KIN 051 BOROUGH OF KINGSTON-UPON-THAMES. ANNUAL REPORT OF THE MEDICAL OFFICER of HEALTH FOR THE YEAR ENDING DECEMBER 31, 1897. KINGSTON-ON-THAMES : Printed by W. Drewett and Sons, Market Place, and East Molesey. REPORT OF THE MEDICAL OFFICER of HEALTH. Clattern House, January, 1898. Gentlemen, I have the honour to submit to you my fifth annual report, and I shall take this opportunity to compare the average of the first four years with the year immediately passed, and also with other statistics. The population to the middle of 1898 is estimated to be 32,516. The birth rate is 29'06 per 1,000 per annum. The male births numbered 490, and the female 455. The highest number of births in any one month was 91 in the month of November, and the lowest 58, in September. The average for the previous four years is 30.3 per 1,000 per annum. The death rate is 15.2 per 1,000 per annum, and is lower than the average of the previous four years, 15.8; whilst the death rate for England and Wales is 18.7 per 1,000 per annum. This is very satisfactory as far as it goes, but it behoves us as a sanitary authority to endeavour to reduce the liability to sickness and so prevent the occurrence of epidemics that come, from time to time, 4 to all places that omit to put in force those precautionary measures that have been recommended by Science and the Legislature. Within recent years much has been done towards enabling people to bring up their children under healthy conditions. Playgrounds have been made, Public Baths built, dilapidated property pulled down or improved, and Bye-laws have been enacted to prevent encroachment on air space, and to ensure the building of healthy houses. Twenty years ago England was in the van on all matters relating to Public Health, but in these latter years we have allowed ourselves to be outstripped by Germany and the United States, while other states are rapidly coming up to us. I shall here only refer to such matters as more immediately concern us. 1st.—The Isolation Hospital. During the last year the want of an isolation hospital has pressed very hardly upon some of the leading tradesmen in the town. The chief need for such a hospital is not, however, to save expense to business men, but to save the lives of those who, from the nature of their home surroundings, are unable to obtain the proper treatment and nursing that will not only permit their lives to be saved, but will give them a fair chance of making a complete recovery, instead of being left with impaired constitutions, which render them burdens on the community for the rest of their lives. 2nd.—The Inspection of Schools. I should like to call the attention of the School Attendance Committee especially to the following remarks on what is being done, and what I think might be done, in this respect, for it is in this 5 direction that I feel confident that most progress can be made toward the ideal sanatory state. On several occasions two or three cases of infectious disease have been observed in connection with certain elementary schools. On each occasion the school has been visited and all suspected persons, together with the brothers and sisters, have been excluded from the school. This has given rise to a considerable amount of discontent among parents, but in each case this weeding out of suspected families has stopped the recurrence of further cases, and has thus staved off an epidemic and so avoided school closure. These remarks do not apply to Measles which, not being notifiable, can only be dealt with when it becomes epidemic. There are other milder diseases in connection with school life, such as infectious Impetigo and the presence of vermin, and Ringworm, which I think call for preventive measures. Something is done, but I think more vigilant inspection and arrangements to provide other means of cure, than the attention of the mother when she has any spare time, would materially increase the record of attendances. The sight and hearing of school children is also of great importance. At Bradford the Medical Officer to the School Board tests the eyesight of each child once a year, with the result that although 40 per cent. of children under seven had defective vision, the early treatment had reduced the number with defects at twelve years to only 15 per cent. A great deal of good might be done by arranging with the school authorities to give lectures to the elder children and such parents as care to attend on elementary matters connected with health. This has been done with great success in several towns, and might be done here with very little expense. 6 3rd.—The Inspection and Control of Lodging Houses. This is a question that is becoming of more and more importance every year. The available land in the Borough is nearly all occupied and there is great demand for house room. The very poorest class has great difficulty in finding accommodation, and in consequence is apt to crowd into the houses that are open to this class. Complaints of overcrowding are frequently made, but it is difficult to prove such cases without having a fixed standard. The census for 1891 shows that there are 1638 tenements of four rooms and under, with a population of 3,276 persons, and although a certain number of such houses have been pulled down, many of the newer houses have been brought into similar use. It will therefore be seen that there is considerable work to be done in connection with this class of property, in the regulation of numbers, the amount of cubic space to be allotted to each individual, as well as in the inspection of cisterns, and keeping in good order all sanitary conveniencies. It has been shown by experience that even the lowest class, when forced by circumstances to obey certain rules of decency and cleanliness, after a very short time acquire a liking for improved sanitary conditions, and willingly co-operate in keeping their houses and persons in a cleanly state. Those amongst us whose duty takes us into this class of property have only too good reason to know that unless these matters are attended to the evils cleared away in the demolition of the old back lanes will re-develop in other parts of the town. Scarlet Fever. There have been two deaths from this disease during the year. There were 50 notifications, giving a case mortality of 4. as compared with 1.7 for the previous four years. 7 Diphtheria. There have been deaths and 54 notifications of this disease during the year. This gives a case mortality of 16.6 per cent., as compared with 18.1 for the previous four years, and 22.5 the case mortality amongst persons treated on the first day of illness in the M.A. B. Hospitals. It is difficult to compare the statistics of different places, but it must always be remembered that this town is an average community, with a fair proportion of the different classes, trades and manufactures. For the past it would therefore appear that our case mortality is about the average. Within the last few months a new factor has been introduced into the treatment of this disease by the perfection of the Anti-toxin treatment. Anti-toxin is prepared in the following manner. Healthy horses are chosen, and they are inoculated with Tuberculin and Mallein to discover whether the recognized re-action appear or not. If no indications are shown of the presence of Tuberculosis or Glanders, the only diseases likely to be transmitted to man, the animals are submitted to rep?ated inoculations of the Diphtheria toxin till they become completely immunised. Scrupulous cleanliness is observed whilst the horse is under treatment, and the discomfort to the animal is quite infinitesimal compared with the kind of work such animals are daily put to. The greater the number of injectionsof toxin injected into the horse, the stronger is the resulting Anti-toxin, and the smaller is the amount of Anti-toxin required to be used on the sufferer from Diphtheria. The point of greatest importance in this mode of treatment is that it should be commenced at the very earliest moment. 8 The injection of the Anti-toxin has no effect on persons not suffering from Diphtheria, so that there is no reason for delay. The percentage mortality of cases treated on different days of the illness, before the introduction of Anti-toxin and since, is shown in the table:— 1st day. 2nd day. 3rd day. 4th day. 5th and later. Without Anti-toxin 22.5 27 29.4 31.6 30.8 With Anti-toxin 4.7 12.8 17.7 22.5 24.6 It will therefore be clearly seen that although the results with Anti-toxin are always more favourable, still it is the results of its use on the first day of the disease that show the most marked difference. The effect of the treatment is also most marked in the case of young children, amongst whom the disease is most fatal. Again, 250 severe cases were treated with Anti-toxin and six died, whilst in 212 mild cases where the throat symptoms were very slight, though the bacillus was demonstrated by culture, there were seven deaths, Anti-toxin not being considered necessary. The use of Anti-toxin in short deprives this disease of all its terrors and brings it down to a level with those diseases which too many parents treat at home without seeking medical advice. A proceeding which accounts for a large proportion of the infectious disease in our midst. By the arrangements you have made every notification of Diphtheria can be verified by culture of the bacillus at the British Institute of Preventive Medicine, without expense to either the patient or the medical attendant. This is a step in the right direction on which I congratulate you heartily, but in order to get this disease thoroughly under control we must secure early treatment and isolation. Many of the homes (?) of the poor are quite unsuited 9 for this treatment, where scrupulous cleanliness and skilled nursing in the acute stages of the disease are absolutely necessary. The first step then is the erection of an Isolation Hospital on the site you have already acquired. One ward with four beds, with four rooms for single beds, would serve very well as a commencement, as the provision for Scarlatina is not so pressing, whilst Enteric can be treated in a general hospital. The next difficulty that arises is how to get hold of the patients in the earliest stage of the disease. Where a medical man is called in no difficulty arises, but a great number of the poorer classes delay seeking for advice on account of the expense, and have an insuperable objection to the aid of the poor law. I would suggest that it might be arranged that every person suffering from sore throat might have the right to send to the Medical Officer of Health for the purpose of diagnosis only. True cases of Diphtheria would then be sent into the Isolation Hospital and others referred to their medical man. Further it may be noted that taking the average mortality in the Borough for the last four years the perfected administration of Anti-toxin would save ten lives every year. In order more completely to keep this disease under control it would be advisable that after supposed recovery swabbings from the throat should be sent to the B.I.P.M. until the throat is shown to be free from the disease and the patient incapable of further spreading the disease. It is always advisable to bear in mind that the chief aim of a sanitary authority is to prevent the incursion of epidemic disease and not to stop its progress after it has broken out. 10 Enteric Fever. There have been four deaths from this disease and sixteen notifications. In one fatal case death was due to oldstanding complications more than to the disease itself. In the non-fatal cases there were in nearly every instance insanitary conditions, though only in a certain number was there any obvious defect. This insanitary condition is sometimes difficult to define. The house may be badly built or designed, the fittings may be second rate and liable to get out of order, there may be possibilities of leakages of sewer gas from adjoining properties. These conditions are only found in old property that was built before the institution of Bye-laws. Gradually such property as belongs to well-to-do owners is being brought up to date, but many owners have not the means to put their houses into proper condition. In one of the fatal cases the drainage had been completely relaid in 1893, but the work was carried out un-approved and un-supervised by any official of the Corporation. This drain was laid upon made ground, it was not in a straight line, one of the joints had a large hole in it and another was leaking considerably. The tenant had only been a few months in the house, but the previous tenant had suffered from impaired health which he attributed to the climate of the Thames valley. The climate of the Thames valley has often been made to bear the blame due to insanitary houses. On application at the Health Department, Clattern House, persons intending to re-drain or improve the sanitation of their houses in the Borough can obtain the assistance and advice of the Medical Officer of Health free of charge, and intending 11 occupiers can find out whether or no a particular house has been built or brought into accord with the Borough Bye-laws. One of the great difficulties to be contended with in investigating the origin of outbreaks of this disease is the difficulty of an early diagnosis. Dr. Widal, of Paris, has introduced the serum diagnosis of Enteric Fever, but at present the method is not sufficiently certain for me to recommend its adoption, as in the case of Diphtheria, though I may probably recommend you to do so when greater perfection has been reached. Cancer. I have arranged the deaths from this disease under the headings of male and female. Most of these deaths are in the Workhouse amongst very old people. Diarrhœa. There were 18 deaths in children under five years during the month of August. These deaths occurred, as is always the case, amongst the poorest classes, and are due to causes to which I have frequently drawn your attention. The rate per 1000 is .8 as against .6 for the previous four years. Puerperal Fever. There have been two fatal cases—both coming from insanitary surroundings. One case brought into the Workhouse Infirmary from another district during the course of the disease has not been counted amongst the notifications. 12 Measles. There were 30 deaths from this disease, of which 27 were under five years of age. This gives a death rate of .9 per 1000, as compared with .32 for the previous four years. These deaths occurred in the continuation of the epidemic that commenced at the end of 1896. The great difficulty in dealing with this disease is that the first intimation that reaches the Sanitary Authority is a notice of death, by which time the epidemic is usually well established, and it is found necessary to close schools. On January 14th, St. Peter's Infant School, Lincoln Road, was ordered to be closed for three weeks, 74 scholars being absent out of 240. All the other schools were then visited and it was found necessary to close St. Peter's Cambridge Road School (Infants) on January 29th, St. John's (Infants) on February 6th, and All Saints' (Infants) on February 27th. I think it would be highly desirable to adopt a modified system of notification. The medical men might be asked whether they would agree to notify the first case only arising in each household. A case so notified would give information as to the family and the school. The family would be at once excluded and the school inspected. As the dual notification is enforced by you, so soon as it became generally known that the head of a family was under a statutory obligation to notify the outbreak of the disease, whether he had called in a doctor or not, you would obtain immediate information of each case. It is the congregation of the children in the schools that causes the rapid rise of the epidemic. A child attends school with what appears to be a 13 simple cold, which after two or three days declares itself to be Measles. During the two or three days the sick child has given the disease to several others. If at this stage the M.O.H. received a notification he would go to the school and exclude all children with the early symptoms, and the outbreak would be stayed. Whooping Cough. This disease prevails and is commonly fatal amongst the infants of the poor. No child of fairly well-to-do persons has died of this complaint within my tenancy of office. This probably is due to the fact that the better off people are the more effectual are their attempts to isolate cases, and to keep very young children out of danger. In this disease, as also in Measles, Diphtheria, and Scarlatina, the older the child when attacked, the greater is the probability of a good recovery. The practice of exposing children to infection, in order that they may have the complaint and get it over, is little short of criminal. Phthisis. The mortality per 1000 is 1.1 as compared with 1.3 the average for the last four years. Tuberculosis. The mortality is .7 per 1000, as compared with .8 the average for the last four years. WARDS and DISEASES IN EACH. Primary Cases. Secondary Cases. Totals. 1st Qr. 2nd Qr. 3rd Qr 4th Qr. 1st Qr. 2nd Qr. 3rd Qr. 4th Qr. TOWN— Scarlet Fever 1 2 1 1 2 7 Enteric Fever 1 3 4 Puerperal Fever 1 1 Diphtheria 6 2 1 1 10 —22 CANBURY— Scarlet Fever 5 13 3 4 5 1 31 Diphtheria 2 I 1 6 1 I 4 16 Enteric Fever 1 1 2 —49 NORBITON— Scarlet Fever 1 1 1 3 6 Diphtheria 2 2 3 1 3 11 Membranous Croup 1 1 Puerperal Fever 1 1 Enteric Fever 1 2 2 2 7 —26 HILL— Enteric Fever 1 1 1 3 Scarlet Fever 3 2 1 2 8 Diphtheria 5 3 7 15 -26 123 Scarlet Fever 7 19 7 6 3 7 1 50 Diphtheria 4 8 13 15 1 3 4 5 54 Membranous Croup 1 1 Enteric Fever 3 1 4 6 2 16 Puerperal Fever 2 2 One case of Puerperal Fever brought into the Workhouse from Tolworth, after having been ill some time, is not included. 15 Dairies and Cowsheds. These have been inspected as usual, but I am sorry to say, with few exceptions, little has been done to bring them up to the modern standard. With such a delicate article of consumption as milk, dairymen ought to endeavour to do something more than comply with the very moderate requirements of the law. The main points to be considered are: — 1.—Sufficient Cubic Space per Cow.—With overcrowding cows are very liable to Tuberculosis, a disease which is probably frequently communicated to children through the milk, yet cowkeepers require constant supervision to see that they are not keeping more cows than are allowed by the Cowshed and Dairies Order. 2.—Means of Cleanliness.—In some cases the room is rather cramped and the arrangements inconvenient, but by the exercise of due care no danger should arise from this cause. 3 —Means of Cooling.— It is most important that milk should be cooled in order that it should keep well and be rendered less liable to the attacks of bacilli. Only one dairyman has a refrigerator at his dairy, but one other has one at the farm where his cows are kept in summer. Various chemicals are used in the trade to preserve milk, but though the sale is large no dairyman has ever been known to confess to their use. These compounds are known under various fancy names, as glacialin, formalin, Jack Frost, preservitas, etc. These are probably injurious, more especially to young 16 children. The greater amount of milk used in the town is "railway" milk, and comes from Hampshire, Wiltshire, and other places where we know nothing of the conditions under which it is stored or carried. 4.—Filtration.—Nothing of the kind is attempted, though filtration discloses the presence in all milk of a large percentage of dung, hairs, human skin scales, and other objectionable matters. 5.—Pavitig of Yards and Sheds.—Considerable improvements have been made, but one or two dairymen ought to do more work of this kind. New Houses. Plans for 197 new dwelling houses have been approved during the year. Bakehouses. One underground bakehouse is now lighted with electricity. This is a great improvement. Workshops. Many visits have been paid, and most of the improvements called for have been carried out. Old Property. Many houses have been inspected and improvements effected. Other property of an insanitary character is being watched and will be dealt with as opportunity serves. In conclusion it will be seen that, although I have many suggestions for further improvements, we are making steady, if slow, progress. I am, Gentlemen, Your odedient servant, H. Beale Collins. 17 Abstract of Work of the Medical Officer. Visits of Enquiry in Cases of Infectious Disease 133 „ in regard to Insanitary Conditions 127 „ on behalf of the School Attendance Committee 122 „ of Inspection to Schools 22 „ to Common Lodging Houses 11 „ to Workshops 46 „ of Inspection to Market 25 „ „ to Dairies 11 „ „ to Bakehouses 64 „ „ Out of District 7 Consultations with Medical Practitioners 7 Total Visits 575 ***Average annual visits for last four years—546. Complaints of Bad Food 3 „ of Overcrowding 1 Letters, &c., Written 155 Notices Served 2 18 INQUESTS DURING 1897. Date. Age. Cause of Death. Verdict when stated. Jan. 2 36 years Phthisis — „ 21 7 months Exhaustion, Convulsions — Feb. 2 72 years Septiæmia Meningitis — „ 9 6 months Scald Accidental Death. „ 15 9 months Adenoids Spasm of Larynx — „ 15 New born Suffocation by tape round neck Wilful Murder. „ 18 2½ years Measles, Congestion of Lungs — March 11 70 years Disease of Heart and Kidneys — „ 20 53 years Laceration of Brain by revolver shot Suicide. April 8 43 years Poisoning by Hydrocyanic Acid „ June 1 62 years Cerebral Hcemorrhage — „ 15 22 years Drowning Accidental Death. July 2 4½ years Burns „ „ „ 21 11 months Exhaustion from Diarrhoea — Aug. 3 7 11-12 years Drowning Accidental Death. „ 28 4 months Convulsions — Sept. 1 1 11-12 years Fracture of Skull Accidental Death. „ 30 5½ months Convulsions, &c. — Oct. 8 23 years Drowning — ,, 9 50 years Meningial Hcemorrhage — Nov. 1 25 years Carbolic Acid Poisoning Suicide. UNCERTIFIED DEATHS. Sept. 24 14 hours Estimated Population 32,516. 1897. Month. BIRTHS. DEATHS. AGES OF THE DYING. CAUSES OF DEATHS- Males. Females. Total. Males. Females. Total. Legitimate, under 1 year. Illegitimate, nnder 1 year. 1 and under 5. 5 and under 15. 15 and under 25. 25 and under 65. Over 65. Small Pox. Scarlet Fever. Diphtheria. Menb. Croup and Laryngitis. Enteric Fever. Typhus Fever. Puerperal Fever. Erysipelas. Measles. Whooping Cough Diarrhoea. Influenza. Rheumatic Fever Phthisis. Bronchts., Pleursy and Pneumonia. Heart Disease. Tuberculosis. Cancer. Injuries. All other Diseases. Total. JANUARY 48 34 82 26 23 49 14 3 12 2 1 10 7 Under 5 10 1 8 1 3 M F 6 29 1 1 2 8 3 1 1 3 20 FEBRUARY 36 43 79 31 34 65 18 2 12 2 1 16 14 Under 5 1 8 4 3 1 4 3 2 7 33 2 3 5 4 3 15 32 MARCH 43 40 83 33 24 57 8 3 15 18 13 Under 5 1 6 2 1 5 2 7 24 2 4 7 4 1 1 14 33 APRIL 34 36 70 20 15 35 4 2 2 1 2 11 13 Under 5 1 I 6 8 2 3 2 4 1 1 14 27 MAY 44 36 80 12 13 25 8 1 2 *1 9 3 Under 5 1 i 1 1 7 11 2 2 2 8 14 JUNE 36 35 71 22 11 33 5 1 2 2 4 11 8 Under 5 1 1 1 4 7 1 4 4 3 1 13 26 JULY 45 45 90 16 11 27 10 3 4 10 Under 5 1 1 1 1 9 13 1 1 1 11 14 AUGUST 32 41 73 22 29 51 26 4 1 11 9 Under 5 1 18 7 5 31 †1 1 1 1 2 1 13 20 SEPTEMBER 32 26 58 21 18 39 10 1 2 3 2 12 9 Under 5 3 2 2 6 13 1 7 2 3 1 1 1 10 26 OCTOBER 42 45 87 13 13 26 3 3 2 2 10 6 Under 5 i 1 4 6 i 1 1 1 2 2 3 1 2 1 5 2C NOVEMBER 45 46 91 16 19 35 5 3 2 1 1 *12 11 Under 5 3 7 10 1 1 1 2 2 5 2 1 10 25 DECEMBER 53 28 81 27 19 46 15 1 10 7 13 Under 5 2 1 1 11 1 10 26 Deaths in Brookwood 3-uths of Total Deaths from Kingston Union. 5 4 9 5 4 1 1 2 2 4 2 8 9 20 9 TOTALS 490 455 945 264 233 497 126 17 69 16 13 136 120 Under 5 5 2 1 27 8 28 4 33 1 20 4 78 211 2 4 3 2 1 3 2 1 32 37 29 5 15 11 6 133 286 Rate per 1000 1502 14.0 29.06 8.1 7.1 15.2 3.8 .5 2.1 .4 .3 4.1 3.7 .01 .02 .006 .01 .006 .003 .9 .02 .8 .006 .003 1.1 2.1 .9 .7 .4 _.3 .3 6.4 15.2 Rate per 1000 for previous four years 156 14.6 30.3 8.2 7.59 15.8 3.5 .38 1.8 .54 .6 4.8 3.7 .008 .06 .37 .17 .07 .02 .09 .32 .27 .6 .27 .03 1.3 3. 1.2 .8 .47 .38 5.8 15.8 Deaths in Workhouse (not belonging to Kingston) 47 41 88 3 1 2 2 1 27 52 Under 5 † And Cirrhosis of the Liver 2 2 2 6 *Surbiton Cottage Hospital. 2. 1 4 9 5 2 3 3 55 82 19 HEALTH DEPARTMENT. Showing the work done by the Sanitary Inspector. Abstract of Notices for the Year 1897. Choked and defective drains 161 Defective closets and syphons 27 Defective soil pipes and ventilators 16 Defective yard, sink, and bath waste traps 32 Defective water apparatus to closets 65 To provide separate cisterns for flushing closets 12 Foul drinking water cisterns 52 To lay on water supply to closets 34 To cleanse and limewash houses 57 To cleanse and disinfect houses and cellars 74 To cleanse and limewash closets and yards 16 To cleanse urinals adjoining public roads 50 To screen urinals adjoining public roads 2 Inspecting urinals 200 Dilapidated house roofs, floors and yards 14 Dilapidated and damp bedroom walls 10 Dilapidated manure and dust places 9 Accumulations of manure, offal, &c— 47 Pig keeping (a nuisance) 10 Fowl keeping (a nuisance) 9 Undrained stables and yards 5 Overcrowding of houses 3 Unsound food (poultry, fruit, &c.) 32 Canal Boats Acts, &c. Canal Boats and Barges inspected 37 Offences in Contravention of Canal Boats Acts Nil 20 Notification of Infectious Diseases Acts. Visits to Infectious Diseases 330 Notices served to Householders 126 Notices served to Attendance Officer 126 Notices served to Schools 140 Disinfecting houses after Infectious Diseases 120 The Slaughter Houses, Cowsheds, Dairies and Milkshops have been visited at various times, and found in a fairly satisfactory condition. Lodging Houses. Registered Lodging Houses, to the number of four, have been constantly visited, and have been kept fairly clean and satisfactory. The total number of Lodgers for the year using these houses amounted to 46,276, being a decrease of 28,967 upon the previous years, two lodging houses being abolished. Petroleum Act. Premises and tanks licensed under this Act have been kept in a satisfactory condition, and have afforded no cause for any complaint. Markets. All stalls occupied by perishable goods have been kept under close observation, and I have had no cause to make any complaint to the Committee. FRED. J. PEARCE, Assoc. San. Inst., Sanitary and Buildings Inspector. January, 1898.