WAL 82 Walthamstow Urban 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 1903. Walthamstow: Printed by Phelp Brothers, 62-64, Beulah Road. To the Chairman and Members of the Walthamstow Urban District Council. Gentlemen, I beg to present to you my Annual Report for 1903. I am pleased to say the Report furnishes abundant evidence of the healthiness and general good sanitary condition of the District. The general death-rate is the lowest recorded for the past twenty-four years, and nearly 2.5 lower than the average for the previous ten years, while the birth-rate, 33.25, is only slightly lower than in 1902, and nearly .5 higher than the average of the previous ten years. Compared with England and Wales, your birth-rate is 4.85 higher and your death-rate 4.32 lower than the country generally. Considering the working-class population you have to deal with, and the situation of your District, these figures are highly satisfactory. The Infantile Mortality rate (the number of deaths of children under one year for every 1,000 births) was the extremely favourable one of 113-7—one of the lowest recorded—and 30 lower than the average for the preceding ten years, as against 132 for England and Wales as a whole and 144 for the 76 Great Towns. The Zymotic death-rate, or the death-rate from the seven principal communicable diseases, was 1.97 compared with 2.65 for the previous ten years. The Sickness and Mortality rates for Infectious Diseases were both low, and compare favourably with previous years, notwithstanding the increased number of cases of Typhoid in September, October, and November. The Infectious Sickness rate, 6.2, was the lowest on record, and the marked diminution in the number of cases of Scarlatina and Diphtheria since the opening of the Sanatorium, would certainly appear to be due to the facility—inadequate though it be—provided for isolation of first cases. 4 Judged by these rates the expenditure involved in the prevention ot dangerous infectious diseases is justified. The Epidemic of Small Pox came to an end in 1902, and 2 cases only were notified in the year under review. The Report of the work dene by the Sanitary Inspectors under Mr. W. W. West, which is appended to this Report, shows the large amount of useful and necessaiy work done in his Department, and in my opinion is a very satisfactory record, and a proof of the capacity and conscientiousness of your officers. The large amount of clerical work entailed in carrying on the sanitary administration of such a large District was well and ably carried out by Mr. Partridge, but the accommodation provided for carrying out the most important work under your Council is neither suitable nor adequate. My work has been made easy and pleasant by the ever-ready willingness to help and sympathy shown by the heads of the other Departments under your control, and I wish to thank those gentlemen for much of the details in this Report. From the Sanitary Committee I have received encouragement and support throughout the year in every proposal made by me for the carrying on of the work entrusted to my care, and to the Chairman and Members I beg to tender my thanks. I beg to 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, 23,600, with a density of 94 4 persons per acre; the Northern Ward contains 23,500, with a density of 10 per acre ; Hoe Street, 22,500, with 64'6 per acre; High Street, 20,000, with 006 per acre; and Wood Street, 16,500, with 33 persons per acre. The whole district has a duplicate system of sewers, and practically every house water-closet accommodation, and water supplied by the East London Water Company. The St. James Street Ward varies from 18 to 54 feet above ordnance datum ; 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, is situated in the St. James Street Ward, and the reservoirs of the East London Water Company, about 330 acres in extent, are in the High Street Ward. POPULATION. In 1901, at the last Census, the enumerated population was 95,131; in 1891 it was 46,346 ; and 10 years previously it was 21,697. The Registrar-General estimates the population for mid year, 1903, as 106,290. A correct estimate of the population is very essential for making out the different birth and death rates, and short of enumeration the ordinary methods of calculating must allow for one to two per cent, error. In 1901 the population was thus distributed, as given by the RegistrarGeneral :— 6 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 1902, plans for 1,186 houses were passed and in 1903 plans for 908 houses were passed. Assuming that the houses of 1902 and half the number of houses of 1903 were completed and occupied at the mid year, the following table will give an approximate population, by a different method to that of the Registrar-General. TABLE II. Ward. No. of Plans Passed 1903. Houses fit for Occupation. Uninhabited (Census 1901). Occupied Mid-Year. Average Number per house in 1901. Population. James Street 197 4,102 1 in 21 3,90 7 6.0 23,442 High Street 16 3,266 1 in 24 3,130 6.3 19,717 Hoe Street 75 4,373 1 in 15 4.082 5.5 22,451 Wood Street 75 2,878 1 in 15 2,686 6.0 16,116 Northern 545 4,355 1 in 7 3,992 5.7 22,754 assumed 1 in 12 Whole District 908 18,974 1 in 17.4 17,797 5.9 104,482 The number of houses occupied is arrived at by assuming the same proportion is empty in 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 This population of 104,482 shows a difference of 2 per cent, compared with the estimated population of the Registrar-General arrived at, by his assuming that the population keeps growing at the same rate as in the intercensal period of 1891-1901. But assuming that the 17,797 houses had an average of 5.9 persons per house at census we arrive at 105,000. As the population of the different Wards, is impossible to get at accurately and allowing for the difference mentioned, I will assume that the numbers of inhabitants for the different Wards are as follows :— St. James St. High St. Hoe St. Wood St. Northern. Total. 23,600 20,000 22,500 16,500 23,500=106,100 These estimates are fairly accurate to base the various rates upon for the different Wards, but as pointed out the figures are only approximate. The population, as enumerated at the census of 1901, according to age, sex, occupation and wards, was received by me too late to make any use of it in last year's report. In the appendix will be found the return as supplied by the Registrar General. These figures are very interesting as showing the numbers of inhabitants at each age group and the sexes. It will be noticed that the sexes are pretty evenly balanced throughout the different ages in all the Wards except Hoe Street. In this Ward the females are a tenth more than the males, and this difference is maintained from 15 years onwards; especially marked from 15 to 35, and from 55 upwards. This may be accounted for by many more female servants being employed in this Ward, owing to the better-class character of the population. It will be seen that there exists a great variation in the characters of the population, according to age, in the different Wards, and this influence on death-rates and infectious sickness rates must not be overlooked. The following table shows how the population in 1901 was made up according to age, compared with England and Wales, and the average death-rate for the different ages throughout the country :— 8 TABLE III. All Ages. Under 5 years. Over 5 and under 10. Over 10 and under 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. England and Wales 1,000 129 119 110 100 90 149 114 85 58 33 13 Walthamstow. 95,131 13,916 12,608 11,079 8,786 7,768 15,810 11,969 7,069 3,721 1,710 695 Average Death-rates England and Wales. 17.7 54.7 3.85 2.25 3.4 4.7 6.3 10.65 16.75 32.7 61.8 153.6 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 „ 95,131 ,, 1903 Assumed Registrar General 106,290 No. of Persons per house (assumed) 5.89 No. of Persons per acre (exclusive of Sewage Farm and Reservoirs) 28.8 Total Births registered 3,535 „ Deaths „ of persons belonging to the District 1,178 No. of Deaths of Persons not belonging to this District 10 Natural increase of Population 2,357 Birth-rate per 1,000 of estimated population 3325 Death-rate 11.08 Death-rate corrected for age and sex 11.89 Zymotic Death-rate 1.9 Infantile Mortality Rate (or proportion which deaths under 1 year bear to 1,000 births) 113.7 9 BIRTHS—BIRTH.RATE. The total number of births registered during the year was 3,535 ; males, 1,754 ; females, 1,781. Twenty.nine of these (males 16, females 13) were born at the Union Workhouse. In 1902, there were 3,426 births; in 1901, 3,210; in 1900, 3,037; and in 1899, 2,835. The birth-rate for 1903 is 33'25, compared with 33.81 for the previous year, and 32.86 for the preceding ten years. The number of births over deaths, or the natural increase of the population, was 2,357, compared with 2,272 in 1902,1923 in 1901, 1783 in 1900, and 1553 in 1899. The birth-rate for England and Wales for 1903 was 28'4, or 4.85 below that for this district. The birth-rate for the country generally is the lowest on record. A diminishing birth-rate in the country must stimulate sanitary authorities to prevent the great wastage of infant life that is preventable. The ratio of male to female births was 100 to 101.5. Distributing the births as supplied by the Registrar over the various wards of the district, we have had in the four quarters :— 10 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 95 107 95 84 76 84 58 61 115 112 3 2 442 450 2nd quarter 101 104 111 88 88 84 59 48 90 105 5 3 454 432 3rd quarter 79 97 94 99 74 78 60 62 118 114 4 6 429 456 4th quarter 77 81 103 101 84 84 47 52 114 123 4 2 429 443 352 389 403 372 322 330 224 223 437 454 16 13 1754 1781 Totals 741 775 652 447 891 29 3535 Population 23,600 20,000 22,500 16,500 23,500 — 106,100 Birth-rate 316 39.1 29.24 27.45 38.1 — 33.25 Do. 1902 33.22 36.65 29.45 30.00 39.55 — 33.81 11 Hoe Street Ward has practically the same rate as in 1902; James' Street 1.6, High Street 2.5 higher; and Wood Street 2.5 and the Northern Ward .6 lower rates, presuming that the assumed populations of the different Wards are correct. Judged by these rates Hoe Street and the Northern Ward populations are fairly accurate, High Street Ward is under and Wood Street over-estimated. James' Street Ward had 23 and Wood Street 33 fewer births than in 1902, while High Street had 42, Hoe Street 4, and the Northern Ward 100 more than in 1902. DEATHS AND DEATH-RATES. WHOLE DISTRICT. During the year 1,065 deaths were registered as occurring in this district. Ten were of non-residents, and eliminated in reckoning the death-rate, while 103 deaths occurring in the Workhouse, 17 deaths at the Sanatorium, and 3 of residents outside the district are added. The total number of deaths belonging to the district was 1,178 ; males, 552 : females, 626. Only a few deaths were registered without a Coroner's or medical practitioner's certificate. No doubt many children, born alive and dying within a short time are certified as still-born, to save the expenses of burial. The corrected general death-rate for the district is 11.08 per 1,000, or 2.48 per 1,000, below the average (13.56) for the previous 10 years, and is the lowest recorded death-rate. The death-rate for England and Wales for 1903 was 15.4, or 4.32 greater than that of Walthamstow, and for the "76 Great Towns" the death-rate was 16.3, or .5.22 in excess of your district. As the populations of different districts vary considerably in their composition as to age and sex, and their death-rates in consequence, to make comparable the rates of one locality with another, these differences have to be taken into account and allowed for. The Registrar-General began in 1883 to apply a method of correcting the recorded death-rates of the Great Towns forage and sex distribution. The principle adopted is the construction for each town of a standard death-rate, i.e. a rate calculated on the hypothesis that the deaths at each age-period, in each sex, occur at the same rates as those obtaining not in the town itself, but in England and Wales, during the latest available decennial period. The standard death-rate thus found for each town is divided into that of England and Wales, and thus is found a factor for correcting, or the figures by which the recorded death-rate should be multiplied in order to correct for variations of age and sex distribution. Applying this method to the census of 1901 for this district the following Table is formed :— 12 TABLE V. Ages. Mean Annual U.R. for England and Wales 1896-1900 Population of Walthamstow, 1901. Calculated Number of Deaths. (Theoretical.) Males. Females. Males. Females. Males. Females. Persons. Under 5 59.6 49.9 6,961 6,951 415 347.3 762 5 under 10 3.8 3.9 6,241 6,367 23.5 25 48.5 10 „ 15 2.2 2.3 5,536 5,543 12 12.5 24.5 15 ,, 20 3.5 3.3 4,449 4,337 15.5 14.5 30 20 „ 25 5.1 4.3 3,752 4,016 19 17 36 25 „ 35 6.7 5.9 7,654 8,156 51 48 99 35 „ 45 11.7 9.6 6,004 5,965 70 57 127 45 „ 55 19.0 14.5 3,548 3,521 67.5 51 118.5 55 „ 65 35.3 28.1 1,721 2,000 60.5 56 116.5 65 „ 75 66.2 57.4 688 1,022 45.5 58.5 104 75 „ 85 144.3 131.2 251 374 36 49 85 85 and upwards 280.2 255.9 23 47 6.5 12 18.5 All ages 18.8 16.6 46,832 48,299 822 747.5 1,569.5 95,131 13 In this table the numbers of deaths at the different age-groups are not the actual but the theoretical deaths that should have taken place in this district. The total is 1,569, compared with the actual number, 1,191. From these figures is found the standard death rate, 16.49, and the factor for correction, 1.07. Multiplying the recorded death-rate, 11.08, for the year 1903 by this factor, a death-rate corrected for age and sex distribution is found, namely, 11.89 per 1,000, or a rate of 5.8 below that of England and Wales in 1896.1900, and 3.5 in 1903. One death was registered for every 90.2 persons of the population compared with 1 in 87'8 in 1902, and 1 in 75 for 1901. The ratio of male to female deaths was 100 to 113.4. ACCORDING TO WARDS. The deaths registered during the year and the death-rates for the Wards were as follows :— St. James Street. High Street. Hoe Street. Wood Street. Northern. Total. No. of deaths, 1903 285 234 229 189 241 1,178 Rate per 1,000 of estimated population 12.08 11.7 10.2 11.45 10.25 11.08 Birth-rate, 1903 31.6 39.1 29.24 27.45 38.1 33.25 No. of deaths, 1902 293 228 224 183 234 1,162 Rate per 1,000 of es. timated population 12.74 11.40 10.2 11.31 11.70 11.38 Birth-rate, 1902 33.22 36.65 29.45 30 39.55 33.81 The death-rates for the different Wards are practically the same as in 1902. Hoe Street has the same rate as last year. The Northern Ward appears to be 1.4 and the James Street .6 lower than in 1902, while High Street has .3 and Wood Street .1 higher than the previous year's record. The improved death-rates in the St. James Street and Northern Wards may be taken as real, and not due to over estimation of population. 14 INQUESTS. During the year 94 inquests were held, compared with 86 in 1902, 105 in 1901, 90 in 1900, and 83 in 1899. In 1898 62 were held, and the deaths requiring investigation vary between 7 and 8 per cent. of the total deaths. The 94 deaths were certified as follows:— 47 died from Natural causes. 10 „ Accidental suffocation through overlying. 1 „ „ „ in bed. 4 „ „ „ through drowning. 3 „ Accidental suffocation. 1 „ Suicide by drowning. 1 „ „ cut throat. 1 „ „ oxalic acid poisoning. 1 „ „ hanging. 5 ,, Shock of accidental burns or scalds. 1 ,, „ operation necessitated by accidental fracture of 1 ,, ,, haemorrhage from lung following tubercular disease. 3 ,, Accidental injuries sustained on G.E.R. 3 „ Injuries caused by being accidentally run over. 1 ,, Pneumonia following accidental fall. 1 ,, Haemorrhage of brain due to accidental fall. 1 „ Dislocation of cervical spine, haemorrhage into brain, and compression of brain, due to a fall. 1 ,, Cystitis, following fracture of femur. 1 ,, Rupture of blood vessel after phthisis. 1 „ Syncope, rapture of intestine. 1 „ Convulsions, due to improper feeding. 2 ,, Want of proper attention at birth. 2 ,, Exhaustion, malassimilation of food. 1 „ Unknown cause. 94 15 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 1903. TABLE VI. 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 2.43 1332 1000 '94 1813 717 32.0 126 1.8 129.6 1096 '95 2021 965 33.2 15.8 35 153.3 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 33.1 13.35 2.82 147.6 1914 '02 3426 1154 33.81 11.38 1.3 115 2272 Average 10 years 2479 1016 32.85 13.57 2.65 143.6 1458 '03 3535 1178 33.25 11.08 1.9 113.7 2357 Total natural increase of Population since 1891, 18,853. Total increase as shown by census, 1901, 48,779. Total increase as estimated to middle of the year 1903. 59,944. Total increase per cent., 129.3. INFANTILE MORTALITY RATE. There were 401 deaths of children under one year of age registered during the year, compared with 394 in 1902, 481 in 1891, 482 in 1899 and 1900. The Infantile Mortality rate, or the proportion which deaths under 1 bear to 1,000 births, is 118.7, the lowest rate since 1890, and 18.3 16 lower than that for England and Wales as a whole for 1903, 30.3 lower than the "76 Great Towns," and 21 3 lower than the "103 Smaller Towns." Looking at the preceding table, it will be noticed that a rate of 113.7 compares very favourably with the average rate, 143.6, for the previous ten years, and that it is to be hoped that under an improved system of education, when domestic economy and hygiene will take a prominent place in girls' schools, this low rate of 1137 will be maintained. That this low rate is largely due to the wet summer we have had, I have no doubt, but it is equally true that many of the causes tending to a high Infant Mortality can be removed by the possession of a fuller and better knowledge by mothers of their duties. To say that very few young mothers possess the requisite knowledge regarding infant feeding is but to repeat what is well known to every medical man, and to get over the rooted prejudices in favour of all kinds of patent foods for infants and to feed them on good fresh milk during the first year of life is the first step in preventing the large wastage of infant life now taking place. The County Medical Officer of Health takes a great interest in this matter of Infant Mortality, and I reported last year that I had every hope that probably one of our large milk vendors would instal plant for the sterilizing and "humanizing" of cows' milk. Unfortunately such installation has not taken place, and not likely to, owing to cost, and while awaiting the time when your authority will do as Battersea and St Helens, and many small towns on the Continent, we must meantime rely upon the distribution of leaflets and the efforts made for a higher standard of personal hygiene among the poor. The following table shows the Birth and Infantile Mortality rates according to Wards. TABLE VII. Whole Area. St. James Street. High Street. Hoe Street. Wood Street. Northern Ward. Births 3,535 747 781 658 453 896 Birth-rate 33.25 31.6 39.1 29.24 27.45 38.1 Deaths 1,178 285 234 229 189 241 Infantile mortality rate 113.7 131.2 115.2 97.3 110.4 110.5 17 The character of the population is reflected by these rates. Hoe Street having a large per centage of well-to-do people, with a low birth-rate, has the most favourable infantile mortality rate. James Street, with a much less birth-rate than High Street, has yet a considerably larger infant death-rate, reflecting the poorer character of this ward. The Northern Ward, with its higher birth-rate, has an equally low infantile death-rate as Wood Street, and its elevated position and semi-rural character may account for this, as the social status of the population, if anything, is better in Wood Street than in the Northern Ward. The deaths under one year of age form 34 per cent. of the total deaths at all ages, and 11 per cent. of the registered births. The following shows in tabular form the numbers and the causes of death in children under 5 years of age during 1903 :— Measles 45 Scarlet Fever 3 Influenza 1 Whooping Cough 34 Diphtheria 13 Diarrhoea 25 Zymotic Enteritis 35 Enteritis 20 Septic Disease 1 Tuberculosis of Meninges 16 „ „ Lungs 3 „ Other Forms 16 Cancer 1 Premature Birth 66 Developmental Diseases 90 Meningitis 14 Acute Bronchitis 44 Lobar Pneumonia 18 Lobular „ 48 Diseases of Stomach 13 Obstruction of Intestines 2 Bright's Disease 2 Accident or Negligence 23 All Other Causes 54 Total 587 Thus half the total deaths in the district are in children under 5 years of age, with a known death-rate of 55 per 1,000. 142 of the 587, or a fourth, die in the first year, within a short time of birth, due to prematurity and constitutional weakness, and 401, or over one-third of the total deaths, occur in the first year of life. The great influence of age upon mortality from particular diseases has been ably expressed by Dr. Farr in his account of the " March of an English Generation through Life." He takes and follows the progress of 1,000,000 children born, and shows of the million some "have been born prematurely; they are feeble ; they are unfinished ; the baby is helpless; for his food and all his wants he depends on others." Of the million born, 149,493, or 14 per cent., die in the first year of life, and within the first five years 263,182 have died, or over 26 per cent. of those born. In your district only 11 per cent. of those born have died during the first year of life. B 18 SENILE MORTALITY. Of the 1,178 deaths recorded, 207—or 17.57 per cent.—were of 65 years and upwards, as compared with 17.8 per cent. in 1902. In the St. James' Street Ward 15 were 75 or upwards. „ High Street Ward 17 „ „ „ Hoe Street Ward 29 „ „ „ Wood Street Ward 20 ,, ,, „ Northern Ward 17 „ „ The following table shows the number and causes of death for the whole districts and the wards. The 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-Pox, Measles, Scarlatina, Diphtheria, Fever (Typhus, Enteric, and Continued), Whooping Cough, and Diarrhoea, caused 193 deaths. If Enteritis in children under 1 year be included the deaths were 210. 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 this lowering of the Zymotic rate, all deaths certified as Enteritis in children under 1 year are included, and consequently the rate is based on 210 deaths. These deaths represent a rate of 1.97, compared with 1.31 in 1902, 2.82 in 1901, 2.72 in 1900, 2.81 in 1899, and an average of 2.65 for the preceding 10 years. The deaths from Measles are greatly in excess of any of the previous 5 years, those from Whooping Cough a little over the average, while Scarlatina and Diphtheria maintain their improved rates of the last few years. The following tabular statement shows the mortality in the last 6 years from Zymotic diseases:— Schedule 33. Table of Deaths daring the year 1903, 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 — — — — — — — — — — — — — 2 Measles 52 8 37 7 — — — 18 4 12 11 7 — 3 Scarlet Fever 6 1 2 3 — — — 3 1 1 — i — 4 Typhus Fever — — — — — — — — — — — — — 5 Epidemic Influenza 11 1 — — 1 5 4 2 2 — 4 3 — 6 Whooping Cough 34 12 22 — — — — 6 6 11 3 8 — 7 Diphtheria, Membranous Croup 17 — 13 4 — — - 6 3 2 2 4 — 8 Croup — — — — —. — — — — — — — — 9 Enteric Fever 19 — — 6 3 10 — 5 7 1 2 4 6 10 Asiatic Cholera — — — — — — — — — — — — — 11 Diarrhoea, Dysentery 28 23 2 — — 1 2 7 11 — 3 7 — 12 Epidemic or Zymotic Enteritis 37 26 9 — — 1 1 7 9 4 5 12 — 13 Enteritis 20 17 3 — — — — 5 1 3 3 8 2 14 Other continued Fevers — — — — — — — — — — — — — 15 Erysipelas 2 — — — 1 1 — 1 — 1 — — - — 16 Puerperal Fever — — — — — — — — — — — — —• 17 Other Septic diseases 4 — 1 — — 3 — 2 2 — — — — 18 Intermittent Fever and Malarial Cachexia — — — — — — — — — — — — — 19 Tuberculosis of Meninges 22 10 6 4 — 1 1 4 5 6 5 2 — 20 Tuberculosis of Lungs 98 2 1 5 14 74 2 26 26 22 11 13 2 21 Other forms of Tuberculosis 22 11 5 1 — 3 2 6 3 3 5 5 1 22 Alcoholism — — — — — — — — — — — — — 23 Cancer 44 1 - — 1 23 19 7 4 17 9 7 1 24 Premature Birth 66 66 — — — — — 15 14 13 9 15 — 25 Developmental Diseases 90 76 14 — — — — 19 19 11 17 24 3 26 Old Age 54 — — — — 2 52 11 9 17 9 8 1 27 Meningitis 15 3 11 — — 1 — 3 3 1 — 8 — 28 Inflammation and Softening of Brain 8 — — — — 4 4 1 1 3 2 1 — 29 Organic Diseases of Heart 21 — — 4 3 8 6 7 2 5 6 1 2 30 Acute Bronchitis 51 32 12 — — 5 2 17 11 12 4 7 — 31 Chronic Bronchitis 52 — — — — 14 38 5 15 11 11 10 — 32 Lobar (Croupous) Pneumonia 41 10 8 — 3 12 8 10 11 7 8 5 6 33 Lobular (Broncho) Pneumonia 53 30 18 1 — 2 2 15 10 9 8 11 2 34 Diseases of Stomach 16 11 2 — — 3 -- 4 6 1 2 3 — 35 Obstruction of Intestines 9 1 1 — — 2 5 4 3 1 1 — 1 36 Cirrhosis of Liver 12 — — — — 11 1 3 2 4 2 1 — 37 Nephritis and Bright's Disease 17 — 2 — — 8 7 2 3 6 4 2 1 38 Tumours and other Affections of Female Genital Organs — — — — — — — — — — — — — 39 Accidents and Diseases of Parturition 11 — — — 2 9 — 1 2 1 3 4 — 40 Deaths by Accident or Negligence 40 14 9 5 — 8 4 10 9 3 7 11 6 41 Deaths by Suicide 4 — 1 3 2 1 1 2 42 Deaths from Ill-defined Causes — — — — — — — — — — — — — 43 All other Causes 202 46 8 5 13 86 44 51 30 41 32 48 3 All Causes 1,178 401 186 45 41 298 207 285 234 229 189 241 39 19 TABLE VIII. Small-Pox. Scarlatina. Diphtheria. Croup. Typhoid. Measles. Whooping Cough. Diarrhoea. Zymotic Enteritis. Total. 1903 0 6 17 — 19 52 34 28 37 193 1902 20 6 17 4 13 14 23 23 5 125 1901 1 13 38 12 43 26 131 10 274 GastroEnteritis. 1900 0 5 71 7 6 3 54 110 27 283 1899 0 6 64 9 19 33 34 144 309 1898 0 3 40 6 9 39 24 162 283 To make comparison with previous years easier, the deaths from Enteritis are not included in the foregoing table. The following Table gives the deaths from the seven principal Zymotic diseases in the four quarters of the year TABLE IX. 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. Totals for 1902. 1st Quarter 0 4 6 0 12 5 5 3 1 36 44 44 31 2nd „ 0 1 4 0 27 8 1 3 0 44 45 51 29 3rd „ 0 1 5 0 12 16 3 40 8 85 142 171 42 4th „ 0 0 2 0 1 5 10 19 11 48 52 34 34 Total 0 6 17 0 52 34 19 65 20 213 283 300 136 The following Table shows graphically the death-rate from these diseases for the previous 10 years, with the rate for 1903 :— 20 TABLE OF ZYMOTIC MORTALITY, 1893 to 1903. TABLE X. 21 DEATHS FROM NOTIFIABLE INFECTIOUS DISEASES. The diseases under this heading are Small-Pox, Scarlatina, Diphtheria and Membranous Croup, Fever (Typhus, Typhoid and Continued), Erysipelas, Puerperal Fever, Cholera and Plague. There were 44 deaths registered from the above diseases during the year compared with 73 in 1902, 74 in 1901, 103 in 1900, and 104 in 1899. TABLE XI. Whole District. Wards, 1903. Names of Diseases. Deaths, 1902. Deaths, 1903. Increase + Decrease - St. James Street. High Street. Hoe Street. Wood Street. Northern Small-Pox 20 0 -20 — — — — — Scarlatina 6 6 — 3 1 1 — 1 Diphtheria 17 17 — 6 3 2 2 4 Membranous Croup 4 — — 4 0 — — — — Typhoid 13 19 + 6 5 7 1 2 4 Erysipelas 3 2 - 1 1 — 1 — — Puerperal Fever 10 0 -10 — — — — — Cholera 0 0 — — — — — — Plague 0 0 — — — — — — Total 73 44 -29 15 11 5 4 9 „ 1902 73 — — 15 10 17 19 12 There were no deaths from Small-Pox, Membranous Croup nor Puerperal Fever during the year, and the number of deaths from Scarlatina and Diphtheria is the same as in 190'2. The St. James Street and High Street Wards have practically the same number of 22 deaths, while there is a considerable reduction in the other Wards. St. James Street Ward had no death from Typhoid in 1902, High Street had 2, Hoe Street 5, Wood Street 3, and the Northern Ward 3. The increase in Typhoid deaths is mainly in the St. James Street and High Street Wards, disproportionately to the number notified. The improvement in the death-rate from Diphtheria noticed in last year's report is maintained, as is that of Scarlatina. The excessive Diphtheria incidence and death-rate noticed in previous years in the St. James Street Ward has materially decreased this year, and the various portions of your district are equally free compared with previous years. ZYMOTIC DISEASES NOTIFIED DURING THE YEAR Infectious Diseases Act, 1889. There were 700 notifications of infectious diseases during the year. Excluding the 13 cases of Chicken-Pox notified as a precautionary measure in January, the number of cases of infectious diseases was 657, compared with 1,083 in 1902. The following table shows number of cases certified each month during the year and the diseases :— 23 The following table shows the distribution of infectious cases according to wards, and the increase or decrease as compared with 1902 :— TABLE XII.—Cases of Infectious Disease notified during the Year 1903. 1903. Notifications. Jan. Feb. Mar, Apl. May June July Aug. Sept Oct. Nov. Dec. Total. Deaths. Small-Pox Under 5 years Over „ 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 2 0 Scarlet Fever Under 5 years Over „ 11 7 8 11 12 9 0 3 10 4 4 10 89 3 19 18 23 19 12 10 17 17 26 14 11 17 203 3 13 Diphtheria Under 5 years Over „ 3 4 10 4 4 3 9 2 4 2 3 2 50 8 12 11 6 8 9 10 6 14 4 6 3 97 4 Membranous Croup Under 5 years Over „ 0 0 0 1 1 0 0 1 1 0 0 0 4 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 Enteric Fever Under 5 years Over „ 0 0 0 0 0 0 0 0 2 0 1 0 3 0 7 3 1 1 3 0 1 5 16 32 7 9 85 19 Puerperal Fever Under 5 years Over „ 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 1 1 0 1 0 1 6 0 Erysipelas Under 5 years Over „ 3 1 1 2 0 0 0 0 1 3 1 0 12 0 12 7 5 6 14 7 5 11 7 13 10 8 105 0 Chicken Pox Under 5 years Over „ 14 0 0 0 0 0 0 0 0 0 0 0 14 0 29 0 0 0 0 0 0 0 0 0 0 0 29 0 Totals 107 53 60 51 55 38 43 46 81 73 43 50 700 42 24 TABLE XIII.—Distribution of Infectious Diseases according to Wards. WARDS. Estimated Population. Small Pox. 1902-3 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 23,600 0 67 31 2 46 28 1 4 179 -297 -100 High Street 20,000 2 73 23 1 21 21 0 12 153 -224 -179 Hoe Street 22,500 0 56 29 1 14 14 2 17 133 -199 -107 Wood Street 16,500 0 27 37 0 22 8 1 3 98 -187 -33 Northern 23,500 0 69 27 1 14 17 2 17 137 -253 -107 1903 106,290 2 292 147 5 117 88 6 43 700 -1,160 -426 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 86 8 0 1,056 — — 25 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 1903 106,290 292 2 147 5 0 88 0 117 6 657 6.2 Mean 357 12.6 206 9.1 0 88 1.5 93 5 776 11.0 Average for previous yars 362 134 211 9.5 0 88 1.6 91 4.9 782 11.4 Extremes High't 608 146 516 17 0 193 6 134 10 113 18-5 Lowest 125 0 124 3 0 28 0 31 3 397 6.2 26 The following Table shows Infectious diseases according to Wards, and the number removed to Hospital TABLE XV. Cases of Infectious Disease notified during the Year 1903. 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 2 - - - 2 - - - 2 — — — — 2 — - - Cholera — — — — — — — — — — - — — — — - - Diphtheria 147 2 48 78 11 8 — 31 23 29 37 27 17 15 14 20 9 Membranous croup 5 1 3 1 — — — 2 1 1 — 1 2 — 1 — — Erysipelas 117 3 9 13 18 70 4 46 21 14 22 14 — — — 1 1 Scarlet Fever 292 3 86 164 26 13 — 67 73 56 27 69 40 46 30 18 31 Typhus Fever — — — — — — — — — — — — — — — — — Enteric Fever 88 — 3 32 10 42 1 28 21 14 8 17 24 12 4 6 7 Relapsing Fever — — — — — — — — — — — — — — — — — Continued Fever - - - - - - - - - - - - - - - - Puerperal Fever 6 — — — 1 5 — 1 — 2 1 2 — — — 1 — Plague — — — — — — — — — — — — — — — — — Chicken Pox 43 5 9 26 2 1 — 4 12 17 3 7 — — — — — Totals 700 14 158 314 70 139 5 179 153 133 98 137 83 75 49 46 48 27 INFECTIOUS DISEASES, AND MEASURES TAKEN TO PREVENT THEIR SPREAD. During the year 657 cases of Infectious Diseases were notified, exclusive of 43 cases of Chicken Pox. A personal visit was made in the case of this latter disease in persons over 12 years, owing to the prevalence of Small Pox in 1902. The compulsory notification of Chicken Pox was discontinued in January, and the expenditure involved the previous year was justified and the precaution of the greatest value. The 657 cases occurred in 505 houses, and a visit was immediately paid by a Sanitary Inspector, followed by the usual routine of precautionary and preventive measures in all instances. Handbills were distributed for the guidance of the householder where treatment was undertaken at home, and special instructions issued in the case of Typhoid. Notification of the illness was at once made to the school authorities, and the children from the infected houses were prohibited attending school. Disinfectants, free of charge, were offered to those unable to purchase them, and isolation and quarantine enforced as far as possible. The visit of the Sanitary Inspector consisted not only in the giving of general instructions and obtaining the necessary information as to milk supply and probable source of infection, but included a systematic inspection of the house. Thus, apart from the measures taken against the spread of disease, the notifications necessitated the thorough inspection of 505 houses, with the result that 209 defects were remedied that otherwise might have been overlooked, including 63 of drainage. The householder and the house are the sanitary units, and when these are made ideal, the Public Health service will be a sinecure. In every instance of Diphtheria, removal to the Sanatorium was offered, and carried out if recommended by the medical attendant, and a large percentage of those suffering from Scarlet Fever desirous of hospital accommodation was removed. In many instances where removal was indicated and necessary, the limited accommodation provided could not permit of the step. On the termination of the illness the rooms or house were thoroughly disinfected by the Council's men, and the clothes and bedding removed to the disinfecting station for treatment by steam under pressure. That disinfection would be effective, it is necessary that all clothes worn by the patient, as well as those exposed to infection, should he 28 removed and treated, but there is reason to think that this is not always so. It is very difficult to make persons realize that in this matter candour and truthfulness are desirable, and the measures taken are for the public good. As reported last year, in spite of efforts made to have all disinfection performed by your servants, skilled in the work, many certificates were received of private disinfection to the satisfaction of the medical attendant, and in April I recommended, and in May the Council decided, that a circular letter should be sent to all the local medical practitioners informing them that no certificate of private disinfection would be accepted by the Council as satisfying the provisions of the Infectious Diseases Prevention Act 1890 (Secs. 5 and 6). The co-operation of the medical profession in this as in other sanitary measures has been freely given, and the desired alteration effected. After recovery from Scarlet Fever and Diphtheria, by order of the Council, three weeks must elapse before children suffering from the former, and two weeks in case of the latter, can resume school attendance. To obviate the necessity of parents and others visiting the Sanatorium to enquire about their children's progress, daily lists are exposed at the Town Hall, showing the condition of each patient. Outfits for early Diphtheria and Typhoid diagnoses are kept at the Town Hall, and supplied gratuitously to medical men, as well as a stock of reliable Anti-Diphtheritic Serum for those too poor to pay for it in the ordinary way. Notification of Phthisis is not compulsory nor resorted to. The weekly returns of the Registrar supply the only information when a case of death from this disease occurs. An offer to disinfect the room and bedding of the patient is made, and during the year 30 such disinfections have been carried out. Owing to the infectious nature of Phthisis this measure, however useful in itself, is but partial, and during the illness of the patient the most stringent precautions should be taken to be effective. SMALL POX. During the year only two cases of this disease were notified; both were removed to hospital and recovered. Vaccination and re-vaccination are believed by ninety-nine per cent. of medical men to be the best preventative of this disease, and the action of the West Ham Guardians in appointing two additional public vaccinators may help to get over the prejudices of some to the operation. 29 As sanitary authorities have to deal with the disease when it arises, it would be well had they the control of the measures to be taken for its prevention. With this disease, the Council is very much in the position of locking the stable door when the steed is stolen. SCARLATINA OR SCARLET FEVER. Two hundred and ninety-two cases of scarlatina were reported during the year; the mean number of cases for the previous ten years being 357. Considering the great increase of the population, the year under review was a very favourable one. On page 25 will be seen the number of cases notified each year since 1889. It will be seen that the incidence of this disease varied greatly, averaging about 5 per 1,000 of the population, compared with 3 per 1,000 for 1903. At no period of this year could the disease have been said to be epidemic. The greatest number, 40, occurred in January and April, and the least number, 15, in November. Six deaths occurred from this disease during the year. Four of the deaths occurred at the Sanatorium and one at West Ham Union. The case mortality—the proportion of deaths to number attacked— was slightly over 2 per 100, and the mean annual death rate per 1,000 was .056, or half what it was for the country generally. Three of the deaths were in children under 5 years, and all the deaths under 15. The greatest number of cases, 73, occurred in the High Street Ward, and the least, 27, in the Wood Street Ward. The large number of "flats" in the High Street Ward may account for the prevalence and easy spread by inter-communication. A typical case of scarlatina is most easily diagnosed, but in recent years the complaint has become so mild an affection that at times the greatest difficulty is experienced, and I have no doubt many very mild cases are never recognised, with consequent spreading of the disease. The opposite error of mistaking rubeola for scarlatina is quite common, but fortunately the error is on the right side, and no harm is done in consequence. Two of the 172 cases sent to hospital as scarlatina were measles—a very small per centage of error. 30 No blame can be attached to medical men for occasional errors of diagnosis, considering that it often happens the characteristic symptoms have disappeared before advice is sought. One hundred and sixty-five of the cases notified were removed to the Sanatorium. Amongst these must be included some of the worst cases. A large number of those sent to hospital were found to have the diphtheria bacillus present in the throat, and undoubtedly had true diphtheria, and thus helped to swell the death-rate. DIPHTHERIA. During the year 147 cases of Diphtheria, and 5 of Membranous Croup were notified compared with 150 cases in the previous year. The sickness rate for these diseases was 1.42 per 1,000 of the population, a rate similar to 1902 and comparing very favourably with 3.4 in 1901, 56 in 1900, and a mean of 3.25 for the years 1890-1901. Seventeen deaths were certified as due to Diphtheria or Membranous Croup, equivalent to a rate of .16 per 1,000 of the population and a rate of 11.6 per 100 affected. In other words, a little over 1 in 10 of these attacked by the disease died from it. The mortality from Diphtheria of 12 per 100 attacked compares very unfavourably with that of Scarlatina with a rate of 2 per 100, and yet many fail to recognise the great value of isolation in hospital for its cure and prevention. The apparent freedom from the disease after a week's illness, when the throat symptoms disappear and the readiness with which certificates are given by the medical attendant that the patients are free from infection within two or three weeks of the onset of the disease, induce many parents to keep their children at home, rather than have them removed to the Sanatorium. That very few suffering from Diphtheria are free from infection for eight weeks from the onset is the experience of those best qualified to judge, and failure of home isolation when the sufferer is still infective must be a great factor in spreading the disease and maintaining its endemic character. The steady decline in the number of notifications and deaths from Diphtheria since the Sanatorium was opened is very encouraging, and during the year every case desirous of Hospital treatment was removed. In consequence 78 of the 152 sufferers, or over 50 per cent., were sent to the Sanatorium. 31 The death-rate for Diphtheria for England and Wales was 18 per or slightly greater than for this district. The marked decline in the sickness and death-rate from these diseases since the Sanatorium was opened has been maintained during the year. With a fuller use of isolation and prompt removal of'first cases, a further decline should take place. 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 XVI. Years. Population. Number of Diphtheria cases. Rate per 1,000. Membranous Croup cases. Death-rate per 1,000 population. 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 3.4 11 .39 1902 101,318 142 1.40 8 .20 1903 106,290 147 1.38 5 .16 The Local Government Board form on page 26, shows the distribution of the cases of Diphtheria according to wards. 32 The following table shows the distribution of cases of Diphtheria in the various wards, since I have been your Medical Officer of Healt :— TABLE XVII. Diphtheria prevalence in Wards for the Years 1898 to 1908. Year. St. James Street. High Street. Hoe Street. Wood Street. Northern. Population. No. of Cases. Rate per 1,000. Population. No. of Cases. Rate per 1,000. 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 3.5 22,019 67 3.0 13,140 65 5.0 11,900 11 1.0 1899 21,942 112 5 19,452 79 4.3 21,523 81 3.0 13,888 45 3.2 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 3.2 1901 23,218 144 6 19,886 74 3.7 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 1.14 16,000 25 1.56 20,000 23 1.15 1903 23,600 31 1.31 20,000 23 1.15 22,500 29 1.29 16,500 37 2.24 23,500 27 1.15 33 It will be noticed that the incidence rate in the various Wards is very similar and an improvement on previous years. St. James Street Ward in 1900 had a rate of 9 compared with 1.31 in 1903. High Street has a slightly lower rate than the previous years. Hoe Street and Wood Street have a higher rate, while the Northern Ward is exactly the same rate as in 1902. What influence the Sanatorium has had in the general improvement is difficult to determine, but the fact remains this year's Diphtheria rate per 1,000 of the inhabitants is the lowest on record, and the improvement has been consistent since the Hospital was opened. ISOLATION ACCOMMODATION The arrangements made in 1902, that one pavilion of 14 beds be reserved for patients suffering from diphtheria and croup, were continued and proved sufficient. Every case of diphtheria desirous of removal was admitted, but no pressure was exercised to get all cases to the Sanatorium. There is every indication that, as parents realise the benefits of hospital isolation, many more will take advantage of the protection offered, and the time is not far off when all patients suffering from such a dangerous infectious disease will be treated in hospital. Had all the cases during the year been so treated, 25 beds, instead of 14, would be requisite, and this in a year of comparative immunity. Seventy-eight, or a little over 50 per cent. of the cases notified, were treated at the Sanatorium, and 13 deaths were registered, equal to a case-rate of nearly 17 per 100. This rate is higher than for the district generally, and may be accounted for by the very worst cases being always sent to Hospital. Especially is this so in cases of croup, two being practically moribund on arrival. Added to this some cases, who declined to be removed at first, subsequently went, when their chances of recovery were less. The accommodation for scarlatina patients desirous of hospital treatment was quite inadequate, and many had to be refused admission. The greater desire of parents to have their children treated at hospital for scarlatina compared with diphtheria is due no doubt, to the longer quarantine apparently required in the former disease, although actually diphtheria patients are sometimes infectious for much longer periods than are scarlatinal. c 34 The peeling of scarlatina gives the parents an object lesson, which is lost in the case of diphtheria when the throat symptoms have disappeared. Of the 292 cases notified as scarlet fever, 167 were admitted into hospital. The Visiting Committee to the Sanatorium, recognising the inadequacy of the present accommodation for our rapidly growing population, have advised, and the Council ordered, that further provision be made. In consequence, the Engineer has submitted revised plans to the Local Government Board for a twelve-bed block for acute cases, with separate cubicles, and a twenty-four bed block for convalescent cases under 12 years of age. There was some difficulty with the planning of the twelve-bed block, and, as it is altogether on principles hitherto unadopted, your Engineer, accompanied by Councillors Good, Anderson, Amos, Barker and myself, had an interview with the Medical Officer to the Board, and, after explanations and a few minor alterations, sanction to the borrowing of the money for the buildings will, no doubt, be given, after the formal enquiry is held. It is possible that the early summer may see building operations commenced. The Council felt more confidence in the advisability of extension on financial grounds, since the County Council, to encourage proper isolation provisions for infectious diseases throughout the county, are contributing ten pounds per bed towards the maintenance of such. With this contribution your authority will be called upon to provide for little more money than under former conditions. . Apart from the question of cost, proper and sufficient isolation hospital accommodation is a necessity in such a district as yours. I have received the following Report from the Resident Medical Officer at the Sanatorium. During the year 1903 there were admitted 258 patients. Of these 172 were sent in as Scarlatina. „ 86 „ „ Diphtheria. 35 The following table gives the number each month:- Month. Scarlet Fever. Diphtheria. Total. January 17 6 23 February 17 11 28 March 17 11 28 April 5 4 9 May 13 12 25 June 13 8 21 July 15 12 27 August 11 6 17 September 21 8 29 October 10 3 13 November 11 5 16 December 22 0 22 The ages of those admitted were as follows:— SCARLATINA. Under 5 years. 5 and under 10. 10 and under 15. 15 and upwards. 54 82 18 22 DIPHTHERIA. 34 31 16 5 The average number of patients in Hospital for the various months was as follows:— January 30 February 33 March 39 April 32 May 29 June 39 July 39 August 37 September 31 October 33 November 28 December 25 Of the cases sent in as Diphtheria, 8 were found on bacteriological examination to be free from the Klebs Loeffer Bacillus; three proved to have Scarlet Fever and Whooping Cough. Two of the cases sent in as Scarlet Fever were cases of Measles, and 19 were cases of mixed infection (Diphtheria). There were 19 deaths during the year. Of these 14 were from Diphtheria, 3 from Diphtheria and Scarlet Fever, and 2 from Scarlet Fever. 36 Tracheotomy was performed on 3 patients, one of whom died from cardiac failure. Among the Diphtheria patients, only 1 case developed post-Diphtheritic Paralysis, 1 had Nephritis, 5 Bronchitis 1 Whooping Cough, 3 Measles, 1 post-Diphtherial Scarlatina. Among the Scarlet Fever patients, 1 had Nephritis, 29 Otitis, 2 Mastoid Abscess, 3 Cervical Abscess, 1 Chorea, 1 Broncho-Pneumonia, 6 Bronchitis, 3 Whooping Cough, 1 Chicken Pox, and 1 Ringworm. During the year great difficulty was found in the isolation of cases of mixed infection, and thus hampered, all the beds allotted to Scarlet Fever were not always available. "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." TYPHOID FEVER. Eighty-eight cases of this disease were notified during the year, compared with 89 in 1902, 73 in 1901, 86 in 1900, 119 in 1899, 76 in 1898, 78 in 1897, and 193 in 1896. On page 23 are given the numbers of cases occurring in each month during the year. It will be noticed that during the months January to August inclusive, the number of cases was less than half in the corresponding months in 1902, but in September the notifications rose to 16, reaching the maximum, 32, in October, followed by a sudden fall to 7 in November and 9 in December. In my monthly report for September I pointed out that the analysis of water supplied to the district during August was very unfavourably reported on by Mr. Leo Taylor, and that Enteric was on the increase and widespread. In October I reported, "during the past two months throughout the district there has been a good deal of diarrhceal sickness in adults, and probably improperly filtered water may account for this. Any person thus suffering would be much more likely to fall a victim to specific infection than those not so affected." In October, 1902, 5 deaths were attributed to Diarrhoeal diseases, whereas this year 26 were attributed to the same cause. The unusual rains causing an excess of organic matter in the drinking water and the high level to which the ground water rose, and consequent displacement of ground air must have contributed largely to these results. 37 Of the 88 cases notified, 53 were removed to hospital, the Walthamstow General Hospital receiving 11, West Ham Infirmary 24, the others going to the general hospitals in London. Efforts were made to have all the sufferers removed to hospital, but for want of accommodation, these were unsuccessful. That a large number of Typhoids nursed at home are a source of danger to any district is well known, and 21 persons contracted the disease for want of removal of primary cases. This shows the need existing for proper provision for such cases at the Sanatorium. All possible precautions were taken with these nursed at home, and I had special instructions issued against the spreading of the disease, and they were given by the Sanitary Inspectors on their visits to those in charge of the sick. The 88 cases occurred in 69 houses, and sanitary defects were found in 11 instances. Enquiry as to the origin of the attack in each case elicited that 21 were from previous cases, 6 were supposed to be due to eating oysters or shell-fish, and the causes assigned for the remainder might or might not be considered sufficient according to the bias or belief of the enquirer. Personally I find it very difficult to assign a definite and unmistakable cause for cases of infectious disease, especially Typhoid, but the patient or his friends find a ready and assignable cause in drinking dirty water, eating eels, oysters, bad fruit, smells, &c. One case notified as Typhoid died, and was certified as Appendicitis and not due to Enteric. Seven of the cases occurred in men who worked at a particular club, and subsequent to a fellow workman who no doubt was infected by oysters. That these persons had a common infection is to be presumed, but the sanitary arrangements of the club could not be blamed. Nor could any real common infection be traced. The sudden decrease in the number attacked in November and December compared with September and October has since been maintained, although apparently the same conditions exist as in those months, except that the reports of the analysis of water are more favourable. The 88 cases notified caused 19 deaths, 6 being between 5 aud 15 years of age, 3 between 15 and 25, and 10 between 25 and 65 years. 38 The greatest number of deaths, 7, occurred in High Street Ward, followed by 5 in St. James Street, 4 in the Northern, 2 in Wood Street, and 1 in Hoe Street. The greatest number of cases, 28, occurred in St. James Street Ward, and the least, 8, in the Wood Street Ward. The cases were thus distributed according to Wards:— St. James Street. High Street. Hoe Street. Wood Street. Northern. 28 21 14 8 17 According to the number in each house:— Number of cases 1 2 3 4 5 Number of houses 57 8 2 1 1 57 16 6 4 5 In 57 houses there was 1 case each; in 8 houses 2 cases each; in 2 houses 3 cases each; in 1 house 4 cases; and 1 house had 5 cases. The death-rate from Typhoid for the district was nearly .18, compared with .1 for England and Wales. 39 The following diagrams show at a glance the number of cases for each month, the number of houses infected, the removals and deaths:— 40 The distribution of the cases according to Wards, and the number of deaths are represented in the following diagram:— SUMMER DIARRHCEA—EPIDEMIC OR ZYMOTIC ENTERITIS. Under this heading 65 deaths occurred during the year, compared with 28 deaths the previous year. Forty-nine of these deaths were in children under 1 year of age, and 11 between 1 and 5 years. 41 The mortality from this complaint is very small compared with previous years, and no doubt the wet summer months contributed largely to this desirable result. Contrary to former years, the deaths attributed to Diarrhceal conditions mainly occurred in September and October, 16 deaths only being registered for August, compared with a hundred in former years. The special efforts made to get local vendors of milk to provide humanized milk for infant feeding failed, and your Sanitary Committee had to fall back on the usual distribution of leaflets on Diarrhoea Prevention, with object Lessons on Milk and Infant Feeding given to the girls of the upper standards in our elementary schools. The following Table shows the death-rate in the various wards from this disease:— TABLE XVIII. St. James Street. High Street. Hoe Street. Wood Street. Northern Ward. Number of Births 747 781 658 453 896 Birth-Rate 31.6 39.1 29.24 27.45 38.1 Number of Deaths 14 20 4 8 19 Death-Rate .6 1.0 .18 .5 .8 The death-rate from Diarrhoea in the whole district was .61 per 1,000. The similar rate for England and Wales was .5 and for the "76 Great Towns " .71. MEASLES AND WHOOPING COUGH. During the year Measles caused 52 deaths and Whooping Cough 34, compared with 14 and 23 in the previous year. Measles has a tendency to recur in epidemic form every few years, with the appearance of susceptible children, and is very fatal in the first two or three years of life. 42 The district has hardly been free from Measles during the year, and in March and May the disease was very rife. The infectivity of Measles is very great, and commences at a time prior to its usual recognition, and therefore measures to prevent its spreading are difficult to adopt. Mr. Jones, Superintendent of the Education Committee's School Attendance Department, transmits to me weekly a list of the numbers of children away from school owing to illness, and thus early intimation is given in the case of Measles and Whooping Cough. In March I advised closure of the St. Saviour's Infant School, owing to the large number of children affected with Measles. I was induced to adopt this measure owing to the fact that no cases occurred in the Board School Infants' Department in the same road, and therefore concluded infection was mainly spread by the school. The closure was attended with good results. In May my attention was drawn to the Maynard Road Infants School, owing to the lowered attendance due to Measles. Further than excluding children from infected houses and disinfection of premises no action was thought necessary. The circumstances of your district, where children mix so freely in the streets, render school closure as a rule undesirable. Leaflets dealing with Measles and Whooping Cough, their origin, spread, symptoms, and prevention, were distributed and were found useful. Children who suffered from Measles were not allowed to return to school for three weeks, following the onset of the disease, and then only if cough and desquamation had ceased. No child was allowed to attend school who had been exposed to infection within the previous sixteen days. The death-rate for Measles was .48 compared with .27 for the country generally. The death-rate for Whooping Cough was .32, that for England and Wales .27. It will be noticed that the deaths from Measles, 52, and Whooping Cough, 34, are greatly in excess of those from Diphtheria and 43 tina, 23, and the question arises what further action might be taken to prevent this wastage of child life. Over £5,000 a year is spent on Scarlatina and Diphtheria prevention, while practically nothing is spent on the prevention of these diseases, causing four times the mortality. In many towns less populous, a lady Health Visitor has been appointed, who devotes her time to visiting the homes of the poorer people giving advice on cleanliness, personal hygiene, ventilation of the house, together with the care and feeding of the infants. In this district such a person could well be employed. When Measles or Whooping Cough was threatening to be epidemic she could visit and give simple instructions as to isolation and the prevention of spreading, and upon the dangerous nature of these diseases in the very young. Meetings of mothers might be held and plain addresses given on the above subjects, and especially infant feeding and the prevention of Diarrhceal mortality. Further useful work might be accomplished in visits to the many workshops and laundries in the district where female labour is mainly employed. Visits might also be made to the girls' and infants' schools under the Council, and a higher standard of general sanitary conditions aimed at. The deaths from Measles and Whooping Cough since 1889 were as follows:— 1889 1890 1891 1892 1893 1894 1895 1896 Measles 40 14 12 83 9 3 87 19 Whooping Cough — 54 16 32 34 25 15 37 1897 1898 1899 1900 1901 1902 1903 Measles 19 39 32 3 4.3 14 52 Whooping Cough 21 24 33 54 26 23 34 The following figures supplied by Mr. Jones, the School Attendance Superintendent, show the number of children away from school during the year from these alleged causes:— 44 TABLE XIX. For the Year Ending December, 1903. Months. Measles. Whooping Cough. Weeks. January 538 291 4 February 501 247 4 March 1208 237 4 April 961 196 3 May 1752 594 5 June 630 550 3 July 661 983 4 August This month is the summer holidays. September 182 284 3 October 107 387 4 November 87 204 4 December 138 303 4 Total 6,765 4,276 42 INFLUENZA. Eleven deaths were registered from this disease during the year, mainly in persons of mature years. Influenza was not in any way epidemic and was usually associated with Bronchitis or Pneumonia. PUERPERAL FEVER LYING-IN FEVER. Six cases of Puerperal Fever were notified but no case of death was certified as due solely to this condition. Eleven deaths however are returned as due to "Accidents and Diseases of Parturition." "Septic- 45 æmia, Pyæmia, Septic Peritonitis, Septic Metritis and other septic inflammation in the pelvis occurring as the direct result of childbirth " should be returned as Puerperal Fever. In every case notice was sent to the nurse in attendance as to the precautions and measures she should take to prevent the spreading of the disease, but in no case could she be held accountable for the infection. The death rate from "Accidents and Diseases of Parturition" was T per 1,000 of the population. PHTHISIS OR CONSUMPTION. Ninety-eight deaths were registered from this disease as compared with 87 the previous year, and 86 in 1901. Including Tuberculosis of the Meninges 22; and other forms of Tuberculosis 22, the deaths due to this preventable disease were 142 equal to a rate of T33 per 1,000 of the population or one-eighth of the total deaths. Of the total deaths, 298 occurring between 25 and 45 years, 74, or one-fourth, occurred from Consumption. Contrasted with the deaths from Measles (52), Scarlatina (6), Whooping Cough (34), Diphtheria (17), Enteric Fever (19), Tuberculosis caused 14 more deaths than all these infectious diseases put together. Bearing in mind the period of life at which Tuberculosis causes the greatest' death-rate, the prevention of this disease assumes a greater importance than all the other infectious diseases put together. The great loss to the community can be further gauged by bearing in mind that the ordinary time consumptives suffer is 30 to 40 times longer than in the other diseases. The only measure taken by your authority is the disinfection of rooms where a consumptive has died. Before death infectivity is constant and active, and last year I suggested that every practitioner should be invited to send the sputum of any suspicious or doubtful case to Dr. Thresh for bacteriological diagnosis and the expense paid by your authority. If the diagnosis prove positive, notification should follow, and a fee paid as under the Act of 1889. The disease is typically preventive, and the loss to the community and the sufferer very great. With the fuller knowledge of the number of sufferers in your midst some further effective measures might be adopted. 46 WATER SUPPLY The District has its water supply from the East London Water Company. There were no systematic monthly analyses made of the water during the earlier months ot the year, as the Reports furnished monthly to the Registrar-General from the Government Laboratory were considered satisfactory and no illness existed in the district that might reasonably be attributed to the drinking water supplied. In July and August there was a greater amount than usual of diarrhoeal sickness in adults, followed by a much greater amount in September and October and an unusual amount of Enteric. In consequence of this sickness, several examinations of the water were made by your Analyst, Mr. Leo Taylor, F.I.C., and were unfavourably reported on by him. In July the Analysis gave the following figures:- Chlorine 2 grains per gallon. Free Ammonia 158 parts per million. Albuminoid Ammonia 224 parts „ Oxygen required to oxidise Organic Matter 1.764 ,, and Mr. Taylor's remarks were—"This water is extremely unsatisfactory. The amount of organic matter present is very excessive, and although it is largely of vegetable origin, renders the water unsuitable for drinking purposes." In August the Analysis furnished the following figures:— Chlorine 2.05 grains per gallon. Free Ammonia .012 parts per million. Albuminoid Ammonia .192 parts „ Oxygen required to oxidise Organic Matter .892 „ and the Analyst remarks—"This is an exceedingly unsatisfactory sample, the Organic contents are very much higher than is permissible in a drinking water, and renders the water in my opinion unfit for consumption. In September the Analysis was:— Chlorine 1.6 grains per gallon. Free Ammonia .008 parts „ Albuminoid Ammonia .208 parts ,, Oxygen required to oxidise Organic Matter .920 parts „ and the remarks—"The organic matter in this water is very excessive and renders the condemnation of the water imperative. In its present 47 imperfectly filtered condition the water is not suitable for drinking purposes. In October a similar Report was received with 960 parts Oxygen per million required to oxidise organic matter, and then weekly samples were taken in November, which proved fairly satisfactory. The Reports of the Bacteriological Examinations in July showed an excessive amount of Bacteria colonies. In August 1 c.c. of water contained 1,400 colonies, and the Analyst reported that "the number was very excessive, and fully confirms the unsatisfactory nature of the water as indicated by the chemical analysis." In September the colonies were still 1,000 per c.c. and the condition commented on very unfavourably by Mr. Taylor. In consequence of these reports your Clerk was instructed to send copies to the East London Water Company, and make complaint to that body as well as to the Local Government Board. The Water Company's Engineer disputed the Analyst's statements, and further added that Sir W. Crooks and Professor Dewar maintained that the Chemical and Bacteriological Examinations in August were exceedingly satisfactory, and that "the water as submitted to Mr. Leo Taylor was certainly not as sent from the Company's works." The report of the Company's own analysts of samples taken at the same time and place as by your Officer, shows to me that the water was unsatisfactory. The "Oxygen required to oxidise the Organic Matter" per million parts by their showing was .671 against .700 of your Analyst. Of this there is no doubt that the oxygen consumed, or measure of organic pollution, was excessive, and the late Professor Corfield held that the excessive prevalence of Typhoid in St. George's, Hanover Square, at certain portions of the year was due to water containing an excess of organic matter. That a water supply as delivered to the consumer should be pure and good is a prime necessity, and the action taken was quite justified. The suggestion here of the Water Company's Engineer is not justified, namely, that the samples had been taken improperly. 48 Mr. West was particularly careful in this respect, and to prevent the possibility of doubting the method of taking samples, Mr. Taylor took one. The result of this analysis was similar to that taken by Mr. West. With the truth or otherwise of Mr. Bryant's excuse we have no concern. If the water as sent out was satisfactory to the Company, it certainly was unsatisfactory as delivered, and shown by the Analyst's reports. In November the reports of the Analyst were more favourable and no further action was taken. OTHER DISEASES. Two deaths occurred from Erysipelas and 4 from "Other Septic Diseases." Cancer caused 44 deaths, Bronchitis 103 deaths, and Pneumonia 94. Cirrhosis of the Liver caused 12 deaths, while none was attributed to Alcoholism. In most cases, the probability is, the latter term should be substituted for the former, and if the deaths, indirectly due to Alcohol's excessive use were recorded the number would probably reach to three figures. It is satisfactory to note the deaths from Cancer are less in this year than in 1902, as are the deaths from diseases of the Respiratory Organs other than Consumption. COW SHEDS, MILK SHOPS AND DAIRIES. The Model Bye-Laws of the Local Government Board governing these are in operation, and generally observed. There are 14 licensed Cow Sheds and 98 Milksellers in the district, but the greater portion of the milk supply comes from places in the country over which you have no control. Repeated visits have been made during the year, and the premises have been generally kept in a satisfactory condition. Having suspected that the milk sold by one vendor might account for some of the cases of Typhoid, I made enquiries into the source of his supply, and had a report from the County Medical Officer of Health as to the conditions existing at the farms supplying the milk, this was quite satisfactory, and no further action was taken. Further than this suspicion no disease could be attributed to the milk supplied to the district. 49 OFFENSIVE TRADES. Only one of these is carried on in your district, namely, fat.boiling in the Northern Ward. No serious complaint was made during the year. At times the smells were far from pleasant. There is every hope that within a very short time, owing to the building going on in the neighbourhood of these premises, that the keeping of pigs will be impossible, and fat. boiling as now carried on will soon cease. During the year proceedings were taken against persons for improperly keeping pigs, and your Sanitary Officers have to keep a sharp look.out for such people, and rightly, for the next step would be the establishment of some form of fat.boiling premises. The keeping of pigs is the primary business, and the fat.boiling a means to that end. REMOVAL OF HOUSE REFUSE. Systematic removal of house refuse takes place twice a week by the Council's workmen, under the supervision of a foreman, who is responsible to the Surveyor. In the main streets where shops predominate, a tri.weekly collection is effected. No serious complaints have been made, and the work, I believe, has been well and efficiently performed. In previous years I referred to the dirty and inadequate receptacles used by householders for the storage of refuse, and suggested the provision of proper dust bins. Bye.laws are now in operation, providing for a galvanised or other suitable metal receptacle for dust, and notices have been distributed to every householder to that effect. Among the poorer inhabitants, compliance with the Bye.laws has not been made, but gradually the change will come about, and already there is an improvement. The Destructor, so long talked of and needed, is not yet provided, but probably will be within this year. The lighting and scavenging of our roads throughout the year has been invariably good and efficient. d 50 SEWAGE DISPOSAL. No further progress has been made in the treatment and disposal of the sewage on previous years. Precipitation by the aid of lime, black ash and iron sulphate, followed by broad irrigation over the sewage farm, sufficed, as in former years, and no complaints of a serious nature have been made by those interested in the production of a satisfactory effluent by your authority. A considerable portion of the farm has been under drained, which will, no doubt, improve its efficiency as a filtering agent. Owing to the excessively heavy rains experienced during the year, which have in some directions been of advantage to the district, there has been serious inconvenience in two or three of the low.lying portions of the town. The sewers, which are quite sufficient for the ordinary rainfall, were absolutely inadequate for carrying off the abnormal downpour, resulting in serious flooding of the cellars of a great number of houses in the months of June and July. The Council at once took into consideration the possibility of improvement in the size or otherwise of the surface.water sewers, and the Engineer and Surveyor were directed to make suggestions .and submit them to the Council. As a result, several improvements at the Sewage Works, and in the sewers of the district, have been made. A new surface water sewer was laid down in Forest Road, Chingford Road, Hoe Street and Queen's Road, and the soil and surface.water sewers in Ashford, Cranbrook and Brunner Roads were reconstructed. In addition, eight new man.holes have been constructed for flushing purposes at the heads of sewers. There were no complaints of smells arising from the sewers in the streets, and no new ventilating shafts have been put down during the year. Those in operation—51 in number—have worked satisfactorily. HOUSING OF THE WORKING CLASSES. As I reported last year, ample house accommodation is provided in your district for the working classes; but the rents prevailing in parts adjacent to the railway stations are too expensive for the ordinary labourer with a family. 51 A Committee has been formed, and has had several sittings throughout the year, to take action under Part 3, "Housing of the Working Classes Act," and to remedy these defects. No practical result has yet come of their deliberations, and the great difficulty is to provide a more suitable house for less rent than already exists in abundance. All the buildings erected during the year have been thoroughly supervised by the Building Inspectors under the Surveyor, and have to conform to the bye.laws in force (Model Bye.laws of L.G B.) Sufficiency of air space about the houses, and cleanliness of surroundings, are insisted upon, and many of the passages, that would otherwise be left in an insanitary condition, have been made up under Section 150, Public Health Act. FACTORY AND WORKSHOPS' ACT, 1901. A Register of Workshops has been kept up to date throughout the year, as well as Workshop Record Book. A Record of Outworkers as per lists received, owing to the constant changes of addresses, has been compiled on the Card Index System in addition to the ordinary Record of Outworkers. During the year visits have been made to all workshops and work places on the Register. The factories have been visited and Section 22 of the Public Health Amendment Act carried out. No complaints under this heading have been received. Workshops and Workplaces.— The number of these premises on the Register under the Act at the close of the year was : 587 outworkers' premises, 19 Laundries, 52 Retail Bakehouses, and 28 other Workshops. Outworkers' Premises.—These consist almost entirely of one or two rooms of the dwelling.house used as a workplace. The sanitary conditions of these were generally very satisfactory throughout the year. (1) Air Space.—Cards are exhibited showing the number of workers that may be employed, and no infringement of this condition was detected. 52 (2) Cleanliness and Ventilation were in all cases satisfactory, and minor defects, when pointed out, were soon remedied. Three rooms were cleaned under this provision. (3) Drainage of Floors was defective in five instances and remedied. (4) Suitable and Sufficient Sanitary conveniences exist in all cases. In three instances drains were reconstructed or repaired, and in one the w.c. accommodation improved. Bakehouses.—These were visited systematically throughout the year, and generally fairly well kept. Seven underground bakehouses were inspected, and, as a result, one was closed. The remainder were reconstructed in accordance with the conditions laid down in last year's Report, and as given in the Sanitary Inspector's Report of this year. Home Work.—Under Sections 107 to 115 important powers are conferred for the controlling of the conditions under which certain classes of work are done in the homes of the worker. The only work carried on here coming under this provision is in connection with clothing, repair of furniture and upholstery. Unwholesome Dwellings (insanitary conditions, want of ventilation or overcrowding).—No action had to be taken under this heading. Infectious Dwellings.—Under this heading comes our most important work, owing to the large number of outworkers. The Act provides for lists of outworkers being supplied twice yearly. This entails a great amount of clerical labour, wrong addresses and names being very often supplied to avoid supervision. In 18 instances work was temporarily prohibited, owing to dangerous infectious disease in the house, the clothing being disinfected before removal. ELEMENTARY SCHOOLS AND PUBLIC HEALTH. Owing to a complaint received in February from the Clerk to the School Board of the alleged prevalence of Scabies in some of the Schools, books of notification forms were issued to all the teachers that they 53 might send to me at once notice of such cases not coming under the Infectious Diseases Notification Act. Owing to misinterpretation at first, the Sanitary Office was flooded with such, but upon further information given, 37 genuine notices were sent and visits were paid to the Schools or homes of the children. The diseases were mainly Mumps, Chicken Pox, Ophthalmia and Impetigo. Those that were dangerous to others were excluded by the School Authority, but the notification and visits entailed a good deal of work. The rapid growth of the district and the enormous child population in our midst with the experience of last year, impresses one with the feeling that now the Elementary Schools are taken over by the Council—the authority responsible for the Public Health—the time has come to consider the more efficient medical supervision of the Schools under your control. The following requirements are needed for the sanitary equipment of your district:— 1. Further Isolation Hospital accommodation. 2. Separate vans for the removal of infected and disinfected articles. 3. More adequate provision for the disposal of sewage. 4. Refuse Destructor. 5. More public conveniences as in St. Tames' Street and Selborne Road. APPENDIX. Local Government Board Forms :— Table I. Table II. Table III. Table IV. Chart showing Birth, Death and Zymotic Death Rates. Table, Census 1901. Tables of Population showing Occupation and Birthplace and Number of Tenements of Less than Five Rooms. Local Government Board Form 1 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 Hospita Deaths of Non. Residents registered in District. Deaths of Residents registered beyond District. Deaths at all Ages. Nett. Number. Rate * Number. Rate per 1,000 Births registered. Number. Rate.* Mumber. Rate.* 1 2 3 4 5 6 7 8 9 10 11 12 13 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 1902. 101,318 3426 33.81 394 115.0 1009 9.95 28 8 153 1154 11.38 Averages for years 1893.1902. 75,432 2479 32.86 358.6 143.6 951.7 12.78 28 9 66 1016 13.56 1908. 106,290 3535 33.25 402 113.7 1065 10.19 39 10 123 1178 11.08 * 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, 95,131. Number of inhabited houses, 16,08? Average number of persons per house, 5.8.—At Census of 1901. 55 I. II. in. Institutions within the Institutions outside the Other Institutions the District receiving sick and District receiving sick and deaths in which have been infirm persons from outside infirm persons from the distributed among the the District. District. several localities in the District Walthamstow, Leyton, Sanatorium, Chingford. Small.Pox Hospital, and Wanstead Child. Union Infirmary, Dagenham. ren's and General Leytonstone. - Hospital. Union Infirmary, King'sCollegeHospital. The Chestnuts. Whipp's Cross. Hospital for Women, The Asylum. Soho Square. 16, Peabody Ave., S.W. 56 Local Government Board Form.] TABLE II. Year. Population estimated to middle of each Year. Births registered. Deaths at all Ages. Deaths under 1 year. 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 1902 101,318 3426 1154 394 Averages of Years 1893 to 1902. 75,432 2479 1020.5 360 1903 106,290 3535 1178 401 Wards. DISTRIBUTION IN 1908. St. James Street 23,600 747 281 98 High Street 20,000 781 230 90 Hoe Street 22,500 658 226 64 Wood Street 16500 453 187 50 Northern 23,500 896 236 99 57 The following Table shows Infectious diseases according to Wards, and the number removed to Hospital:— Local Government Board Form.] TABLE III. Cases of Infectious Disease notified, during the Year 1908. 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 2 — — — 2 — — — 2 — — — — 2 — — — Cholera — — — — — — — — — — — — — — — — — Diphtheria 147 2 48 78 11 8 — 31 23 29 37 27 17 15 14 20 9 Membranous croup 5 1 3 1 — — — 2 1 1 — 1 2 — 1 — — Erysipelas 117 3 9 13 18 70 4 46 21 14 22 14 — — — 1 1 Scarlet Fever 292 3 86 164 26 13 — 67 73 56 27 69 40 46 30 18 31 Typhus Fever — — — — — — — — — — — — — — — — — Enteric Fever 88 — 3 32 10 42 1 28 21 14 8 17 24 12 4 6 7 Relapsing Fever — — — — — — — — — — — — — — — — — Continued Fever — — — — — — — — — — — — — — — — — Puerperal Fever 6 — — — 1 5 — 1 — 2 1 2 — — — 1 — Plague — — — — — — — — — — — — — — — — — Chicken Pox 43 5 9 26 2 1 — 4 12 17 3 7 — — — — — Totals 700 14 158 314 70 139 5 179 153 133 98 137 83 75 49 46 48 58 TABLE VII. Birthplaces of Males and Females enumerated in the Urban District of Walthamstow in 1901. Place of Birth. Males. es. Total 46,832 48,299 London 20,071 22,011 South Eastern Counties 2,229 2,479 South Midland Counties 3,430 3,573 Eastern Counties 15,546 15,549 South Western Counties 977 979 West Midland Counties 746 799 North Midland Counties 406 397 North Western Counties 418 383 Yorkshire 373 343 Northern Counties 151 166 Monmouthshire and Wales 229 216 England (County not stated) 123 162 Isle of Man and Channel Isles 27 27 Scotland 331 310 Ireland 218 252 British Colonies or Dependencies 183 171 Foreign Countries 671 476 At Sea 3 6 Local Government Board Form.] TABLE IV. Schedule 33. Table of Deaths during the year 1903, 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 — — _ — — — — — — — — — — 2 Measles 52 8 37 7 — — — 18 4 12 11 7 — 3 Scarlet Fever 6 1 2 3 — — — 3 1 1 — 1 — 4 Typhus Fever — — — — — — — — — — — — — 5 Epidemic Influenza 11 1 — — 1 5 4 2 2 — 4 3 — 6 Whooping Cough 34 12 22 — — — — 6 6 11 3 8 — 7 Diphtheria, Membranous Croup 17 — 13 4 — — — 6 3 2 2 4 — 8 Croup — — — — — — — — — — — — — 9 Enteric Fever 19 — — 6 3 10 — 5 7 1 2 4 6 10 Asiatic Cholera — — — — — — — — — — — — — 11 Diarrhœa, Dysentery 28 23 2 — — 1 2 7 11 — 3 7 — 12 Epidemic or Zymotic Enteritis 37 26 9 — — 1 1 7 9 4 5 12 — 13 Enteritis 20 17 3 — — — — 5 1 3 3 8 2 14 Other continued Fevers — — — — — — — — — — — — — 15 Erysipelas 2 — — — 1 1 — 1 — 1 — — — 16 Puerperal Fever — — — — — — — — — — — — — 17 Other Septic diseases 4 — 1 — — 3 — 2 2 — — — — 18 Intermittent Fever and Malarial Cachexia — — — — — — — — — — — — 19 Tuberculosis of Meninges 22 10 6 4 — 1 1 4 5 6 5 2 — 20 Tuberculosis of Lungs 98 2 1 5 14 74 2 26 26 22 11 13 2 21 Other forms of Tuberculosis 22 11 5 1 — 3 2 6 3 3 5 5 1 22 Alcoholism — — — — — — — — — — — — — 23 Cancer 44 1 . — 1 23 19 7 4 17 9 7 l 24 Premature Birth 66 66 — — — — — 15 14 13 9 15 — 25 Developmental Diseases 90 76 14 — — — — 19 19 11 17 24 3 26 Old Age 54 — — — — 2 52 11 9 17 9 8 1 27 Meningitis 15 3 11 — — 1 — 3 3 1 — 8 —. 28 Inflammation and Softening of Brain 8 — — — — 4 4 1 1 3 2 1 — 29 Organic Diseases of Heart 21 — — 4 3 8 6 7 2 5 6 1 2 30 Acute Bronchitis 51 32 12 — — 5 2 17 11 12 4 7 — 31 Chronic Bronchitis 52 — — — — 14 38 5 15 11 11 10 — 32 Lobar (Croupous) Pneumonia 41 10 8 — 3 12 8 10 11 7 8 5 6 33 Lobular (Broncho) Pneumonia 53 30 18 1 — 2 2 15 10 9 8 11 2 34 Diseases of Stomach 16 11 2 — — 3 — 4 6 1 2 3 — 35 Obstruction of Intestines 9 1 1 — — 2 5 4 3 1 1 — 1 36 Cirrhosis of Liver 12 — — — — 11 1 3 2 4 2 1 — 37 Nephritis and Bright's Disease 17 — 2 — — 8 7 2 3 6 4 2 1 38 Tumours and other Affections of Female Genital Organs — — — — — — — — — — — — 39 Accidents and Diseases of Parturition 11 — — — 2 9 — 1 2 1 3 4 — 40 Deaths by Accident or Negligence 40 14 9 5 — 8 4 10 9 3 7 11 6 41 Deaths by Suicide 4 — — — — 1 3 2 — — 1 1 2 42 Deaths from Ill-defined Causes — — — — — — — — — — — — — 43 All other Causes 202 46 8 5 13 86 44 51 30 41 32 48 3 All Causes 1,178 401 186 45 41 298 207 285 234 229 189 241 39 Chart shewing the Birth,, Death and Zymotic Death-rates, for the years 1880 to 1903 Census 1901.—Ages of Persons, Males and Females, in the Urban District of Walthamstow and its Several Wards. All Ages. Under 1 Year. 1— 2— 3. 4. Under 5 Years 5 — 10 — 13 14— 15— 16— 17 18— 19— 20— 21 — 25 — 30— 35— 40 — 45 — 50— 55 60— 65— 70- 75— 80— 85 - 90— 95- 100 Upwards. WALTHAMSTOW (U.D.) p. 95131 2924 2700 2781 2767 2744 13916 12608 6829 2225 2025 1944 1884 1717 1650 1591 1589 6179 8130 7680 6677 5292 4071 2998 2125 1596 1032 678 428 197 61 7 2 0 M. 46832 1472 1344 1362 1424 1363 6965 6241 3412 1098 1026 1006 913 898 850 782 797 2955 3924 3730 3337 2667 2045 1503 1010 711 421 267 173 78 19 4 0 0 F. 48299 1452 1356 1419 1343 1381 6951 6367 3417 1127 999 938 971 819 800 809 792 3224 4206 3950 3340 2625 2026 1495 1115 885 611 411 255 119 42 3 2 0 WARDS :— ST. JAMES STREET P. 22774 692 671 663 679 693 3398 3257 1780 553 526 493 483 421 411 358 381 1361 1706 1686 1552 1320 985 737 498 334 224 157 92 49 10 2 0 0 M. 11391 343 338 328 367 330 1706 1588 907 263 277 258 241 217 211 189 218 689 856 816 785 677 503 387 240 153 91 61 35 21 2 0 0 0 F. 11383 349 333 335 312 363 1692 1669 873 290 249 235 242 204 200 169 163 672 850 870 767 643 482 350 258 181 133 96 57 28 8 2 0 0 HIGH STREET P. 19498 687 638 645 645 633 3248 2687 1416 453 394 382 347 294 287 275 288 1196 1799 1692 1433 1026 755 562 347 234 177 105 62 25 11 2 1 0 M. 9811 35f 332 316 327 323 1657 1322 739 235 213 205 178 168 166 126 149 568 879 835 736 526 379 297 176 113 68 33 30 8 4 1 0 0 F. 9687 328 306 329 318 310 1591 1365 677 218 181 177 169 126 121 149 139 628 920 857 697 500 376 265 171 121 109 72 32 17 7 1 1 0 HOE STREET P. 21099 559 528 512 520 515 2634 2433 1353 442 425 419 430 419 401 390 379 1550 1891 1707 1519 1258 998 722 582 471 267 199 129 67 12 1 1 0 M. 9975 285 258 260 248 244 1295 1203 684 214 207 195 179 198 191 164 163 708 890 827 723 601 487 349 260 186 99 71 53 24 3 1 0 0 F. 11124 274 270 252 272 271 1339 1230 669 228 218 224 251 221 210 226 216 842 1001 880 796 657 511 373 322 285 168 128 76 43 9 0 1 0 WOOD STREET P. 15208 425 380 400 380 392 1977 1961 1141 420 359 346 315 303 289 282 279 960 1235 1200 1073 815 692 489 357 269 194 115 84 36 16 1 0 0 M. 7381 221 177 202 198 191 989 978 558 216 174 188 157 160 143 146 124 418 561 572 527 410 351 233 159 124 90 50 31 14 7 1 0 0 F. 7827 204 203 198 182 201 988 983 583 204 185 158 158 143 146 136 155 542 674 628 546 405 341 256 198 145 104 65 53 22 9 0 0 0 NORTHERN P. 16552 561 483 561 543 511 2659 2270 1139 357 321 304 309 280 262 286 262 1112 1499 1395 1100 873 641 488 341 288 170 102 61 20 12 1 0 0 M. 8274 264 239 256 284 275 1318 1150 524 170 155 160 158 155 139 157 143 572 738 680 566 453 325 237 175 135 73 52 24 11 3 1 0 0 F. 8278 297 244 305 259 236 1341 1120 615 187 166 144 151 125 123 129 119 540 761 715 534 420 316 251 166 153 97 50 37 9 9 0 0 0 TABLE V.— Grouped Occupations of Males aged 10 years and upwards in the Urban District of IValthamstow ; also Propoi.tion of Children of 10 and under 14 years of age engaged in Occupations, 1901. Males aged 10 and under 14 years. NAME OF DISTRICT. MALES AGED 10 YEARS AND UPWARDS. Engaged in Occupations. Proportion per cent. Engaged in Occupations to Total. Total Occupied and Unoccupied. Retired or Unoccupied. Engaged in Occupations. Commercial or Business Clerks. Conveyance of Men, Goods and Messages. Agriculture—on Farms, Woods and Gardens. Engineering and Machine Making. Building and Works of Construction. Wood, Furniture, Fittings and Decorations. Brick, Cement, Pottery and Glass. Chemicals, Oil, Grease, Soap, etc. Skins. Leather, Hair, Feathers. Paper, Prints, Books and Stationery. Dress. Food, Tobacco, Drink and Lodging. All other Occupations. 165 3 7 Walthamstow 33626 611*2 27514 1911 3562 288 826 5438 1709 193 406 372 1706 1363 2729 7011 TABLE VI.—Grouped Occupations of Females aged 10 years and upwards in the Urban District of Walthamstow ; also Proportions of Children of 10 and under 14 years of age and of Married or Widowed Women engaged in Occupations, and Proportion of Female Domestic Servants to separate Occupiers or Families, 1901. Females aged 10 and under 14 years. NAME OF DISTRICT. FEMALES AGED 10 YEARS AND UPWARDS. Engaged in Occupations. Proportion per cent. Engaged in Occupations to Total. Total Occupied and Unoccupied. Retired or Unoccupied. Engaged in Occupations. Teaching. Domestic Indoor Servants (not in Hotels, etc.) Charwomen. Laundry and Washing Service. Commercial or Business Clerks. Chemical, Oil, Grease, Soap, etc. Paper, Prints, Books, Stationery. Textile Manufactures. Tailoresses. Milliners, Dressmakers, Shirtmakers, Seamstresses. Food, Tobacco, Drink. Lodging. All other Occupations. Proportion per cent, of Married or Widowed engaged in Occupations. Proportion per cent. of Domestic Servants to total number of separate Occupiers or Families. Unmarried. Married or Widowed. 40 0.9 Walthamstow 34981 26737 6618 1626 387 1909 157 619 280 152 343 120 327 2061 505 1384 8.1 9.6 59 TABLE VIII. Country of Birth of Foreigners enumerated in the Urban District of Walthamstow in 1901. Country of Birth. Males. Females. Total 513 322 Europe. Russia 50 33 Poland (Russia) 13 8 Sweden 8 3 Norway 3 1 Denmark 5 1 Holland 35 26 Belgium 45 39 France 35 22 Germany 217 142 Austria 26 12 Hungary 1 — Switzerland 9 2 Spain 3 — Portugal 1 — Italy 34 17 Greece 1 — Servia, Roumania, Bulgaria 1 — Turkey 1 — Asia. China 1 — Japan 3 1 Other Countries — — Africa. Egypt .. — Other Countries — — America United States 21 15 Other Parts of America — — TABLE IX. Shewing Total Tenements of less than Five Rooms, distinguishing those occupied by various numbers of persons in the Urban District of Walthamstow, igoi. DISTRICT. Number of Rooms in Tenement. Number of Tenements of less than five rooms. NUMBER OF PERSONS PER TENEMENT. 1 2 3 4 5 6 7 8 9 10 11 12 WALTHAMSTOW. Total tenements, 19,830. Tenements of less than five rooms, 7,358. 1 537 317 139 62 15 4 — — — — — — — 2 837 135 290 210 128 49 21 2 1 — 1 . 3 2296 73 467 586 453 338 190 112 54 18 2 2 1 4 3688 57 569 684 784 608 450 258 164 77 30 5 2 60 61 TO THE CHAIRMAN AND MEMBERS of the Walthamstow Urban District Council. Gentlemen, I have the honour to present to you my report on the work carried out through my department during the year 1908. The work of the department, once almost solely engaged in the remedying of nuisances complained of by occupiers, becomes year by year more varied, and what formerly almost constituted the whole, and still demands as much attention, becomes a smaller and smaller section. Work in connection with infectious disease, unsound or adulterated food, workshops and special premises all grow apace, in some cases at a remarkable rate; and it is only just that I should acknowledge the loyal and zealous co.operation I have received from my assistants Messrs. T. J. Barnes, F. Sendell, and J. B. Pointon, without which the work could not have been satisfactorily dealt with. I am, Gentlemen, Your obedient Servant, W. W. WEST, Asso. San. Inst. Inspector of Nuisances. Factories and Workshop Acts.—The work devolving upon this department in connection with these Acts increases yearly by leaps and bounds. Outworkers.—There were on the 1st of January, 1903, 501 Outworkers' premises on the register. During the year 229 have been struck off the list, the occupiers having moved away or ceased to take in work, this leaves on the Register 272 outworkers from the year 1902, as, however, 315 new ones have been added, the total on December 31st is 587 ; these 816 premises have had to be visited in the course of the year, to make the list complete, many of them several times. The work is further complicated by the great number of incorrect addresses sent to us from other districts, by the unwillingness of many to have it known that they take in work to do, which leads them to give an incorrect (perhaps a maiden) name to their employer, and to deny to us knowledge of anyone of that name living in the house, and by the constantly moving habits of the class from which they are mostly drawn. The lists from which these names are taken are sent to us in accordance 62 with the Act, twice in each year, so that the bulk of this visitation has to be carried out twice during the year. The following is a list of the various kinds of work carried on by Outworkers in the district (a remarkable one being that of a landscape painter), showing the number engaged under each heading :— List of Outworkers. Blouse and Pinafore Making 325 Tailoring 85 Ties, Belt and Brace Making 33 Ladies' Underclothing 57 Boots, Shoes and Leatherwork 30 Dress and Mantle Making 30 Millinery 9 Linen Collar Making 7 Umbrella Making 2 Embroidering 2 Button Making 2 Shawl Making 1 Furriers 1 Cardbox Making 1 Optical Turning 1 Landscape Painting 1 Forty-three of these premises have been cleansed and whitewashed on notice from me, and 28 have been provided with cards showing the number of workpeople allowed by the Act. Workshops.—In addition to the Outworkers, there are 28 premises, described under the Act as "workshops" within the district, and upon the register, and include the following trades :— Tailoring 7 Cabinet Making 1 Boot Making 3 Wheelwrights 1 Ladies' Underclothing 2 Gelatining 1 Blouse Making' 2 Sweet Making 4 Mantle Making 1 Cycle Making 5 Millinery 1 Corset Making 1 Dressmaking 1 Brush working 1 Tinworking 1 Blind Making 1 Pickle Making 1 In 9 cases cards have been provided showing the number of persons allowed in the rooms by the Act, One case of overcrowding has been abated, and 4 premises cleansed and whitewashed after notice. Laundries.—There are 49 laundries registered under the Acts within the district, in which the following works of improvement have been ordered and carried out during the vear. Washhouse paving repaired and drained in 5 case: W.c. flush reinstated ,,3 „ Yards paved and drained „ 5 „ Drains reconstructed or repaired „ 3 ,, W.c. accommodation improved ,, 1 „ Rooms cleansed „ 3 „ 63 Bakehouses.—There were at the beginning of the year 51 bakehouses within the district, of which 7 were underground. There have been 2 newly opened during the year, and 1, an underground one, has been closed, leaving on the register a total of 52, while 1 has been built but not yet occupied. The most noteworthy work in connection with the bakehouses of the district, has been the making of those which are underground suitable to the requirements of the Council. There were at the beginning of the year 7 underground bakehouses in use. With reference to one of these, the Council ultimately decided that it could not be made to suit their requirements, and the owner and occupier, both recognizing the fact, made no application for a certificate, and the place has been closed. In 5 of the others, the occupiers placed their premises under one firm of surveyors, who were empowered to negotiate with the Council, and in these cases, as well as in the remaining one, the requirements adopted by the Council after visits by the Committee specially appointed for that purpose, were carried out under the superintendence of your Medical Officer of Health and myself, to whom the work was left with power to act on behalf of the Council. The occupiers themselves readily acknowledge the immense improvement of the conditions under which they and their men are now working. The following were the requirements ultimately decided upon as necessary, before a certificate would be granted for the use of an underground bakehouse :— (1) The height must be 8 feet at least, from floor to ceiling. (2) Each bakehouse must have at least a cubic capacity of 1,500 feet. (3) The floor must be constructed of hard, smooth, and impervious material. (4) The walls must be rendered smooth. (5) Every staircase leading to a bakehouse must be adequately lighted, ventilated, and properly constructed. No outside staircase shall terminate within the bakehouse, nor any opening for any purpose, which tends to the undue admission of dust from the adjoining street. (6) Proper sanitary conveniences must be provided, which must be easily accessible to the workers, and include a lavatory basin and clean water for washing purposes outside the bakehouse. Provision for the depositing of wearing apparel outside the bakehouse to be also made. (7) All troughs, tables, or other furniture standing on the floor of the bakehouse must be provided with strong castors or wheels, and raised at least six inches from the floor. 64 (8) Proper provision must be made for the storage of flour elsewhere than in the bakehouse. (9) The bakehouse must be adequately lighted. (10) Ventilation must be adequate. In the early part of the year the bakers in the district were desirous to anticipate any steps which the Council might propose to take with reference to the construction or regulation of their premises ; being uncertain to what extent the New Act gave new powers over above. ground and underground premises. I accordingly availed myself of this feeling, as your representative, at the earliest moment, and before the Council had dealt with the question of the underground premises, by making an effort to obtain from those whose premises were entirely above.ground some desirable improvements in their construction and arrangement. A number of them were not constructed so as to prevent dust falling from the floor above ; in some the space between the top of the oven and the floor above was open, but not of sufficient depth to be properly cleansed, and became often a deposit for rubbish; one or two needed some improvement in ventilation or lighting, and in methods of coal storage. I therefore pressed upon the various occupiers the need for these improvements, and after much correspondence and many interviews, and with modifications rendered desirable by individual circumstances, I obtained what I asked for, even in some matters more than was subsequently insisted upon by the Council in the underground bakehouses. In 17 instances a ceiling of plaster or of matched boards was provided. In 4 cases the space over oven was closed. In 16 cases improved arrangements were made for coal storage. In 21 cases special cleansing was carried out. In 3 cases improvements were made in ventilation or lighting, or both. It is noticeable, however, that the good to be derived from these improvements is much minimized by the indifference of occupiers. In few instances is there evinced the least desire to do more than can be enforced by law, which of course is a minimum. It is difficult to get them to recognize that a place for the preparation of food is not a proper place for storing old boots or working clothes, or accumulation of rubbish. It is discouraging when walls are lined with glazed bricks or tiles to find no care taken to clean more frequently than the law requires, which seems to be thought more than enough. In fact, some of the best constructed places are the worst kept. 65 House to house inspection has been carried out in the following roads and streets:—Albion Road, Beaconsfield Road, Brandon Road, Brunner Road, Cambridge Road, Clarkson Road, Colebrook Road, Gaywood Road, Glenthorne Road, King Street, Lancaster Road, Leigh Road, Manby Road, Maynard Road, Rutland Road, Parkestone Road, Telford Road, Union Road, Waverley Road, Woodland Road, Mark. house Place, Mission Grove, and Waverley Avenue. Premises to the number of 2,722 have been inspected, and works of sanitary improvement have been carried out in 1066 of them. The reconstruction and repair of drains, as usual, form a considerable portion of work, resulting from inspection. The drains of 113 premises were reconstructed and 100 repaired, including, amongst the first, the following blocks of premises :— 39 and 41, Myrtle Road. 17 and 18, Gamuel Road. 65 and 67, Acacia Road. 4y and 51, Acacia Road. 107, 109, 111,113 and 115, Longfellow Road. 2 and 3, Church End. 375 and 377, Forest Road. 5 and 7, Maynard Road. 29 and 31, Maynard Road. 38 to 42, Maynard Road. 9 to 17, Maynard Road. 28 and 30, Prospect Hill. 14 and 16, Brandon Road. 1, 3 and 5, Raglan Road. 27 and 29, Ravenswocd Road. 57 and 59, Thorpe Road. 1 to 6, Byfield Road. 8 and 22, Mayfield Road. 10 and 12, Shakespeare Road. 69 to 79, Walpole Road. 3, 5, 7 and 9, The Links. 56 and 58, Blackhorse Road. 11 to 15, Oakfield Road. 46 to 60, Oatland Rise. 1 and 3, Apsley Road. 127 to 131, High Street. 181 and 183, Higham Hill Road. 37 and 39, Buxton Road. 107 and 109, St. Andrew's Road. In the course of inspection 252 suspected house drains were tested with chemical test or smoke, and 213 were found to be defective. It is of course probable that some of those which did not reveal defects by these means, were more or less faulty, but as no nuisance was discovered no present objection can be taken to them. In a few special cases the hydraulic test was used, generally, with success, for the purpose of convincing owners of the need of reconstruction. The disputed question of responsibility for the maintenance of combined systems of drains, as between the Council and the owner or owners, continues to be a cause of difficulty and delay as well as much friction, and it would be a boon to all parties if a definite settlement could be arrived at. There appears however little likelihood of any steps being taken to relieve local authorities of that which by piecemeal legislation is cast upon them under the present monstrously absurd state of the law on the e 66 subject, and the cost to the local authority, must tend to increase year by year. Summary:— Drains tested .. 252 „ reconstructed 113 „ repaired 100 Obstructed drains removed 109 Manholes and clearing-eyes provided 71 4-in. vents provided 62 Pans and traps provided 136 New gully traps provided 172 Bell traps abolished 36 Drain vent-pipes repaired or heightened 40 Soil pipes provided or repaired 9 Rain-water pipes repaired or disconnected from drains 65 New roofs 8 Roofs repaired 102 Gutters repaired or new provided 86 W.C. flush provided 26 „ reinstated 145 ,, disconnected from drinking water 9 „ lighting and ventilation improved 3 Sinks and bath wastes repaired or renewed 38 Drinking water supplied from main 12 Water supply reinstated to premises 35 Yards paved and drained 232 Sculleries paved .. 19 W.C.'s cleansed and repaired 41 New sinks provided .. 21 Dirty houses cleansed 72 „ rooms cleansed 458 Floors repaired 24 Ventilation provided under floors 45 Cisterns cleansed and repaired . 29 Cesspools abolished 3 Offensive accumulations removed 94 Stables paved and drained 7 Overcrowding abated 7 Animals kept so as to be a nuisance, removed 7 Infectious Disease. — Infectious disease has been notified as occurring in 505 premises, which have been visited at once on receipt of the notification, and careful inquiry made as to possible source of infection, condition of premises, schools attended by inmates, source of milk supply, nature of work (if any) carried on in the house, use of library books, need for isolation, etc 67 The following table gives the results :— Houses inspected and disinfected 505 Houses having some insanitary condition 146 „ „ defective drainage 63 Articles disinfected with Council's apparatus : Beds 607 Bolsters 4n9 Pillows 1,142 Blankets 1,134 Miscellaneous 1,328 4,080 Books from libraries disinfected 28 Premises having needlework, &c., carried on, and goods disinfected, and further work prohibited 13 Persons suffering from infectious disease have been removed to Hospital as follows:— In Council's Ambulance. By other Means. Total. To Council's Sanatorium 24) — 241 Walthamstow General Hospital 13 — 13 West Ham Infirmary — 28 28 London Hospital 6 3 9 N.E. Hospital for Children 2 2 4 St. Bartholomew's Hospital 2 3 5 Metropolitan Asylums Board Hospitals — 6 6 Woodford Jubilee Hospital 1 - 1 Dagenham Smallpox Hospital 1 — 1 267 42 309 Cowkeepers and Milksellers.—There are within the district 16 registered cowkeepers and 98 milksellers. All these have been repeatedly visited and the bye-laws enforced, and the following works carried out:— Cowkeepers.—Specially cleansed 2 Properly paved 1 Dung receptacle provided 1 Dairy floor repaired 1 Milksellers.—Paving repaired 3 Rooms cleansed 2 House cleansed 1 Shops cleansed 3 W.c. flush repaired 1 68 Slaughter-houses.—There are twelve licensed slaughter-houses within the district which are kept in satisfactory repair. In three of these during the year the paving has been found in a defective condition and has been thoroughly repaired, and in other respects the regulations as to cleaning, etc., have been complied with. Fishmongers.—The premises occupied by Fishmongers, of which there are 89, within the district, have been constantly visited throughout ihe year, and the following works ordered and carried out:— Paving repaired 13 New paving works 1 Repairs and drains 3 Cleansing 2 Improvement in smoking-shed 1 Ice-cream Vendors.—Sixteen premises are occupied by Ice-cream Vendors, and are kept in good condition. Fish Offal.—The nuisance caused by the removal of fish offal, though during permitted hours, yet at a time when our streets are most crowded, has still given rise to many complaints, especially during the warm weather. The regulations of the Metropolitan Police Acts dealing with this subject are only concerned with the hours during which the removal is effected. As, however, it is essential, and quite possible, to prevent nuisance in course of removal, the question of the hours is a secondary consideration, and our efforts should be directed to the prevention of nuisance. The new bye-law, which has been sanctioned by the Local Government Board, is drafted so as to prevent nuisance from the stench, whatever the hours during which the removal is effected, and has been printed and circulated amongst the fishmongers of the town and the offal removers. The bye-law reads as follows:— Every person who, by himself, or his servant, or agent, shall remove or convey or assist in the removal or conveyance of any filth, ashes, or rubbish, emitting a stench across, through or along any stieet, within the district, shall, unless the filth, ashes or rubbish is so covered as to prevent such emission, cause such matter to be mixed or covered with a sufficient quantity of a suitable and effective deodorant, or shall adopt such other precautions as may be reasonably necessary to prevent the emission of noxious or offensive effluvia from such filth, ashes, or rubbish. Food Supply. —The food exposed for sale in the town generally, and specially in the market places on Fridays and Saturdays, continues to be of wholesome quality. A regular visitation of the markets, as well as observation in the course of ordinary duties, has not revealed any conditions requiring action, except in one case—i.e., swine fever. In the month of June, in the course of my visits, I had reason to believe that several pigs suffering from swine fever had been killed in 69 Walthamstow, and the carcasses sent to London. As I knew where it was customary for this particular owner to send meat to, I went at once to the Central Meat Market and saw the Meat Inspector there, and found that some of the carcasses had arrived there ; but the salesman to whom they were consigned had put them aside for inspection, and they were destroyed at the market. I then went to the Chief Sanitary Inspector of Southwark and informed him of the circumstances, and a subsequent visit to the shop of a pork butcher in that borough resulted in the discovery of the remainder of the consignment. After destruction of the meat by order of a magistrate, a summons resulted in a fine of ,£20 and costs. There have been submitted to me during the year by the owners, for destruction as unfit for food, the undermentioned articles, which had been purchased in market, and on arrival at the retailers' homes were found to be unsound. A certificate of destruction enabled the purchaser to secure the return of most, if not all, of the purchase-money from the salesman at the market, thus removing any temptation to recoup the cost by offering unwholesome articles for sale: March 25th 11 Boxes of cod roes. May 29th 1 Box of roker. June 2nd 1-i- Bushels of whelks. July 18th 1 Box of hake. „ "28th 1 Case of roker. Aug. 4th 1 Box of plaice. ,, llth 1 ,, roker. ,, 13th 1 „ herrings. Sept. 2nd 1 roker. ,, 30th 1 Barrel of herrings. Oct. 12th 2 Cases of witches. Nov. 24th 1 Case of roker. There is no doubt that a cheap food supply does possibly more than any amount of inspection and punishment to maintain a wholesome supply, by making it less profitable to purchase for sale that which is unwholesome. Sale of Food and Drugs Acts. I he number of samples submitted to the County Analyst during tr year was 116, being as follows: — Description. No. of samples. No. of samples sold contrary to Acts. Milk 62 7 Butter 29 2 Cheese 18 0 Dripping 31 1 Lard 4 0 Colouring matter 1 0 Honey 1 II 70 Water Supply.—During the year 35 premises were reported to us by the East London Water Works Company as having had the water supply cut off. The premises were at once visited and intimation sent to the owner, with the result that in all cases with one exception the water supply was reinstated within a day or two. In the exceptional case, the right of occupying of the premises was in dispute, and the premises remained without a water supply for some weeks, until the legal question was settled. Fourteen samples of water from the mains of the East London Water Works Company were submitted for analysis; 11 for chemical, and 3 for bacteriological examination. The following matters, as to which notices had been ordered by the Council, were still outstanding at the close of the year. Particulars as to proceedings, &c., will be found in the following table:— No. Description. If summoned. Offence charged. Result. 9 Butter. Yes Selling margarine unlabeled 10s. and costs. 82 „ „ „ „ 10s. and costs. 41 Milk. „ Selling milk not of the quality demanded Dismissed, defendant having warranty. 42 „ „ „ „ 4s. costs. 67 „ „ 10 per cent, cream extracted Dismissed, being unable to prove the ownership of the milk. 88 „ „ 16 per cent, added water Defendant absconded. 89 „ „ 20 per cent, cream abstracted, 16 per cent, added water Mo hearing, summons delayed in service. 106 Dripping. „ 25 per cent, cotton seed oil 10s. fine and costs. 112 Milk. No. 10 per cent, cream abstracted Seller produced warran ty 127 „ „ 6 per cent cream abstracted Seller cautioned. 71 Nuisance from drains at:— 42, 44 and 46, Hazlewood Road. 87 and 89, Hoe Street. 92, Shemball Street. 35, Wingfield Road. 10, Buxton Road. In the general work of the department it has not been necessary to take any legal proceedings during the year.