owners:— May 21st, 1902.—1 box of mackerel. „ 27th, 1902.—1 „ June 30th, 1902.—2 boxes of haddock. Aug. 2nd., 1902.—2 „ skate. Sep. 9th, 1902.—1 barrel of white herrings. „ 10th, 1902.—6 boxes of roker. „ 30th, 1902.—1 box „ Oct. 4th, 1902.—1 ,, „ „ 7th, 1902.1 „ ,, „ 17th, 1902.—2 boxes of codling. Dec. 22nd, 1902.—2 ,, skate. „ 30th, 1902.— 1 box of haddock. Sale of Food and Drugs.—Samples to the number of 143 have been submitted to the County Analyst, consisting of:— Milk 74 Butter 42 Coffee 23 Pepper 4 58 Of this total 135 were genuine, and 8 not in accordance with the law. Proceedings were taken against 7 vendors for various breaches of the Acts, with results as follows:— No. Article. Offence charged. Result. 4 Coffee. Mixture of 35 per cent, chicory Withdrawn, owing to informality. 16 „ ,, 65 „ ,, Summons dismissed. 18 „ ,, 70 ,, ,, 2s. 6d. and costs. 33 Butter. Margarine unlabelled £2 10s. and costs. 84 Milk. 9 per cent, added water Dismissed, warranty proved. 115 „ 20 „ ,, £5 and costs. 129 Butter. Margarine unlabelled and containing more than 10 per cent, of butter. £2 and costs. Ornamental Waters.—The removal of offensive deposit from the lake at Highams Park, referred to in last year's Report, has undoubtedly much improved the condition of the water; but at the time of the fall of the leaves this year—1902—complaints again arose as to smell. At one of my visits a very distinct and unpleasant smell was perceptible, but it subsequently ceased, and I have not perceived it since. The same trouble arose in connection with the ornamental waters in Lloyd Park, which contained the remains of several years' leaf-fall from the surrounding trees. The smell at last became so bad as to prevent many people from visiting the Park, and necessitated the emptying of the lake and the removal of the deposit from the bottom. As we know that nothing in the shape of sewage enters the lake in the Council's own waters, it is clear that the trouble entirely arises from vegetable accumulations, and if care is taken at the fall of the leaf to prevent them sinking, no serious trouble need arise in the future. Offal Removal.—The nuisance arising in the removal of fish offal every summer evening when the main streets are crowded has still continued, but as a result of renewed application to the Local Government Board, that Board has intimated its readiness to consent to a bye-law casting upon the person removing any such offal, the duty of conveying in receptacles of such a form and method of construction, as shall prevent the omission of effluvium therefrom, or shall effectually deodorise the material contained in them. If formal consent can be obtained to the bye-law in its final form before the hot weather returns, it will tend to remove what has been a source of an immense amount of trouble to your officers for many years. 59 Water Supply.—Seven samples of drinking water were submitted to the analyst, being one from a domestic well, and six from the East London Water Company's mains. The latter were approved, and the former was condemned, the use of water from the well being thereupon discontinued. The bulk of our work has needed only the service of informal notices and communications, verbal or otherwise, and in the general work of the department I sought the authority of the Council to serve statutory notices in reference to 118 cases, and in one case legal proceedings were necessary. In conclusion, I append a summary giving the details of the work, and Remain, Gentlemen, Your obedient Servant, W. W. WEST, Assoc. San. Inst Inspector of Nuisances SUMMARY. Drains tested 202 „ reconstructed 212 „ repaired 71 Manholes and clearing-eyes provided 120 Manhole covers 13 Obstructions removed 103 4-in. ventilation pipes fixed 112 New pans and traps provided to W.C.'s 205 Gully traps provided 296 Bell traps abolished 23 Rain-water pipes repaired or disconnected from drains 112 „ new 15 W.C. flush repaired or reinstated 165 „ new provided 26 „ disconnected from drinking water 43 60 SUMMARY—continued. Drinking water on main 41 Sinks or bath water repaired or renewed 143 Roofs repaired 67 Guttering repaired or new 115 Dirty houses 71 „ rooms 340 Overcrowding 8 Floors repaired 14 Yards repaired or paved 185 Sculleries paved 38 Ventilation provided under floors 78 Animals, improperly kept, removed 14 Dungpits provided or repaired 8 Cesspools abolished 2 Offensive accumulations removed 64 Cisterns cleaned or repaired 21 Vents repaired or lengthened 62 Cleansing notices 572 House pulled down 1 New floors 5 Service repaired 3 Yards drained 2 New sashs and frames, &c. 5 Brick arches repaired 5 W.C.'s cleansed and repaired 44 „ new 12 Ventilation improved (Factory and Workshop Act) 2 New sinks 19 Water reinstated 12 Soil pipes fixed or repaired 6 Premises disinfected 813 Articles disinfected at Chamber 7,615