BROU 2 THE ANNUAL REPORT on the HEALTH and SANITARY CONDITION of the URBAN DISTRICT OF BROMLEY (KENT), For the Year 1893, by ARTHUR F. G. CODD, m.b., f.r.c.s., san: sci: cert: MEDICAL OFFICER OF HEALTH. Bromley, Kent: S. Bush and Son, Steam Printers, 42, High Street. 3 URBAN DISTRICT OF BROMLEY (KENT). Report of the Medical Officer of Health for the Year 1898. To the Chairman and Members of the Urban District Council of Bromley. March 21st, 1899. Gentlemen, I have the honour to present to you my Tenth Annual Report, relating to the year ending December 31st, 1898. VITAL STATISTICS. For the purposes of statistics the population is always calculated for the middle of the year. At the last census, taken on April 6th, 1891, our population was 21,685, being an increase since the previous census of 6,532. On the supposition that the last intercensal increase will be maintained, the population in the middle of 1898 may be approximately estimated at 26,409. The District comprises 4,706 acres, having a population of 5-6 persons to the acre. 4 BIRTHS. The births during the year were 618, of which 309 were males and 309 were females, giving a birth rate of 23*4 per 1000, compared with a rate of 29-4 for England and Wales, and 27-3 for the outer ring of London. The outer ring is that portion of the Metropolitan Police District which is outside the district of Registration London, and includes such districts as Croydon, Wimbledon, Richmond, Beckenham, Uxbridge, Harrow, Enfield, and Walthamstow; many of which may be fairly compared—from a health point of view—with our own district. MARRIAGES. During the year there were registered 261 Marriages, of which number: 145 took place in Churches. 53 ,, ,, Nonconformist Chapels. 3 ,, ,, the Roman Catholic Church. 60 ., ,, the Superintendent Registrar's Office. The marriage rate for Bromley was therefore 19.7. The rate for England and Wales for the year ending September 30th, was 16.0. DEATHS. The number of deaths registered in the district was 296. By adding 27 deaths of Bromley persons, which occurred in our Union Infirmary, which is outside the district, and by deducting 9 which occurred in the Infectious Hospital (these not belonging to the district) and 5 from outside districts which took place in the Cottage Hospital, we have a 5 total of 309, of which 156 were males and 153 were females. This is equal to a rate of 11.7 per 1000. The rate for England and Wales was 17.6 and for the outer ring of London 13.7. In the first quarter there were 74 deaths. „ second „ „ 58 third „ „ 97 fourth „ „ 80 The excess of births over deaths was 309 being a natural increase in the population of 11.7 per 1000. The following table epitomises the ages at death: Under 1 year 96 Over 1 year and under 5 years 27 „ 5 years „ 15 „ 11 ,, 15 ,, ,, 25 ,, 12 ,, 25 ,, ,, 65 ,, 82 )> 65 " ... 81 3°9 Two inhabitants reached the age of 95 years. Deaths under 5 years of age 134 over „ „ 175 The proportion of deaths under one year of age to registered births (i.e., the Infant Mortality) was 155 per 1000 compared with 161 per 1000 for England and Wales. 6 DEATHS FROM ZYMOTIC DISEASES. The deaths from all causes included: From Diarrhœa 37 ,, Whooping Cough 11 ,, Diphtheria 4 „ Enteric Fever 2 ,, Measles 3 57 There were no deaths from Small Pox or Scarlet Fever. Thus 57 deaths were attributed to these principal zymotic diseases, being at the rate of 2.15 per 1,000 living, compared with a rate of 2.22 for England and Wales, and 2.33 for the outer ring of London. I append the death-rates and the zymotic death-rates in Bromley since 1883, i.e. for the past 16 years.— Death-race. Zymotic Death-rate. 1883 13.4 2.4 1884 15.8 2.4 1885 13.0 1.3 1886 11.6 1.2 1887 15.0 2.7 1888 12.8 0.9 1889 11.7 1.2 1890 13.7 2.4 1891 13.3 1.0 1892 12.4 1.5 1893 13.6 1.5 1894 12.9 1.6 1895 11.0 1.0 1896 11.6 2.5 1897 10.2 1.1 1898 11.7 2.1 Average 127 1.6 7 There were 39 deaths from Tuberculous Diseases of which 19 were due to Pulmonary Consumption. There were 41 deaths from inflammatory diseases of the respiratory organs. Cancer was the cause of 24 deaths,—a decided increase. There were 10 deaths from Epidemic Influenza. Generally speaking, the effects of sanitary improvements and precautionary measures are best indicated by a lower death-rate from Infectious Diseases, Fever, Diarrhoea and Consumption, and, amongst children under 5 years of age, from all causes. I therefore show these rates in Bromley during the last 5 years. 1894 1895 1896 1897 1898 Infectious Diseases. 1.68 1.02 2.5 1.16 2.15 Fever .21 .08 .04 .03 .07 Diarrhœa .42 .73 .39 .66 1.40 Consumption .75 .73 .91 .81 .71 Children under 5 years of age from all causes 3.9 3.9 4.6 3.2 5.0 A death rate of 11.7 for a town of over 26,000 inhabitants is remarkably good, and it would have been better still but for the unusual number of deaths from Diarrhoea among infants. INFECTIOUS DISEASES. Under the Infectious Diseases (Notification) Act, 176 cases of the diseases to which this Act applies, were reported during the year. The following shows the number of cases reported during the last 5 years: 8  1894 1895 1896 1897 1898 Scarlet fever 52 40 60 192 110 Diphtheria 25 10 11 19 33 Erysipelas 22 10 20 14 15 Enteric fever 20 6 9 3 17 Puerperal fever 1 2 2 3 1 120 77 102 231 176 Of the 176 cases, 121 were removed to the Infectious Hospital and 55 were treated in their own homes. The 176 cases occurred in 140 houses. The Infectious Hospital contains 84 beds, and during the year 240 patients were treated under the care of Dr. Shannon the Medical Superintendent. The return of admissions from the adjoining districts is also given as it shows the amount of infectious disease which was prevalent around Bromley. From the Bromley Urban District with a population of over 26,000 inhabitants— Scarlet fever 99 Diphtheria 18 Enteric fever 4 From the Bromley Rural District— Scarlet fever 34 Diphtheria 44 Enteric fever 7 From the Beckenham Urban District- Scarlet fever 23 Diphtheria 5 Enteric fever 2 There were 11 deaths in the Hospital, 10 being from Diphtheria and 1 from Scarlet Fever and Enteric Fever. 9 SCARLET FEVER. During the year no cases of this disease were reported. Although this is considerably less than the number occurring in 1897, is much above the average recorded since the Notification Act came into force, and for the last two years there can be no doubt that Scarlet Fever has been unusually prevalent in Bromley, when we compare the weekly returns sent out by the Local Government Board. That the cases were of a very mild type is shown by the fact that there was not a single death from Scarlet Fever out of all this number. In the milder forms of Scarlet Fever, infection is more likely to be spread, owing to the true nature of the attacks in many instances being overlooked. Every year some of these cases are traced out, but no doubt many escape detection and continue to spread infection. We were fortunate in having no " return " cases during the year. The largest number occurred in May and December : there were so many in the latter month that it became necessary to close the Mason's Hill and Aylesbury Road Schools for a fortnight. With the exception of the cases occurring at this time there was no tendency during the year for the disease to assume an epidemic character. I may point out that Scarlet Fever, both here and elsewhere, has assumed such a mild type, that the dread of it is no longer so well founded as it was 20 years ago, when the mortality was high, and the complications and sequelae were serious. Measles, a disease so lightly regarded as a rule by parents, is much more infectious, and has a higher mortality, 10 and in our own district every year kills more children than Scarlet Fever, which is often looked upon with the greatest alarm. For disinfection we use the liquified Sulphurous Acid Gas in tins. We find this a decided improvement on the old fashioned method of burning the Sulphur. DIPHTHERIA. 33 cases of this disease were reported, with 4 deaths. The low mortality, 12.1 % is worthy of note when we compare it with that of previous years. Last year the case mortality in the district was 26 % and before this it had in some years been as high as 40 %. The results obtained this year correspond almost identically with those in the hospitals of the Metropolitan Asylums Board. The wise action of the District Council in bearing the expense of Bacteriological examination, has enabled practitioners to avail themselves more freely of a means of accurate diagnosis in cases of suspected Diphtheria, and although by the use of this method some of the cases which would otherwise have been notified as Diphtheria, have been proved not to be such on examination, yet many others which but a few years ago would have been diagnosed as cases of Follicular Tonsillitis or Laryngitis have, by means of an adequate examination, been proved to be cases of Diphtheria. That the more accurate diagnosis by the Bacteriological method has swelled or diminished the total number of cases notified may be open to question. In this connection I may 11 mention that during the year 23 tubes were sent up to the Clinical Research Association for examination and report. Of these 14 were found to contain the Klebs-Loffler bacillus, the pathognomonic organism of Diphtheria, 5 were found to contain Hoffmann's Pseudo Diphtheria bacillus, and in 4 cases the specific organisms were absent. In cases when the specific organisms were found, notification of Diphtheria was given, but the others were excluded. In several cases, owing no doubt to the clinical symptoms being considered unmistakable, the bacteriological test was not applied, and in some others it was obtained through private agency : of these I have no record, but it would appear that many cases which would otherwise have been notified, have been excluded, and as such cases take a much more favourable course, they would have helped to make the mortality still lower. With the increasing prevalence of Diphtheria, no proof has been brought forward that the type of disease has altered to any considerable extent, but that the more extended use in treatment of the Antidiphtheritic serum during the last four years, may justly be claimed as the cause of the largely diminished mortality can hardly admit of doubt. ENTERIC FEVER. 17 cases of this disease were notified, the largest number in any year since notification became compulsory, with the exception of 1894, when 20 cases were reported. There were 2 deaths—an average mortality. At least four of these were contracted out of our district. In four others the drainage of the houses was found to be 12 defective, and in the remainder the source of infection was not traced. In four of the cases which occurred within a short time of one another, the milk supply came from a common source, and accordingly, samples were taken of the milk and sent up to the Clinical Research Association for examination and report, with negative results. On three separate occasions water was taken from the Kent Company's mains and submitted to bacteriological examination, but in each case the water was found to be of more than usual purity. DIARRHœA. 37 deaths occurred from this disease. One was in an adult, five were in children between one and five years of age, and the remainder, 31 in number, occurred in infants under one year of age. This number is more than double our average and is the chief cause of our zymotic death rate reaching the high figure of 2-I5. 33 of these deaths occurred between August nth and September 23rd, when we had a spell of very hot and dry weather, which was favourable to fermentative changes in food. In my last report I emphasised the importance of getting the public to recognise the fact that these deaths were due entirely to preventible causes. VACCINATION. During the last five years Vaccination, which has never been very strictly enforced in this district, has been more and 13 more neglected, until last year the number of vaccinations among the poor fell to about a quarter of the proper number. This means that there are in Bromley at the present time among the class who are most liable to be attacked, a very large number of persons of an age at which they are most susceptible to the infection of Small-pox. The better class as a rule have obeyed the law. I believe that very few of the Bromley inhabitants have so far taken advantage under the New Act of the "Conscientious Objection" clause, and that most of the parents who have neglected to have their children vaccinated, have done so more through carelessness or procrastination than through any deeprooted objection to Vaccination. The existence amongst us of a large un-vaccinated community becomes a source of danger, and it is to be hoped that those who have neglected to be vaccinated or re-vaccinated, will take steps to have the operation done at once, as experience has shown the great risk of waiting until they are in the actual presence of an outbreak. I am glad to say that the poor with few exceptions are submitting to the New Act, which allows them to have their children vaccinated at their own homes free of expense. The Local Government Board are providing the best glycerinated calf-lymph, and stringent rules are laid down to prevent any contamination during and after the operation. Owing to the laxity in enforcing the Act in the past few years, it must be many months before the arrears are made up. 14 RAINFALL. I am indebted to Mr. James Batten, J.P., of the High Field, Bickley, for the following particulars of the local rainfall: Inches. Inches. January .59 July .39 February .95 August .84 March 1.49 September .32 April 1.06 October 2.96 May 2.92 November 3.22 June 1.07 December 2.36 Total local rainfall 18.17 inches. Total Greenwich rainfall 18.85 inches. HOUSE ACCOMMODATION. During the year 278 plans of new houses, not including additions, were approved. This is an immense increase over any previous year, and shows the rapidity with which the population is increasing, indeed it appears probable that when the time arrives for the next census to be taken, it will be found that the calculations of the increase of population, have erred on the side of under estimation. House accommodation for the working classes is decidely inadequate in our district. Not only are the cottages deficient in number, but the rentals are so high that it is not uncommon for a working man to be obliged to pay away a a quarter of his earnings in house-rent. With land at its present high price, it appears impossible for labourers to live within easy reach of their work, and in the future they will have to seek further afield for cottages within their means. 15 The difficulty in connection with the erection of an underground convenience outside the Town Hall, has been overcome and the work will shortly be commenced, but other public conveniences are still badly needed in the town. Appended is the report of your Sanitary Inspector, Mr. Matthew Bates, showing in detail the Sanitary Work carried out during the year. I am, Gentlemen, Your obedient servant, ARTHUR F. G. CODD, Medical Officer of Health. 16 Annual Report of Sanitary Inspector. Summary of Sanitary Work &c., carried out in the Urban District of Bromley, Kent, during the year ended December 31st, 1898. SANITARY WORK. (Other than that included in House to House Inspection.) Tenement Houses and premises visited 521 House Drains tested 146 Defective Drainage relaid in part 20 „ ,, throughout 59 ,, house drains unstopped and repaired 94 House-refuse receptacles provided 16 Scullery and Bath wastes disconnected from drains 17 New pans and traps provided to closets 49 Water cisterns repaired and cleansed 7 Ventilation shafts repaired, and drains ventilated 56 Water supply to closets reinstated 18 Manure receptacles provided and reconstructed 11 Insanitary premises cleansed throughout 17 Water supply to houses reinstated 8 Houses declared unfit for Human habitation 9 Although trouble was experienced in getting owners to comply with notices served to abate nuisances, mostly due to defective drains, it was not found necessary to resort to legal proceedings in any instance. Six houses in Hookers Place were condemned as unfit for human habitation, owing to their being in a bad state of repair, and sanitary conveniences inadequate; a report was 17 submitted by the Medical Officer of Health and myself as to the necessary repairs &c. to be carried out, to put such houses into a habitable condition; these repairs &c. were carried out by the owner, and the houses were then allowed to be occupied. Two cottages at Botany Bay were condemned and closed permanently. PERIODICAL INSPECTION. The Dairies, Bakehouses, and Slaughter Houses, have been regularly inspected, and kept in a satisfactory condition, and all lime-washed at the regular periods and whenever found necessary. One Bakehouse has been discontinued for use as such. One entirely repaired throughout, and in five other instances, minor sanitary defects existed. Three applications were received during the year for registration under the Dairies and Cowsheds order in respect of new premises, viz: 59, Mason's Hill, as Purveyor of milk. 14, Mason's Hill, ,, ,, ,, 2, Skym Corner, Purveyor and Cowkeeper. The application was granted in each case, the premises being satisfactory. Three applications were made in respect of premises already registered, but in which there had been a change of ownership. These applications were granted. There are at present in the District: Slaughter houses 12 Bakehouses 16 Dairies, Cowsheds, &c. 33 18 The Market has been regularly inspected, and various samples taken from the Vendors during the year and submitted to the Public Analyst, but none were certified to be adulterated. INFECTIOUS DISEASES. One hundred and seventy-six cases of Infectious diseases have been reported during the past year, as compared with 231 cases in 1897. The 176 cases occurred in 140 houses, 121 were removed to the Infectious Hospital, the remaining 55 were treated in their own homes. Two cases, viz: Diphtheria, occurred amongst the Staff at the Infectious Hospital, which is situate in this district. There is a large diminution in the number of cases of Scarlet fever, as compared with the previous year, but the number of cases of Typhoid fever is more than has occurred in recent years, yet several of them were evidently contracted outside the district. The drains of the houses where typhoid existed, and also the sewer receiving these drains were carefully and thoroughly flushed two or three times a week with Perchloride of Mercury. The number of cases of each disease as compared with 1896 and 1897, is as follows: 1896 1897 1898 Diphtheria 11 19 33 Scarlet fever 60 192 110 Erysipelas 20 14 15 Puerperal Septicaemia 2 3 1 Enteric fever 9 3 J7 19 The number of cases in each quarter compared with 1897:— 1st quarter. 2nd quarter. 3rd quarter. 4th quarter. 1897. 104 32 19 76 1898. 28 51 29 68 The number of rooms disinfected, cleansed, &c. 179 The number of articles treated in disinfector 1004 Towards the close of the year a number of cases of Scarlet Fever occurred in the Mason's Hill, Newbury and Aylesbury Roads portion of the district, they were evidently contracted from two or three cases of a mild character which had not come under medical treatment, and were attending school; the schools in this district were closed and every room thoroughly disinfected, and all the slates treated with Carbolic acid and afterwards thoroughly washed with scalding water and soap. Where cases of Typhoid occurred the premises and drains were carefully examined and sanitary defects, where found, remedied; in five instances the drains were found to be very defective and were entirely relaid, in 6 houses no defects could be found, the drains in most of them being new and recently laid. In connection with the cases of Diphtheria, since September last in most cases of suspected throat illness swabs have been submitted to the Clinical Research Association, for bacteriological examination, and the result communicated to the medical practitioner in each case before the notification was sent in. 20 FOOD AND DRUGS ACTS. During the year 49 samples of food were taken and submitted to the Public Analyst for analysis, viz.: Milk 22 Rum 3 Butter 14 Gin 3 Bread 2 Coffee 3 Lard 2 Of this number two were certified to be adulterated, viz. : two samples of milk. i. 38% added water—convicted and fined 10/- and costs. ii. 23% added water—convicted and fined £2, 14/- costs 10/6 Analyst's fee. Several other samples of milk during the year, were certified to be of poor quality, but owing to the low standard adopted by Somerset House, certificates of adulteration were not given. All the samples of butter were certified to be pure and of good quality. PETROLEUM ACTS. The various stores of those licensed have been inspected from time to time and samples taken and tested. Samples have also been taken of oils offered for sale by itinerant vendors; in no case was any oil found to flash below the legal limit which is a low one, viz.: 73 degrees. Number of renewal of licenses, 9. FACTORY and WORKSHOPS ACTS. The workshops and laundries have been frequently inspected, as to overcrowding and sanitary condition. 21 One laundry was found to have insufficient water-closet accommodation, and was also overcrowded. Six notices were received in accordance with Sec. 26, Sub-Sec. 2, Factory and Workshops Act, 1891, and Sec. 41, 1895, viz: commencement to use premises as a workshop. These were inspected, the number of workers, &c. fixed and particulars entered on the Register. OTHER NUISANCES. Accumulation of trade refuse and manure 35 Animals kept uncleanly 5 Overcrowded premises (cases abated) 11 Overflowing cesspool and pollution of stream 1 Removal of house refuse (complaints attended to) 21 Overflow of cesspool disconnected from ditches 2 It was found necessary to take legal proceedings to abate the nuisance from overflowing cesspool, which was polluting the stream. The defendant was convicted and fined 20/- and costs. Very few complaints have been made of offensive smells from sewer manholes, and wherever such existed the Sanitary Committee took immediate steps to abate the nuisance. HOUSE TO HOUSE INSPECTION. 275 Houses were inspected under this head during the year, to this number 45 must be added, as representing the number dealt with, these being inspected the end of December in the previous year, but the notices served and the work carried out in January of 1898. 22 Very great difficulty was experienced with several owners of property to carry out the work, and legal proceedings had to be threatened in several instances, causing often a delay of several weeks in getting the work carried out. SUMMARY. No of Houses inspected and drains tested 275 ,, House drains relaid in entirety 16 ,, ,, ,, ,, partially 34 ,, Ventilating shafts, &c. repaired 20 ,, Flushing apparatus provided 39 ,, Sanitary dust receptacles provided 47 ,, Dangerous dilapidations remedied 2 ,, Water cisterns repaired and cleansed 14 ,, Damp walls, ceilings, &c., cleansed and repaired 26 ,, Insanitary dwelling houses cleansed throughout 16 ,, Roof and waste water pipes disconnected from drains 12 ,, W.C's, and traps renewed 35 „ Drains unstopped 8 I am, Gentlemen, Your obedient servant, MATTHEW BATES, Sanitary Inspector. To the Chairman and Members of the Urban District Council of Bromley, Kent. January, 1899.