WAL 86 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 1909. Walthamstow Printed by J. C. Phelp & Son, 62-64, Beulah Road. TO THE CHAIRMAN AND MEMBERS of the Walthamstow Urban District Council. Gentlemen, I beg to submit to you the Annual Report for 1909, dealing with the Public Health and the circumstances affecting it, so far as these are under my control. Dealing as it does with matters well within your own knowledge, much of it will appear superfluous. This is the twelfth report I have had the honour of making, but increasing years make the task no less easy of presenting statistics and records of deaths and diseases more interesting. However, I trust the report will be a source of great satisfaction to you, revealing as it does the good conditions under which our people live, as evidenced in the death and other rates, and the district's immunity from diseases inimical to life, compared with other large towns. Our death-rate is the lowest recorded, and lower than that of any district around London, except Hornsey. Our crude death-rate was 8.8 and the corrected 9'8, compared with 14.5 for England and Wales, and 15.6 for the "76 Great Towns." The Zymotic death-rate, or that resulting from deaths caused byMeasles, Scarlatina, Diphtheria, Whooping Cough, Typhoid, and Diarrhoea, was less than 1 per 1,000 of our people ; equally good as in 1908, and considerably less than half that prevailing for the years preceding. All these diseases are more or less preventable by appropriate measures undertaken on behalf of the public health, but, however good the administration, a permissible or unavoidable mortality will ensue. 4 Excluding Whooping Cough, our death-rate for each disease in this group was an improvement on 1908, and lower than the permissible. The death-rate from Measles was less than in the preceding year, half that of the "Great Towns," and less than in the country generally. The deaths from Scarlet Fever were no greater than for the country generally, and less than in the "Great and Smaller Towns" of England. Diphtheria caused six fewer deaths than in 1908, and our death-rate from this disease was considerably less than that prevailing in the rural or urban districts of England and Wales. Since 1898 our decline in deaths rate from this disease has steadily fallen from 1 per 1,000 to 1 per 10,000 of the population, largely due, I believe, to the facilities given by your Authority for treatment and isolation. The deaths of children under 1 year of age were nearly 100 less than in 1908—a year most favourable to child-life—and our infantile mortality rate in consequence is the lowest ever recorded. The rate is considerably less than that of the "Great Towns," and Huddersfield, and less than that of rural England. Our birth-rate, unlike the death-rates, shows no improvement, and now approximates that of the country generally. In this respect we are not alone Of the remaining seven large districts within the Metropolitan outer ring, Tottenham, West Ham, and Willesden only have a higher birth-rate. The same influences seem to be in operation in town and country, and the high birth-rates of former years are not likely to be repeated. Economic conditions explain in part the lessened birth-rate, but the main influence is the changes resulting from the better education of women and their consequent more self-reliance. This is reflected in the age incidence of those marrying. While the marriage-rate now is no less than in 1886, a continuous decrease has taken place in the marriage-rates of persons 15-25 years, and a proportionate increase above these ages. 5 In 1886, 200 of every 1,000 married females were minors in 1908 there were 140 only. The decline has thus taken place in the most prolific period of the life of the woman, and hence fewer births result. That this change has its compensating advantages, may be seen in the greater care exercised in the rearing of those born, and their probable more favourable ante-natal conditions, as observed in the lowered infantile death-rate throughout the country. The following tabular statement is given to show the grounds upon which comparisons have been made. Bi?-th-rate Death-rate and Analysis of Mortality in the year igog. Annual Rate per 1,000 Living. Deaths under one year 1 to 1,000 Births. Births Death-rate. Principal Epidemic Diseases Cols. 4-10. Small-Pox. Measles. Scarlet Fever. Diphtheria. Whooping Cough. Fever. Diarrhoea. Crude. Corrected. Cols. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. England and Wales 25.6 14.5 14.5 1.12 0.00 0.35 0.09 0.14 0.20 0.06 0.28 109 76 Great Towns 25.7 14.7 15.6 1.42 0.00 0.48 0.11 0.15 0.24 0.06 0.38 118 143 Smaller Towns 24.8 13.9 14.5 1.08 0.00 0.33 0.09 0.16 0.17 0.06 0.27 111 England and Wales less the 219 Towns 25.6 14.5 13.6 0.80 0.00 0.21 0.06 0.14 0.16 0.06 0.17 98 Walthamstow 24.66 8.8 9.3 0.98 0.00 0.22 0.08 0.10 0.33 0.01 0.22 83.3 „ 1908 26.48 9.56 10.1 0.95 0.00 0.7 0.08 0.15 0.01 0.9 0.0 100.8 Not only have the deaths from the dangerous infectious diseases shown a marked decline, but the numbers affected by them have also considerably lessened. Instead of an average rate of attack of 10 per 1,000 for the country, we have had only half that number during 1909. 6 Considering the large number of school children, the working-class character of the population, and our Isolation Hospital accommodation below the standard laid down by the Local Government Board, the infectious sickness rate is most favourable. This result is mainly due to the better supervision exercised over our schools than was possible heretofore, and under the circumstances the necessity of further extensions at the Sanatorium does not seem urgent. While recognising the great value of the Hospital in helping to prevent the spread of infectious diseases, and the possible good results from the adoption of the Notification of Births Act, your Authority, rather than incurring further expense in these directions, would much more likely do far greater service on behalf of the public health, by devoting the money to the better and more efficient control of such diseases as Measles and Whooping Cough. The work entailed in the supervision and organisation of the medical inspection of school children has been very considerable, and has occupied a very great deal of my time. In consequence the duties of the Medical Officer of Health and those of the Sanitary Inspector have been more differentiated than heretofore, and I have assumed no control or responsibility with respect to those as carried out by Mr. West and his assistants. In his Report will be found a full account of the work performed under his authority, and I have therefore referred only to those matters coming within my own knowledge. With the Housing, Town Planning, etc., Act, 1909, new in force, considerable power under section 17 is given to local authorities, and sections 14 and 15 should make easier much of the work of the Sanitary Inspector. There need be no fear on the part of the landlords that thest powers will be exercised in any but a fair and judicial spirit. With this Act supplementing the numerous Public Health Acts already adopted and in operation here, ample powers are given to "raise the general standard of health, and to prevent sickness and presenile mortality." 7 No changes have occurred during the year in the staff, and the work of each, in my judgment, has been good, and efficiently carried out; but, with the increasing and new duties imposed, some re-arrangement and strengthening will be necessary. The need for more office accommodation has been recognised, and its provision only awaits a decision as to how it may best be accomplished. The relations of the staff, one to the other, and my own with all, have been most cordial, and the courtesy and kindness which your Council have extended to us has made our work most agreeable, and I hope no less efficient. I beg to remain, Gentlemen, Your obedient Servant, J. J. CLARKE. 8 SANITARY AREA. PHYSICAL FEATURES—CHARACTER OF POPULATION. The Urban District of Walthamstow has an area of 4,355 acres, and lies between the River Lea on the west and Epping Forest on the 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. There are two small streams—the Ching and the Dagenham Brook. The former enters the district at Highams Park, in the Northen Ward, and winds its sluggish course through Hale End and Chapel End to the River Lea; the latter, the Dagenham Brook, is the outlet for the drainage of the district, and, having received the effluent of the Sewage Farm, winds its course through the neighbouring parish of Leyton, and joins the River Lea near Temple Mills. The water of neither stream at any point is used for drinking purposes. The whole district has a duplicate system of sewers, and practically every house water-closet accommodation. The sewage is received into precipitating tanks, treated with lime and alum, the solids removed and the effluent subsequently passed over the Farm before finally passing out of the district. The Sewage Farm, about 182 acres in extent, and the Sewage Works, with the Refuse Destructor, are situated in the St. James Street Ward, or western portion of the district. The drinking water is supplied by the Metropolitan Water Board, and is constant. The amount used per head per day is between 25 and 30 gallons. The district is divided into five Wards for administrative purposes; St. James Street, varying 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, from 25 to 220 feet. The character of the population and its age distribution have undergone but little change since 1901. 9 The great majority is made up of the working classes, who go daily to work in London and return at night to sleep. The district is one of the City's Dormitories, with a large child and "working age" population compared with the country generally. A small amount of local labour is absorbed by the factories situated in the Northern Ward, but from their position and the industries carried on they have no appreciable effect on the general health. According to the last Census only 9.6 per cent. of the householders employed a domestic servant. Of the 33,626 occupied males aged 10 years and upwards in 1901, 5,438 were in the building trades; 3,562 were engaged in the conveyance of men, goods or messages; 1,911 as commercial or business clerks; 1,709 were engaged in the furniture, fittings, and decorative trades, and 826 in engineering and machine-making. What has been said in "West Ham—A Study in Social and Industrial Problems,'' fairly applies to this district, and on page 55, "Report—Cost of Living of the Working Classes," will be found a full description of the housing accommodation. Of the five Wards Hoe Street generally has the best residential character, portions of Wood Street and the Northern Wards come next, while the High Street is intermediate, and is largely studded with the Warner Flats, leaving the St. James Street and Wood Street areas— particularly the portions near the railway stations—as the poorest portions of the district. The same tendency to migrate from the older and more congested parts to the outlying districts, is shown here as elsewhere, and may account for the larger number of empty houses in the St. James Street district compared with Census year. The electric trams, which cover a large portion of the district, help materially in this connection, and the Northern Ward in consequence is fast losing its semi-rural character. No Ward in the district is without a fair proportion of good-class houses, ranging in rateable value from £20 to £50, and shop property is mainly grouped around the railway stations situated in St. James Street, Hoe Street, Wood Street and Highams Park. 10 VITAL STATISTICS. POPULATION. The Registrar General estimates that the mid-year, 1909, population of this district was 136,602. This is an increase of 5,116 over that of 1908, and 15,268 over that of 1906. The natural increase of the population, or the excess of births over deaths, for the latter period was 7,352. Since 1906, building operations have been practically at a standstill, and our rate of growth was in no way like that prior to 1901, but it is on an assumption that such growth was similar, that a population of 136,602 is based. The population assigned may be accepted as a basis for comparing our birth and death-rates with those of other "Large Towns," since their populations are estimated on a like assumption, but in dealing with the constituent portions of the district, I estimate each Ward's population on the basis of 129,500 for the whole district. These figures are probably more nearly correct than those given by Somerset House, and we must await the official enumeration of 1911 for absolute accuracy. In arriving at the populations of the Wards, I have followed the methods of previous years, and thus comparisons made between the Wards have a like basis, and a continuity which makes such comparisons of some value. The following table is compiled from information supplied me by Mr. Jones, the Superintendent of the Schools' Attendance Officers, who make a yearly enumeration of the houses within the district. Owing to the limited time at these officers' disposal, an accurate return could not be expected, and approximate numbers can only be assumed. 11 TABLE I. Number of Houses in the Parish of walthamstow arranged in Wards, as given to Education Committee. t.James Streetward. High Street Ward. Hoe Street Ward. Wood Street Ward. Northern Ward. No. of Occupied Houses. No. Empty. No. in Construction. No. of Occupied Houses. No. Empty. No. in Construction. No. of Occupied Houses. Number Empty. No. in Construction. No. of Occupied Houses. No. Empty. No. in Construction. No. of Occupied Houses. No. Empty. No. in Construction. 1909 4118 283 2 3617 220 — 4744 230 10 3007 164 — 7059 594 42 1908 4100 335 1 3703 148 — 4588 299 4 3050 194 6 6868 600 45 1907 4130 266 — 3690 99 - 4593 276 15 3044 152 12 6733 451 112 1906 4089 337 1 3666 161 4527 283 38 2925 200 5 6008 768 108 1905 4114 362 2 3504 240 12 4284 294 10 2864 249 16 5541 803 271 1904 4139 228 31 3555 131 30 4324 254 36 2994 262 13 5151 726 255 Houses fit for Occupation. Houses Empty. Houses Occupied. Houses in Course of Construction. Population (at 5.9 per House.) 24,036. 1,491. 22,545. 53. 133,015. Registrar-General's Estimate 136,602. 12 From the foregoing, a probable population of 133,000 might be inferred, presuming that every house was occupied by 5.9 persons—the average in census year. But the Northern Ward with 7,000, and Hoe Street Ward with 4,500, or more than half the houses of the district, were occupied respectively by 5.7 and 5.5 persons in 1901, and this ratio is probably maintained. Presuming that this is correct the population deduced from the figures given by the Education Authority is overstated by at least 2,400. The following table is official, and taken from the Census returns of 1901:— TABLE II. 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 16,083 125 1,099 425 46,832 48,289 95,121 17,759 Presuming that every house has been built for which plans have been deposited since 1901, the total number now in existence would be 23,649. The Overseers in their official returns certify as empty the following:— Shops. Houses. Tenements. Total. 1909 180 1,268 574 2,022 13 As compared with previous years:— Shops. Houses. Tenements. Total. 1908 154 1,246 497 1,897 1907 117 1,268 352 1,737 1906 53 1,540 281 1,874 1905 75 1,654 611 2,340 1904 112 1,294 593 1,999 Assuming two tenements as one house, we have for the purpose of estimating the population to reckon as empty 1,735 houses, and as a number of those for which plans were passed in 1909 could not be completed in the mid-year, the total number then occupied could not exceed 21,914. Were each of these houses occupied by six persons, a population of 131,484 was possible, but unless the character of the district has much changed and the number of persons per house is now greater than in 1901, the total population for 1909 did not exceed 129,000. The following table will help to make clear the foregoing, and shews how the Ward populations are estimated. In the High Street Ward I assume that the average number of persons per house is now 6.6, rather than 6.3 as in Census year, thus increasing that Ward's population by 1,000, and bringing the total nearer to that given by the Education Authority. TABLE III. Wards. Possible No. of Houses fit for Occupation, 1908. Plans passed, in 1909. Greatest possible number Existing. Empty, June 1909 (Overseers' Lists). Possible Occupied Midyear, 1909. Occupied Education Returns. Numbers probably occupied M.O.H.'s Estimate. Proportion empty in 1909. Proportion empty at Census, 1901. Average number per House Census. Population, 1909. St. James Street 4,300 — 4,300 427 3,873 4,118 3,900 1 in 10 1 in 21 6 23,400 High Street 3,457 8 3,465 161 3,304 3,617 3,300 1 in 21.5 1 in 24 63 21,780 Hoe Street 4,779 31 4,810 316 4,494 4,744 4,500 1 in 15.2 1 in 15 5.5 24,750 Wood Street 3,118 23 3,141 247 2,894 3,007 2,900 1 in 12.7 1 in 15 6 17,400 Northern 7,787 146 7,033 584 7,349 7,059 7,000 1 in 13.6 1 in 7 5.7 39,900 Whole District 23,441 208 23,649 1,735 21,914 22,545 21,600 1 in 13.5 1 in 13.8 59 127,230 (or 127,440, 5.9 persons to house). EDUCATION AUTHORITY'S FIGURES. Houses fit for Occupation. Houses Empty. Houses Occupied. Houses in Course of Construction. Population (at 5 9 per house) 24,036 1,491 22,545 53 133,015 Registrar-General's Estimate... 136,602 14 15 As accuracy of Ward population is impossible, I assign to each, for comparative purposes, numbers approximating those of previous years. I assume that probably St. James Street and High Street have larger populations than in 1908, not because fewer houses are unoccupied, but rather that, owing to economic conditions, each house shelters a greater number than in 1901. WARD POPULATION FOR 1909 AND YEARS PRECEDING. St. James St. High St. Hoe St. Wood St. Northern. Total. 1909 24,500 22,500 24,500 18,000 40,000 129,500 1908 23,500 21,500 24,000 17,500 37,000 123,500 1907 24,000 22,000 24,000 17,000 37,000 124,000 1906 24,000 21,000 24,000 17,500 35,000 121,500 1905 24,000 21,000 23,500 17,000 32,000 117,500 1904 23,600 20,400 23,100 16,600 24,300 108,000 1903 23,600 20,000 22,500 16,500 23,500 106,000 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 TABLE IV. 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 England and Wales (assumed). 95,131 12,271 11,320 10,464 9,513 8,561 14,174 10,844 8,086 5,517 3,139 1,236 Walthamstow. 17-7 j 95,131 54-7 j 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. 3-85 2'25 3-4 4-7 63 1065 16-75 32-7 61.8 1536 16 There is no reason to assume that the age constitution differs from that prevailing in 1901, and we have therefore a proportionately smaller number of persons over 45 years of age than the country generally. It will be noticed that the death-rate of persons above 45 is much greater than in any of the other age groups, except that under 5, and doubtless this unequal age distribution in our population slightly favours our death-rate. The character of our population, too, changes but little—as in 1901 so it is in 1909. The following Summary of the Sanitary and other data of importance are given for easy reference :— WHOLE DISTRICT. Population. Rateable Value. General District Rate, Poor Rate, Education Rate, £. per £. per £. per £. 1881 Census 21,697 97,111 3/4 2/5 0/2 1891 „ 46,346 156,959 2/9 1/9½ 14¾ 1901„ 95,131 328,756 3/8 l/6¾ 1/11¾ 1904 Estimated 111,282 404,101 3/2 1/10¾ 2/4½ 1905 „ 116,300 423,241 3/10 2/4 2/7 1906 „ 121,334 426,703 4/1 3/9 1/8 1907 „ 126,397 431,937 4/1 3/9 1/8 1908 „ 131,486 437,127 4/1 3/4 1/9 1909 „ 136,602 444,582 4/1 3/5 2/0 The population was estimated to be 4,780 in 1851, 6,880 in 1861, and enumerated as 10,692 in 1871. Average for previous 10 years. Total Births registered, 1909 3,369 3,378 ,, Deaths ,, „ 1,205 1,282 Number of deaths of persons not belonging to this district 11 11 Natural increase of population 2,164 2,096 Birth-rate per 1,000 estimated population 24.66 31.42 Death-rate 8.8 12 Death-rate corrected for age and sex 9.3 12.6 Zymotic Death-rate .98 2.16 Infantile Mortality Rate 83.4 128 Infectious Sickness Rate 5.9 9.7 Number of persons per house 5.9 „ „ „ acre (exclusive of Sewage Farm and Reservoirs) or Density of Population 35 17 EDUCATION COMMITTEE'S RETURNS FOR DEC., 1909. Summary. Schools. Capacity. On Books Present. Average. Percentage Refused Admission, mainly under 5. Original. Present. 16 Boys'. 6894 6954 7277 6818 6622.6 91 5 17 Girls'. 7077 5899 7071 6525 6235.2 88.1 - 19 Infants' 7443 7251 7734 6669 6333.6 81.8 56 9 Mixed 3233 3161 3112 2864 2763.7 88.8 3 24647 24265 25194 22876 21955.1 87.1 65 3 Special 150 150 116 107 101.9 87.8 — M'th end'g Dec. 23,'09 24797 24415 25310 22983 22057 87.1 65 „ 23,'08 24167 24521 25307 22082 22339.1 88.2 252 Decrease - 106 - 99 282.1 1.1 165 22 Increase 630 3 — under 5 yrs. over 5 yrs. b TABLE V. WARDS.— Acreage, Population, Density, Birth and Death Rates, etc. Wards. Acreage. Acreage excluding Farm & Reservoirs. Number of Houses, 1901. Estimated number of Houses occupied. Mid-year 1909. Estimated Population, 1909. Density (Excluding Sewage Farm & Reservoirs). Birth Rate, 1909. Death Rate, 1909. Height in feet above Sea Level. St. James Street 489 307 3937 3900 24,500 79 29.4 10 18 to 54 High Street 660 1/3 415 1/3 3220 3300 22,500 54 27.4 9 21 to 60 Hoe Street 347 1/3 347 1/3 4084 4500 24,500 69 21.8 10.2 50 to 140 Wood Street 499 499 2716 2900 18,000 36 23.6 11.2 75 to 176 Northern 2359 1/3 2237 1/3 3377 7000 40,000 18 27 0 7.4 25 to 220 Whole District 4355 3806 17,334 21,600 129,500 33.8 26.1 9.3 18 SUB-DISTRICTS. 19 BIRTHS—BIRTH RATE. The total number of births registered during the year was 3,369— males 1,652, females 1,717. Thirty-three of these (males 18, females 15) were born at the Union Workhouse, and 4 males and 1 female elsewhere. Of the total births 59 were illegitimate, and of these 32 were males and 27 females. Eighteen of them took place at the Workhouse, 5 elsewhere without, and the remainder within the district. The number of these births has varied but little since 1901. The number of births yearly since the last census was as follows :— 1901, 3,210; 1902, 3,426; 1903, 3,535; 1904, 3,649; 1905, 3,389; 1906, 3,594; 1907, 3,629; and 1908, 3,482. The births in 1909 were fewer than in any year since 1901, and assuming the population of the Registrar-General to be correct our birthrate was 24-66, the lowest recorded since 1880. The discrepancy in the number of births registered, as given by me (3,369), and in the four quarterly returns of the Registrar-General (3,291), is not easy to explain, and although making little difference in the birth-rate it vitiates the infant mortality rate by 7.6 per 1,000. A birth-rate of 26 per 1,000 on an estimated population of 129,000 would be a more correct expression of what the birth-rate actually was, and more in consonance with the rate of 25.7 of the 76 Great Towns. "We must expect that here as elsewhere similar forces are operating to check the rate of growth to which we had become accustomed, and we may attribute much of our decline to slackness of work and the competition of women with men in the London labour market. I have no knowledge that in your district less moral reasons have much to do with it." "Care to preserve and render efficient those children born counterbalances the small birth-rate, and some compensation for it has been also found in the lower general and infant death-rates." 20 The following table shows the births distributed over the various Wards for the four quarters of the year:— TABLE VI. St. James Street. High Street. Hoe Street. Wood Street. Northern. Workhouse and others. Totals. M. F. M. F. M. F. M. F. M. F. M. F. M. F. 1st quarter 88 93 81 99 57 69 55 53 112 130 4 7 397 451 2nd quarter 103 105 78 83 82 69 68 54 140 148 10 4 481 463 3rd quarter 73 78 53 61 69 65 51 61 126 150 3 4 375 419 4th quarter 92 75 75 83 60 52 41 35 128 136 3 3 399 384 356 351 287 326 268 255 215 203 506 564 20 18 1652 1717 Workhouse 6 5 2 3 0 1 5 3 5 3 Others 3 1 0 0 0 0 0 0 1 0 Totals 722 618 524 426 1079 — 3,369 Population 24,500 22,500 24,500 18,000 40,000 — 129,500 Birth-rate 1909 29.4 27.4 21.4 236 27.0 — 26.0 Do. 1908 30.2 30.7 23.4 23.8 30.5 28.2 21 The birth-rates for the various Wards from Census year onwards are as follows:— St. James Street. High Street. Hoe Street. Wood Street. Northern. 1901 33 35.7 28 28.4 39.8 1902 33.22 36.65 29.45 30 39.55 1903 31.6 39.1 29.24 27.45 38.1 1904 33.3 37 27 28.1 40.6 1905 29 30 25.07 24.9 31.8 1906 30.4 35 24.7 26.2 30.2 1907 29 33.3 25 25 31.6 1908 30.2 30.7 23.4 23.8 30.5 1909 29.4 27.4 21.4 23.6 27 The decline in the birth-rate in the different Wards in 1909 compared with 1901 varies from 36 in James Street to 12'8 in the Northern Ward. The probable diminution in birth-rate for the whole district does not exceed 7 per 1000, and the inference is that the Northern and High Street Wards are over-estimated rather than that the economic conditions or social habits of the people have undergone a violent change. Compared with 1901, there is for 1909 a shrinkage of 1,240 births upon an assumed increased population of 41,471. And in every Ward (the Northern excepted) an actual decrease in the numbers born. The registered births for the two years were:— St. James Street. High Street. Hoe Street. Wood Street. Northern. 1901 767 710 600 441 673 1909 722 618 524 426 1079 DEATHS AND DEATH-RATES. WHOLE DISTRICT. During the year 982 deaths were registered as occurring within the district under the Council's authority—males 480, females 502. Eleven of these (males 5, females 6) were of non-residents and are excluded. Particulars of these deaths were sent to the Medical Officers of Health of the respective localities to be included in their returns. 22 The deaths of residents dying without the district, as far as I was able to get returns, are now added. These were 42 at the Workhouse, 167 at the Infirmary, 15 at the Isolation Hospital, and 10 transmitted from Health Officers elsewhere. These latter do not embrace all the deaths of Walthamstow's inhabitants, and until a proper system of interchange, whereby the deaths wherever occurring would be transferred to the appropriate locality, is established, a death-rate based on the returns received from the local Registrar will be considerably less than that assigned to it by the Registrar-General. Week by week I have compared the death and birth returns as sent to me, with those given in the weekly reports of the Registrar-General, and I cannot remember the figures agreeing for a single week. I accept the figures from Somerset House as correct, and from the four quarterly returns of the Registrar-General I find that 101 persons belonging to this district have died during the year, and of whom we have no record. This I account for by the large number of our people, who die in the London Hospitals and elsewhere, being registered in the localities where death takes place; and while probably such deaths are excluded by the Medical Officers of Health concerned, no intimation of such is sent here, but when the death certificate reaches Somerset House the allocation is made to this district. One would expect for the "76 Great Towns" that the RegistrarGeneral would transmit the particulars of such deaths, so that a correct appreciation of the mortality figures might be of service to those entrusted with the care of the public health. I have referred in previous reports to the loose certification of death, and the little real reliance that can be placed on many of the causes assigned; and it is to be hoped that at an early date changes may be made in the present methods of registration, and the transmitting of returns to local authorities. The total deaths ascertained for the year were 1,205— males 610, females 595. 23 All the deaths registered were certified by a doctor or the coroner, that of a male child aged 8 months, returned as dying from Bronchitis, excepted. The deaths represent a crude death-rate of 8'8, or a corrected rate for differences of age and sex in the population, as compared with the whole country, of 9.3 per 1,000 of the estimated population. The death-rate for England and Wales was 14.5, and for the "76 Great Towns" 15.6. The death-rate for the "143 Smaller Towns" was 14.5, and excluding these and the Great Towns the rate for the country was 13.6. Our death-rate is based on a like assumption for other towns as to increase of their population since the last Census, and, taking into account the 101 deaths already mentioned as unaccounted for, our death-rate is 3.6 less than Rural England, 4.5 less than the " 143 Smaller Towns," 5.6 less than the "76 Great Towns," and 4.5 less than that of the country as a whole. The birth, death, and infantile mortality rates of the following districts of the outer zone of London, compared with your own, will be of interest. The localities are selected as presenting many features in common; Croydon. Willesden and Hornsey being the most favoured from their position and economic conditions. The others are more nearly like Walthamstow, and represent working-class districts that serve mainly as "dormitories" for London's workers. Population. Birth- Rate. Death-rate. Infantile Mortality rate or Proportion of Deaths of Children under one year to 1,000 Births Croydon 161,078 24.3 11.6 80.4 Willesden 160,424 25.1 10.4 96.5 Hornsey 95,628 15.2 8.3 61.0 Tottenham 129,464 29.3 11.4 88.8 West Ham 321,767 27.1 14.0 123.9 East Ham 149,575 23.5 9.8 99.7 , Leyton 129,614 24.0 10.2 81.8 Walthamstow 136,602 24.0 9.5 91.0 24 DEATHS AND DEATH-RATES. ACCORDING TO WARDS. The total deaths are credited to the various Wards, and are correct so far as the returns enable me to allocate them. How many of the unreturned deaths already referred to belong to one or other Ward is impossible to say, but presumably they would make but a slight difference in the death-rate of any one of them. Care has been taken in arriving at the populations assigned to the Wards, but at best these figures can be only approximates, and any deductions drawn from marked differences in death-rates, must be to that extent discounted. The deaths and death-rates for 1909 and the death-rates for previous years are as follows:— St. James St. High St. Hoe St. Wood St. Northern. Population, 1909 24,500 22,500 24,500 18,000 40,000 Deaths, „ 253 202 251 203 296 Death-rate „ 10 9.0 10.2 11.2 7.4 „ 1908 13.1 9.8 11 9.9 8.1 „ 1907 14.3 10.8 9.9 12.8 9 1906 12.9 11.7 11 11.7 10.8 „ 1905 12.7 11.4 9.8 10.2 9.3 „ 1904 13.85 12 10.6 11.08 13.45 „ 1901 15.03 12.8 11.5 12.05 15.27 (Census year.) It will be noticed that these death-rates are based on a population of 129,500, rather than on that assumed by the Registrar-General, namely, 136,602. There can be little doubt about the total population being at least 129,000, and in noticing the great difference in the death-rates of St. James Street and the Northern Wards, and comparing their rates with those in 1901, it strikes one that either the Northern Ward's population is overestimated, or that its death-rate since Census year has fallen much more proportionately than that of St. James Street. Assuming the birth-rates are alike in both Wards—thus making the Northern Ward's population 38,000—on this basis the death-rate shows 25 that, in 1909, 76 fewer deaths took place in that area than would have occurred among the same number of people located in St. James Street, and that 266 fewer people have died in 1909 than would have in 1901. A lowered death-rate is a feature of all the Wards, but the least noticeable is that in Hoe Street, the Ward offering the least scope for improvement. Its favoured position, and the general better social condition of its people, as reflected in its general and infantile mortality rates, have been referred to in previous reports. Bearing in mind that St. James Street has a large population of the poorest of our people, and a high birth-rate, its general mortality figure is a great improvement on previous years, and equally with the other portions of the district has shared in the general improvement. The following figures give the total deaths and the deaths of children under 5 years of age from Zymotic or preventable diseases in the five Wards :—- Bt. James St. High St. Hoe St. Wood St. Northern. Births 722 618 524 426 1,079 Deaths—Total 253 202 251 203 296 Death-rate 10 9 10.2 11.2 7.4 Deaths under 5 year from Zymotic diseases 30 14 26 24 42 Percentage of total deaths— For 1909 11.8 7.0 10.3 11.8 14.2 For 1908 9.7 11.7 4.5 7 8 For 1907 17.3 14.7 9.6 11.8 17.8 For 1906 19.6 15.9 9.5 14.1 21.5 There are 33 more deaths in 1909 than in 1908, and their percentage to the total deaths in the various Wards differs considerably. This is accounted for by the epidemic prevalence of Measles in 1908 being followed in 1909 by Whooping Cough, causing many more deaths in those Wards previously free of the disease than in those already affected Of the 46 deaths from Whooping Cough, 18 occurred in the Northern 11 in Wood Street, and 5 in the Hoe Street Wards, where no death had taken place in 1908, and the unfavourable rates of these districts are thus explained. The improvement of 1908, noticed in the poorest area, has been well maintained, owing to its freedom from Scarlet Fever, Diphtheria and Diarrhœal diseases. 25 INQUESTS. During the year 109 Inquests were held. Nine of these were concerning the deaths of persons belonging to other districts. The ten deaths of residents enquired into by the Coroner, at the Workhouse and Infirmary, are now added, and the causes of all deaths certified, are as follows:— Under One Year: Want of attention at birth, 2; Convulsions, 5; Broncho-Pneumonia and Congestion of Lungs, 5; Prematurity, Inanition, Want of Vitality, 3; Suffocation—overlaying, 6; Tuberculosis of bowels, 1; Meningitis due to fall, 1; Malnutrition due to neglect of parents, 1. Over One Year : 1—5 Years. 5—15 Years. 15—25 Years. 25—65 Years. 65 and upwards Total. Natural Causes 4 1 1 12 10 28 Apoplexy ... ... ... 7 ... 7 Rupture of Heart and Aneurism ... ... ... ... 2 2 Croup—Asphyxia ... 1 ... ... ... 1 Strangulation of Bowel 1 ... ... ... ... 1 Epilepsy ... ... ... 1 ... 1 Syncope—Tight Lacing ... ... ... 1 ... 1 Pneumonia, following accident ... ... ... ... 1 1 Do. Cold & Exposure ... ... ... 1 ... 1 Do want of attention 1 ... ... ... ... 1 Accidents 1 ... ... 1 7 9 Do. Drowning ... ... ... 1 ... 1 Do. and Negligence 1 ... ... ... ... 1 Hæmorrhage after Confinement ... ... ... 1 ... 1 Suicides ... ... ... 8 1 9 Do. Insane ... ... ... 4 1 5 Burns and Scalds 6 ... ... 1 ... 7 Septic Poisoning ... ... ... ... ... 1 Do. following wounds 1 1 ... ... ... 2 Asphyxia by Coal Gas ... ... ... ... 2 2 Strychnine Poisoning (Cause ?) ... 1 ... ... ... 1 Chloroform Admin. (operation) ... l ... ... ... 1 Tetanus ... l ... 1 ... 2 Poisoning by Eating Brawn ... ... ... 1 ... 1 Totals 15 6 1 41 24 87 27 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 eighteen years, and the average for the preceding ten years compared with 1909:— TABLE VII. Year. Births. Deaths. B. Rate. D. Rate. Zymotic D. R. Infantile Mortality Rate. Natural Increase of Population 1891 1756 694 37.3 14.7 1.9 120 1062 1892 1717 915 34.75 18.0 3.9 145.6 802 1893 1809 809 34.78 15.55 2.43 133.2 1000 1894 1813 717 32 12.6 1.8 129.6 1096 1895 2021 965 33.2 15.8 3.5 153.3 1056 1896 2101 817 32.3 12.5 2.4 127.5 1284 1897 2246 832 32.08 11.88 2.8 132 1414 1898 2294 1034 29.8 13.4 3.67 169.5 1260 1899 2835 1282 34.14 15.44 2.94 170.0 1553 1900 3037 1254 33.37 13.78 2.8 158.7 1783 1901 3210 1296 33.1 13.35 2.82 147.6 1914 1902 3426 1154 33.81 11.38 1.3 115 2272 1903 3535 1178 33.25 11.08 1.9 113.7 2357 1904 3649 1330 3279 11.95 2.89 135.9 2319 1905 3389 1249 29.14 10.7 1.69 104.4 2140 1906 3594 1447 29.60 11.90 2.54 129.7 2147 1907 3629 1376 28.55 10.88 1.83 104.7 2253 1908 3482 1258 26.48 9.56 .95 100.8 2224 Average for 10 years 3378 1282 31.42 12.00 2.16 128.05 2096 1909 3369 1205 24.66 8.8 .98 83.4 2164 Total natural increase of Population since 1891, 32,100. Total increase as shown by census, 1901, 48,785. Total increase as estimated to middle of the year 1909, 90,256. Total increase per cent. since 1891, 194. Total increase per cent. since 1901, 43. 28 INFANTILE MORTALITY. During the year 281 deaths occurred in children under one year of age. The deaths for preceding years were: 351 in 1908; 380 in 1907; 466 in 1906; 854 in 1905; 496 in 1904; 401 in 1903; 394 in 1902, and 481 in 1901. The infantile mortality rates are given on the preceding table. These rates based on the number of deaths to 1,000 registered births are accurate as not depending upon assumed but ascertained figures. The slightly lower rate given by me for 1909, compared with that given by the Registrar-General is due to the faulty (and the only) methods of obtaining our death returns. From the figures it will be noticed that the much improved and satisfactory rates of 1907-8, compared with previous years, are more than maintained; and it would be most gratifying if one could believe that the improvement was due to the efforts made to conserve infant life, and to improved hygienic surroundings in the homes of our people. Infant mortality depends on so many varying causes, acting before and after birth, that it is unsafe to attribute the fewer deaths of infants in recent years to any particular measures taken on their behalf. The recent wet summer and consequent lessened mortality from Diarrhoea, and the decreasing birth-rate ensuring greater care in "mothering," account for much. Since 1905, by the instructions of the Local Government Board, the deaths of all children under one year are classified as in the following Table VIII. (Local Government Board, Form V.). Of the 281 children so dealt with, 129 died within the first month of life, and of these the great majority were from prematurity and developmental defects—sheer inability to live. The number so dying in preceding years was no greater, although the birth-rate was much higher, and contrary to what one would expect social conditions do not seem to influence much the proportion of these deaths to the total from all causes. TABLE VIII. Causes of Deaths. Under 1 Week 1-2 Weeks. 2-3 Weeks. 3-4 Weeks. Total under 1 Month. 1-2 Months. 2-3 Months. 3-4 Months. 4-5 Months. 5-6 Months. 6-7 Months. 7-8 Months. 8-9 Months. 9-10 Months. 10-11 Months 11-1? Months Total Deaths under One Year. All Causes Certified 69 25 14 21 129 21 21 17 10 13 16 11 15 10 10 7 280 Uncertified — — — — — — — — — — — — 1 — — — 1 COMMON INFECTIOUS DISEASES. ' Small-Pox — — — —— — — — — — — — — — — — — — Chicken-Pox — — — — — — — — — — — — — — — — — Measles — — — — — — — 1 — — — 1 1 2 2 2 9 Scarlet Fever — — — — — — — — — — — — — — — — — Diphtheria; Croup — — — — — — — — — — — — — — — — 1 Whooping Cough — — — — — 4 4 — — 1 4 — 3 — 2 3 21 DIAR RHCEAL DISEASES. Diarrhoea, all forms — — — — — — — 1 — 3 1 3 1 2 1 — 12 Enteritis, Muco tis, Gastro Enteritis. — — — — — 1 1 3 1 — — — — 1 — — 7 Gastritis, Gastrointestinal Catarrh ... — — — — — 1 — — — — 1 — — — — — 2 WASTING DISEASES." Premature Birth 41 7 4 4 56 1 1 — — — — — — — — 58 Congenital Defects 5 2 — — 7 1 — — 1 — — — — 1 — — 10 Injury at Birth 5 1 — — 6 — — — — — — — — — — — 6 Want of Breast-milk — 1 — — — — — — — — — — — — — — 1 Atrophy, Debility, — — — — — — — — — — — — — — — — — Marasmus 5 3 5 5 18 6 8 5 2 2 1 1 1 I — — 45 Asthenia: Inanition 9 2 1 1 13 — — — — — — — — — — — 13 TUBERCULOUS DISEASES. Tuberculous Meningitis — — — — — — — — — 1 — — — — 1 — 2 Tuberculous Peritonitis: Tabes Mesenterica . — — — — — — 1 — 1 — 1 — 1 — — — 4 Other Tuberculous Diseases — — — — — — — — — — — — 1 — — — 1 OTHER CAUSES. " Erysipelas — — — — — — — — — — — — — — — — — Syphilis — — — 1 1 — — — — — — — — — — — 1 Rickets — — — — — — — — — — — 1 — — — — 1 Meningitis (not Tuberculous) — — — — — — — — — — — — — — — — 5 Convulsions 2 6 2 4 14 — 1 1 — 1 — 1 1 — — — 19 Bronchitis — — — — — 1 2 2 1 2 4 2 2 1 1 I 19 Laryngitis — — — — — — — — — — 2 — — — — — 2 Pneumonia — 2 1 2 5 2 1 — 2 2 2 2 2 2 2 — 22 Suffocation, overlaying 1 — — — 1 1 2 1 1 — — — — — — — 6 Other Causes 1 1 1 4 7 3 1 1 1 — — — — — — 1 14 69 25 14 21 129 21 21 17 10 13 16 11 16 10 10 7 281 District (or sub-division) of Walthamstow. Births in the year legitimate, 3310. illegitimate, 59. Population. Estimated to middle of 1909, 136,602. Deaths from all Causes at all Ages. 1205. 29 The percentage of these deaths to total births for the Wards, were : St. James St. High St. Hoe St. Wood St. Northern. 4.7 8.7 8.8 4.7 3.6 And the percentage to total births : 10.4 7.4 7.6 9.4 7.4 Birth-rate: 29.4 27.4 21.4 23.6 27.0 The high percentage of these deaths in the St. James Street and Wood Street Wards may be accounted for by the poor circumstances of their people, and the more difficult social conditions under which many of the mothers have to live; but why in well-to-do Hoe Street, with a birth-rate of 21-4, should one in every six children born die in the first month from 4<sheer inability to live"? Do such figures lend colour to the view that the taking of drugs to prevent child-bearing is practised more by the better classes and accounts for much of this mortality ? Of the 59 illegitimate children born during the year 14 died, equivalent to a mortality rate of 220 per 1,000, or more than double that of legitimates. Miss Davis, during the year, visited these and others born towards the end of 1908. She reports that in the great majority of cases the children were well looked after, and in pursuance of this work 163 home visits were made. In the Children Act, 1908, are some excellent provisions for safeguarding the lives of boarded-out children—many of them of this class —but in the appointment of the Guardians of the Poor as the authority, I fear much of its value is lost. An occasional visit by a Poor-Law official to unwanted children is insufficient, and the work could be much more efficiently carried out by your Health Visitors. The Act provides for combination lu with any other Local Authority for the purpose of executing the provisions of the Act, and for defraying the expenses thereof"; but no overtures have been made to your Council to co-operate in the work. 30 The following; shows in tabular form the number and causes of death in children under five years in 1909, 1908, 1907, 1906, 1905 and 1904:— Diseases. 1909 1908 1907 1906 1905 1904 Measles 28 31 30 35 34 45 Scarlet Fever 4 7 13 9 9 7 Influenza 1 — 2 1 0 1 Whooping Cough 45 2 72 18 31 29 Diphtheria 10 12 24 29 15 20 Croup 2 2 1 3 — 2 Enteric Fever — — — — 1 1 Diarrhoea 5 23 29 106 52 82 Zymotic Enteritis 9 14 15 49 26 99 Enteritis 7 7 6 11 12 4 Gastric-Enteritis 5 8 12 — — 13 Septic Diseases 9 3 5 7 8 4 Tuberculosis of Meninges 12 12 26 13 13 13 Do. Lungs 3 — — 4 4 3 Do. other forms 11 11 16 20 13 22 Cancer 1 1 — — — 1 Premature Birth 60 65 68 83 56 62 Developmental Diseases 76 89 76 88 84 94 Meningitis 9 10 13 14 16 18 Acute Bronchitis 29 41 42 34 31 32 Lobar Pneumonia 9 14 23 15 19 18 Lobular Pneumonia 45 56 59 49 54 .. 45 Diseases of Stomach 2 7 4 2 2 6 Obstruction of Intestines 2 2 1 2 2 — Bright's Disease 1 1 — 1 1 3 Accidents or Negligence 18 15 21 30 14 23 Congenital Syphilis 1 10 9 — — — All other causes 26 47 41 66 47 46 430 493 608 689 545 693 Four hundred and thirty deaths out of a total of 1,205 were of children under 5 years of age, and of the 430, 129 were in the first month and 281 within the first year of life. TABLE IX. Table showing deaths for the four quarters of the year, and the total deaths for the entire district and for the Wards. No. CAUSE OF DEATH. AT ALL AGES. UNDER 1 YEAR. 1 TO 5 YEARS. 5 TO 15 YEARS. 15 TO 25 YEARS. 25 TO 65 YEARS. 65 AND UPWARDS. In Public Institutions in the District and elsewhere. 1st Qr. 2nd Qr. 3rd Qr. 4th Qr. Total. 1st Qr. 2nd Qr. 3rd Qr. 4th Qr- Total. 1st Qr. 2nd Qr. 3rd Qr. 4th Qr- Total. 1st Qr- 2nd Qr- 3rd Qr- 4th Qr- Total. 1st Qr. 2nd Qr- 3rd Qr. 4th Qr- Total. 1st Qr- 2nd Qr. 3rd Qr. 4th Qr- Total. 1st Qr- 2nd Qr. 3rd Qr- 4th Qr- Total. 1 Small Pox — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 2 Measles 10 10 8 2 30 3 3 3 — 9 7 6 4 2 19 - 1 1 - 2 — — — — — — — — — — — — — — — 4 3 Scarlet Fever 3 4 1 3 11 — — — — — 2 1 — 1 4 1 3 1 5 1 1 2 4 Typhus Fever — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 5 Epidemic Influenza 6 7 2 1 16 1 — — — 1 — — — — — 2 — — — 2 — — — — — 3 6 2 1 12 — 1 — — 1 1 6 Whooping Cough 8 6 18 14 46 2 3 11 5 21 5 3 7 9 24 1 — — — 1 — — — — — — — — — — — — — — — 9 7 Diphtheria, Membranous Croup 4 2 5 3 14 1 — — — 1 2 1 3 3 9 2 — 2 — 4 — — — — — — — — — — — — — — — — 8 Croup — — — 3 3 — — — 1 1 — — — 2 2 — — — 2 2 — — — — — — — — — — — — — — — — 9 Enteric Fever — — 1 1 2 — — — — — — — — — — — — — 1 1 — — — — — — — 1 — 1 — — — — — — 10 Asiatic Cholera — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 11 Diarrhoea, Dysentery 2 1 2 2 7 1 1 1 1 4 — — 1 — 1 — — — 1 1 — — — — — — — — — — 1 — — — 1 1 12 Epidemic or Zymotic Enteritis — 3 6 1 10 — 2 5 1 8 — 1 — — 1 — — 1 — 1 — — — — — — — — — — — — — — — — 13 Enteritis 4 — 3 2 9 1 — 1 1 3 2 — 1 1 4 1 — — — 1 — — — — — — — 1 — 1 — — — — — 4 14 Gastro Enteritis I — 2 2 5 1 — 1 2 4 — — 1 — 1 — — — — — — — — — — — — — — — — — — — — — 15 Other continued Fevers — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 16 Erysipelas 2 2 — 3 7 — 1 — — 1 — — — — — 1 — — — 1 — — — — — 1 1 — 3 5 — — — — — 3 17 Puerperal Fever — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 18 Other septic diseases 4 8 3 5 20 1 2 1 2 6 — 2 1 — 3 — 1 — — 1 — — — — — 2 2 — 3 7 1 1 1 — 3 5 19 Intermittent Fever and Malarial Cachexia — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 20 Tuberculosis of Meninges 7 2 3 4 16 1 1 — — 2 5 1 1 3 10 1 — — 1 2 — — 2 — 2 — — — — — — — — — — 4 21 Tuberculosis of Lungs 24 34 23 27 108 — — —— — — 1 1 1 — 3 — 2 1 1 4 — 9 6 3 18 22 21 14 23 80 1 1 1 — 3 33 22 Other forms of Tuberculosis 3 9 11 5 28 1 1 2 1 5 1 1 3 1 6 — 3 3 — 6 — 1 1 — 2 1 3 2 3 9 — — — — — 5 23 Alcoholism — 1 1 3 5 — — — — — — — — — — — — — — — — — — — — — 1 1 3 5 — — — — — — 24 Cancer 13 17 10 21 61 — — — — — — 1 — — 1 — — — — — — — 1 — 1 9 10 4 12 35 4 6 5 3 24 19 25 Premature Birth 24 8 15 13 60 24 8 15 13 60 — — — — — — — — — — — — — — — — — — — — — — — — — 1 26 Developmental Diseases 25 16 10 25 76 24 15 10 25 74 1 1 — — 2 — — — — — — — — — — — — — — — — — — — — 10 27 Old Age 25 12 9 18 64 — — — — — — — — — — — — — — — — — — — — — — — — — 25 12 9 18 64 22 28 Meningitis 3 4 2 2 11 1 2 — 1 4 2 1 2 — 5 — 1 — 1 2 — — — — — — — — — — — — — — — 2 29 Inflammation and Softening of Brain 1 1 — — 2 — — — — — — — — — — — — — — — — — — — — — — — — — 1 1 — — 2 — 30 Organic Diseases of Heart 12 12 8 6 38 — — — — — — — — — — 1 1 2 — 4 2 3 — 1 6 4 7 4 4 19 5 1 2 1 9 9 31 Acute Bronchitis 18 9 3 10 40 5 7 2 7 21 5 1 1 1 8 — — — — — — — — — — 2 — — 2 4 6 1 — — 7 3 32 Chronic Bronchitis 33 17 4 14 68 — — — — — — — — — — — — — — — — — — — — 10 7 2 6 25 23 10 2 8 43 7 33 Lobar (Croupous) Pneumonia 23 15 8 10 56 — — — — — 5 1 1 2 9 2 2 — — 4 2 1 — — 3 13 9 3 7 32 1 2 4 1 8 6 34 Lobular (Broncho-) Pneumonia 16 14 8 21 59 7 6 2 7 22 2 4 5 12 23 3 1 — — 4 — 1 — — 1 2 2 1 2 7 2 — — — 2 7 35 Diseases of Stomach — 2 2 2 6 — 2 - - 2 - - - - - - - - - - - - - - - - - 1 2 3 - - 1 - 1 - 36 Obstruction of Intestines 1 1 2 1 6 - - 1 - 1 - - 1 - 1 - - - - - - 1 - - 1 - - - - - 1 - 1 1 3 3 37 Cirrhosis of Liver 3 1 1 3 8 - - - - - - - - - - - - - - - - - - - - 3 - 1 2 6 - 1 - 1 2 1 38 Nephritis and Bright's Disease 5 5 5 15 30 - - - - - - - - 1 1 1 - - 1 2 - - - - - 2 2 2 8 14 2 3 3 5 13 7 39 Tumours and other Affections of Female Genital Organs - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 40 Accidents and Diseases of Parturition 3 6 1 1 11 - - - - - - - - - - - - - - - 2 1 - - 3 1 5 1 1 8 - - - - - 2 41 Deaths by Accident or Negligence 12 8 9 8 37 4 2 1 2 9 2 1 4 2 9 1 1 1 - 3 - - - - - 2 1 1 2 6 3 3 2 2 10 12 42 Deaths by Suicide - 10 4 - 14 - - - - - - - - - - - - - - - - - - - - - 9 4 - 13 - 1 - - 1 1 43 Deaths from Ill-defined Causes 1 - - - 1 - - - - - - - - - - - - - - - - - - - - -1 - - - 1 - - - - - - 44 Syphilis - 2 - 1 3 - 1 - - 1 - - - - - - - - - - - - - - - - 1 - 1 2 - - - - - 1 45 All other Causes 52 42 54 69 217 6 5 3 7 21 2 - - 2 4 - 2 3 3 8 2 1 2 2 7 22 21 26 29 98 20 13 20 26 79 52 All Causes 348 291 245 321 1,205 84 62 59 76 281 43 27 37 41 148 17 18 14 11 60 8 18 12 6 44 100 108 72 115 395 96 57 51 72 276 234 TABLE X. Schedule B. Table of Deaths during the year 1909, 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 & upwards St. James St. High Street Hoe Street Wood Street Northern Total Deaths in Public Institutions (Workhouse and Infirmary included). 1 Small-Pox - - - - - - - - - - - - - 2 Measles 30 9 19 2 — — — 8 3 9 5 5 4 3 Scarlet Fever 11 — 4 5 — 2 — 1 — 3 3 4 — 4 Typhus Fever — — — — — — — — — — — — — 5 Epidemic Influenza 16 1 — 2 — 12 1 4 4 4 — 4 1 6 Whooping Cough 46 21 24 1 — — — 7 5 5 11 18 9 7 Diphtheria, Membranous Croup 14 1 9 4 — — — 1 3 3 2 5 — 8 Croup 3 1 1 1 - - - - - 1 1 1 — 9 Enteric Fever 2 — — 1 — 1 — — — — 1 1 — 10 Asiatic Cholera — — — — — — — — — — — — — 11 Diarrhoea, Dysentery 7 4 1 1 — — 1 4 — 2 1 — 1 12 Epidemic or Zymotic Enteritis 10 8 1 1 — — — 3 2 1 — 4 — 13 Enteritis 9 3 4 1 — 1 — i 1 2 2 3 4 14 Gastro Enteritis 5 4 1 — — — — 1 — 1 — 3 — 15 Other continued Fevers - - - - - - - - - - - - — 16 Cerebro Spinal Meningitis - - - - - - - - - - - - - 17 Erysipelas 7 1 — 1 — 5 — 1 2 2 — 2 3 18 Puerperal Fever — — — — — — — — — — — — — 19 Other Septic diseases 20 6 3 1 — 7 3 4 1 2 4 9 5 20 Intermittent Fever and Malarial Cachexia — - - - - - — — — — — — — 21 Tuberculosis of Meninges 16 2 10 2 2 —- — 5 3 3 1 4 4 22 Tuberculosis of Lungs 108 — 3 4 18 80 3 22 19 21 20 26 33 23 Other forms of Tuberculosis 2 5 6 6 2 9 — 3 4 9 4 8 5 24 Alcoholism - — — — — 5 — — 1 2 1 1 — 25 Cancer 6 — 1 — 1 35 24 7 11 19 12 12 19 26 Premature Birth 6 60 - — — — — 19 10 9 4 18 1 27 Developmental Diseases 76 74 2 — — — — 15 13 11 15 22 10 28 Old Age 64 — — — — — 64 13 7 19 7 18 22 29 Meningitis 11 4 5 2 — — - 4 3 — 1 3 2 30 Inflammation and Softening of Brain 2 — — — — — 2 — 1 — — 1 — 31 Organic Diseases of Heart 38 — — 4 6 19 9 5 13 9 8 3 9 32 Acute Bronchitis 40 21 8 — — 4 7 10 8 7 5 10 3 33 Chronic Bronchitis 68 - - — — 25 43 13 14 10 14 17 7 34 Lobar (Croupous) Pneumonia 56 — 9 4 3 32 8 15 8 13 12 8 6 35 Lobular (Broncho) Pneumonia 59 22 23 4 1 7 2 19 11 7 9 13 7 36 Diseases of Stomach 6 2 - — — 3 1 2 1 2 — 1 — 37 Obstruction of Intestines 6 1 1 — 1 - 3 1 1 1 3 — 3 38 Cirrhosis of Liver 8 - - — — 6 2 — 2 3 1 2 1 39 Nephritis and Bright's Disease 30 — 1 2 — 14 13 4 5 4 10 7 7 40 Tumours and other Affections of Female Genital Organs - - - - - - - - - - - - - 41 Accidents and Diseases of Parturition 11 — — — - 8 — 3 2 3 2 1 2 42 Deaths by Accident or Negligence 37 9 9 3 — 6 10 9 6 10 4 8 12 43 Deaths by Suicide 14 — - — — 13 1 3 4 — 4 3 1 44 Deaths from Ill-defined Causes 1 - - — — 1 — — 1 — — — — 45 Syphilis 3 1 - — — 2 — — 1 1 1 — I 46 All other Causes 217 21 4 8 7 98 79 46 32 53 35 51 52 All Causes 1,205 281 149 60 44 395 276 253 202 251 220 279 234 31 SENILE MORTALITY. Of the total deaths recorded, 276, or nearly 23 per cent., were 65 years and upwards, as compared with 22 per cent, for 1908, 19 in 1907, 17 in 1906, and 21 in 1905. Of the 276 Seniles, 102, or nearly 40 per cent., were over 75 years and 28 of these were over 85 at the time of death. In the St. James Street Ward 18 were over 75, and 6 over 85 years. „ High Street Ward 16 „4 „ „ Hoe Street Ward 25 „10 „ „ Wood Street Ward 17 „2 „ „ Northern Ward 26 „6 „ The preceding tables show the numbers and causes of death for the whole district and the several Wards. Table IX. gives the deaths in quarters, and Table X. is a combination of Schedule B (Form of the Medical Officers' of Health Society) and Table IV. (Local Government Board Form). 32 ZYMOTIC MORTALITY. Included under this heading are the deaths from the " Seven Principal Epidemic Diseases " :—Measles, Scarlet Fever, Diphtheria, Whooping Cough, Enteric Fever and Diarrhoea. The rate based on these deaths is '98 per 1,000 of the population, and similar to that of last year. The rate for the "76 Great Towns" was T42, and for England and Wales 112. Our favourable rate is largely due to absence of Summer Diarrhcea and our comparative immunity from Typhoid. All the Zymotic diseases are preventable, and until some further steps are taken in the control of Whooping Cough and Measles, an annual expenditure of £7,000 on Scarlet Fever and Diphtheria is not justified, considering the deaths from these diseases are rarely half those from Measles and Whooping Cough. In this connection the good effected by an additional Health Visitor would be well worth the money expended. Our death-rate for each individual disease of the Zymotic group— Whooping Cough excepted—was less than that prevailing in the "76 Great Towns," and were it not for the epidemic prevalence of this disease our rate would be considerably less. The following tabular statement shows the numbers of deaths from these diseases since 1898 :— 38 TABLE XI. Small-Pox. Scarlatina. Diphtheria. Croup. Typhoid. Measles. Whooping Cough. Diarrhœa. Zymotic Enteritis. Total. 1909 0 11 14 3 2 30 46 7 10 123 1908 0 11 20 2 13 36 2 26 14 124 1907 0 22 35 1 5 22 76 56 15 232 1906 0 21 54 3 8 39 18 113 51 307 1905 0 17 28 0 8 35 31 52 26 197 1904 1 14 27 2 10 55 32 84 99 324 1903 0 6 17 0 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 GastroEnteritis. 274 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 DEATHS FROM NOTIFIABLE INFECTIOUS DISEASES. The deaths under this heading include those arising from Erysipelas and Puerperal Fever, but exclude those due to Measles, Whooping Cough and Diarrhoea; with this difference the deaths are those usually classed as Zymotic. The deaths under both heads are from " Preventable Diseases," as in theory all diseases ought to be, and old age the sole cause of death; but in this connection we only refer to the diseases amenable to Public Health Administration and due to infection from person to person There were 34 deaths registered from these diseases; 15 of them occurring at the Isolation Hospital. The deaths are considerably less in number than in previous years, and comparatively so as to population. The following table shows these deaths for 1908 and 1909 for the whole district and for the Wards :— C 34 TABLE XII. Names of Diseases. Whole District. Wards, 1909. Deaths, 1909. Deaths, 1908. Increase + Decrease - St. James Street. High Street. Hoe Street. Wood Street. Northern. Small-Pox - - - - - - — — Scarlatina 11 11 — 1 — 3 3 4 Diphtheria 14 20 6 1 3 3 3 4 Membranous Croup ) Typhoid 2 13 - 11 — — — 1 1 Erysipelas 7 5 + 2 1 2 2 1 1 Puerperal Fever — 5 - 5 — - - — — Cholera — — — — — — — — Plague — — — — — — — — Total 34 54 -20 3 5 8 8 10 The deaths from these diseases in previous years were—71 in 1907 ; 96 in 1906 ; 60 in 1905 ; 65 in 1904 ; 55 in 1903 ; 72 in 1902 ; 74 in 1901; 103 in 1900 ; and 104 in 1899. The death-rates from these diseases vary considerably in the different Wards. The mortality in St. James Street Ward is very noticeable and contrasts favourably with that prevailing in previous years, and with the other Wards in 1909. The deaths from Diphtheria, though few, are in excess of what really might have been if the precautionary measures advised in previous reports were adopted. Under the Factory and Workshops Act, 19ol, section 73, "every medical practitioner attending or called in to visit a patient whom he believes to be suffering from Lead, Phosphorus, Arsenical or Mercurial poisoning, or Anthrax, contracted in any factory or workshop, shall notify the fact to His Majesty's Chief Inspector of Factories." 35 DISEASES NOTIFIED DURING THE YEAR 1909. Infectious Diseases Act, 1889. The following table shows the number of cases of the various diseases certified each month during the year :— TABLE XIII.—Cases oj Infectious Disease notified during the Year 1909. 1909 Notifications. Jan. Feb. Mar, Apl. May June July Aug. Sept Oct. Nov. Dec. Total. Deaths. Small-Pox Under 5 years 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Over „ 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Scarlet Fever Under 5 years 11 13 8 7 9 12 8 7 14 9 15 6 119 4 Over „ 27 24 31 33 35 36 36 37 46 36 30 16 387 7 Diphtheria Under 5 years 4 6 3 6 1 5 3 4 6 6 1 5 50 Under5, 10 Over 5, 4 Over „ 17 20 5 6 14 10 7 14 18 6 8 7 132 Membranous Croup f Under 5 years 0 0 0 0 0 0 0 1 0 0 0 o 1 Over „ 0 0 0 0 0 0 0 0 0 0 0 0 0 Enteric Fever Under 5 years 0 0 0 0 1 0 0 0 0 0 0 0 1 0 Over „ 1 2 3 0 0 0 0 1 1 1 0 12 2 Continued Fever Under 5 years 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Over „ 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Puerperal Feve Under 5 years 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Over „ 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Erysipelas f Under 5 years 1 0 0 3 1 0 1 0 1 0 0 1 8 1 . Over ,, 10 6 11 9 8 6 8 7 7 13 13 6 104 7 Totals Under 5 yrs. 179 71 71 61 64 69 69 63 71 93 71 67 44 814 34 Over „ 635 36 The following table shows the distribution of Infectious Cases according to Wards, and the increase or decrease compared with 1908 TABLE XIV.—Distribution of I?ifectious Diseases according to Wards. WARDS. Estimated Population. Small-Pox Scarlet Fever. Diphtheria. Croup. Erysipelas. Enteric Fever. Puerperal. Totals. Increase + or Decrease on last year. St. James Street 24,500 0 112 40 0 27 3 0 182 -40 High Street 22,500 0 68 44 0 29 2 0 143 - 8 Hoe Street 24,500 0 82 31 0 20 4 0 137 -61 Wood Street 18,000 0 47 11 0 11 2 0 71 -17 Northern 40,000 0 197 57 0 15 2 0 281 -74 1909 Registrar General. 136,602 0 506 183 112 13 0 814 -200 1908 131,486 0 635 233 0 111 37 8 1,014 -187 1907 126,397 0 815 251 6 105 21 3 1,201 - 52 1906 121,334 0 809 287 6 107 f Con. 1 I 33 10 1,253 + 65 1905 117,500 0 756 254 4 122 50 2 1,188 + 213 1904 108,000 49 527 177 13 143 56 10 975 + 328 1903 106,290 2 292 147 5 117 88 6 647 -436 1902 101,000 146 560 142 8 131 89 7 1,083 - 55 1901 97,000 3 608 322 11 111 73 10 1,138 + 82 The following table is of interest to show the estimated Population, number of cases of Infectious Diseases notified, with Infectious Sickness rate for the years since the Notification Act came into operation. The estimated Population is that of the Registrar.General :— TABLE. XV. Estimated Population, Number of Infectious Diseases notified, with "Infectious Sickness Rate," and the Afean for the Years under cotisideration. 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 1904 111,282 527 49 179 13 0 56 0 143 10 975 8.76 1905 116,300 756 0 254 4 0 50 0 122 2 1188 10.2 1906 121,334 809 0 287 6 0 33 1 107 10 1253 10.3 1907 126,397 815 0 251 6 0 21 0 105 3 1201 9.5 1908 131,486 635 0 220 3 0 37 0 111 8 1014 7.7 1909 136,602 506 0 183 0 0 13 0 112 0 814 5.9 Average for previous years 352 12 213 8 0 72 1 100 5 863 10.3 Extremes High't 815 146 516 17 1 193 6 143 10 1253 18.5 Lowest 125 0 124 3 0 13 0 31 0 397 6.2 38 INFECTIOUS DISEASES AND MEASURES TAKEN TO PREVENT THEIR SPREADING. During the year 814 cases of notifiable Infectious Diseases were dealt with, and represent 678 infected premises. An experienced and qualified fever Nurse, holding the diploma of the Sanitary Institute, devotes practically the whole of her time in connection with these diseases, and the routine methods of previous years were continued. Every house invaded was visited without delay, and the necessary information concerning the patient and his surroundings obtained. If removal to Hospital were necessary or desired, it was carried out with as little delay as possible. Nearly 80 per cent, of the Diphtheria patients and 70 per cent, of those suffering from Scarlet Fever were removed to the Isolation Hospital. Five of the 13 Typhoids were also removed to Hospital. There is no provision for these at the Sanatorium, and their removal and isolation depend upon accommodation being found for them at the General Hospital here or in London. Those coming under the Poor Law are removed to Whipps Cross Infirmary. Upon removal of the patient or his recovery, disinfection was carried out; where removal was impossible or unnecessary, adequate printed instructions were given, and subsequent visits were made by Miss Lamb or myself to ensure that proper and suitable precautions were taken against the spreading of the disease. In cases of doubt or difficulty, when asked. I personally visited the patient. Children from infected premises are excluded from school, and section 110 of the Factory and Workshops Act enforced. There was no difficulty during the year under this heading. 89 The measures adopted to control the spreading of Phthisis are given elsewhere. Outfits for early Diphtheria and Typhoid diagnoses are kept at the Public Health Offices, and anti-diphtheritic serum for gratuitous injection is supplied to all practitioners requiring it. A supply of the latter is kept at the Fire Station, so that no delay may be caused in its use in cases of emergency occurring in the night time. One hundred and thirty-three bottles of serum were supplied to practitioners during the year, and of these 13 were paid for. When school attendance was suspected as the cause of disease, the class rooms were visited, and scholars with suspicious symptoms excluded. Special precautions at the begining of each school term were advised to be taken by all teachers, and children with a history of Sore Throat during the holidays or any suspicion of peeling were excluded until visited and certified for by me as fit to attend school. Sunday and other Schools are dealt with in the same way as Elementary Schools, and children from infected homes are excluded by those in charge. 40 The following table shows Infectious Diseases according to Wards, and the number removed to Hospital :— TABLE XVI.— Cases of Infectious Disease notified during the. Year 1909. Name of District—Walthamstow. Notifiable Disease. Cases Notified in Whole District. Total Cases Notified in Each Locality. No. of Cases Removed to Hospital from Each Locality. Total Cases Removed to Hospital. At all Ages. At Ages—Years. St. James Street. High Street. Iloe Street. Wood Street. Northern. St. James Street. High Street. Hoe Street. Wood Street. Northern. Under 1 1 to 5 5 to 1.5 15 to 25 25 to 65 65 and upwards Small Pox - - - - - - - - - - - - - - - - - - Cholera — — — - — — — — — — — — — — —. — — - D iphtheria (including Membra- nous Croup) 183 2 49 106 15 11 — 40 44 31 11 57 35 37 22 6 44 144 Erysipelas 112 4 4 11 9 78 6 27 29 20 11 25 4 0 3 0 5 12 Scarlet Fever 506 5 114 329 41 17 0 112 68 82 47 197 97 53 48 32 134 364 Typhus Fever — — — — — — — — — — — - - — — — — — Enteric Fever 13 — 1 4 2 6 — 3 2 4 2 2 1 0 2 0 2 5 Relapsing Fever - - - - - - - - - - - - - - - - - - Continued Fever - - - - - - - - - - - - - - - - - — Puerperal Fever - - - - - - - - - - - - - - - — - — Plague - - - - - - - - - - - - - - - - - — Totals 814 11 168 450 67 112 6 182 143 137 71 281 128 86 68 37 170 489 Isolation Hospital—Walthamstow Sanatorium, Chingford. Total available beds—93. Number of Diseases that can be concurrently treated—4 at least. 41 SMALL POX. No case of this disease has occurred here since 1904. During the year there were a few cases in a neighbouring district. In the Weekly Returns of Infectious Diseases received from the Local Government Board, your Authority was made acquainted with this, and the possibility of your district being invaded noted. The agreement with the West Ham Corporation, for the reception and treatment of all Small Pox cases arising here, is still in operation. One death of an un-vaccinated child under 1 year, from Chicken Pox, was registered, and I visited the home and satisfied myself that the major disease was non-existent. SCARLET FEVER. Five hundred and six cases of this disease were notified in 1909, compared with 635 in 1908, 815 in 1907, 809 in 1906, and 756 in 1905. Three of the notifications were subsequently withdrawn. Compared with previous years the number attacked is small, but the case mortality was slightly greater than in 1908. The Wards most affected were St. James Street and the Northern ; the type of disease in the latter being much more severe than in the former. One person died in every 50 attacked in the Northern, whereas only 1 death occurred among the 112 notified in St. James Street. The incidence in the other Wards was considerably less than in 1908, the number notified in Hoe Street being less by 50. The attack rate for the whole district was 4 per 1000, that for the Wards as follows :—James Street and Northern over 5 ; High Street and Wood Street under 8 ; and Hoe Street over 4 per 1,000 of their estimated populations. The increase in the Northern Ward was mainly due to missed cases, causing spreading and continued infection among the children attending the Blackhorse Road Infants' School. 42 After a considerable amount of school visiting and personal examination of the children, I traced the source of infection to a boy ill with the fever, but with whom no precautions were taken by the parents. The latter believed that the boy had "a bit of a sore throat," and allowed the other children of the house to attend school. Subsequent to the Mid-summer holidays, a fresh outbreak was averted by the vigilance of the teachers. In response to a circular letter, several children with suspicious symptoms were referred to me, and among them I found two in varying stages of peeling. Parents are not expected to be always able to recognise Scarlatina when occurring in the home, but certainly every mother should accept it as a duty to the community, and to her children, to at once isolate any child showing symptoms of Sore Throat ox Feverishness accompanied by a Rash however faint, and to call in a doctor. Were such simple precautions taken it would not be possible that the 26 cases discovered by me could escape recognition before causing infection to others. It is this neglect of a simple duty on the part of parents which negatives so much of the work carried out by the Public Authority on behalf of the children. With the co-operation of the parents and teachers, results commensu" rate with the money spent on our Isolation Hospital would accrue in the lessened incidence of Scarlet Fever. The greater susceptibility of the young to attack and death from this disease, and the decreasing liability acquired with age, should induce parents to exercise more care in the oversight of their children, whether of school age or under. The deaths resulting from Scarlet Fever were 11. Four occurred in children under 7 years of age, and 7 in those over that period. The death-rate was five times greater in the former than in the latter. 43 The number of cases removed to hospital from each Ward was as follows:— St. James St. High St. Hoe St. Wood St. Northern. 1909 97 53 48 32 134 and for previous years— 1908 78 55 83 26 168 1907 83 86 61 83 118 1906 57 65 50 73 68 1905 50 70 44 31 62 1904 50 36 50 37 30 1903 59 63 53 67 45 Per cent, removed— 1905 33 31 33 38 33 1906 41.6 37.5 38.4 42.2 347 1907 56 58 38 67 47 1908 68.4 78.5 63 42.5 65 1909 83 80 60 69 69 DIPHTHERIA—MEMBRANOUS CROUP. During the year, 183 cases of this disease were notified, compared with 223 in 1908, and 251 in 1907. The attack rate for the whole district was 1*3 and the death.rate '10 per 1,000 for the year—rates for us the most favourable on record. One hundred and forty.four of the cases (80 per cent, of the total) were removed to Hospital, those remaining at home being properly isolated and kept under observation. Of the patients admitted into the Sanatorium, seven died ; and of the 39 nursed at home seven also died. The apparent greater mortality among those not entering the Hospital is partly due to the delay on the part of parents in sending for medical advice until the patient was moribund, and skilled treatment unavailing. Of the 14 deaths, 10 were of children under five years, and every year advice has been given as to the necessity for calling in a doctor when children under ten years show symptoms of cold, running at the nose, with langour and loss of colour, as well as to those with symptoms of sore throat and croupiness, which parents associate with diphtheria. 44 The difficulty of recognising this disease in its early stages from clinical signs alone may be judged from the Sanatorium report, and all doubtful cases should be isolated at once, treated with serum and a bacteriological examination subsequently made. With this routine many of those sent to Hospital would be equally well at home. The distribution of the cases over the various portions of the district, the numbers removed to Hospital, the deaths resulting, and the deathrate per cent, of those notified, were as follows:— St. James Street. High Street. Hoe Street. Wood Street. Northern. No. Notified 40 44 31 11 57 No. of Deaths 1 3 3 2 5 No. removed to Hospital 35 37 22 6 44 No. of Deaths in Hospital 1 3 1 0 2 Death-rate per cent. of those removed to Hospital 2.8 8.1 4.5 0 4.5 No. remaining at home 5 7 9 5 13 No. of Deaths 0 0 2 2 3 Death.rate per cent. of those remaining at home 0 0 22 40 23 The following figures taken from the Registrar-General's Quarterly Returns are of interest to show our position in reference to Scarlet Fever and Diphtheria, as compared with our immediate neighbours:— Population. No. Notified. Deaths. S.F. Diph. S.F. Diph. Tottenham 129,464 568 143 9 21 West Ham 321,767 1,624 477 53 41 East Ham 149,575 574 379 15 24 Leyton 129,614 487 202 9 29 Walthamstow 136,602 506 182 12 15 45 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 XVII. Years. Population. Number of Diphtheria cases. Rate per 1,000. Membranous Croup cases. Diphtheria and Croup 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 1904 111,282 177 1.59 13 .26 1905 116,300 254 2.18 4 .24 1906 121,500 287 2.3 6 .44 1907 126,397 251 2 6 .27 1908 131,486 220 1.6 3 .15 1909 136,602 182 1.3 0 .10 46 The following table shows the distribution of cases of Diphtheria and roup in the Wards, giving the total numbers for each, and the rate of attack per 1,000 of the population. TABLE XVIII. Diphtheria prevalence in Wards for the Years 1899 to 1909 St. James Street. High Street. Hoe Street. Wood Street. Northern. Year. 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. 1899 21,942 112 5 19,452 79 43 21,523 81 3.0 13,888 45 32 10,478 28 2.6 1900 23,133 203 9 19,936 107 5.0 23,039 64 3.0 14,767 104 6.9 14,508 49 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 1.16 22,500 29 1.29 16,500 37 2.24 23,500 27 1.15 1904 23,600 36 1.56 20,400 61 2.9 23,100 21 .9 16,600 18 1.08 24,300 41 1.68 1905 24,000 57 2.37 21,000 58 2.8 23,500 58 2.46 17,000 31 1.8 32,000 50 1.5 1906 24,000 75 3.1 21,000 47 2.2 24,000 51 2.1 17,500 33 1.9 35,000 87 2.5 1907 24,000 89 3.7 22,000 51 2.3 24,000 42 1.7 17,000 22 1.3 37,000 53 1.4 1908 23,500 68 2.9 21,500 44 2.0 24,000 39 1.6 17,500 16 .9 37,000 56 1.5 1909 24,500 40 0.04 22,500 44 .13 24,000 31 12 18,000 11 .11 40,000 57 .12 47 ISOLATION HOSPITAL. Diphtheria.—Nearly 80 per cent of all the cases notified as suffering from Diphtheria were removed to the Sanatorium, and the accommodation provided—24 beds in two pavilions—proved more than sufficient for the needs of the district. In August, due to our continuing freedom from this disease, and Scarlet Fever prevalence, the Hospital Committee decided to reduce the Diphtheria accommodation one-half, and since then no trouble has been experienced in accommodating all the cases seeking admission. The change was effected on my advice, as I considered it much easier to control the spreading of Diphtheria than Scarlet Fever by efficient oversight of our school children. Half of those admitted to Hospital failed to give a positive bacteriological reaction, although 16 of the 70 negatives were undoubtedly Diphtheria. Allowing for the difficulty of recognition of Diphtheria in its early stages, the proportion of cases needlessly removed from home, seems high, and where the circumstances of the family permit of efficient isolation, recourse to bacteriological diagnosis before notification should be more frequently made. Every facility for such is provided for by your Authority, and with its fuller use and early serum injection much expense to the public might have been avoided. Scarlet Fever.—The beds now set apart for this disease are nominally 69. but actually more, as the 12-bed cubicle pavilion is mainly occupied by Scarlatinal patients. The beds are distributed in four blocks; two for patients with acute and sub-acute symptoms, one for convalescents, and one used as a discharge block, where patients are kept for a week or so under conditions simulating home life. About 70 per cent. of all the cases notified went to the Sanatorium, and a further 6 per cent. were dealt with in hospitals elsewhere. During July and August every bed became occupied, and the Hospital unable to accommodate all willing and anxious for removal. In consequence, some were refused admittance, and others were not removed for some days following notification. 48 Being unable to deal with all the cases, a further difficulty was experienced in determining whether the removal of all new cases as they arose and before infection from them could be conveyed to others, should be undertaken, or admit those who were in different stages of convalescence, but clamouring for removal. In giving preference to the new cases, unfortunately, a child, already ill for 14 days and believed to be efficiently isolated, caused others to contract the disease, and one of them died. This led to a complaint to the Local Government Board, who advised early provision of further Isolation Hospital accommodation. The Public Health Committee seriously considered this request, but in view of the facts placed before them, decided that whatever provision they might make, short of extravagance, it would at times prove inadequate, and that for all the legitimate needs of the district the Hospital had a sufficient number of beds. As stated, 76 per cent. of all the notified cases in 1909 were treated in Hospitals, and considering that a capital expenditure of £41,000 has already been incurred for the Sanatorium, that the cost of maintenance and upkeep yearly exceeds £7,000, and that the County Medical Officer of Health reported in 1905 that to provide for all cases of Scarlet Fever would be waste of public money, the decision of your Authority was justified. Scarlet Fever is a disease very difficult to control, and impossible to eradicate by isolation in Hospital, owing to the uncertainty of the period of infectivity of those treated there, and to the number of missed and doubtful cases constantly turning up in the general community. Our knowledge of Scarlatina! infection is so limited, and the circumstances of season and locality determining its spread so little understood, that before the Hospital is enlarged we ought to know why a child, suffering from Scarlet Fever for three weeks and daily in attendance at school, does not convey the infection to other school children, but does to his neighbours; and yet another child, with fewer signs of his illness, will infect one after another of his classmates and others with whom he is brought in contact; or why a child after eight weeks' isolation in hospital, and who is apparently perfectly well, upon his returning home will infect one or two of his brothers and sisters and not the remainder. Why we should have an increased incidence yearly under similar circumstances in certain months and not in others, or why a child treated in a General Hospital for scalds should contract Scarlatina while all the other children of the Ward escape, are problems that want 49 solving before we can say that in providing a very large number of beds in an Isolation Hospital we do all that is needful. No doubt it would be much safer for the community and easier for those responsible for the public health if all known cases of Scarlet Fever could be treated in Hospital; but there are other considerations to be taken into account. Every year's experience proves that to minimize still more the volume of Scarlet Fever infection, what is needed is a strict supervision of our school children, the co-operation of the parents and teachers, and a reasonable number of beds for first cases, rather than the provision of a large Hospital with beds for every possible case that may arise. I have received from the Resident Medical Officer the following report upon the work carried out at your Isolation Hospital. In it will be found Dr. Gallatly's remarks on the utility of the cubicle pavilion, bearing out the claims made in former reports for this type of hospital in the treatment of doubtful and mixed infections. SANATORIUM REPORT, 1909. ADMISSIONS, DISCHARGES, DEATHS. Scarlet Fever. Diphtheria. Mixed Infections. Total. Remaining on Dec. 31st, 1908 59 20 1 80 Admitted during 1909 370 158 — 528 Total 429 178 1 608 Discharged during 1909 375 167 1 543 Died during 1909 9 7 — 16 Remaining on Dec. 31st, 1909 45 4 — 49 The patients are entered in the above table, and also in the following two tables, according to the disease notified from the Town Hall. In some, additional information regarding the presence of other infectious disease was given, and these "mixed" cases are referred to separately later. Fourteen of the Diphtheria cases admitted were from Edmonton and Enfield. One Scarlet Fever patient was admitted from Loughton. Three Scarlet Fever cases were admitted from West Ham Infirmary. D 50 AGES OF PATIENTS ADMITTED. Scarlet Fever. Under 5 years. From 5 to 10 years. From 10 to 15 years. 15 years and upwards. Total of Total. m f m f m f m f m f January 6 6 7 6 1 3 3 2 17 17 34 February 5 4 3 8 2 2 1 — 11 14 25 March 2 3 6 3 1 3 3 2 12 11 23 April 2 4 6 11 1 5 1 — 10 20 30 May 7 1 3 9 3 3 2 4 15 17 32 June 5 5 16 6 1 5 — — 22 16 38 July 3 1 9 4 2 1 3 5 17 11 28 August 2 5 5 6 5 5 3 2 15 18 33 September 5 5 8 17 6 3 1 2 20 27 47 October 4 4 3 8 6 2 1 — 14 14 28 November 7 6 4 11 2 2 2 2 15 21 36 December 2 3 1 5 — 2 2 1 5 11 16 Total 50 47 71 94 30 36 22 20 173 197 370 97 (26.2%) 165 (44.5%) 66 (17.8%) 42 (11.3%) 370 AGES OF PATIENTS ADMITTED.—DIPHTHERIA. Under 5 years. From 5 to 10 years. From 10 to 15 years. 15 years and upwards. Total of Total. m f m f m f m f m f January 8 1 6 7 1 2 1 1 16 11 27 February 2 1 4 6 4 1 2 2 12 10 22 March 1 1 1 3 1 — — — 3 4 7 April 2 — 3 — — — 1 — 6 — 6 May 2 — 1 4 2 3 — 1 5 8 13 June 4 1 1 4 — — 1 4 6 9 15 July 1 2 2 1 1 — — — 4 3 7 August 3 1 3 3 2 1 — 3 8 8 16 September 2 2 8 4 1 3 1 1 12 10 22 October 4 — 2 2 — — — 1 6 3 9 November — 2 2 2 1 — — — 3 4 7 December 2 — — 2 — 2 1 — 3 4 7 31 11 33 38 13 12 7 13 84 74 158 42 (26.5%) 71 (44.9%) 25 (15.8%) 20 (12.6%) 158 51 DEATHS. Disease. Under 5 years. From 5 to 10 years. From 10 to 15 years. 15 years and upwards. Total of Total. m f m f m f M f m f Diphtheria* 4 1 1 2 — — — — 5 3 8 Scarlet Fev. 2 1 0 3 — — 1 1 3 5 8 Total 6 2 1 5 — — 1 1 8 8 16 8 6 — 2 16 * One of these deaths was that of a patient from Enfield. The average daily number of patients in Hospital was as follows:— January 81.58 February 92.27 March 89.96 April 68.60 May 67.61 June 82.93 July 72.35 August 62.93 September 82.23 October 85.93 November 61.26 December 61.70 Complications of Diphtheria were:- No. of Cases. Antitoxin rash 10 Albuminuria 23 Adenitis 10 Cardiac complications 13 Nasal discharge 28 (4 had extensive membrane in nasal passages). Diphtheritic paralysis 14 Laryngeal cases 16 Ear discharge 6 Bronchitis 2 Catarrhal jaundice 1 Recrudescence of Sore Throat 3 52 Over 480 bacteriological examinations from throats and noses were made during the year. Of the Diphtheria cases sent into Hospital, 70, or very nearly 50 per cent., failed to give bacteriological evidence of the disease, 16 of these had, however, other definitely diagnostic signs or symptoms of Diphtheria. Eight were found to be suffering from Scarlet Fever. They were not a cause of infection to others, having been isolated in the cubicles. Complications of Scarlet Fever:— Acute Nephritis 13 Adenitis 5 Adenitis (suppurative) 6 Albuminuria. (Those having a trace of albumen during height of fever only are not included.) 7 Angina (late) 4 Arthritis 10 Bronchitis 1 Cellulitis (of neck, face or scalp) 2 Endocarditis 1 Ear discharge 36 Mastoid abscess 3 Meningitis 1 Nasal discharge 17 Pericarditis 1 Relapse 5 Tonsillar abscess 1 Four patients admitted as Scarlet Fever developed the disease subsequent to admission. There was a slight outbreak of Chicken Pox in the early part of the year ; nine patients in the convalescent Scarlet Block were affected. Apart from these two groups, no patient has contracted any infection in Hospital; it is also very satisfactory to note that no member of the Staff has suffered from any infectious disease during the past year. The few cases of illness that have occurred have been slight and unimportant. In only three cases did the absence of duty extend to one week. 53 CUBICLE ("G") BLOCK. The cubicle block continues to be of the very greatest value in securing thoroughly efficient and economical isolation of mixed and doubtful cases. During the past year 132 patients (i.e., 25 per cent. of the cases admitted) were treated wholly or in part in this block of 12 beds. It is unfortunately not possible to give statistics relating to the results of treatment in the cubicles as compared with the general wards, nor to give any idea of the possible effect of separate isolation on the number of return cases. There is, as a rule, such a demand on the accommodation in this block, that septic and doubtful cases have to be moved to the convalescent wards as soon as possible, so that only a part of their time is spent in the cubicles, and they are, therefore, almost useless for purpose of comparison. In spite of the varied nature of the cases, and the high infectivity of some of the diseases treated—such as Chicken Pox and Mumps—no case of infection being carried from one cubicle to another has occurred. From the following diagram the cases actually in the cubicles on June 20th, 1909, are shown, and the possibilities of such a ward may be appreciated. It is taken at random from a number of such records, and was not specially chosen in any way, except that it was made when the cubicles were all occupied. R.L.—Admitted as Diptheria, symptoms suggest Scarlet Fever only. H.C.-Is suffering from Diphtheria, but has shown some desquamation very suggestive of Scarlet Fever also. D.A.—Admitted as Diphtheria, proved to be suffering from S.F. only; very septic. J.F.—Scarlet Fever symptoms on admission, were suggestive of Measles. E.F.—Scarlet Fever; septic; has purulent conjuncturlis. D.N.—Scarlet Fever + Diphtheria. E.E.—Diptheria, but was convalescent from Whooping Cough on admission. D.P.—Scarlet Fever, complicated by acute nephritis. E.W.—Scarlet Fever, complicated by acute nephritis. O.L.—-Scarlet Fever + Diphtheria. S.G.—Admitted as Scarlet Fever; two days after admission developed measles rash. M.A.—Scarlet Fever; other members of family have measles at present. 54 Of the 182 patients treated in the cubicles 18 showed indefinite signs of any infectious disease during their stay in Hospital; 20 were cases of Scarlet Fever, which had no definite signs or symptoms on admission, but later showed typical desquamation; 9 were cases of Scarlet Fever and Diphtheria; 26 were removed to "G" after admission on account of suspicious symptoms. The majority of these were patients admitted as Diphtheria, who proved to have no Diphtheria bacilli present, and whose other symptoms suggested that they might have had a slight attack of Scarlet Fever; 12 were cases of acute Nephritis complicating Scarlet Fever. These are found to make very satisfactory progress in the cubicles, owing probably to the warm, equable temperature it is possible to maintain there. These few particulars may perhaps serve to illustrate what an important part this block plays in the administration of the Hospital It should also be taken into consideration that each cubicle can be thoroughly disinfected without any delay and without any inconvenience to any other patients in the block, and that it is not necessary to provide any sick-room accommodation for the staff, as any illness, infections, or otherwise can be satisfactorily dealt with in a cubicle. TYPHOID FEVER. Thirteen cases of this disease were notified during the year—the smallest number recorded since 1890. The attack rate is less than 10 per 100,000 of the population compared with an average of 58 in preceding years. In no infected home did a second case arise within the year, and this is the more extraordinary, considering that, of all the notifiable diseases, with Typhoid the least care seems to have been exercised for its early recognition or treatment, judging from the interval elapsing between the date of onset of illness and subsequent notification. In ten instances an interval of nearly a month had elapsed, and in one eighteen days, before a doctor was called in to see the patients. In one instance the notification came subsequent to death, in one after five weeks' attendance by a doctor, and not until other members of the family contracted the disease, and in another within fifteen days the patient was pronounced to be well and the contents of the sick room were disinfected. 55 Of the two deaths, one was a maid who, owing to illness, was sent from Forest Hill to her home here, and died within a week; the other was that of a boy, aged 12 years, who was apparently quite well and at school daily up to ten days before death. In five of the houses no defects were noted, in three were defective drains, and in the remainder nuisances of a minor character. The probable cause assigned was the eating of mussels for two of the cases, and watercress for a third; in the remainder no definite reason was assigned, nor did investigation throw any light on the true source of infection. The drinking water cisterns in six of the thirteen houses invaded were improperly kept. I referred in last year's Report to the powers acquired under the Public Health Act of 1907, for dealing with this form of nuisance, and from Mr. West's monthly reports I notice that over 250 of them have been dealt with, so that cisterns so kept as to render water liable to contamination, will become yearly less. Where the supply is constant, as here, there is no necessity for the drinking water to pass through a cistern and expose to contamination an otherwise pure supply. The distribution of the cases as to Wards was as follows— Wards:—St. James St. High St. Hoe St. Wood St. Northern. 3 2 4 2 2 And removals to Hospital were— 1 0 2 0 2 And the deaths occurring were— 0 0 0 1 1 The death-rate for Typhoid was .01 per 1,000 compared with .06 for the "76 Great Towns," and England and Wales. SUMMER DIARRHCEA—EPIDEMIC OR ZYMOTIC ENTERITIS. During the year, seven deaths were registered from Diarrhœa, ten from Zymotic Enteritis, nine from Enteritis, and five from GastroEnteritis, or a total of 31, compared with 67 in 1908, 178 in 1906, and 73 in 1905. 56 All these deaths are given, although not rightly coming under the above heading, to make comparison alike with previous years. The deaths represent a mortality rate of .22 per 1,000, against .5 for 1908, 1.04 in 1906, and .67 in 1905. The corresponding rate for the "Large Towns" was .38. Summer Diarrhœa is a disease mainly affecting children of immature years, especially hand-fed babies, and its prevalence depends largely on summer heat, and unwholesome home conditions in tenement houses of one or two rooms. The year under review has been a markedly favourable one owing to abundant rain and inconsiderable heat in the third quarter of the year. The measures of former years taken in the interests of hand-fed babies, by the distribution of leaflets, were continued; and the Notification of Births Act, if adopted, would enable your Authority to do still more by visits to the homes of the poor by "tactful and judicious health visitors." MEASLES AND WHOOPING COUGH. The deaths from these diseases were greater by one-half than all the other Zymotic Diseases, and three times as many as those for Scarlatina and Diphtheria combined. The preventive measures possible against Measles and Whooping Cough are dissimilar to those taken on behalf of the so-called dangerous infectious diseases specified in the Act of 1889. Compulsory notification has been tried and failed, and isolation in hospital is out of the question. Exclusion from our infants' schools of sufferers and contacts, with occasional visiting to homes affected, and the distribution of leaflets of advice, have been the only measures undertaken. Much more might be done with a larger staff of Health Visitors. It always appeals to me so unwise to spend yearly £7,000 on an Isolation Hospital for the suppression of Scarlet Fever and Diphtheria 57 —diseases more controllable, and less fatal in their results—and yet hesitate to spend a few hundreds yearly in checking the ravages of Measles and Whooping Cough. We accept cheerfully the larger burden through fear or pressure, and we fail to grapple with a greater danger, because the public has become so familiar with these diseases that they have come to be regarded as inevitable, and of little moment. Nothing is further from the truth. These diseases are peculiarly those of childhood. Of the 76 deaths recorded, 30 were of children under one year, and 43 between one and five years of age. These deaths are the known result, but how much serious permanent injury has been inflicted on those who have recovered it is impossible to say. Certainly it is very great, judging by the history usually given by mothers of those children found physically or mentally defective. "My child has never been the same since it has had the Measles or Whooping Cough," is the commonly told story. Deaths from these diseases occur principally among the children of the poor, owing to want of early treatment and a correct appreciation on the part of the parents of the seriousness of the diseases. During the year 716 visits have been paid to homes attacked, and while it is to be hoped that these visits were productive of much good, one cannot but feel that the work was too limited for a district with 25,000 school children. Were first cases immediately dealt with, and home visits to our poorer people kept up with advice as to appropriate treatment, many deaths could be obviated. A trained nurse as Health Visitor, devoting the whole of her time to this and kindred work, would be a good Public Health investment as well as an asset to the Education Authority. The death-rate from Measles was .22, and that for Whooping Cough .33 per 1,000 of the population. The death-rate from Measles was one-half; that of Whooping Cough slightly in excess of the corresponding rate for the "76 Large Towns." The fatality from Measles was greatest in the first two quarters of the year, and from Whooping Cough in the two last. 58 The deaths from Measles and Whooping Cough since 1889 onwards were as follows:— 1889 1890 1891 1892 1893 1894 1895 1896 1897 1898 1899 Measles 40 14 12 83 9 3 87 19 19 39 32 WhoopingCough — 54 16 32 34 25 15 37 21 24 34 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 Measles 3 43 14 52 55 35 39 31 36 11 WhoopingCough 54 26 23 34 33 32 18 76 2 46 The following figures are supplied by Mr. Jones, Superintendent of Attendance Officers, and show the number of children away from school during the year owing to Measles and Whooping Cough:— TABLE XIX. Sickness Return, from January, 1909, to December, 1909. Month Ending Measles. Whooping Cough. Total. January 18 89 107 February 75 78 153 March 175 83 258 April (Easter Holiday—1 week) 294 125 419 May (Whitsun Holiday—1 week) 380 308 688 June 343 541 884 July 478 1,001 1,479 August - - - (Midsummer Holiday—4 weeks) September 78 708 786 October 39 802 841 November 11 588 599 December (Christmas Holiday—2 weeks) 9 583 592 Total 1,900 4,906 6,806 The numbers for each month are the sum of the weekly returns, and therefore represent nearly four-fold the actual number affected. 59 INFLUENZA. This disease at no time of the year assumed epidemic prevalence, and the deaths attributable to it were mainly in persons of advanced years. The greatest number of deaths took place in the first and second quarters of the year, and were mainly influenced by conditions affecting the respiratory organs. Of the 16 deaths registered, one was that of a child under 1 year of age, 2 of children between 5 and 15 years, the remainder occurring among old people. PUERPERAL FEVER. No death was registered from this disease. From Table IV., following page 80, it will be noticed that 11 deaths are attributable to "Accidents and Diseases of Parturition." Although these deaths were in lying-in women, no notification was received that any of them suffered from Puerperal Fever. The conditions to which the name "Puerperal Fever" may be given are numerous, but evidently are not interpreted by all medical men alike. In addition to Sæpticemia Pyæmia, Septic Peritonitis, and Septic Metritis, "all septic inflammation in the pelvis, occurring as the direct result of child-birth," should be so classed. Investigation was made of all cases that might possibly come under this heading, and the usual precautions were advised to be taken by the nurses concerned. The Mid-wives Act, 1902, was called into being in the interests of lying-in women of the poorer classes, but it is to be feared that, in the absence of a doctor, our poorer women in their confinements will run a greater risk than ever. Five deaths resulted from Puerperal Fever in 1908, and 3 in 1907. 60 PHTHISIS OR CONSUMPTION. The deaths registered from this disease were 108, as compared with 103 in 1908, 104 in 1907, 128 in 1906, 93 in 1905 and 96 in 1904. Sixteen deaths were also registered from Tuberculosis of Meninges, and 28 from other forms of the disease, as compared with 18 and 20 in 1908, and 27 and 26 in 1907. The total deaths, 142, represent a rate of 1.04 per 1,000 of the population, and 12 per cent. or one-eighth of the deaths from all causes. Were these deaths and those under 1 year of age excluded, our crude death-rate would be 6 instead of 9 per 1,000 or a possible saving of 423 lives. The deaths from Tuberculosis are as truly preventable as those from Diphtheria, both diseases being the results of specific infections. In the early part of the year I sent to every medical practitioner of the district, and to every member of the Council, a copy of the "Memorandum, by the Medical Officer of the Local Government Board, on the Administrative Measures that were suggested to be taken against Tuberculosis, in pursuance of the Public Health (Tuberculosis) Regulations Order of 1908." The administrative measures suggested have been carried out as far as the loose methods in carrying out the regulations would permit. The regulations stipulated that the Medical Officer of a Poor-Law Institution shall, within 48 hours after his first recognition of the symptoms of Pulmonary Tuberculosis in the case of a poor person, post to the Medical Officer of Health for the Sanitary District in which the person resided, immediately before he becomes an inmate of the institution, a notification of the case, and that a similar notification shall be posted by the District Medical Officer in the case of any poor person suffering from the disease, on whom he is in medical attendance according to his agreement with a Board of Guardians. In two instances death preceded notification by five and four days, and followed within three days two notifications, and within a week in four others ! Added to this, many futile visits were made owing to incorrect information supplied. 61 Apart from these drawbacks, the Order has been of great service, and much useful work has been accomplished by its aid. There were 72 notifications received under the Order, and of these 28 died within the year. Visits were made and instructions given to all except in those cases already referred to. A good deal of tact had to be exercised in visiting and in obtaining the family history of the patients. They had already been questioned by the Relieving Officer and the doctor in attendance, and the friends required a good deal of persuasion that further visiting and enquiry was in their own interests. Few of them knew what the patient was suffering from, and this I attributed to assumed ignorance or the unwillingness of the medical attendant to give the disease a name which might alarm the patient. In most cases, this preliminary difficulty overcome, the Health Visitor was welcomed. Only in three instances was a family history of Phthisis given, and in one home only were two cases found. Early in the year I prepared a leaflet, detailing what consumption was and how acquired, with suggested measures of precaution on the part of sufferers and others. These were given to sufferers and those in contact with them in the homes by the Lady Inspector, and Dr. Hall has been good enough to give one to the parents of children medically inspected at the schools, if any family history of Phthisis were elicited. In this way I hope a gradual education of our people will be effected, and with a fuller knowledge of the disease better habits will be formed and a healthier mode of living adopted by those suffering from and those predisposed to the disease. The disinfection of premises and infected bedding and clothing in cases of death in those not notified has been continued, and as a result 39 such disinfections were carried out. The behaviour of the better-to-do of our people in this respect contrasts favourably with those coming under the Poor Law; the latter 62 permitting of disinfection in one case in twelve, compared with one in three of the former. Endeavours will be made to have disinfection carried out in every instance, and I have hopes that this will soon come to pass. As the local press yearly gives a resume of my Annual Report, and a large section of the public thus reached, I reproduce the leaflet with the hope that attention may be in this way drawn to its contents. WALTHAMSTOW URBAN DISTRICT COUNCIL. INSTRUCTIONS to those suffering from PHTHISIS or TUBERCULOSIS OF LUNGS (CONSUMPTION) By the Medical Officer of Health. What Phthisis or Consumption is, how Contracted or Acquired, and the Conditions Predisposing to its Influence. Consumption or Tuberculosis of the Lungs is an acquired disease and not hereditary. It is caused by the growth in the lungs of minute germs (tubercle bacilli), and all persons are liable to be infected and to suffer from the disease. How Acquired.—Almost entirely by inhalation into the lungs of the dried sputum or phlegm of persons suffering from the disease. The expectoration of consumptives contains myriads of disease producing germs (tubercle bacilli), and these are set free when the matter spat up dries on the floor, in the street, trams, trains, etc., and becomes converted into very fine dust, which is then inhaled, and thus sets up the disease in those susceptible to its influence. Conditions Causing it.—Overwork, insufficient sleep, bad and insufficient food, badly ventilated dwellings, intemperance, and all causes tending to lower the general state of health. 63 Persons Suffering from Consumption can much improve their own condition as well as prevent the spread of their disease to others by the following precautions: 1. Phlegm or Expectoration.—Never spit on the floors while indoors, nor in conveyances, nor on the streets while out of doors. Use a spittoon with a little carbolised water in it while indoors, and use a small portable glass spittoon while outdoor. If a portable spittoon is not adopted spit over a gully rather than on the roadway, and spit in either place rather than swallow it, or better, spit into rags or tissue paper, which can be rolled up and burned on the first opportunity before the sputum dries. N.B.—On no account allow the sputum to dry in rags or paper. 2. Where the handkerchief is used or becomes soiled by expectoration, it should be kept from drying until it is boiled, and thus rendered harmless. 3. Spittoons or flasks should be emptied into the W.C. and then thoroughly washed with boiling water. 4. Sleep alone in a well ventilated room, with as little furniture therein or hangings about the bed as possible. N.B.—Sunlight and Fresh Air are the greatest enemies of Consumption. The bedroom window should always be kept open, except through stress of weather, while dressing and undressing. The walls of the bedroom should be periodically rubbed with bread crumb, and the floor rubbed over with moist cloths every morning. No dust should be allowed to accumulate. Wet tea leaves come in handy for sprinkling over the floor and capturing the microbes. All dust should be burned, and never put in the dustbin, and all cloths used for cleansing should be boiled. The room occupied by a consumptive should be disinfected periodically. Application to the Lady Inspector, or the Medical Officer of Health, will ensure this. 5. The bed clothes and linen should be kept scrupulously clean and boiled before washing. 64 6. All cups, spoons, knives and forks, etc., used, require thorough cleansing before use by others. No food, not required for immediate use, should be kept in the occupied room. 7. Consumptive mothers should not suckle their babies; and consumptive men should be clean shaven to prevent soiling of moustache or beard by expectoration. Neither should kiss or be kissed except on the cheek or forehead. 8. As the tubercle bacilli are killed by sunlight, plenty of fresh air and light in the bedrooms, in the house and in the surroundings of the patient, is the best medicine, the best preventative for those about him, and the best antidote to the microbe. 9. The clothing should be of wool next to the skin, and amply sufficient to enable the patient to bear the necessary amount of fresh air in the living and sleeping rooms and to be comfortably warm when outdoors. 10. Thorough cleanliness in and about the house; fresh air, and plenty of it; plain food, and a plentiful supply of fat in it; and the avoidance of all excesses, are absolutely essential. By carrying out these simple precautions a consumptive is a perfectly harmless person, free from danger to others, and may work in the same room or workshop with his tubercle free companions, and be no danger to them. He may lead a useful life and perform his duties of citizenship without let or hindrance, and with the probability of improvement in health and possible cure of his complaint. Consumptives are advised to give notice to the Medical Officer of Health of any change of address, and that Officer will be pleased to help them by advice at any time. Diseases of the Respiratory Organs other than Phthisis.—These caused 233 deaths, compared with 213 in 1908, 299 in 1907, 208 in 1906, and 236 in 1905. OTHER DISEASES. Erysipelas.—Seven deaths resulted from this disease, four being in persons under one year of age. The deaths from Erysipelas are yearly a negligible quantity, and many of those notified as suffering from it are well in a few days. 65 The expense incurred in its notification is hardly justified, but as it remains on the schedule of dangerous infectious diseases the usual precautions against these are carried out. No spreading from those infected has taken place. Cancer.—Sixty-one deaths were attributed to this disease as against 94 in 1908 and 75 in 1907. Twenty-four of the deaths occurred in persons over 65 years of age. The deaths are considerably less than in previous years. CIRRHOSIS OF THE LIVER AND ALCOHOLISM. Eight deaths were attributed to Cirrhosis and five to Alcoholism. Five deaths directly due to Alcoholism are not many, and in no way represent the mortality from this cause. Under the present system of death registration, there is a reluctance on the part of practitioners to certify bluntly the cause of death as due to Alcoholism if a contributory cause is also present. WATER SUPPLY. The whole district is served by the Metropolitan Water Board. The supply has been constant, and no complaint has been received. Considerable attention has been paid during the year to the cisterns, and the powers given under the Public Health Act of 1907 have been utilized for effecting the cleansing and covering of about 250. No analyses have been made during the year, and no circumstances arose to indicate the necessity for such action. The Public Baths have been freely used by the Education Authority for the teaching of swimming to the boys and girls in our elementary schools. During the year there were 112,476 bathers, made up of 77,052 men 16,618 women, 10,986 boys and 7,820 girls. E 66 OFFENSIVE TRADES. The only process coming under this heading carried on in this district is the cooking of offal and extraction of fat in connection with the keeping of pigs. There now remains but one place of this kind, which so far has not been the cause of nuisance or complaint. The premises are under the constant supervision of the Sanitary Inspector, and from past experience such places require all the care and attention given them. Complaints have in past years occasionally been made as to nuisance arising from the curing of fish, and the cause was easily remedied by alteration or improvements in the construction of the "smoke hole," but during 1909, a series of complaints were made by one ratepayer concerning the nuisance from a "smoke hole" in a neighbouring yard. The complaints had the attention of Mr. West and myself, and failing to satisfy the complainant, a sub-committee visited the premises. While not admitting that this particular "smoke hole" was a nuisance, such places could be readily erected where, if not a public health nuisance, they might be a source of great annoyance and a serious detriment to neighbouring property. With this possibility in view, I saw Dr. Parsons with reference to the possibility, under Sect. 51 of the Public Health Act, 1907, of declaring fish curing as an offensive trade, and to make bye-laws governing the process. As no sufficient number of complaints had arisen, and as no strong case could be made out for such a procedure from past experience, nothing further was done. It would be. much more satisfactory had the Central Authority agreed to your suggestions, and in sanctioning bye-laws to safeguard, if necessary, against any possible undue restrictions that might be proposed against the carrying on of such businesses. Having the power to control would simply mean that the process of fish curing could only be carried out in suitable premises, and without risk of annoyance to neighbours. 67 SLAUGHTER- HOUSES. These have been well supervised during the year by frequent visits, and generally, as far as structure and arrangement will allow, the premises have been well kept. The buildings are all old, and only one slaughter-house has been licensed under the powers of the Public Health Amendment Act. Facilities for carrying out the inspection of meat in the slaughterhouses and in the shops have been freely given by the butchers, and no difficulty with the Inspectors has arisen. Two emaciated carcasses of beef were seized on the premises of a licensed cow-keeper and the owner summoned. The meat had been destroyed by a Justice's order, but the case against the defendant was dismissed without costs. The defence was that the meat was not for human consumption although "London dressed." Similar meat was seized in a slaughter-house this month (Feb., 1910), and a severe fine imposed, with revocation of license. Successful prosecution of those who slaughter old, worn-out and injured cows is not easy. If the Inspector does not happen to be present when the internal organs are exposed, these are soon got rid of if diseased, and under these circumstances it is not easy to satisfy the Justices that the meat is unfit for human food. There are but a few engaged in this kind of trade, and they require a deal of watching. The list of meat condemned will be found in Mr. West's report. HOUSE REFUSE REMOVAL AND SCAVENGING. The roads have been well kept, and the wet weather experienced, by the allaying of dust, served the public health well. 68 The dust is collected bi-weekly in all parts of the district by the Council's workmen, and no complaints have been received. The collected refuse has been disposed of by the Destructor, and no nuisance has arisen from the process of burning, nor complaint made to me. The complaint of former years, as to remissness in enforcing the byelaws of the Essex County Council against the sweeping from shops and houses into the roadway of waste-paper, shavings, etc., and against billposters throwing down and leaving in the street paper torn off hoardings, does not so much apply as in former years, but there is still room for stricter supervision. Approximately 16,000 tons of house refuse were collected, and burnt in the Destructor, and the resulting 6,000 tons of clinker were disposed of on works undertaken by the Council. COWSHEDS, MILKSHOPS AND DAIRIES. The new bye-laws governing these have not yet come into operation. They are a great improvement on those in existence, and will materially help in the maintaining in all cowsheds of ample lighting, ventilation, air space and cleanliness by the adoption of a standard. The bye-law providing that the hands and clothing of the milkers are to be thoroughly clean and free from all infection and contamination is strengthened by one placing on cowkeepers the responsibility of supplying at or near the cowsheds the means to effect such cleanliness. Stringent and specific bye-laws are no doubt valuable as means to an end, but without scrupulous cleanliness on the part of the milkers and those subsequently handling the milk, no satisfactory or clean milk is possible for the consumer. Many of those engaged in the tending and milking of cows have no conception of this, and a standard of purity for milk as sold is essential if the public are to be safeguarded. That a much cleaner and more wholesome supply of milk, than at present is supplied to the consumer, can be obtained without a costly outlay in premises or special apparatus has been clearly shown in a report made in. 1907-8 for the County Councils and County Boroughs of Yorkshire. 69 There are thirteen cowsheds now in occupation, and the number of cows vary from two to three hundred, so that the milk produced here is but a fraction of that consumed. Many of the defects pointed out in my 1907 report still remain, and many improvements have been effected. All the cowsheds as well as the milkshops are systematically visited, and much time and trouble are spent in stimulating cowkeepers and milksellers to maintain cleanliness in every detail of their trade. The Veterinary Surgeon, appointed under Article 15 of the Dairies, Cowsheds and Milkshops Order, has submitted a report on all the cowsheds and the cows examined by him, and so far as the cowsheds are concerned it is but a replica of that already presented. As to the health of the cows, Mr. Carroll was of opinion that in one herd of 73 there were 15 suffering from tuberculosis of the udder. The cows were in a very dirty condition, badly kept, and the byres were close, ill-ventilated and dirty upon inspection. As this was the first inspection by the Veterinary Surgeon, and the cowkeeper had parted with the peccant cows by the time I had the report, nothing could be done. I am arranging that more frequent visits will be in future paid by the Veterinary Surgeon, and that samples of milk will be taken from the suspected cows for bacteriological examination. A cow was found with probable tubercular udder in each of two other byres, and with these exceptions all the cows were said to be sound and well kept. The report dealing with the cows of the three principal distributing dairymen was most satisfactory:— (a) "A well-kept establishment in every detail." (b) "This herd (44 cows) is kept as cows ought to be." (c) "The cows are in good condition and well kept." Of another small owner with eight cows the report says of the cowshed, "A very nicely kept little place, and a credit to its owner"; and of the cows, "They are in first-class condition and perfectly kept." 70 SEWAGE DISPOSAL. The production of an effluent at all times satisfactory to the Lee Conservancy has not been accomplished, but no complaint as to nuisance on the Farm, or arising from the tanks or the effluent, has been reported. At my visits none existed. That an effluent of a high standard of purity should be insisted on under existing conditions is not reasonable. Nevertheless, in the month of September the Stratford Justices imposed a fine of £10 10s. in respect of each of two summonses, with £10 18s. costs. Negotiations have been carried on during the year with the County Council of London for the reception of the sewage from the districts of Walthamstow, Leyton, Edmonton, Enfield and Southgate. Unfortunately, no definite agreement has yet been arrived at, and it is to be hoped that the solution of a very large and urgent problem in public health administration will not fail for want of the needful pressure. Either sanction for borrowing the money required for a comprehensive scheme for dealing locally with our sewage should be granted by the Local Government Board, or a means found to relieve your Authority from the onus of providing an effluent satisfactory to the Lee Conservancy, or the scheme agreed to by four of the five Authorities concerned should be made compulsory on all. HOUSING OF THE WORKING CLASSES. There are no registered lodging houses in this district, nor was any action taken or needed during the year under the Housing of the Working Classes Acts. There is ample housing accommodation available in all portions of the district, at rentals varying from 5s. 6d. to 9s, weekly, rates included. The lesser rentals command flats of three or four rooms and the larger houses with five or six rooms. The mortality from summer diarrhcea in hand-fed children under one year of age is so closely related with housing accommodation that tenements of one or two rooms should be discouraged as much as possible, and except for old couples there is here little necessity for such accommodation, owing to the low rents prevailing. At the last census there were five persons occupying one room in four houses; four persons to one room in 15 houses; and three persons 71 to one room in 62 houses. The numbers occupying two-roomed tenements were considerable ; in some instances, the family consisting of six, seven and eight persons. It is for such folk that the adoption of the Notification of Births Act might prove a great help. Strict supervision is exercised by the Surveyor over the building of new houses, and they are erected in accordance with the bye-laws recently sanctioned. Application has been made under the Customs and Inland Revenue Act, 1890, section 26, for certificates for 20 premises. Certificates were given for two, as the requirements as set forth in previous reports were not complied with. The following table filled in for your district gives the information under the Factory and Workshop Act as required by the Home Office :— ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH FOR 1909 FOR THE URBAN DISTRICT OF WALTHAMSTOW. Factories, Workshops, Laundries, Workplaces and Homework. 1.—INSPECTION. Including Inspections made by Sanitary Inspectors or Inspectors of Nuisances. Premises. Number of Inspections. Written Notices. Prosecutions. Factories (Including Factory Laundries.) 71 - - Workshops (Including Workshop Laundries.) 389 — Workplaces (Other than Outworkers' premises included in Part3 of this Report.) 348 — — Total 808 — — 72 2.—DEFECTS FOUND. Particulars. Number of Defects. Number of Prosecutions. Found. Remedied. Referred to H.M. Inspector. Nuisances under the Public Health Acts Want of cleanliness 56 56 - - Want of ventilation - - - - Overcrowding 3 3 - - Want of drainage of floors 7 7 - - Other nuisances 60 60 — — †Sanitary accommodations insufficient 1 1 — — unsuitable or defective 13 13 - - not separate for . sexes — — — — Offences under the Factory and Workshop Act:— Illegal occupation of underground bakehouse (s.101) — — — — Breach of special sanitary requirements for bakehouses (ss. 97 to 100) — — — — Other offences - - - - (Excluding offences relating to outwork which are included in Part 3 of this Report). Total ... 140 140 — — * Including those specified in Sections 2, 3. 7 and 8, of the Factory Act as remediable under the Public Health Acts. † For districts not in London state here whether Section 22 of the Public Health Acts Amendment Act, 1890, has been adopted by the District Council; and if so what standard of sufficiency and suitability of sanitary accommodation for persons employed in factories and workshops has been enforced. 3.—HOME WORK. NATURE OF WORK.* Outworkers' Lists, Section 107. Number of Inspections of Outworkers' premises. Outwork in Unwholesome Premises Section 108. Outwork in Infectep Premises, Sections 109, 110. Lists received from Employers. Numbers of Addresses of Outworkers received from other Councils. Numbers of Addresses of Outworkers forwarded to other Councils. Prosecutions. Instances. Notices served. Prosecutions. Instances. Orders made (s. 110). Prosecutions (ss. 108, 110. Twice in the Year. Once in the Year. Failing to keep or permit inspection of lists. Failing to send lists. Lists.† Outworkers.† Lists. Outworkers. (1) (2) (3) (4) (s) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) Wearing Apparel— (1) making, &c. 24 197 35 186 852 60 ... ... 509 14 ... ... 2 ... ... (2) cleaning and washing ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Lace, lace curtains and nets ... ... ... ... 1 ... ... ... ... ... ... ... ... ... ... Furniture and Upholstery ... ... ... ... 2 1 ... ... 1 ... ... ... ... ... ... Fur pulling ... ... ... 2 9 ... ... ... 3 ... ... ... ... ... ... Umbrellas ... ... ... ... 15 ... ... ... 3 ... ... ... ... ... ... Paper Hags and Boxes ... ... ... ... 34 ... ... ... 5 ... ... ... ... ... ... Brush making ... ... 1 26 27 15 ... ... 13 ... ... ... ... ... ... Stuffed Toys ... ... ... ... 2 ... ... ... 2 ... ... ... ... ... ... File making ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Electro Plate ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cables and Chains ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Anchors and Grapnels ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cart Gear ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Locks, Latches and Keys ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Total 24 197 36 212 942 76 535 14 2 * If an occupier gives out work of more than one ot the classes specified in column 1, and subdivides his list in such a way as to show the number of workers in each class of work, the list should be included among those in column 2 (or 4 as the case may be) against the principal class only, but the outworkers should be assigned in column 3 (or 5) into their respective classes. A footnote should be added to show that this has been done. † The figures required in columns 2 and 3 are the total number of lists received from employers who sent them both in February and August as required by the Act and of the entries of names of outworkers in those lists. They will, therefore, usually be double of the number of such employers and (approximately) double of the number of individual outworkers whose names are given, since in the February and August lists of the same employer the same outworker's name will often be repeated. 73 74 4.—REGISTERED WORKSHOPS. Workshops on the Register (s. 131) at the end of 1908. Number. Private Workshops 71 Outworkers' Workshops 90 Men's Workshops 70 Laundries 48 Domestic Workshops 110 Bakehouses 56 Total Number of Workshops on Register 445 5.—OTHER MATTERS. Class. Number. Matters notified to H.M. Inspectors of Factories:— Failure to affix Abstract of the Factory and Workshop Act (s. 133) 25 Action taken in matters referred by H.M. Inspectors as remediable under the Public Health Acts, but not under the Factory and Workshop Act (s.5). Notified by H.M. Inspector 2 Reports (of action taken) sent to H.M.Inspectors 2 Other - Underground Bakehouses (s.101) :— Certificates granted during 1908 — In use at the end of 1908 6 Note.—The Factory and Workshop Act, 1901 (s. 132), requires the Medical Officer of Health in his Annual Report to the District Council to report specifically on the administration of that Act in workshops and workplaces, and to send a copy of his Annual Report, or so much of it as deals with this subject, to the Secretary of State (Home Office). If the Annual Report is presented otherwise than in print, it is unnecessary to include in the copy sent to the Home Office the portions which do not relate to factories, workshops, laundries, workplaces or homework. The duties of Local Authorities and the Medical Officer of Health under the Act of 1901 are detailed in the Home Office Memorandum of December, 1904. A further Memorandum, on the Home Work Provisions of the Factory Act, was issued to all District Councils and Medical Officers of Health in October, 1906. 75 The Out Workers' Premises were mainly supervised by the Lady Inspector, and the defects found or nuisances discovered were remedied under Mr. West's supervision. Sections 2, 3, 7 and 8 of the Act, dealing with cleanliness of premises, overcrowding, ventilation, and dryness of floors in connection with laundries, etc., have received special attention, and any defects found were remedied without resort to legal pressure. The instances of overcrowding, in two workrooms, were of a trivial character. Factories.—The only duty imposed in reference to these has been carried out, and in the early portion of the year every factory was visited to ensure that the standard for w.c. accommodation for the sexes laid down by the Home Office was maintained. Workshops.—These are systematically visited. Those sheltering women workers are dealt with by the Woman Inspector, and five workshops were reported for failure to affix Abstract of the principal Act. Workplaces.—Under this heading are grouped laundries, bakehouses, homeworkers' premises, coffee and eating houses, fishmongers, ice cream makers' premises, cab proprietors' yards, etc., and are mainly supervised by the Sanitary Inspectors. Laundries and Bakehouses.—There are now 10G of these premises, and they have been regularly visited during the year. Five of the laundries were partially or entirely cleansed, and in others some minor defects were found and remedied, including paving and drainage, etc. Bakehouses.—Visits are systematically made to these and the Regulations, ensuring cleanliness and wholesome conditions, carried out- In Mr. West's report will be found an account of the action taken by him, and the alterations and improvements secured from time to time. The six underground bakehouses have been kept up to the standard adopted in 1902. Outworkers' Premises.—These are well supervised, and generally cause but little trouble. Outworkers so often change their addresses, and employers failing to notify these in the lists sent, many futile visits are in consequence made. 76 Air Space.—Very seldom is this provision violated. Cleanliness and Ventilation.—Particular attention has been given to these, and no difficulty experienced in effecting what was necessary. Home Work.—Under this heading. Sections 107-15 give power to deal with (a) unhealthy dwellings, (b) premises where there is dangerous infectious disease. Scarlet Fever occurred in three premises, and Diphtheria in one : the necessary disinfections were carried out. The provisions of the Act under both headings were carried out. ELEMENTARY SCHOOLS. The sanitary condition of these has been well maintained, and only a few minor defects were found upon systematic inspection by the Sanitary Inspectors. Each School has been visited at least twice during the year by Dr. Hall under the Education (Administrative Provision) Act, 1907, and on several occasions by myself. All the Schools built within the last seventeen years are of modern type with large central halls and moderate sized class-rooms. The " provided " in existence prior to 1893 have been brought up to date, so that it would be difficult to find Schools superior in design and equipment to those under the direct control of your Council. The "non-provided" schools have accommodation for 241 boys, 456 girls, 509 infants ; and the St. George's (R.C.) Mixed School has 189 children on its rolls. This latter school has been recently brought up to date, and the lighting and ventilation are very good. Improvements in the cloak room accommodation at St. Mary's (Church of England) Infants' School, and in the playground of St. Saviour's (Church of England) Boys, are about to be effected. The water supply of all the Schools is from the Metropolitan Water Board. The number of children attending Elementary Schools is 25,479. RETURN showing the number of Cases of SCARLET FEVER and DIPHTHERIA notified each month of Children attending the PUBLIC ELEMENTARY SCHOOLS. 1909. SCHOOL. DEPARTMENT. JAN. FEB. MAR. APRIL. MAY. JUNE. JULY. AUG. SEPT. OCT. NOV. DEC. TOTALS. s f. d. s.f. d. s.f. d. s.f. d. s.f. d. s.f. d. s.f. d. s.f. d. s.f. D. s.f. d. s.f. d. s.f. d. s.f. d. W.C. William Morris Boys, High. Elem. - - - - - - - - 1 - - - - - - - 1 - - - 2 - - - 4 - Girls „ - - - - - 1 2 - - - - - - - - - 1 - - - - - - - 3 1 Mixed - - - - - - - - - - 2 - - - - - - - - - - - - - 2 - Pretoria Avenue Boys — 1 — — — — — — — — — — — — - — 1 — — — — — — — 1 1 Girls - - 1 - - - 2 - 1 1 - - - - 1 - - - - 1 - - 1 - 6 2 Infants — 2 — — — — 1 — — 1 — 1 — 1 — — 3 1 — — 1 — — — 5 6 Deaf Centre ... — — — — — — — — — — — — — — — — — — — — — — — — — E. Maynard Road Boys - - - - - - - - 1 - - - - - - - - - 1 - - - - - 2 — Girls — — — — — 1 — — - - - - - - - - - 1 3 — — 1 — — 3 3 Infants — — 1 — — — 2 — 2 - - - 2 - - - 1 - 2 - - 1 - - 10 1 St. Mary's Girls - - - - - - - - - - - - - - - - - - - - - - - - - - Infants — — — — — — 1 — 1 — — — 1 — 1 — — — — — — — — — 4 — N.W. Blackhorse Road Boys — — — — — — — — 1 — 2 — 1 — 3 — 4 — — — — — — — 11 — Girls — — — — — — 1 — 2 — 3 — — — 2 — 2 - 1 - — - — - 11 - Infants 1 1 — — 5 1 3 — 2 1 14 1 2 — 2 — 8 — 1 — 2 — — — 40 4 Higham Hill Junior Mixed - - - - - - - - - - - - - - - - - - - - - - - - - - Boys - - - - - - 1 - 1 - 1 - - - - - - - 1 - - - - - 4 - Girls — — — — — — 1 — 2 — — — — — — — — 1 1 - 1 - - - 5 1 Infants 1 — — — — — — 1 2 — 1 — — 1 — — — — — - 1 — - - 5 2 Temp. Infants - - - - - - - - - - - - - - - - - - - - - - - - - - N.E. Wood Street Boys - - - - - - - - - - - - - - - - - - - - - - - - - - Girls - - - - - - - - - 1 - - - - - - - - - - 1 - - - 1 1 Infants - - 1 - 1 - - 1 1 - - - - - - - - - 1 - - - - - 4 1 Joseph Barrett Bovs - - - - - 1 - - - - - - - 1 - - - - - - - - - - - 2 Girls - - - - - - - - 1 - - - - - - - - - - - - - - - 1 - Infants - - - - - - - 1 - - - - - - 1 - - - - - - - 1 — 2 1 Shernhall Street Special (Girls) - - - - - - - - - - - - - - - - - - 1 - - - - - 1 - (Boys) - - - - - - - - - - - - - - - - - - - - - - - - - - St. George's Mixed — - - - - - - - 1 - - - - - - - - - - - - - - - 1 — C. Coppermill Road Boys — — — 1 — — — — — — — — — — — — 1 1 - - - - - - 1 2 Girls - - - - - - - - - - - - - - 1 - - - - - 2 - - - 3 — Infants — 3 3 — 4 — — — — — — — — — 1 — — — — — — — 1 — 9 3 Mission Grove Girls — — — 1 — — —• — 1 — — 1 — — — — 1 2 — — — — — — 2 4 Infants - - - 1 - - - - - 1 - - - - - - - - 2 - - - - - 2 2 N. Chapel End Senior Boys - - 1 - - - - - - - - - 1 - - - - 1 1 1 — — — — 3 2 Senior Girls - - - - 1 - - - - - - - - - - - - - - - - - - - 1 — Infants — 1 — — 1 — — — — — — — — — — — — 3 1 — — 1 — — 2 5 Junior Mixed 1 - - - - - 1 - - - - - - - - - - - - - - - - - 2 — Selwyn Avenue Senior Mixed 1 - - - - - - - - - - - - - 1 - - - - - - - - - 2 — junior & Infants 4 — 1 — 1 — 1 — — — - — — — — — — — — — — — 2 — 9 — s.w. St. Saviour's Boys - - - - - - 1 - - - - - - - - - 1 - - - - - - - 2 — Girls - - - - - - 1 - - - - - - - - - - - 1 - 2 - 1 - 5 - infants - - 1 - 1 - 1 - - - - - - - - - - - 2 - - - - - 5 — Markhouse Road Boys — — - - - - - - - - - - - - - - - 1 - - - - - - - 1 Girls - - - - - - - - - - 1 - - - 1 - 2 - - - - - - - 4 — Junior Mixed - - - - - - - - - - - - - - - - - - - - - - - - - - Infants 2 — 1 — — — 1 — 1 1 1 — — — 1 — 1 - — — — - - - 8 1 s. Queen's Road Boys - - - - 1 - - - - - 1 - - - 9 - - - 1 1 - - - - 5 1 Girls 2 - - - 2 - - - - - - - - - 1 - - - - - 1 - - 1 6 1 Infants — — — — 2 - — — — — — — 3 — 1 — 1 — — I — 2 1 — 8 3 Gamuel Road Boys — — — 2 — — — — — 2 — — 1 — — 1 — 1 — — 1 — — — 2 6 Girls - - - - - - - - - - - - - - - 1 - - - - - - - - - 1 Infants - - - - - 1 - - - - - - - - - 1 - - - - 4 - - - 4 2 Marsh Street Boys - 1 - 3 - - - - - - 1 - - - - - 1 - - - - - - - 2 4 Edinburgh Road Junior Mixed 2 - - - - - - - — — 1 — 2 — — — 1 1 1 - 2 — - 1 9 2 E.C. Forest Road Boys - - - - - - - - 1 1 - - - 1 - - - - - - - - - - 1 2 Girls - - - 1 - - - - - 2 - - - - - - 1 - 2 1 1 - - - 4 4 Infants - - 1 - - - - - 2 1 - 1 - 1 - 1 2 - 1 - - - - - 6 4 Winns Avenue Boys - - - - - - - - - - - - - - - - - - - - - - - - - 1 Girls - - - - - - 1 - - - - - - - - - - - - - - - - 2 1 2 Infants 1 — — — — — 1 — — — 1 — 3 — 3 — 1 — 2 — — — — — 12 — junior Mixed 1 — - - - - - - - - - - 1 - 1 - 1 - - - - - - - 4 — TOTALS 16 9 14 9 19 5 22 3 24 12 29 4 17 5 23 4 35 13 26 5 21 6 7 4 253 79 Casks Notified 38 21 35 26 39 8 40 12 44 15 48 15 44 10 44 19 60 24 45 12 45 9 22 12 506 183 77 Infectious Diseases in Schools.—A great deal of time is devoted to the prevention of infectious disease among school children, and no school or department of a school has been closed during the year. The measures taken against the dangerous infectious diseases have already been described under its appropriate heading. The preceding tabular statement shows for Scarlet Fever and Diphtheria the numbers of children failing with those diseases, and the Schools invaded:— With the exception of the Blackhorse Road Infants' School, already referred to, the numbers compare favourably with previous years. The following requirements are needed— 1. More adequate provision for the disposal of sewage. 2. More public conveniences. 3. An improved Disinfecting Station, and the provision of a porary Shelter in accordance with Section 15 of the Infectious Diseases (Prevention) Act of 1890. This is necessary if the provisions of Section 122 (Sub-Section 2) of the Children Act, 1907, are to be carried out. APPENDIX. Local Government Board Forms :— Table I. Table II. Table III. Table IV. Table V. Chart Showing Birth, Death and Zymotic Death-Rates. Chart Showing the Number of Notifications of Infectious Disease. Local Government Board Form ] TABLE I.—For Whole District. Year. Population estimated to Middle of each Year. Births. Deaths under One Year of Age. Deaths at all Ages. Total. Deaths in Public Institutions W'stow General Hospital Deaths of NonResidents registered in District. Deaths of Residents registered beyond District. Deaths at all Ages. N ett. Number. Rate * Number. Rate per 1,000 Births registered. Number. Rate. * Number. Rate.* 1 2 3 4 5 6 7 8 9 10 11 12 13 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 1903. 106 290 3535 33.25 402 113.7 1065 10.19 39 10 123 1178 11.08 1904. 111,282 3649 32.79 496 135.9 1175 10.55 38 13 168 1330 11.95 1905. 116,300 3389 29.14 354 104.4 1046 8.9 33 16 219 1249 10.7 1906. 121,334 3594 29.60 466 129.7 1206 9.9 35 10 251 1447 11.9 1907. 126,397 3629 28.55 380 104.7 1129 8.9 36 16 263 1376 10.88 1908. 131,486 3482 26.48 351 100.8 1017 7.7 32 11 252 1258 9.56 Averages for years 1897-1908. 102,701 3194 31.34 415 130.1 1083 10.82 31 10.6 149 1224 12.11 1909. 136,602 3369 24.66 281 83.3 982 7.2 31 11 224 1205 8.8 * Rates calculated per 1,000 of estimated population. Area of district in acres (exclusive of area covered by water), 3,988 Total population at all ages, 95,131. Number of inhabited houses, 16,083. Average number of persons per house, 5'8.—At Census of 1901. 78 LoCal Government Board Form.] TABLE II. Vital Statistics of separate Localities in 1909 and previous years. Year. Names of Localities. St. James Street Ward. High Street Ward. Hoe Street Ward. Wood Street Ward. Northern Ward. Whole District. Population estimated to middle of each year. Births registered Deaths at all Ages. Deaths under 1 year. Population estimated to middle of each year. Births registered. Deaths at all Ages. Deaths under 1 year. Population estimated to middle of each year. Births registered. Deaths at all Ages. Deaths under 1 year. Population estimated to middle of each year. Births registered. Deaths at all Ages. Deaths under 1 year. Population estimated to middle of each year. Births registered. Deaths at all Ages. Deaths under 1 year. Population estimated to middle of each year by Registrar General. Births registered. Deaths at all Ages. Deaths under 1 year. 1897 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 70,000 2246 832 306 1898 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 77,000 2291 1034 399 1899 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 83,000 2835 1232 482 1900 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 91,000 3037 1254 482 1901 23,218 772 349 124 19,886 714 255 105 21,500 604 247 79 15,512 443 187 68 16,884 677 258 105 97,000 3210 1296 481 1902 23,000 766 293 89 20,000 735 228 81 22,000 650 224 55 16,000 482 183 64 20,000 793 234 105 101,318 3426 1154 394 1903 23,600 747 281 98 20,000 781 230 90 22,500 658 226 64 16,500 453 187 50 23,500 896 236 99 106,230 3535 1178 401 1904 23,600 793 327 125 20,400 762 246 98 23,100 628 246 68 16,600 471 184 66 24,300 995 327 139 111,282 3649 1330 496 1905 24,000 705 305 90 21,000 640 240 82 23,500 589 232 45 17,000 429 173 46 32,000 l026 299 91 116,300 3389 1249 354 1906 24,000 735 317 110 21,000 734 247 97 24,000 595 273 65 17,500 465 212 67 35,000 1065 398 127 121,334 3594 1447 466 1907 24,000 697 344 100 22,000 733 238 68 24,000 601 238 38 17,000 426 219 65 31,000 1172 337 109 126,397 3629 1376 380 1908 23,500 711 308 88 21,500 660 212 66 24,000 563 264 57 17,500 417 173 46 37,000 1131 301 93 131,486 3482 1258 351 Averages of Years 1901-8 102,701 3194 1224 415 23,615 741 315 103 20,723 720 237 86 23,075 611 243 59 16,701 448 189 59 28,210 969 298 108 Average of Years 1897 to 1908 1909 24,500 722 253 75 22,500 618 202 46 24,500 524 251 40 18,000 426 220 40 40,000 1079 279 80 79 I. Institutions within the District receiving sick and infirm persons from outside the District. II. Institutions outside the District receiving sick and infirm persons from the District. III. Other Institutions, the deaths in which have been distributed among the several localities in the District Walthamstow, Leyton, and Wanstead Children's and General Hospital. The Asylum. Sanatorium, Chingford. Union Infirmary, Leytonstone. Union Infirmary, Whipp's Cross. Small-Pox Hospital Dagenham. Local Government Board Form.] TABLE III.—Cases of Infectious Disease notified during the Year 1909. Name of District—Walthamstow. Notifiable Disease. Cases Notified in Whole District. Total Cases Notified in Each Locality. No. of Cases Removed to Hospital from Each Locality. Total Cases Removed to Hospital. 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 - - - - - - - - - - - - - - - - - - Cholera — — — — — — — — — — — — — — — — — — Diphtheria(including Membranous Croup) 183 2 49 106 15 11 — 40 44 31 11 57 35 37 22 6 44 144 Erysipelas 112 4 4 11 9 78 6 27 29 20 11 25 4 0 3 0 5 12 Scarlet Fever 506 5 114 329 41 17 0 112 68 82 47 197 97 53 48 32 134 364 Typhus Fever - - - - - - - - - - - - - - - — — — Enteric Fever 13 — 1 4 2 6 — 3 2 4 2 2 1 0 2 0 2 5 Relapsing Fever - - - - - - - - - - - - - - - - - - Countinued Fever - - - - - - - - - - - - - - - - - - Puerperal Fever - - - - - - - - - - - - - - - — - - Plague - - - - - - - - - - - - - - - - - - Totals 814 11 168 450 67 112 6 182 143 137 71 281 128 86 68 37 170 489 Isolation Hospital—Walthamstow Sanatorium, Chingford. Total available beds—93. Number of Diseases that can be concurrently treated—4 at least. 80 Local Government Board Form.1 TABLE IV. Schedule B. Table of Deaths during the year 1909, 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 & upwards St. James St. High Street Hoe Street Wood Street Northern Total Deaths in Public Institutions (Workhouse and Infirmary included). l Small-Pox - - - - - - - - - - - - - 2 Measles 30 9 19 2 — — — 8 3 9 5 5 4 3 Scarlet Fever 11 — 4 5 — 2 — 1 — 3 3 4 — 4 Typhus Fever — — — — — — — — — — — — — 5 Epidemic Influenza 16 1 — 2 — 12 1 4 4 4 — 4 1 6 Whooping Cough 46 21 24 1 — — — 7 5 5 11 18 9 7 Diphtheria, Membranous Croup 14 1 9 4 — — — 1 3 3 2 5 — 8 Croup 3 1 1 1 - - - - - 1 1 1 — 9 Enteric Fever 2 — — 1 — 1 — — — — 1 1 — 10 Asiatic Cholera — — — — — — — — — — — — — 11 Diarrhoea, Dysentery 7 4 1 1 — — 1 4 — 2 1 — 1 12 Epidemic or Zymotic Enteritis 10 8 1 1 — — — 3 2 1 — 4 .— 13 Enteritis 9 3 4 1 — 1 — L 1 2j 2 6 4 14 Gastro Enteritis 5 4 1 — — — — 1 — 1 — 3 — 15 Other continued Fevers — — - - - - - - - - - - — 16 Cerebro Spinal Meningitis — — — - - - - - - - - - - 17 Erysipelas 7 1 — 1 — 5 — 1 2 2 — 2 3 18 Puerperal Fever — — — — — - — — — - — — — 19 Other Septic diseases 20 6 3 1 — 7 3 4 1 2 4 9 5 20 Intermittent Fever and Malarial Cachexia — — — — - -- — — — — — — — 21 Tuberculosis of Meninges 16 2 10 2 2 — — 5 3 3 1 4 4 22 Tuberculosis of Lungs 108 — 3 4 18 80 3 22 19 21 20 26 33 23 Other forms of Tuberculosis 2 5 6 6 2 9 — 3 4 9 4 8 5 24 Alcoholism — — — — 5 — — 1 2 1 1 — 25 Cancer 6 — 1 — 1 35 24 7 11 19 12 12 19 26 Premature Birth 6 60 — — — — — 19 10 9 4 18 1 27 Developmental Diseases 76 74 2 — — — — 15 13 11 15 22 10 28 Old Age ... 64 - - - - - 64 13 7 19 7 18 22 29 Meningitis 11 4 5 2 — — — 4 3 - 1 3 2 30 Inflammation and Softening of Brain 2 — — — — — 2 — 1 - — 1 — 31 Organic Diseases of Heart 38 — — 4 6 19 9 5 13 9 8 3 9 32 Acute Bronchitis 40 21 8 — — 4 7 10 8 7 5 10 3 33 Chronic Bronchitis 68 — — — — 25 43 13 14 10 14 17 7 34 Lobar (Croupous) Pneumonia 56 — 9 4 3 32 8 15 8 13 12 8 6 35 Lobular (Broncho) Pneumonia 59 22 23 4 1 7 2 19 11 7 9 13 7 36 Diseases of Stomach 6 2 — — — 3 1 2 1 2 — 1 — 37 Obstruction of Intestines 6 1 1 — 1 - 3 1 1 1 3 — 3 38 Cirrhosis of Liver 8 — — — — 6 2 — 2 3 1 2 I 39 Nephritis and Bright's Disease 30 — 1 2 — 14 13 4 5 4 10 7 7 40 Tumours and other Affections of Female Genital Organs - - - - - - - - - - - - - 41 Accidents and Diseases of Parturition 11 — — — 3 8 — 3 2 3 2 1 2 42 Deaths by Accident or Negligence 37 9 9 3 — 6 10 9 6 10 4 8 12 43 Deaths by Suicide 14 — — — — 13 1 3 4 — 4 3 1 44 Deaths from Ill-defined Causes 1 — — _ — 1 — — 1 — — — — 45 Syphilis 3 1 — — — 2 — — 1 1 1 — 1 46 All other Causes 217 21 4 8 7 98 79 46 32 53 35 51 52 All Causes 1,205 281 149 60 44 395 276 253 202 251 220 279 234 Local Government Board Form.] TABLE V. Causes of Deaths. Under 1 Week 1-2 Weeks. 2-3 Weeks. 3-4 Weeks. Total under 1 Month. 1-2 Months. 2-3 Months. 3-4 Months. 4-5 Months. 5-6 Months. 6-7 Months. 7-8 Months. 8-9 Months. 9-10 Months. 10-11 Months 11-12 Months Total Deaths under One Year. All Causes Certified 69 25 14 21 129 21 21 17 10 13 16 11 15 10 10 7 280 Uncertified — — — — — — — — — — - - - - - - 1 COMMON INFECTIOUS DISEASES. Small-Pox - - - - - - - - - - - - - - - - - Chicken-Pox - - - - - - - - - - - - - - - - - Measles - - - - - - - 1 — — — 1 1 2 2 2 9 Scarlet Fever - - - - - - - - - - - - - - - - - Diphtheria; Croup - - - - - - - - - - - - - - - - 1 Whooping Cough — — — — — 4 4 — — 1 4 — 3 — 2 3 21 DIARRHEAL DISEASES. Diarrhoea, all forms - - - - - - - 1 — 3 1 3 1 2 1 — 12 Enteritis, Muco Enteritis,, Gastro Enteritis - - - - - 1 1 3 1 — — — — 1 — — 7 Gastritis, Gastrointestinal Catarrh - - - - - 1 — — — 1 — — — — — 2 WASTING DISEASES." / Premature Birth 41 7 4 4 56 1 - 1 - - - - - - - - 58 Congenital Defects 5 2 — — 7 1 — — 1 — — — — 1 — — 10 Injury at Birth 5 1 — — 6 — — — — — — — — — — — 6 Want of Breast-milk — 1 - - - - - - - - - - - - - - 1 Atrophy, Debility, Marasmus 5 3 5 5 18 6 8 5 2 2 1 1 1 1 — — 45 V Asthenia : Inanition 9 2 1 1 13 — - - - - - - - - - - 13 TUBERCULOUS DISEASES. Tuberculous Meningitis - - - - - - - - - 1 - — — — 1 — 2 Tuberculous Peritonitis: Tabes Mesenterica . - - - - - - 1 - 1 - 1 - 1 - - - 4 Other Tuberculous Diseases - - - - - - - - - - - - 1 - - - 1 OTHER CAUSES. Erysipelas - - - - - - - - - - - - - - - - - Syphilis — — — 1 1 — — — — — — — — — — — 1 Rickets — — — — — — — — — — — 1 — — — — 1 Meningitis (not Tuberculous) - - - - - - - 1 - 1 - - 2 - 1 - 5 Convulsions 2 6 2 4 14 — 1 1 — 1 — 1 1 — — — 19 Bronchitis - - - - - 1 2 2 1 2 4 2 2 1 1 1 19 Laryngitis — — — — — — — — — — 2 — — — — — 2 Pneumonia — 2 1 2 5 2 1 — 2 2 2 2 2 2 2 22 Suffocation, overlaying 1 — — — 1 1 2 1 1 — — — — — — — 6 Other Causes 1 1 1 4 7 3 1 1 1 - - - - - - 1 14 69 25 14 21 129 21 21 17 10 13 16 11 16 10 10 7 281 District (or sub-division) of Walthamstow. Births in the year legitimate, 3310. illegitimate, 59. Deaths from all Causes at all Ages, 1205. Population. Estimated to middle of 1909, 136,602. Chart shewing the Birth, Death and Zymotic Death-Rates, for the years 1880 to 1909. Birth-Rate. General Death-Rate. Zymotic Death-Rate. 81 TO THE CHAIRMAN ANI) MEMBERS of the Wcilthamstow Urban District Council. Gentlemen, I have the honour to present to you my report of work done through my Department during the year 1909. The new bye-laws as to New Streets and Buildings which, as far as relates to drainage, are now made to apply to existing buildings under the supervision of the Inspectors of Nuisances, and are being found to be of considerable service in securing uniformity of work by various owners in that connection. The increase in the number of factories using steam power is gradually increasing the amount of smoke discharged into the air, and requires careful and judicious attention to prevent nuisance to neighbouring residents. My endeavour is to do this without vexatious interference with the factory owners. The several thousands of intimation notices sent to owners as to work required to be done have, in most cases, been sufficient for their purpose; in only 73 cases has it been necessary to ask for authority to serve statutory notices, and in every case these have been successful. I desire once more to testify to the unfailing loyalty and interest displayed by those under my superintendence in the work of the Council. I am, Gentlemen, Your obedient Servant, W. W. WEST, Fellow San. Inspectors' Assoc., Assoc. Roy. San. Inst., Inspector of Nuisances. f 82 House-to-House Inspection has been carried out in the under mentioned streets during the year :— Barrett Road. Barclay Road. Bristol Park Road. Chingford Lane. Castle Yard. Clarendon Road. Elm Road. Gamuel Road. Gainsford Road. Granville Road. Grove Road. Hawthorne Road. Hervey Park Road. Jeffries Square. Ickworth Park Road Kingsley Road. Linford Road. Longfellow Road. Markhouse Place. Markhouse Avenue. Mill Lane. North Road. Roland Road. St. Stephen's Avenue. Spruce Hills Road. Suffolk Park Road. Spring Gardens. Vallentin Road. West Street. Sanitary improvements have been carried out in connection with 2,198 premises out of a total number of 5,506 which were inspected. Reconstruction of Drainage.—Included in this work during the year, entire reconstruction has been effected of the drains of 247 premises. In the case of 12 blocks of houses, comprising 62 separate premises, the main drainage has been carried out by the Council under the provisions of the law regulating the respective definitions of drains and sewers. These were situated as follows :— Eden Road, nine houses. Eden Grove, ten houses. Clarendon Road, three houses. Granville Road, six houses. Higham Street, three houses. Longfellow Road, two houses. Maynard Road, four houses. Oatland Rise, nine houses, Pembroke Road, six houses. Somers Road, five houses. Vallentin Road, six houses. In the remainder of the cases the work has been done by the owners, in most cases with little delay. 83 The number includes the following parts of the district:— 90, 92 and 94, Acacia Road. 47 and 49, Alexander Road. 109 and 111, Barclay Road. 125, 127 and 129, Barclay Road. 50 and 52, Beaconsfield Road. 51, 53 and 55, Buxton Road. 1 to 10, Castle Yard. 21 and 22, Cairo Road. 78, 80 and 82, Clarendon Road. 14 to 42, Chingford Lane. 20 and 21, Eastfield Road. 17 and 19, Eden Road. 1 to 18, Eden Grove. 16 to 24 (nine houses), Forest Rise. 10 to 20, Granville Road. 5, 6 and 7, Gamuel Road. 21, 22 and 23, Gamuel Road. 73 to 79, Grange Road. 10 and 12, Grange Road. 41 to 47, Glenthorne Road. 74 and 76, Glenthorne Road. 8 and 10, Hazelwood Road. 46 and 48, Hazelwood Road. 54 to 58, Hervey Park Road. 32 to 36, Hervey Park Road. blocks and pairs of houses in all 57 and 59, Hervey Park Road. 1, 3, 5, 7 & 9, Hervey Park Road. 15 and 17, Herbert Road. 9, 11 and 13, Higham Street 24 and 26, Ickworth Park Road. 52 and 54, Ickworth Park Road. 28 and 30, Ickworth Park Road. 119 and 121, Longfellow Road. 50 to 56, Maynard Road. 103 to 119, Oatland Rise. 1 to 11, Pembroke Road. 76 and 78, Queen's Road. 98, 100 & 102, St. Andrew's Rd. 60 and 62, St. John's Road. 2 and 4, Stafford Road. 17 to 23, Springfield Road. 11 to 19, Somers Road. 18 and 20, Summit Road. 27 and 29, Vallentin Road. 57 to 61, Vallentin Road. 11 to 21, Vallentin Road. 27 and 29, Wingfield Road. 4 and 6, West Avenue Road. 56 to 62, Woodland Road. The following is a summary of the various works to remedy nuisances and defects discovered in the course of inspection :— Drains tested .. ... ... ... ... ... ... 656 „ reconstructed ... ... ... ... ... 247 „ repaired ... ... ... ... ... ... ... 150 ,, cleared of obstruction ... ... ... ... ... 559 Inspection chambers and clearing eyes provided ... ... 165 Ventilation shafts provided ... ... ... ... ... 156 ,, ,, repaired and heightened ... ... 114 Soil pipes repaired ... ... ... ... ... ... ... 46 Rain-water pipes provided or repaired ... ... .. ... 161 ,, ,, disconnected from drains .. ... ■■■ 119 Roofs repaired or renewed ... ... ... ... ■ ■ • 206 Guttering „ ,, ... ... ... ... ... 342 84 New w.c. pans and traps 868 New gulley traps .. 867 Bell traps abolished 70 New water waste preventers to w.c. 128 Water waste preventers repaired 279 W.c. floors concreted 229 VV.c.'s repaired or cleansed 45 W.c. lighting and ventilation improved 35 New sinks provided 119 Sink and bath wastes repaired or renewed 331 „ „ trapped 11 Sculleries paved 53 Yards and forecourts paved and drained 627 Water supply reinstated or improved 156 Overcrowding abated 54 Dirty houses cleansed 196 Dirty rooms cleansed 1524 Floors repaired 45 Ventilation under floors provided 182 Cisterns cleansed or covered 241 Stables paved, drained or cleansed 19 Offensive accumulations removed 111 Nuisance from keeping of animals abated 28 Manure receptacles provided 25 „ „ repaired 1 Manhole covers re-sealed 13 New damp-proof courses to houses provided 26 New w.c.'s built 9 Smoke nuisances 2 Sites concreted 5 Cesspools cleansed and abolished 6 Infectious Diseases.—Eight hundred and twenty seven houses have been disinfected after the occurrence of infectious disease, and inspection made with the view of ascertaining their sanitary condition and the possibility of a local contributory cause, and 76 books in use from the 85 Fublic Library removed and disinfected, and returned to the Chief Librarian. The inspection has resulted in the discovery of more or less insanitary conditions in 459 of the premises, which have been remedied, in addition to the fumigation of the infected rooms, and, where necessary, stripping, whitewashing and cleansing. The bedding and clothing removed from infected premises have been disinfected at the Council's disinfecting chamber. The undermentioned articles have been dealt with:— Beds 956 Bolsters 497 Pillows 1278 Blankets 1205 Miscellaneous 7824 Rooms fumigated or sprayed 988 Schools, throughout 9 „ cloakrooms 80 Library books disinfected 96 Overcrowding.—This nuisance has been found to exist in fifty-four premises during the year, in most cases being confined to one or two of the rooms, and in a considerable number of the cases is associated with dirty conditions, as well as frequently with dire poverty. In every case it was abated without resort to legal proceedings ; often by a rearrangement of the occupancy As far as I have been able to ascertain by careful enquiry, in no case has the overcrowding been simply transferred to another house, as is sometimes the case Unwholesome as overcrowding in rooms undoubtedly is, the surrounding conditions in Walthamstow, of open thoroughfares and good air space at the rear of the houses, renders it of course much less of an evil to the town than in older towns where there is also overcrowding on area. Damp Houses.—In some of the older houses, dampness is occasionally found to exist, due to want of a proper damp-proof course, or want of adequate ventilation of the space beneath the ground floor, and inefficient surface drainage. In nine cases during the year this has been remedied, and the homes made dry and warm by owners at my instance, by the provision of paving, drainage, damp-proof course and ventilation. Bakehouses.—There are 56 bakehouses in the district, of which 6 are underground. The periodical cleansing required by Act of 86 ment has been supervised, and in addition various other improvements effected. In one instance only, in which the firm had gone into liquidation, was it necessary to threaten legal proceedings after undue delay in carrying out the required periodical cleansing in accordance with the law. In every other case the work was done at the stated periods. Special cleansing 7 Improper accumulations removed 3 Manure receptacles improved 1 Repairs to paving and floors 6 Other repairs 11 Slaughter-houses and Butchers' Shops. — Fifteen slaughterhouses and 91 butchers' shops have been under constant supervision. In the case of slaughter-houses, by persistent visitation at the hours of killing, the most thorough inspection of the entire animal has been possible, and any abnormal condition discovered under circumstances most advantageous to both the owner and the public. There has been in nearly every case a readiness to assist us, and to surrender for destruction any meat found to be unwholesome. The following have been destroyed :— 2 carcasses of beef. 5 ox livers. 18 pairs of lungs (4 tuberculosis). 2 abdominal organs (beef). 10 lbs. beef. 25 pieces of beef. 1 lb. pieces of beef. 10 lbs. pork. 10 lbs. veal. 4 sheeps' heads. During the year, after somewhat prolonged negotiations with owners and mortgagees, one slaughter-house has been thoroughly over-hauled, and improved lighting, ventilation and drainage effected to the advantage of those engaged there, and to us for purposes of inspection. In others, and in butcher's premises, the following improvements have been carried out:— 87 Special cleansing Paving improved Manure receptacles provided Walls rendered in cement Receptacles for offal provided Improper accumulations removed Other repairs ... 21 11 2 2 2 4 4 Cowkeepers and Milksellers.—There are now 13 cowkeepers in the district, 3 having given up occupation during the year. The new regulations have been before the Local Government Board twice, and have been returned to the Council for their final drafting. While we have not succeeded in obtaining all the provisions asked for, there will be much improvement, and this will apply even more extensively to the milksellers, of whom there are 93 under supervision. During the year, in these premises the following improvements have been effected:— Factories and Workshops.—Supervision has been exercised over the various premises recognised respectively as factories, workshops, outworkers, and workplaces. Factories consist of premises in which power is employed, and in which supervision is exercised under the Public Health Acts as to sanitary accommodation. The trades carried on under this heading are:— Drainage repaired Paving repaired Special cleansing Water supply improved Improper accumulations removed Ventilation improved... Other improvements ... 16 10 3 3 1 12 8 Motor Works. Saw Mills and Joinery Works. Engineers and Tool Makers Butchers. 88 Ice Cream Makers. Cowkeepers. Brush-handle makers. Printers. Builders, Stone and Slate Workers. Mineral Water Manufacturers. Instrument Makers. Shirt and Collar Makers. Medical Plaster Works. Picture frame makers, die sinkers, baker, bootmaker, fire appliance maker, mantle maker, pipe maker, flower pot maker, mica insulator maker, cardbox maker, laundry, piano desk maker, dyer, xylonite makers, chenille makers, paper waxer, pickle and sauce makers. Workshops.—Under this description the following trades are carried on in the district, viz., wheelwright's, confectionery, lamp maker's, upholstery, spectacle case making, piano manufacture, organ building, ironworking, shop fitting, cloth staining, printing, blind making, joinery, flower pot making, mica working, boot making, tinplate making, carbon paper making, cabinet making, currying, picture frame making. In connection with these two classes of premises the following works of improvement have been carried out:— Special cleansing 29 Additional w.c. accommodation 1 Improvements in w.c.'s 13 Drainage repaired 11 Paving repaired 3 Offensive accumulations removed 2 Smoke nuisance abated 2 Manure receptacle provided 2 Outworkers.—These constitute the greater proportion of premises supervised under the Factory and Workshop Acts. The work carried on is, of course, of a most varied nature, as is shown in the following list of trades Aprons 2 Artificial flowers 7 Blouses216 Boots 53 Belts 17 Boxes 17 Books (pattern) 8 Brushes 36 Brevetts and Stocks 1 Bon-bon fancies 1 Baby linen 8 Corsets 1 Collars 12 Children's costumes H Children's pelisses 1 Coats 2 Dressing gowns 4 Dress trimmings 8 Dress shields 3 Embroidery 10 Fur 7 Hats 2 Fancy leather goods 8 Juvenile clothing 42 Millinery 10 Muffs 1 Masonic trimmings 1 Pyjamas 1 Shoes 5 „ infants 8 Sun bonnets 2 Shoe bow and ties 14 Shirts 7 Skirts 5 Mantles 6 Shoe vamp beading 7 90 Ties Tailoring Tea gowns Toys Underclothing Underskirts Umbrellas „ tassels Vests Waistcoats 54 40 2 1 54 7 8 8 8 11 In connection with these premises the following works have been carried out:— Cleansing 11 Drain repairs 6 Paving 3 Overcrowding abated 1 Sundry repairs 2 Laundries.—In these premises during the year the defects found and remedied under my supervision, have been as follows : — Special cleansing 5 Drains reconstructed 1 Paving provided 1 Other repairs 2 Fishmongers.—Sixty-six premises used by fishmongers have been under constant supervision, and any conditions likely to give rise to nuisance noted, as well as the nature of the material sold. No complaints have been received during the year in connection with the removal of offal. The removal at midnight every day in hot weather, and two or three times a week at other seasons, being still continued. In connection with the premises there have been carried out the following works:— Special cleansing 17 Paving repaired 17 New offal receptacles provided 5 91 Smoking and frying premises improved 3 Animal, improperly kept, removed 1 Drainage repaired 11 Other improvements 7 The following articles have been destroyed during the year— 4 boxes of plaice. 26 mackerel 2 boxes of hake. 84 lbs. of eels. 5 boxes of kippered herrings. 1 sack of potatoes. 2 boxes of haddock. Coffee Houses.—Frequent visits have been paid to the forty-eight coffee houses in the district, and no difficulty has been experienced in remedying defective conditions where found desirable. The following improvements have resulted : — Special cleansing 19 Paving improved 4 Cisterns cleansed 2 Drainage repairs 5 Ventilation improved 1 Other improvements 3 Ice Cream Vendors.—Premises to the number of 143, where ice cream is made, have been supervised during the year, with reference to their sanitary conditions and the cleanliness exercised in the preparation of the article. In one case a quantity of ice cream was found which appeared to be unwholesome, and the owner readily acceded to the suggestion to destroy it. The following improvements have been effected:— Cleansing of premises 11 Yard paving made satisfactory 5 Receptacle for storage provided 1 Water supply improved 5 Drainage repaired 5 Other improvements 6 92 Sale of Food and Drugs Acts.—I have submitted to Dr. Bernard Dyer, the Analyist for the Essex County Council, during the year, one hundred and thirty-three samples purchased under the provisions of these Acts, as follows :— Description of Article. Number Submitted. Contrary to Law. Milk 73 3 Butter 31 3 Coffee 6 2 Lard 6 — Pepper 5 — Mustard 5 — Dripping 8 — Margarine 3 1 Cocoa 1 — SALE OF FOOD AND DRUGS ACT. Table showing how the samples found to be sold not in accordance with the law were dealt with : No. of Sample Description of Article. Offence. Fine Inflicted. Analyst's Fee. Costs. Remarks. £ s. d. £ s. d. £ r. d. 3 Milk 50 p.c. added water 5 0 0 ... ... ... 0 4 0 22 Coffee 50 p.c. chicory 0 1 0 0 10 6 0 4 0 27 Margarine- Sold without a label ... ... ... 0 10 6 0 4 0 28 Butter Margarine 2 0 0 0 10 6 0 4 0 39 Coffee 35 p.c. chicory 0 5 0 0 10 6 0 4 0 64 Milk 5 p.c. added water 1 0 0 0 10 6 0 4 0 These two samples, as well as an informal sample, No. 69, containing 20 p.c. of added water, were from the same vendor. 73 Milk 17 p.c. added water 2 10 0 0 10 6 0 4 0 75 Butter Margarine ... ... ... ... ... ... ... ... ... No proceedings, vendor having closed his shop and ceased to carry on the business. 2 Butter 1 p.c. boric acid ... ... ... ... ... ... ... ... ... In these cases, the vendor was cau-tioned. 3 Butter 19 p.c. water ... ... ... ... ... ... ... ... ... 98 94 Offensive Trades.—There remains but one premises coming under the category of ail offensive trade, and no complaint has been received with reference to it during the year. Tentative enquiries have been made as to the obtaining of the sanction of the Council for the establishment of others, but the subject has not been pursued. Unsound Food.--Visits are regularly made to the market places in addition to the special premises already indicated, and careful observation kept upon the articles displayed for sale During the year, the following articles have been destroyed, besides those already mentioned :— 13 cases of tomatoes. 16 cases of tomatoes. 27 pecks of strawberries.