BRO 64 Borough of Bromley THE ANNUAL REPORT on the HEALTH and SANITARY CONDITION of the BOROUGH, FOR THE YEAR 1905, by ARTHUR F.G. CODD, m.b., f.r.c.s., san. sci. cert., MEDICAL OFFICER OF HEALTH. Bromley, Rent. Strong A- Sons, Ltd., 39, East Street. 1906. Borough of Bromley. REPORT OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR, 1905. To the Mayor and Corporation of Bromley. March 27th, 1906. Gentlemen, I have the honour to present to you my Seventeenth Annual Report relating to the year ended December 31st, 1905. VITAL STATISTICS. For the purposes of statistics the population is always calculated for the middle of the year. At the census taken April 1st, 1901, our population was .27,354, being an increase since the previous census of 5,669. On the supposition that the rate of increase has been maintained, the population in the middle of 1905 may be approximately estimated at 29,788. 4 The Borough comprises 4,706 acres, having a population of 6.3 persons to the acre. BIRTHS. The births during the year were 707, of which 379 were males and 328 were females. This gives a birth rate of 23.7 per 1,000, compared with a rate of 27.2 for England and Wales, and 28.3 for the Outer Ring of London. The mean birth rate for 10 years, 1895-1904, was 23.7, against 29.0 for England and Wales in the same period. 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. Our birth rate is the same as the mean for the last ten years, but it is very low. This is partly to be explained by the fact that Bromley is a residential locality where large numbers of unmarried servants are employed, and that many of the residents are of middle age, having moved out here from the districts nearer London, in which the earlier and reproductive years of their married life were spent. 21 illegitimate births were registered, i.e., 2.9 per cent, of the total number of births. This includes 7 births in the Union. MARRIAGES. During the year there were registered 217 marriages, of which number:— 5 132 took place in churches of the Established Church. 17 took place in Nonconformist Churches and the Roman Catholic Church. 68 took place in the Superintendent Registrar's Office. The marriage rate for Bromley was therefore 14.5. The rate for England and Wales for the year ending September 30th was 15.1. The mean marriage rate in Bromley for the 10 years, 1895-1904, was 17.9, against a mean rate in England and Wales for the same years of 15.8. DEATHS. The number of deaths registered in the Borough was 253. To this number must be added the deaths of 34 Bromley persons which occurred in our Union Infirmary, which is outside the district, and 9 must be deducted which occurred in the Infectious Hospital and local institutions, these persons not belonging to the district. There is no means of ascertaining the total number of Bromley residents who may have died away from the district. We have thus a total of 278 deaths, of which 138 were males and 140 were females, which is equal to a recorded death rate of 9.33 per 1,000. The death rate for England and Wales was 15.2, and for the Outer Ring of London 11.8. The mean death rate for 10 years, 1895-1904, in Bromley was 11.2. 6 Years. Death Rate. 1895 112 1896 11.8 1897 10.4 1898 11.9 1899 12.5 1900 11.8 1901 11.3 1902 10.8 1903 10.7 1904 10.4 The mean of the death rates in the 10 years prior to the above was higher than that for the years 1895-1904. Up to and including the year 1900 I have corrected the death rates to correspond with the census returns of population, and for these years the death rates are absolutely correct. Since that year the death rates have been computed on an approximate estimation of the population, and will be subject to revision after the census of 1911. There is good reason to believe from a comparison of the figures in the Building Register that since the last census our population has increased in a larger ratio than in the intercensal period 1891-1901, but as on that basis there are variations from year to year and more room for error, I have preferred to keep to the old method and a low estimate, which has the advantage at least of not making our statistics appear better than they are in reality. In 1904 our death rate was 10.4. This year it is 9.3 per 1,000, the lowest death rate for more than 20 years, and probably the lowest ever recorded in this district. 7 The excess of births over deaths was 429, being a natural increase in the population of 14.4 per 1,000. The number of deaths in the various wards of the Borough was as follows:— Town Ward 53 Plaistow Ward 41 Bickley Ward 32 Sundridge Ward 43 Martin's Hill Ward 41 Bromley Common Ward, No. 1 56 Bromley Common Ward, No. 2 12 278 Owing to building having taken place during the last few years, much more rapidly in some wards compared with others, I have been unable to estimate the population, and therefore the death rates in the respective wards. The age periods were as follows:— Under 1 year, 43. Over 1 year and below 5 years, 16. Over 5 years and below 15 years, 17. Over 15 years and below 25 years, 9. Over 25 years and below 65 years, 96. Over 65 years, 97. One man reached the age of 91 years. Deaths under 5 years of age, 59. Deaths over 5 years of age, 219. 8 INFANT MORTALITY. The proportion of deaths under one year of age to registered births (i.e., the Infant Mortality) was 60.8 per 1,000, compared with 128 per 1,000 for England and Wales. DEATHS FROM ZYMOTIC DISEASES. The deaths from all causes included:— Rate per 1000 Bromley. England and Wales. From Scarlet Fever 2 .06 .11 „ Whooping Cough 5 .16 .25 „ Diarrhoea 8 .26 .59 „ Diphtheria 10 .33 .16 There were no deaths from smallpox, enteric fever or measles. Thus 25 deaths were attributed to these principal zymotic diseases, being at the rate of .83 per 1,000, compared with a rate of 1.52 for England and Wales, and 1.53 for the Outer Ring of London. Mean of 10 years. Death Rate Zymotic Death Hate. 1885-1894 13.0 1.53 1895-1904 11.2 1.52 Generally speaking, the effects of sanitary improvements and precautionary methods are best indicated by a lower death rate from Infectious Diseases, Fever, Diarrhœa, Consumption, and amongst children under 5 years of age from all causes. I therefore show these rates in Bromley during the last 10 years. 9 Death Rate from certain diseases in Bromley during the last 10 years. 1896 1897 1898 1899 1900 1901 1902 1903 1904 1905 Infectious Diseases 2.50 1.18 2 20 2.54 1.52 .90 .85 1.32 1.40 .83 Fever .04 .03 .07 .07 .03 .10 .03 .06 .06 .00 Diarrhoea .39 .66 1.40 1.77 .54 .50 .82 .83 .82 .26 Consumption .91 .81 .71 .96 .72 .90 .74 .45 .51 .65 Children under 5 years of age, from all causes 4.6 3.2 5.0 4.3 3.4 3.3 3.16 4.08 3.79 1.9 JOINT ISOLATION HOSPITAL—accommodation 113 Beds. Districts. Population, 1901 Census. Admissions. deaths Scarlet Fever. Diphtheria. Enteric. Smallpox. Scarlet Fever. Diphtheria. Enteric. SmallPox. Bromley Borough 27.354 63 61 .. 1 1 8 .. .. Beckenham Urban 26,330 43 46 4 .. 1 1 .. .. Chislehurst Urban 7,429 23 8 .. .. .. .. .. .. Bromley Rural 24,636 16 22 3 .. .. .. .. .. Foot's Cray Urban 3,487 13 5 .. .. .. .. .. .. 10 INFECTIOUS DISEASES. Under the Infectious Diseases (Notification) Act, 180 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:— 1901 1902 1903 1904 1905 Scarlet Fever 58 52 39 31 80 Diphtheria 36 38 9 13 74 Erysipelas 21 29 21 24 20 Enteric Fever 8 8 2 9 3 Puerperal Fever 1 1 3 1 2 Small-pox 10 25 2 0 1 Of the 180 cases, 124 were removed to the Isolation Hospital, the case of Small-pox was removed to the Cheam Small-pox Hospital, and 55 were treated in their own homes. The 180 cases occurred in 141 houses. The following table shows the time of occurrence of the infectious cases:— Month. Jan. Feb. Mar. April. May. June. July. Aug. Sept. Oct. Nov. Dec. Total. Scarlet Fever 3 10 12 8 8 6 7 3 5 3 7 8 80 Diphtheria 2 3 2 1 3 7 7 2 13 18 11 5 74 Enteric - - - - 1 - 1 - - - 1 - 3 Puerperal Fever - - - - 1 - - - 1 - - - 2 Erysipelas 2 3 3 - - - 2 1 3 1 1 4 20 Small Pox - - - 1 - - - - - - - - 1 7 16 17 10 13 13 17 6 22 22 20 17 180 11 SCARLET FEVER. Average number of cases each year during the last 10 years, 1895-1904, equals 78.8 cases. 80 cases were notified during the year, of which 64 were removed to the Isolation Hospital and the others were treated in their own homes. The disease was of a mild type, there being only two deaths. As regards distribution, about 77 per cent. of the cases occurred in the houses of the working classes. The districts most affected were (1) the streets leading off Bromley Common, in St. Luke's Parish, and (2) the streets in the neighbourhood of Farwig Lane, in St. Mary's Parish. The cases were fairly evenly distributed throughout the year, and were not traced to milk supply or widespread infection at school, although in our routine enquiries special attention is always directed to these common sources of infection. Many of the cases were multiple, i.e., 11 houses contributed no less than 32 cases; 5 cases at the same time were notified from one house. The others were single cases. It seems to be not generally known that Scarlet Fever is as infectious in the earlier as in the later stages when the skin is disquamating. The experience of the last few years has shown indeed that the inflamed condition of the mucous membrane of the throat, nose and mouth, which is often present during the whole course of the disease, is a more 12 potent source of infection than the dead particles of shed skin. A discharge from the ear is known to be infectious, and latterly carious teeth have been suspected of harbouring the germs of the disease. Notwithstanding all the precautions which Dr. Shannon takes at our Isolation Hospital, we had two "return" cases in one family. It is interesting to note that our systematic enquiries in each case very rarely show the disease to have been carried indirectly by clothing or toy a second person. It should toe borne in mind that the Scarlet Fever poison may have in some people no other effect than to produce a slight sore throat, and this being unrecognised, but nevertheless infectious, may lead one to suppose that infection has been carried indirectly in the clothing or by the hands, whereas in fact it may be a case of direct infection. Two of our cases were clearly proved to have been contracted in this manner. In no instance was there reason to suspect that a medical man had carried the disease from one patient to another, although 16 cases were treated in their own homes. DIPHTHERIA. Average number of cases each year during the last 10 years, 1895-1904 = 24.5 cases. 74 cases were notified. 60 were removed to the Infectious Hospital and the others were treated at home. All except six of the cases occurred in the homes of the working class. 13 The areas round Bromley South Station, Mason's Hill, Havelock and Chatterton roads were the parts of the district chiefly affected, St. Luke's Parish having more than its proportionate share of the cases. More than half of the total cases were reported in the months of September, October and November. During the first half of the year we had no undue prevalence of diphtheria, but in June and July a rather larger number of cases were notified than is usual. Several of the children attended the Addison Road and the Widmore Schools. In August, probably owing to the holidays, only 2 cases occurred. About the middle of September cases of diphtheria were notified in rapid succession, and as many of the children had been attending the Mason's Hill Infant School, this school was closed from September 25th for three weeks. This measure had the effect of checking the disease to some extent, but in November cases were notified in other parts of the town, especially among children attending the Raglan Road School. As the number of children attacked was small in proportion to the total number on the roll of this school, which accommodates over 1,000 scholars, it was decided not to advise the closure of the school, but to trust to the usual preventive measures. This seemed to be effectual as regards this school, but cases were still notified in other parts of the Borough. These shortly diminished, and in December only 5 cases were reported. During the New Year the number of cases notified has been above the average, but on the whole 14 the disease shows a distinct decline. The outbreak caused a good deal of anxiety and work to your officials. At one time as it was not clear that school influence was the sole cause at work, and as we could not trace the infection to the milk of any particular vendor, a systematic enquiry was made as to the sources from which the vendors obtained their wholesale supplies. Each vendor as a rule gets his milk from three or four sources, and as it is not always mixed 'before distribution, it became necessary to go further back and obtain information with regard to these. A list was compiled to ascertain whether there was any overlapping, but it was found that there was none, and we came to the conclusion that the disease was not being spread by milk. Later on evidence was obtained showing that many of the children throughout the district were suffering from slight sore throat, and I have no doubt that the infection beginning in the school was afterwards sown broadcast in the district by these children whose brothers and sisters often attended other schools. It is well recognized that both diphtheria and scarlet fever are often propagated in this manner, and that when diphtheria is in a school, the specific organism of the disease may be demonstrated to exist even in the throats of children who are apparently in good health. School influence, direct or indirect, would not account for some of the cases, but experience shows that we have still a good deal to learn as to the occurrence of this sporadic form of the disease. 15 16 of the cases were multiple, i.e., they occurred in 7 houses. The remainder were single cases. In two instances diphtheria recurred in the houses towhich patients had some time before returned from the Hospital; in one after an interval of 17, and in the other after an interval of 36 days. Knowing as we do, how infection clings in some cases, it is possible that these were instances of re-infection, although Dr. Shannon never discharges a patient until two swabs, taken at an interval of a week, have both been reported as free from the specific organism. There were 10 deaths, showing a mortality of 13.5 per cent. There was no means of knowing to what extent and at what stage, if any, the anti-toxine serum was used. If opportunities were given for the medical attendant to use this remedy at an early stage, the disease should show a lower mortality than this. 57 swabs were submitted to the Clinical Research Association, and specific organisms were reported to be present in 30 instances. Failure to find the specific organism at the first examination is not accepted as definite proof that the disease is not diphtheria. SMALL-POX. One case of this disease occurred. The patient, a married man with a family, was thought to have been exposed to infection when visiting Deptford on April 14th. He was removed to the Cheam Small-pox Hospital, where accommodation is specially reserved until our new hospital 16 is ready. The house (a general dealer's shop, etc.) was closed by arrangement for 4 days, and the family was lodged in our temporary shelter, while the Council's Officers carried out a thorough cleansing and disinfection. The walls were stripped and distempered, and a considerable quantity of miscellaneous goods was burned in the Destructor. Although further cases were looked for among the numerous people who had visited the shop during the incubation period, none occurred. ENTERIC FEVER. Average number of cases each year during the last 10 years, 1895-1904 = 7.6 cases. Three cases were notified. There were no deaths. There was good reason to believe that infection in each case was contracted outside the district. Tests showed no sanitary defects in the premises. One of the cases was suspected to be due to eating oysters. INFANTILE MORTALITY. Our infantile mortality was exceptionally low last year. Of the 43 deaths under 1 year of age, the causes were as follows :— Infectious Diseases (Whooping Cough) 5 Diarrhoeal Diseases 7 Wasting Diseases 19 . Tuberculosis Diseases 2 Other causes 10 43 17 The deaths from diarrhœal diseases which is the heaviest item in our infantile mortality as a rule, were comparatively few last year, probably owing to the fact that in the middle of the month, when diarrhoea appears with great regularity, the weather was cooler than usual and the rainfall was good viz., 2½ inches for the month. With regard to this subject, evidence is accumulating to show that the common house-fly plays an important role in the causation of diarrhoea. Carrying germ laden filth on its proboscis and legs it contaminates the milk or other food of the children, and in milk it is well known that germs multiply with extraordinary rapidity especially at a warm temperature. It is not generally known that the breeding place of the house-fly is manure, especially horse-manure. This points to the necessity of enforcing, especially in the summer months, the regulation which requires that manure pits shall be emptied once a week and be kept properly covered. The influence of diarrhœa as one of the most important factors in our infant mortality has been dwelt upon fully in past reports, but there are many other causes from which large numbers of infants die every year. A large proportion of them are preventable and the children's lives could have been saved by attention on the part of the parents to the elementary principles of the laws of health. Many of the children who survive their illnesses suffer much in after life as a result of this neglect, growing up weakly and stunted. With the object of diminishing this mortality and physical deterioration, I wish to bring to the notice of the Council, 18 an excellent little booklet entitled, "How to Manage a Baby," which is published at the price of Id. I have spoken to Mr. Darby Jones, the Registrar of Births, who, if the Council agree to the proposal, has expressed his willingness to keep a supply of the booklets in his office, and hand a copy to each person of the poorer class registering a birth. This would be a very simple and practical method of putting' information at the right time in the hands of those who most require it. CONSUMPTION. In 1904 the Council adopted a system of Voluntary Notification of Consumption, and a register is now kept of the cases notified. The information given by the medical men of the district is private, and the action of the Sanitary Authority is only exercised in those cases in which through poverty or ignorance, it is considered that the health of others may be in risk. Up to the end of the year only 13 cases had been notified, but as there is reason to believe that many more cases than these exist, I recommend that the medical men shall be reminded every year of the arrangement to which they have agreed. During the year there were 20 deaths from consumption registered. Although this record is not so good as for the years 1903 and 1904, it is considerably below the mean of the preceding 10 years, 19 Eighty per cent. occurred among the poorer classes and of these (numbering 16) 4 occurred in the Workhouse Infirmary. Although consumption is diminishing year by year throughout the country, it is not being eradicated fast enough, and I pointed out in my report for 1903 the need there was for some form of Sanatorium treatment supported out of the rates, for the poorer classes. If the districts around Bromley were to combine, the scheme would undoubtedly greatly conduce to the public health and need not necessarily entail a very heavy expense. In considering the latter point it should be remembered that in most cases of consumption among the working classes, a large proportion of the expense has eventually to be borne either by private individuals in the shape of charity, or by the ratepayers in the form of poor relief. The accommodation for poor consumptives is utterly inadequate to their needs, and it is not fitting that the task of coping with this difficulty should be left to private benevolence. OTHER CAUSES OF DEATH. Among the other causes of death, the following were the most numerous:— Heart diseases 36 Cancer 34 Diseases of the respiratory organs 26 Cerebral Haemorrhage (apoplexy) 16 Diseases of the digestive organs 15 20 Tuberculosis diseases (other than Consumption) 15 Diseases of the urinary organs 12 Accident 9 Diseases of the nervous system 7 Alcoholism 4 Influenza 3 Old age, and its complications, was the cause of 20 deaths. The four deaths from alcoholism represent only the worst cases. Many of the other diseases were no doubt directly caused or influenced by over indulgence in alcohol. MILK SUPPLY. The Veterinary Inspector, Mr. A. W. Reid, F.R.C.V.S., made his quarterly reports on the condition of the cows in the district, and it is evident that they serve a very useful purpose. In the first report, on one farm the cows were stated to be "mostly indifferent animals," but none could be pointed out as being actually diseased. In the second report, no case could be discovered of inflammation of the udder which could be recognized as of tubercular origin. In the third report 17 cows were found to be suffering from inflammation of the udder affecting the milk. In the fourth report 3 cows were found to be suffering in the same manner. The respective owners were at once written to by the Council, calling attention to the fact, and assurances were obtained that the milk from these cows would not be used as food. 21 Although under the regulations of the Dairies, Cowsheds, and Milk Shops Order, the Council compels those who are in charge of the cows and milk supply in the districts to have everything necessary for a pure and wholesome supply, it is found impossible in practice to enforce strict cleanliness, either during the milking or afterwards in the cooling and distribution of the milk. One has only to examine the sediment in the bottom of a tumbler of milk to see how much dirt it contains. This dirt is teeming with germs which speedily cause putrefactive changes in the milk. Such milk has to be given to children and invalids, often with disastrous results. A company which would establish a model farm where the strictest cleanliness was enforced, in a residential district like this, would be able to charge more for their milk, and would certainly receive the support of scores of families who, to my knowledge, are seeking for pure milk, but cannot get it. The expensively fitted shop means money spent at the wrong end. 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 1.00 July .75 February .83 August 2.46 March 3.29 September 1.86 April 1.29 October 1.12 May 1.42 November .66 June 6.52 December .53 22 Total local rainfall, 25.36 inches. Total Greenwich rainfall, 23.03 inches. Observations extending over many years show that our mean annual rainfall is nearly two inches more than that of Greenwich. WATER SUPPLY. The quarterly reports of the bacteriological examination of the water were quite satisfactory. The water supplied to the Borough is the purest of any under the Metropolitan Water Board, and is taken as the standard with which the supplies of all the other districts under the Board's control are compared. The Board has lately appointed a director of water examinations who proposes to issue monthly reports of the analysis and bacteriological tests of the water supply of the metropolis. Although quite satisfied as to the purity, we have much to complain of in the hardness of the water. I often receive enquiries from those who are considering Bromley with a view to residence, and am frequently asked as to the character of the water. With many, the hard water is considered a great objection, and I have no doubt that as a residential suburb Bromley suffers on this account. If it is possible for the Council to do anything in the matter by petition or otherwise to the Metropolitan Water Board, I trust they will do so without delay. 28 HOUSE ACCOMMODATION. 79 plans were deposited for the erection of 272 houses 14 plans were deposited for 14 additions, 34 plans were deposited for 34 drainage relays. MEDICAL INSPECTION OF SCHOOLS. I think the time has come for the Council to consider the question of the medical inspection of the elementary schools under their charge. The subject is a large and important one, for it concerns not only the efficient working of the schools, but the health of the general community of the district. Much could be done by frequent medical inspection to check the spread of infectious diseases before they assume an epidemic form, and by the routine periodical examination of all children, physical defects could be discovered, and in many cases remedied; thus securing a better physique and more satisfactory results from the point of view of the teacher. At present the responsibility thrown upon the teacher of excluding from school any children suspected of having any of the diseases, such as Measles, Whooping Cough, Chicken Pox, or Mumps which cause so much loss in school attendance, is too great, and calls for a larger amount of independence of judgment and medical knowledge than can reasonably be expected. In my opinion in addition to the general supervision which so far 1 have exercised as Medical Officer of Health, there should be some provision made by which in certain areas the services of a local practitioner would be available either 24 on occasion when needed, or, preferably, every morning by attendance at the school within certain hours. The salary could be proportionate to the number of children on the roll of the school or schools in his charge. The question of the expense is an important one, but it must be borne in mind that infectious and contagious diseases cost every year a loss in the grant, that every case of infectious disease removed to the Infectious Hospital has to be maintained and paid for out of the rates, and that the interference with the education of the children due to the exclusion not only of the infected child, but often also of his brothers and sisters is considerable. Moreover, regular inspections would enable us to a great extent to dispense with the closing of the schools by sifting out at the earliest possible time, those cases which were in any way suspicious. The prevalence of Diphtheria during the past year has been a good object lesson in this respect. There are over 4,500 children on the rolls of the Borough elementary schools, and a certain proportion of these children are not in a fit state to receive the full benefit of the instruction given owing to defective vision, deafness, ill health or physical deformity. From ignorance or neglect on the part of the parents these defects are often not attended to, but a routine examination of each child at fixed intervals would reveal these cases and something could be done by calling the parents' attention to the fact to get their condition improved, or to make special arrangement for them in classes, 25 Special measures have already been adopted for the care and teaching of backward and mentally defective children. Although on the Continent and in America, for some years, the regular medical inspection of the public schools has been in force, in England the subject has only lately received serious attention, and comparatively few districts have adopted it; but the movement in its favour is rapidly growing and soon will no doubt be general. If it is acknowledged to be necessary, the attendant expense should not stand in the way of its adoption. Mr. Wall, the Clerk to the Education Committee, has kindly supplied me with a table of the number of children on the books of the public elementary schools in the Borough during March, 1906 Boys. Girls. Infants Total. Holy Trinity 150 Mixed 57 207 Addison Road — 115 110 225 Raglan Road 251 231 268 1055 „ 280 Juniors „ 25 Special Class Widmore 163 139 217 519 Wharton Road 157 240 127 524 Mason's Hill — 200 131 331 Aylesbury Road 174 — — 174 Bromley National 273 259 141 673 Plastow 118 — 92 210 Valley 199 276 188 663 4581 26 PHYSICAL DETERIORATION. At the end of the year the Council had under consideration the placard prepared by the Metropolitan Borough of Camberwell, with respect to Physical Deterioration and Alcoholism, together with the effects of juvenile smoking. There was a feeling in favour of making use of similar posters in this Borough, but some opposition was experienced owing to the doubt whether this measure came within the province of the Council. After much discussion the matter has been droooed for the present, but I hope that should it come up again the proposition will receive good support. It seems to me that such a measure, taken for the improvement of the general health of the community concerns the Council quite as much as the measures taken for the prevention of Tuberculosis or Diarrhoea. The posters deal not with the use of alcohol, but with its abuse, and cannot be reasonably construed as an interference with the lawful trade of the Licensed Victuallers, many of whom I am convinced would not wish to oppose a measure which attacks only the evils induced by the excessive use of alcohol. SANITARY WORK, NUISANCES, ETC. In the course of the year many sanitary matters mostly connected with nuisances of various kinds were brought to my notice, and were dealt with in the usual manner. A record of these will be found in the report of the Sanitary Inspector. 27 Sundridge Hall Farm and Hook Farm were specially inspected and reported upon. Considerable difficulty was experienced in getting the necessary alterations carried out in accordance with our regulations, but the work was eventually done to the satisfaction of the Council. At the beginning of the year the closet accommodation at the Bromley National Schools was found to be defective and insanitary. Steps were at once taken to minimise the evil, and during the Easter holidays the old iron open trough closets in each department (boys, girls, and infants) were replaced by modern white glazed stoneware closets of the isolated type, with syphon.ic action and automatic flushing cisterns. At the end of June it became necessary to close the Addison Road Schools, as it was found that the drains had becomc choked, and were leaking badly, and the trough closets were defective. As the whole system was bad and beyond repair, the Council caused the drainage to be entirely reconstructed on modern lines with new isolated pedestal closets, automatically flushed. The work was carried out before the re-opening in August. During the closure of the Mason's Hill (Infants) School in September, owing to the outbreak of Diphtheria, they were thoroughly cleansed and disinfected. Several letters were reoei-ved from ratepayers asking for a bi-weekly collection of house refuse, but the Council did not see their way to accede to the request. 28 THE REFUSE DESTRUCTOR. During the year there were frequent complaints of smells alleged to be due to the Refuse Destructor. At one time it was not working well, partly due to some temporary defect and partly to the large amount of house refuse which had become sodden with rain owing to the dust-bins being left uncovered. This was remedied, but later on fresh complaints came in, and in consequence the patentees were communicated with. Their representative made an inspection and reported that the smell complained of came from the neighbouring gasworks, and from the brickfields, where London refuse was being burned. As the complaints still continued, at the end of October, in company with the Mayor and the members of the Health Committee, 1 made an inspection of the brickfields and presented a report on the subject, in which I stated that the burning ballast and brick clamps undoubtedly gave off unpleasant effluvia, but it was difficult to be absolutely certain of the origin of the smells complained of, as the gasworks, brickfields, and refuse destructor were all in one area. As the gases given off from heated masses at first rise upward, they may not be very perceptible to anyone standing in close proximity, but as they are carried away by the wind, become cooled, and fall downwards at some distance from their place of origin, they may cause serious nuisance. In such cases there is great difficulty in localizing their exact origin. I saw no refuse deposited in the brickfields which could cause offensive emanations appreciable at a distance, except that which was undergoing combustion, 29 Since November there has been no serious complaint with regard to the refuse destructor. The Kent County Council have entered into an agreement with the Bromley Corporation whereby by payment of a small sum annually the carcases of stray dogs are allowed to be cremated in the destructor, but it was decided not to give permission for the use of the destructor to cremate the carcases of larger animals which have died of infectious diseases, such as anthrax, etc. The question whether the collection of trade refuse should be made without charge is still under consideration. We still receive occasional complaint of the smoke from the shaft of the Electric Light Works. The underground Bakehouse at 6, Cherry Orchard Road, after considerable alteration was inspected and approved. There were very few complaints of sewer smells during the year. There is a great need for public conveniences in various parts of the town, and for a public swimming bath. It would be a boon to invalids and aged and infirm persons if garden seats were to be placed in a few of the most suitable places in the district. FACTORY AND WORKSHOP ACT, 1901. The Medical Officer of Health is required to report annually to the Secretary of State and the Council, specifically on the administration of this Act in the Borough, so far as relates to workshops and workplaces. 30 Such matters arising out of inspections, requiring report by the Sanitary Officers, are dealt with by the Health Committee. Each report is entered against the respective premises in the Register, which discloses the results of any action taken in relation to the various matters reported on. There are 196 workshops on the Register besides certain "Factories" briefly summarised as follows:— Workshops. Approximate No. of Workers. Factories. Approximate. No. of Workers. Bakehouses 22 60 1 About 500. Dressmakers 52 280 Tailors 16 43 Bootmakers 15 30 2 Laundresses and Cleaners 27 228 14 Miscellaneous 64 222 24 Totals 196 863 41 500 Total Premises, 237. Total Workers, 1363 (approximately). In respect of the 41 "Factories" (where other than manual power is used) known and registered, for which H.M. Inspectors are responsible for many sanitary matters, the Council's Officers only inspect when necessary on complaint, or in relation to various other powers vested in the Council, 31 494 inspections have been recorded in the year, but this does not include many casual visits, which it is difficult to keep an account of. Comparatively few matters have called for report, owing' to the fact that many defects in the existing workshops having been remedied since the new Act of 1901 came into force. The following is an example of the defects remedied to comply with notices served :— Overcrowding abated 2 Workshops cleansed and whitewashed 20 Drains repaired 3 Drains unstopped 2 W.C's repaired, improved, etc 13 Soil pipe and drain ventilator repaired 1 Floor drainage provided to laundry 1 Workshops ventilated 3 Additional W.C. provided 1 Very little Infectious Disease was found to occur among the workers of the various premises, but in a few instances such cases were notified from small Cottage laundries, and all necessary steps were taken to prevent infection being conveyed from such laundries in the wearing apparel and house linen belonging to various householders. It is also found that where infectious diseases existed in private houses, there was little evidence to suppose that infection was conveyed to, or through, the laundries, through any laxity o» the part of Nurses and others responsible for disinfecting the bed-linen etc., from patients under their charge. 32 OUTWORKERS AND HOMEWORK. Of the lists of Outworkers supplied half-yearly, 51 persons were found to take work to their own premises (wearing apparel, etc.), many living outside the district, of which the various Sanitary Authorities were duly notified. 20 of such Outworkers were registered as homeworkers residing within the district, and their home workrooms inspected at various times, as to the different sanitary precautions required by the Act to be observed, in respect of the articles made or altered therein. BAKEHOUSES. One underground Bakehouse was granted a certificate under the 101st Section in June, such having been previously withheld in consequence of the alterations required by the Council not hav.ing been completed to the satisfaction of the Medical Officer of Health. The four such Bakehouses in the district have been in existence for many years, and are fortunately situated, so that after the improvements obtained under the Section, in the ligliting, ventilation, construction and sanitary matters, they will rank by no means lowest among the 22 Bakehouses in the Borough, as to their sanitation and good condition. The limewashing and cleansing of all the Bakehouses have been attended to at the required times, special halfyearly and other casual inspections being made to see that the requirements of the Act were being observed. In conclusion, the report for the year 1905 is, on the whole, not entirely satisfactory. 33 Although the death rate of 9.3 is the lowest ever recorded In Bromley, it must be remembered also that the general death rate in England and Wales was lower than that of any other year on record. Our chief gains were the lower mortalities from Diarrhœa and Whooping Cough and the absence of any mortality from Measles, while the chief loss was in the higher mortality from Diphtheria. But the death rate is not absolutely a criterion as to the general health of a district. There can be no doubt that the disease rate as shown by the Notification of Infectious Diseases was much higher than usual, the most unsatisfactory items being the increased number of cases of Scarlet Fever and Diphtheria. Although by the adoption of stricter preventive measures in checking the spread of these diseases by school influence we may hope to show an improvement in our disease rate, we can hardly look for a much lower death rate than that recorded in 1905. The work of Mr. Butler, your Sanitary Inspector, and his assistants, so far as it deals with the work under my supervision, has been most thoroughly and ably carried out. Appended is the report of the Sanitary Inspector showing in detail the sanitary work executed during the year. I am, Gentlemen, Your obedient servant, ARTHUR F. G. CODD, Medical Officer of Health. Borough of Bromlen. Annual Report of Sanitary Inspector for Year 1905. To the Chairman and Members of the Health Committee. 27th March, 1906. Gentlemen, I have the honour to submit the customary Annual Report of the various matters dealt with by the Sanitary Department during- the past year, and, in doing so, beg to remind you that the following are the principal branches of the work, by which it is endeavoured as far as possible to meet the needs of the district. Complaint Inspections (on any information of Nuisance). House-to-house Inspection (of Cottage Property). Cottage Visitation (of Cottage Property). Inspection of Premises (on occurrence of Infectious Disease). Inspection of Dairies, Cowsheds and Milk Stores. Inspection of Workshops, Factories and Workplaces. Inspection of Slaughter Houses. 36 Inspection of Schools. Inspection of " Petroleum " Stores. Inspection of Food, Water, etc. SUMMARY OF NUISANCES ABATED. The following table gives an idea of the works carried out, In consequence of the varous notices authorized to be issued. The requirements of such notices have been so well attended to by the different persons on whom they were served, that no legal proceedings have been ordered by the Council in connection therewith. Premises inspected and reported on (re-visits excluded) 1252 House drains renewed entirely 41 Other drains renewed partially 80 Drains repaired (small items) 65 Drains unstopped only 59 Drain ventilators renewed, repaired etc 86 R.W.P's, waste pipes, etc., repaired or disconnected from drains 88 W.C.'s repaired (pans, traps, apparatus, etc.) 262 Sanitary dustbins provided 84 Overcrowding abated 5 Nuisances from animals abated 8 Houses where roofs, gutters, etc., were repaired to remedy damp walls, etc 83 Premises cleansed and whitewashed (wholly or partially) 37 Cisterns cleansed or repaired 12 37 Manure receptacles built, repaired, etc 10 Dangerous dilapidations remedied (floors, ceilings, etc.) 22 Cowsheds, Dairies, and Stables redrained, paved, etc 13 Offensive accumulations removed 27 COMPLAINT INSPECTIONS. Complaints were registered, alleging nuisances in respect of 211 premises. Each matter was promptly investigated and reported on in the Report Book (with all other matters requiring report or action), for consideration by the Health Committee, and for authority to serve the necessary notices, etc. The respective premises were afterwards revisited (often frequently), and kept under observation until the notices were satisfactorily complied with. HOUSE TO HOUSE INSPECTION. This branch of the work has not received so much attention as in previous years, only 280 cottages having been inspected. This is due to the transient shortness of staff, and to the increase of Infectious Disease work, for which less pressing duties are put aside. This is not a mere inspection only, but includes the testing of the drains of each house with the smoke machine, as well as investigation for other purposes. 38 The initial inspection takes but a small part of the time, much more time being occupied in getting the various items of the notices complied with, after such notices have been served. This work commenced in 1894, when the then Local Board resolved on a "House-to-House inspection of Cottage property in the district." Since that date very few can have escaped inspection, beyond those more recently erected, and many have been insipected on two or more occasions. There must be quite 3,000 such houses to be dealt with in this way, being occupied by weekly tenants at rentals of about eight to twelve shillings per week, a small proportion being from six to eight shillings. It is not possible to proceed with the work to any extent during the winter months, as the more serious nuisances would not be discovered, owing to the frost, etc., which interferes with the testing of drains or fittings, as well as the works of abatement. The nuisances most commonly found are defective w.c.'s, drain connections, and dustbins, leaky roofs, wet walls, etc. The percentage of defective drains is comparatively low compared with the earlier years, many of such drains having been repaired or renewed after former inspections. COTTAGE VISITATION. 241 other cottages have been dealt with under this inspection, which is practically a " house-to-house1 inspection " of cottage property, without the testing of the drains. It is found that it takes four or five years to get through all the 39 cottages (about 3,000) with the drain testing, and as there are numerous defects apparent on mere inspection only, these can be discovered and dealt with at times, when, for various reasons, it is inconvenient or impossible to test the drains. INFECTIOUS DISEASE (Notifiable). Of the number of cases notified (180), 125 were required to be removed to the Isolation Hospital, viz. :— Scarlet Fever 64 Diphtheria 60 Small Pox (to Cheam) 1 125 The remainder were isolated at their own homes, except two, which were notified when already inmates of Nursing Institutions. The patients' rooms are disinfected promptly on being vacated by formalin gas and spray, and, when necessary, the beddiing, etc., is disinfected in the Council's steam apparatus (Washington Lyon's patent). No. of rooms disinfected 267 Beds and other articles disinfected (by steam) 885 Articles destroyed by fire (bedding, garments, etc.) 135 In considering whether the infection is spread from insufficient disinfection, or neglect of other precautionary measures, I find the 180 cases occurred in 141 different houses, and in 75 different thoroughfares. 40 In 118 houses there was no spread of the disease, as a second case did not occur. In only 23 houses did more than one case occur, which is: due, in most instances, to two or more cases being notified from one house simultaneously, or following quickly, and being evidently contracted before the first case was discovered. DAIRIES, COWSHEDS, AND MILKSHOPS. There are 29 persons on the Register, carrying on businesses at 38 different premises. Of these, 13 keep cows within the district. The total number of milch cows kept by such persons is albout 320. A complete inspection is made of these premises at least twice a year, in addition to other casual inspections. Any breach of regulations, or matter requiring report, isdealt with in Report Book, and the number of report recorded against the premises in the Register. The 38 premises are all supplied with the Kent water, and 32 are drained to Council's sewers, the six other premises (where cows are kept) have cesspool drainage. Of the 38, 15 have had the drains constructed, or reconstructed, during recent years, and in 14 others the drains have been repaired or partially renewed, to remedy defects discovered from time to time. FACTORY AND WORKSHOP ACT, 1901. This branch of work involves the periodical inspection of some 240 premises, as to various sanitary matters, especially the cleanliness, lighting, ventilation, and air space for 41 the number of workers employed, also the state of the sanitary conveniences, and other duties to prevent the possible spread of infection in the workshops, or the homes of the workers, through the making, altering, or cleaning of wearing apparel, upholstery, etc. This subject is more fully dealt with in the Annual Report of the Medical Officer of Health, as required by the Statute. SLAUGHTER HOUSES. There are now nine registered or licensed slaughter-houses in the district, one being only a knacker's license. These slaughter houses are not much used, as the greater part of the meat sold in the town comes through London markets. All are inspected at various times, and kept in good condition. SCHOOL VISITATION. The ten Public Elementary Schools are visited on complaint, or under directions of the Medical Officer of Health, for the purpose of checking the spread of infectious diseases, by excluding scholars from infected houses. Special "Exclusion Notices" are sent to the head teacher and also the parent, and a "pressed" copy forwarded to the Clerk of the Education Committee. Such notices exclude children from particular houses for a specified time, according to the ascertained instructions of the Medical Officer of Health. One such school was entirely re-drained, and another provided with modern closets. 42 PETROLEUM STORES. For many years the Sanitary Inspector has been responsible for certain duties under the Petroleum Acts, and subsequent legislation, dealing with the safe keeping of substances included in the definitions of " Petroleum." Certain petroleum products which flash below 73 deg. Fahrenheit, and calcium carbide, can only be kept under license of the Council (who have certain regulations to safeguard the mode of storage, etc.), except in some instances where the regulations of the Secretary of State are substituted in favour of persons keeping the spirit in moderate quantities for private use only, such as for motor cars. Other petroleum, such as the oil sold for illuminating purposes, is subject to no license or condition, unless samples, which are taken from time to time and tested in the Council's apparatus (Abel test), are found to give off inflammable vapour below the 73 deg. This branch of the work is increasing considerably, owing to the growth of the motor car trade, the duties principally consisting of inspections to see that there are no infringements of the Petroleum Acts, Home Office Regulations, or the conditions printed on the licenses issued by the Council. At the present time 20 licenses are in force for keeping petroleum to which the Acts apply, and four other persons have notified the keeping of spirit under Home office regulations. The quantity allowed to be kept by the different licensees varies according to the amount of open space and the distance of buildings from the storage vaults, and ranges from 10 to 400 gallons. 43 FOOD, WATER, Etc. The Market is inspected two or three times on every market day, and other places and shops frequently. During the year no food was discovered which appeared intended for human consumption and was unfit for the purpose, which is an improvement oh the previous year. In one instance, however, I found some 80 lbs. of beef at the rear of a butcher's shop, which had been removed from a refrigerator, and was going bad. The same was declared to be not intended for sale, and was surrendered. Such meat was destroyed in the Council's destructor on the advice of the Medical Officer of Health, to prevent the possibility of the same being prepared and sold in the form of sausages. 59 samples of food were taken under the provisions of the Acts, relating to the adulteration of food and drugs, and duly submitted for analysis to the Public Analyst. None were certified to he adulterated, but in six instances the samples were slightly below the standard. In such cases the Health Committee usually direct the vendors to be warned. The kinds of food taken for analysis are those which are mostly consumed, or lend themselves to fraudulent practices,, viz. :— Milk 18 Butter 22 Coffee 14 Miscellaneous 5 59 44 To keep abreast of the times, two of your Inspectors have voluntarily qualified and passed the new examination as " Inspectors of Meat and other Foods," which involved considerable personal expense, and a course of practical instruction in one of the City Corporation Cattle Markets, from' the slaughter houses of which quantities of diseased carcases, organs, etc., are available in the condemned store-house, as object lessons for the officers, who are eligible for the special course under the Veterinary Inspector of the Market. WATER SUPPLY OF THE DISTRICT. Four samples of water were taken from the local water mains of the Metropolitan Water Board and submitted to the Clinical Research Association for bacteriological examination. All were examined quantitatively. The reports thereon were considered quite satisfactory by the Health Committee, so that no qualitative examination of the organisms was considered necessary. All houses have a constant supply from such mains, except in a very few instances where wells exist. Seldom are defective or dirty water cisterns found, as the water is in so many instances drawn direct from the main, rendering storage cisterns unnecessary. CONCLUSION. It has been a busy year, the unusual prevalence of diphtheria, the growth of the district, and the progressive application of sanitary principles, make it necessary at times to 45 put aside the less important duties to prevent an accumulation of matters which least admit of delay, so that the House-to-House and Cottage Inspections have suffered, but I hope to be able to make more progress in these during the present year. 1 have the honour to be, Gentlemen, Your Obedient Servant, THOMAS BUTLER, Sanitary Inspector, etc.