1160 advises that food should be taken every 50 miles, if it were only milk or bread-and-milk. Many people would feel rather tired at the end of a railway journey of 165 miles. I am afraid bicycling is putting constitutional walking out of fashion-in fact, numbers of good bicyclists are bad walkers and tire very quickly. I am, Sirs, yours faithfully, WILLIAM O’NEILL, M.D. Aberd., M.R.C.P. M,R.C.P. Lond. Lincoln, Oct. 24th, 1898.
SANITATION AND DIPHTHERIA AT TUNBRIDGE WELLS. (FROM OUR SPECIAL COMMISSIONER.) FOR
time there has been
of diphtheria Tunbridge Wells. The Local Government Board complained that this matter had not received sufficient attention and finally held a local inquiry on the. MEDICAL FEES FOR LIFE INSURANCE subject. The report giving the results of this inquiry has EXAMINATIONS. not yet been published. The deaths from diphtheria during the last ten years, from 1888 to 1897, were for each To the Editors of THE LANCET. SIRS,-You are no doubt aware that it is the general successive year as follows: 9, 3, 5, 4, 5, 9, 5, 9, 14. practice of life insurance offices to pay a fee of one guinea 10. In 1896 there were 67 cases of diphtheria notified, for the medical examination of proposers for insurance, but resulting in the 14 deaths mentioned above, and in that when the sum assured is small only half that fee is 1897 no less than 117 cases of diphtheria were notified, allowed, the reason being that the smallness of the premium though there were only 10 fatal cases. The fact that so will not admit of the payment of the full fee. It may many cases produced so few deaths may be in part due to The medical officer of interest you to learn that, as the result of the discussions in the extensive use of antitoxin. the section for life insurance at the recent meeting here cf health is always ready to supply antitoxin gratuitously forthe British Medical Association, the directors of this office use among the poor. Considering that the population of have decided to double the fee when the sum assured is Tunbridge Wells barely exceeds 30,000 the above figures and upwards, thus allowing two guineas for the show, not merely a high proportion, but a steady increase in .&2000 the number of cases of diphtheria, which has continued medical examination in these cases. I am, Sirs, your faithfully, during the present year, and these were the facts which led the Local Government Board to institute a speciaf DAVID PAULIN, Manager, the Scottish Life Assurance Company, inquiry. In other respects, however, the death-rate of Limited. Limited. 1898. Edinburgh, Oct. 26th, Tunbridge Wells is not high. The zymotic death-rate onlyamounted to 0-97 per 1000 in 1896, while that of the country generally was equal to 2’18 per 1000, and in 1897 itswas A CORRECTION. equal to 0’95 per 1000, as opposed to 2’55 for London and 2-15 per 1000 for England and’ 1000 per To the Editors of THE LANCET. Wales during the same period. The mean general deathSIRS,—The statement on page 1090 of the issue of rate for the ten years from 1t38t3 to lc9/ amounts to 13’7 perTHE LANCET for Oct. 22nd that I am a candidate for the 1000, and amounted to 12’22 per 1000 in 1897. But if from appointment of extra-physician to the Sick Children’s this we deduct the deaths occurring among visitors who had’ resided in the borough for a period of less than threeHospital is incorrect.-I am, Sirs, yours faithfully, FOWLER. J. S. FOWLER. months the death-rate for last year is reduced to 11’1 per Edinburgh, Oct. 26th, 1898. 1000. At the same time it must be borne in mind that thebirth-rate is exceptionally low- namely, 20’32 per 1000 in 1897, as against 29’7 per 1000 for England and Wales. Not POOR-LAW MEDICAL APPOINTMENTS. only are there few births, but the infant mortality is low. In?. To the Editors of THE LANCET. 1896 the deaths of infants under one year of age was equal SIRS,-I shall feel very much obliged if through the to 117’6 per 1000 born, while for England and Wales the promedium of THE LANCET you would answer the following portion was 148 per 1000 born. In 1897 the figures for questions: 1. Is it compulsory that all Poor-law medical Tunbridge Wells amounted to only 87’8 per 1000 born, asappointments should be advertised by a board of guardians ? against 156 per 1000 born in England and Wales. If judgecl 2. Is it legal to appoint a medical officer to a Poor-law dis- only by these statistics it would seem that Tunbridge Wells; trict who resides out of the district when other eligible men is an exceptionally healthy place. The question, however,. arises whether this low death-rate is the result of good sanireside in the district and are applicants for the same ? tation and administration of the town or the consequence of I am, Sirs, yours faithfully, the special character and circumstances of the inhabitants. Oct. 19th, 1898. MEDICUS. The medical officer of health in his annual reports has. ** The guardians are not bound to advertise their several times pointed out that at Tunbridge Wells there is vacancies in point of law, but when they proceed to an exceptionally low birth-rate, an extra complement of’ appoint without having previously advertised the vacancy aged lives, an excess of invalid visitors, a very small prothey render themselves very liable to public criticism, and portion of operative workers, and a great excess of opulent if the question was raised by the Local Government Board people. As a matter of fact, Tunbridge Wells can hardlyof the word. be considered as a town in the usual they would have to justify their action and show that the There are very few streets where acceptation the houses touch each person whom they appointed was very highly qualified for other. It is rather a vast accumulation of villas and the post in every respect. As regards the second question, mansions standing in their own grounds and separated’ from each other by trees, gardens, and flowers. A great a district medical officer is not necessarily obliged to reside within his district though it is very desirable he should do number of the inhabitants are thus leading country rather than town lives and they are able to supplement In point of law the guardians are not obliged to appoint so. the abundant supply of pure air with all the ease and a gentleman residing within his district to the medical comforts which the possession of ample means enables them officership of that district, but, other things being equal, iti to secure. Under these circumstances the death-rate ought is eminently desirable that he should do so; and if, to be exceptionally low, and the question arises whethercandidates residing within the district and otherwise qualifiedl with a more efficient sanitary administration the death-rate might not be lower than that on record. In any case, many came forward the guardians would again have to satisfy the of the inhabitants who ought to know are far from satisfied Local Government Board as to the grounds for their action tc’ with the present state of affairs. Nor is this dissatisfaction the contrary. If our correspondent thinks it worth while hEJ a mere platonic expression of opinion. It has given rise, on might very well submit these points to the Local Govern. the contrary, to an active agitation and has brought forward ment Board, with whom the confirming of such appointments; fresh candidates for municipal honours, who base their prinrests absolutely. As a rule, however, these appointment;,, cipal claim for support on their determination to press forward energetic measures of sanitary reform. Strange as are so poorly paid and service under the guardians is s() it may seem, considering the luxurious appearance of most. irksome that medical men rarely find it worth while to g() of the dwellings and the large gardens with which they areout of their way to secure such appointments.-ED. L. surrounded, the chief complaint is that of overcrowding. The< at
grievance arises partly from the fact that there is no com- difficult to say how some parts of the town are drained. Thepetition in the sale or leasing of land for building purposes. nledical officer of health, Mr. William Stamford, and theIt nearly all belongs to three or four large land-owners sanitary inspector, Mr. James Cave, have not failed to point who do not want to be bothered with poor tenants. They are out some of these defects in their official annual reports. willing enough to see villas and mansions arise on their land,’Irhus, dealing with the 14 deaths from diphtheria which,a but they have a strong objection to workmen’s cottages. coccurred in 1896, Mr. Stamford says that this disease" was Such dwellings, they think, would depreciate the value of the I)revalent in the boundaries of the borough, at Rusthall and surroundings, and therefore they refuse to let their land on INewton, and children attending an infant school which was. building leases unless high-class houses are to be erected, in a bad state of sanitation became infected. The school Thus, though the working-class population is not numerous,iwas at once closed, as soon as it was found to havethere is a much keener demand for workmen’s cottages than 13een a source of infection." Concerning house sanitation, for middle-class villas. But anyone seeking to supply thisjhe i medical officer of health advises the town council to avail’ demand would find it almost impossible to obtain the neces- themselves i of the Act of Parliament bearing upon this. and to erect about 200 cottages for "the exclusivesidenc sary land. Yet, on the other hand, if a big villa or residencerematter is erected the tenants bring with them a coachman and theyoccupation of the respectable and provident poor." This. require the services of gardeners and others who do not liverecommendation is all well and good in its way, but there;in the villa. Where, however, are these attendants to live ? are two objections-first, that the town council did not They must rent one of the few workmen’s cottages that seem at all inclined to thus run in competition against do exist, and as this necessity is most imperative they private interests ; and secondly, that from the sanitary. Thus the rents point of view it is precisely those poor who are neitherare compelled to bid against each other. for workmen’s cottages have risen in a fabulous manner; provident nor respectable that require the most attention and now it often happens that a third of a workman’s and legislative interference. Both the sanitary inspector earnings is absorbed merely in the payment of rent. Under and the medical officer of health protest against the keepthese circumstances the tenants of workmen’s cottages are ing of poultry, rabbits, and sometimes even pigs, in smalt obliged to take in lodgers so as to help them to pay the rent, back yards ; but it is because the people are poor that they seek to eke out their slender earnings by rearing such animals. and this occasions the overcrowding. That this grievance is serious is proved by the petition Now one of the most evident causes of this poverty is thewhich was drawn up on the subject some time ago. It was exorbitant rents charged. If the municipality would provide,entitled "An Urgent Necessity" and was worded as follows :- cottages at a low rent then they would have the right to should not be kept on theWe, the undersigned, consider that for some years the number of stipulate that poultry, &c., houses for the working classes resident in Tunbridge Wells has been premises. and still is grievously deficient. We know from our own experience Concerning the 117 notified cases of diphtheria which took that much overcrowding has resulted, and are convinced that evils, both physical and moral, have been prevalent in consequence. We place in 1897 the medical officer of health states that an outoccurred at Rusthall and Lower Green on the boundary urge that efforts should at once be made to discover the best means of removing this serious danger to the physical welfare of our town and "which was traceable to the water-supply, derived from a its general reputation as a health resort. ! pring at Lower Green, not forming part of the town supply. This petition was signed by thirty out of the thirty-two ’JChis spring was found to be contaminated, the dip-holelocal medical practitioners. The two medical men who did r’eceiving a back flow from a contaminated pond. The’ not sign were in no way opposed to the petition, but could"ivater was examined by Dr. Stevenson and on receipt not testify that they had personal knowledge of the over- ()f his report water was supplied gratuitously from a crowding. On the other hand, all the Poor-law guardians,sstandpipe and steps were taken to enforce a supply Notice was all the clergy, all the ministers of Dissenting chapels, all theij0 each house from the borough mains. ’, trade union officials and the chief house-agents withoutalso posted that the water from the spring was unfit J domestic use." On the other hand, this town) exception signed the petition. Finally, the petition for was confirmed and adopted at a public meeting con-supply does not seem to be all that can be desired. Landi voked by the mayor of the borough and held onhas recently been purchased to establish filter-beds, and it is. Feb. 25th, 1897. A somewhat elaborate house-to-house to be hoped that these will be placed in working order at theinquiry was instituted in the poorer quarters. It was earliest possible date. So also has Part III. of the Housing: then shown that cottages containing only four rooms and a of the Working Classes Act (1890) been recently adopted by small lumber room were rented at 7s. and sometimes even 8s. the town council and some steps have been taken for th The question is, however, whether theper week. There certainly is one little lane where some acquisition of land. I
weather-board cottages are rented at 4s. a week, but these new town council, to be elected at the commencement of’ November this year, will show more energy and a genuin were such wretched structures that they had to be rebuilt. To avoid, however, the submitting of plans to the town desire to carry out an effective scheme for the housing of the-council each wall was pulled down separately and the working classes. It will likewise be necessary to act with work done was described as repairs and not as rebuilding. much more rigour against the owners of bad property,. Where for 7s. 6d. or more a cottage with six rooms can be In his report for the year 1897 the sanitary inspector obtained, it will be found that, though built for one single says: "Many drains which have been found defectivefamily, it is inhabited by two or three families. Of course, have been repaired and reconstructed and many hundreds. there is not the necessary accommodation. The family of defects in sanitary fittings have been attended to. Many that occupies the kitchen may be able to cook a decent houses, however, still remain in a condition which renders improvement necessary." Evidently what is wanted is a meal, the other families cannot do so. As the demand for these cottages is so keen the landlords house-to-house inspection and the careful testing of every can afford to neglect necessary repairs. If the tenants are drain. But even when this is done it is very possible that not satisfied they can easily be replaced by others who will a new drainage scheme will have to be devised, at least for not be so difficult to please ; therefore it is not surprising some portions of the town. In his report for the year 1896> to hear that many of the cottages are in a very insanitary the medical officer of health says that "during the year a condition. Thus in some cases it has been found that the large number of surface sewer ventilators have been removed house drain, instead of communicating direct with the or closed and nearly all the open gullies have been trapped,. sewer, first passed under a whole row of cottages. Then ventilation for the sewers being provided by a ventilation these drains were so badly built that they burst and shaft whenever required." But in the following year we saturated the subsoil. On pressing on the thin boarding of find that still more complaints were made as to thethe cottage floor the gurgling of the sewage underneath effluvia coming from street sewer ventilators and gullies... could be heard. When a case of diphtheria occurred in Evidently the ventilation shafts were not placed such a cottage the flooring was taken up and the drain was wherever required or were not effective, for now therelaid. But sometimes there were other cases of diphtheria medical officer of health reoommends that the wholeafter these repairs had been effected and some people con- subject of sewer ventilation should be submitted to, The real fact i& cluded from this that sanitation was of no use as a pre- and studied by, sanitary engineers. ventative for this form of disease. They forgot, however, that that in all probability the sewers in many instances are though the drain had been repaired the subsoil remained in not properly laid and are not self-cleansing, and hence that constant complaints as to the escape of unpleasant effluviaa polluted condition. It seems quite evident that sanitary matters have, at least Till these defects are remedied the bad odours had betterin the past, been much neglected. The building of houses escape on a level with the streets than inside the houses o3r over old brick drains has been allowed and it would still be be conveyed by shafts to the neighbourhood of the bedroom
sanitary an admixture of sandstone and clay, by far the most interestthe inha- ing geological feature being the peculiar character of the bitants of Tunbridge Wells had better be made aware of the rocks which underlie the district. The population is about ’fact by the constant escape of bad odours in the streets. 30,000, the birth-rate is 20-32 per 1000, while the corrected Whether all these sanitary defects are the only cause of death-rate is 11’1 per 1000-a rate which will compare rthe increase of diphtheria it is difficult to say. Doubtless very favourably with other health resorts. The corpora’they have aggravated the evil. But there; can be no denying tion have adopted several of the most salutary Acts ttbat school attendance, though not the original cause of of Parliament relating to public health questions-in .diphtheria, contributes largely towards its spread. Children particular the notification of infectious diseases ; the general ,lick their slates, put their pencils in their mouths, sanitary regulations relating to dairies, cowsheds, and trades; bite from the same apple, and instead of taking a glass the housing of the working classes and public baths; and ,put the water-tap in their mouths. Thus by means of they have secured a generally efficient system of street main -their saliva and directly from mouth to mouth the disease drainage, street lighting, watering, and sweeping. During - can be communicated from one child to the other. It 1897 three infectious diseases were particularly prevalent is difficult to see how this can be altogether prevented. within the limits of the borough-namely, scarlet fever, 129 Even adults, when duly warned, are often most careless notified cases ; diphtheria, 117 notified cases ; and whooping..-and we cannot expect greater forethought from little cough, which caused 12 deaths. The cases of scarlet fever "children. Nevertheless, more severe regulations could were, on the whole, of a mild type. The cases of diphtheria be established than are at present enforced and the centred in the main among the poorer labouring classes - school teachers should watch, and reprove, or advise, living overcrowded in more or less insanitary houses, the children more frequently in regard to such matters. affecting mostly the children attending three of the Again, it must be confessed that the climate of Tun- Church schools. A localised outbreak also occurred bridge Wells is perhaps not so favourable as is generally at Rusthall and Lower Green, within two miles of ,supposed. It has been urged that diphtheria is more the borough but in part outside its boundary. This outprevalent in the presence of damp and there is a consider- break was clearly traced to the water-supply, which was .-able amount of clay soil. The rocks which stand out on the derived from a spring at Lower Green and did not form a .common seem to indicate that the town is built on sandstone. part of the borough general main supply. There was But this is not the case. In some places there is clay to a undoubted evidence of contamination of this spring, the .depth of 14 ft. From the Pantiles down to the new athletic dip-hole receiving a back flow from a contaminated ; grounds the soil is practically all clay, and where there h pond. The prevalence of diphtheria in the borough sandstone there are indentations which retain water and this is, by a general consensus of expert opinion, due to in evaporating occasions fog and dampness. As a proof oi the day schools and, moreover, it is noteworthy that the this it may be noticed that the trees outside the town an first cases during the earlier half of this year occurred ,covered with lichen. The soil, in fact, alternates betweeI almost entirely among those children attending one :sand and clay. The water does not escape easily in thE , or other of two parish schools in particular. The local subsoil ; therefore it ultimately evaporates and hence then i urban sanitary authority was not at the time able to stamp its probably more damp than is generally supposed. In thl i out the disease completely; consequently a series of cases .-absence of careful hygrometric observation it would, o , has been kept going by means of personal infection among - course, not be safe to dogmatise on this point, but it seem ; the children, among the most frequent and effectual means being the cup at the street drinking-fountains, the proved likely that there is more damp than is desirable. On the other hand, visitors to Tunbridge Wells will be gla< l fact that children suffering from the disease in question or ,to hear that a system for the giving of sanitary certificate , those convalescent, though possibly still infectious, had wto lodging- and boarding-house keepers has now bee] i given sweetmeats which they themselves had partially - instituted. Some time ago Mr. George Abbott, a retirel i dissolved in their own mouths to other children, the medical practitioner residing in Tunbridge Wells, started a i constant carelessness of their parents as to the common ..agitation in favour of such certificates. At first th 3 use of feeding utensils, cups, spoons, and of all articles town council were not inclined to take the matter i i used to wipe discharges from the mouth and nosThe &c. ’hand, and then Mr. Abbott said he would endeavou r.....trils, including vessels used to receive sputa, "YV"I",..t-n1;i-,.,. #""oVV’lo"""’’’’’’ 1-hl’B. 117 - -4-, r, -A . 1QOl7 1 1tB - two form a private association to inspect houses and certify t was 10. Lur, cases in LUUI 11[ JJLiUJLLtLlUjy .Y CLLLLUJA6 ’the condition of their drains, &c. Finally, however, tb It is comparatively a difficult and intricate matter to - town council yielded and themselves organised a service ( prosecute a very searching inquiry into the absolute this description. The sanitary certificates issued during tb fons et origo of these outbreaks in the town. The water-first year have brought in to the borough an income of .E2 and milk-supply generally being to all appearances above as fees for and certificates. This measm inspection -paid suspicion, we are naturally led to ’an examination of the -will add greatly to the attractions of the town and will hel system (or its absence) of the house-drainage among the to dispel whatever alarm may be caused by the cases ( dwellings of the poorer classes, the disease never having . diphtheria which have been recorded and by the insanitm gained much ground among the well-to-do and usually - condition of certain quarters and houses. better-housed residents. One general conclusion which may reasonably be drawn is that the drainage in many of the houses of the poor is undoubtedly defective WE have received the following communication from a and that in some instances there is also overcrowding, ,resident, which is in many ways so confirmatory of our coupled with the keeping of fowls and other domestic in confined spaces such as unclean backyards . Special Commissioner’s report that we think it interesting to animals and outhouses. The chief points to which sanitary efforts Sprint them next each other. should be directed appear to be the reconstruction of a large To the Editors of THE LANCET. number of house-drains, the proper fitting of both inside and SIRS,—Tunbridge Wells has been visited within the past outside water-closets with flushing tanks, the erection of eighteen months with some pronounced outbreaks of diph- ventilation shafts, the total abolition of all cesspools, the theria, confined mainly to the eastern and northern divisions fitting of satisfactory manholes, soil-pipes, and approved .of the borough, though several cases have occurred from time traps, and the supply of water from the town mains As there have been frequent indications - two time in the south and south-west, as well as at Rusthall, a to every house. neighbouring village about l mile distant in a westerly I, of mild cases of tonsillitis, pharyngeal catarrh, and "sore. direction. As is well known, the town is famed for throat"occurring in the neighbourhood of infected houses its excellent and somewhat chalybeate water, its bracing it would appear essentially important for local practitioners .air, and its beauty of inland scenery, while the district to "look out"for any such "doubtful cases," treating The main them upon prophylactic lines as if they were actual ; abounds in beds of secondary iron ore. water-supply of the town is derived from reservoirs, 7! cases of diphtheria, as well as to aim at prompt and ..acres in extent, situated at the village of Pembury, about complete isolation of all first cases, the corporation having : 3t miles distant, supplemented by water from bore-boles. provided an isolation hospital. It would also be advisable if There is a constant supply ; it is, however, generally admitted all cases of illness in which children have been sent home 4vhat it is desirable that filtration should be carried out from school were visited at once, the teachers endeavouring . owing to the presence of a variable amount of harmless to render every assistance to the medical officer of health of "vegetable debris. The soil of Tunbridge Wells may, speaking the borough as well as to the other local members of the I am, Sirs, yours faithfully, uroadly, be divided into two main divisions-that in which profession. RESIDENT. t’.’:lae sandstone rock predominates and that in which there is "-windows. A bad smell has often been described
sentinel, and if the