BEC 14 BOROUGH OF BECKENHAM REPORT ON THE HEALTH OF THE DISTRICT DURING 1947 BY T. PHILIPS COLE, M.B., D.P.H. Medical Officer of Health BOROUGH OF BECKENHAM REPORT ON THE HEALTH OF THE DISTRICT DURING 1947 BY T. PHILIPS COLE, M.B., D.P.H. Medical Officer of Health REPORT OF THE MEDICAL OFFICER OF HEALTH FOR 1947 TABLE OF CONTENTS Page 1. Members of Health & Welfare Committee 3 2. Staff of the Department 3 3. Introduction 5 4. Infantile Mortality, 1947 9 5. Natural and Social Conditions9 6. Sanitary Circumstances of the Area 9 7. Housing—Report of Survey carried out in June, 1947 At end 8. General Provision of Health Services in the Area: (a) Hospitals provided by Public Authorities 10 (b) Local Services provided by Voluntary Organisations 10 (c) Ambulance Service 11 (d) Clinic Services provided by Public Authorities 12 9. Maternity and Child Welfare: (a) Ante-Natal Scheme 13 (b) Welfare Centres and Home Visiting 15 (c) Unmarried Mothers 17 (d) Adoption Act 17 (e) Premature Infants 18 (f) Boarded-out Children. 19 (g) Special Treatments 19 (h) Obstetric Consultant's Service 20 (i) Dental Clinic 21 (j) Day Nurseries. 21 10. Maternity Hospital Accommodation. 23 11. Infectious Disease: (а) Diphtheria Immunisation 26 (b) Table of Cases 27 (c) Comments on Major Infectious Diseases 28 (d) Poliomyelitis 28 (e) Tuberculosis—Incidence and Deaths 33 12. Sanitary Inspection of the District—-Report by Mr. G. A. Webber, Chief Sanitary Inspector: 35 (a) Nuisances found and remedied 37 (b) Complaints 38 (c) Abatement of Nuisances 39 (d) Rats and Mice (Destruction) Act 40 (e) Milk Sampling 43 (f) Food Sampling 43 (g) Meat Inspection 45 (h) Shops Act Inspections 46 (i) Ice Cream Regulations 46 Vital Statistics Inset MEMBERS OF HEALTH AND WELFARE COMMITTEE FROM NOVEMBER, 1947 Chairman: Councillor C.P. Christie Deputy Chairman: Councillor Mrs. K.M.F. Constable Gray Alderman C. Guy Brook Alderman Mrs. E. Campbell Alderman Dr. R.P.S. Edden, O.B.E. Councillor W. J. Brooks Councillor C.B. Curtis, M.B.E. Councillor R.J. Elmes Councillor E.F. Hall Councillor K.M. Price Councillor F.R. Took Councillor A.W. Waller C. Eric Staddon, O.B.E., Town Clerk. STAFF OF THE PUBLIC HEALTH DEPARTMENT Medical Officer of Health T. Philips Cole, M.B., D.P.H. Assistant Medical Officer Mrs. M. H. Mack, M.B., Ch.B. (Appointed 1.5.47) Chief Sanitary Inspector G. A. Webber, Cert. R.San.I. and Sanitary Inspectors' Examination Joint Board. Certificated Food Inspector. Sanitary Inspectors H.G. Richards, Cert. R.S.I., Cert. Food Inspector. E.U. Williams, Cert. R.S.I, and S.I.E.J.B., Cert. Food Inspector. W.Newman, Cert. R.San.I. W.T.G. Woodward, Cert. R.San.I. and S.I.E.J.B., Cert. Food Inspector. (Appointed 24.2.47) 3 STAFF OF THE PUBLIC HEALTH DEPARTMENT—contd. Health Visitors Miss M.G. Kendall, S.R.N., S.C.M., H.V.'s Cert. Miss D. Furse, S.R.N., S.C.M., H.V.'s Cert. (Resigned 24/2/47). Miss G. Baker, S.R.N., S.C.M., H.V.'s Cert. (Resigned 28/2/47). Miss G. Williamson, S.R.N., S.C.M. H.V.'s Cert. (18/3/47 to 30/4/47). Mrs. C. French, S.R.N., S.C.M. H.V.'s Cert. (Appointed 23/6/47). Miss I. Gatherer, S.R.N., S.C.M., H.V.'s Cert. (Appointed 24/7/47). Mrs. D.K. Anderson, S.R.N., S.C.M., H.V.'s Cert. (Appointed 18/8/47). Maternity Hospital— R.M.O. Dr. K. H. Traub (Resigned 4/4/47). Dr. L. White (14/6/47 to 22/2/48). Matron Miss D. Beard, S.R.N., S.C.M. Assistant Matron Miss H. Lomax, S.R.N., S.C.M. Day Nurseries- Matron of Springfield Nursery Miss I. Williams, S.R.N. Matron of Beckenham Nursery Miss E. Taylor-Smith, S.R.N. Clerical Staff— Chief Clerk S.W. Collett, Cert. R.San.I., Cert. Food Inspector. Senior Assistant J. Dungay Assistants K. Wood. M. Graham Williams. Miss E. Hocking. Miss J. Sparling (Resigned 28/9/47). Mrs. E. Best. Miss J. Roberts. Mrs. D. Foster (Appointed 6/10/47). Miss J. Fenn. 4 INTRODUCTION The year under review has been an unquiet one. The prolonged cold winter, the fuel shortage with its consequent interference with industry, the more stringent rationing of some foods, the restrictions on travel and the anxiety over matters affecting the future peace of the world, all hindered the recovery from the weariness left behind by nearly six years of war. Few of these things, however, could be proved to have had an immediately harmful influence on health, but the cumulative effect of numerous small privations must inevitably become manifest in time. There is some evidence already of this cumulative strain and, as might be expected, it concerns the housewives and mothers: there is evidence that the toxæmias of pregnancy are of more frequent occurrence. The cold winter was followed by a warm, dry summer: although welcome in many ways this had its own disadvantages in this particular year; it provided the climatic conditions in which Infantile Paralysis, if it happens to be prevalent, spreads most easily. A full account of the outbreak of Infantile Paralysis will be found in another section of this Report. Housing. It could not be expected that the Housing situation would show much improvement, though considerable progress was made with the Corporation's permanent housing programme. Requests for assistance in finding adequate living accommodation were as numerous as in previous years, but there seemed to be, if not more resignation at the state of affairs, at any rate more apathy; people seemed to feel in advance that they made their requests with little real hope. A Housing Survey was conducted during the year; the results of this survey were printed in full in a Report of the Health and Welfare Committee to the Council, but since it was a part of the year's work, it is reprinted in this Report. The Housing problem is, of course, a National one and conditions similar to or possibly worse than those existing in Beckenham must exist in most places in the country. The problem actually seems to be more a shortage of materials and labour than a shortage of land. There are undoubtedly many families, at present inadequately housed in Beckenham, who could solve their own problems if the supply of materials and labour were sufficient to enable private enterprise to resume the erection of houses. Whether it would be possible for private enterprise to build these houses in Beckenham is, however, another question. The Council has already indicated that in their view it is most desirable to retain the existing open spaces in the Borough as open spaces; moreover, in the long term development plan for Greater London, it is suggested that no further extension of building in Beckenham is desirable. The Council have not been able to find any more land in the Borough for the erection of Corporation houses; private enterprise is not likely to be more successful. Nutrition. Sharply conflicting views have been expressed during the year in the National and Medical Press on the adequacy of the country's food supply. To a large extent the controversy has been based on "calories." Strictly speaking, calories are units which express the nutritive value of food in terms of heat production: they are generallyregarded as a measure of the general food needs of the body. It is considered that the daily food needs of an adult human being are equivalent to from 2,700 to 3,500 calories—or even higher than that— according to the body-weight of the individual and the nature of his occupation. Different foods have different calorific values, and so there are many ways in which the necessary number of calories can be obtained; obviously, a much smaller quantity is needed of foods with a high value than of foods whose value is low. Therefore the quality of the food must be considered as well as the quantity. No two individuals are exactly alike and so individual needs must vary. In the animal kingdom the class of animals known as ruminants eat almost continuously because their staple food is of a low calorific value and they need a large quantity : their digestive system is naturally designed anatomically to meet this need. It is a fair presumption that Nebuchadnezzar could not have remained for very long in reasonable health if he had adhered to his diet of grass. In other words, calories are highly important, but the nutrition, of the human being needs more than mere calories. Different constituents of our food achieve different purposes; growth, repair, replacement of ordinary wear and tear, physical energy, heat production, etc. To be satisfactory, food intake should be not only adequate, but properly balanced: and a properly balanced diet should contain a specified proportion of what are called first-class proteins—which are in the main proteins of animal origin. (Milk, cheese and eggs as well as meat, fish, etc.). I think that the chief objection to the national food supply to-day is that a larger bulk of food must be consumed to secure an adequate number of calories: in practice this means that generally speaking there is an excessive intake of the starchy foods. Those whose daily work entails a good deal of physical exertion can deal with large quantities of starch—in fact they need it; but so far as the sedentary workers are concerned excessive intake of starch over a prolonged period will in the end lead to digestive disturbances. Although it is quite possible to obtain the requisite number of calories from starchy foods alone, I do not think that man's digestive organs were designed for this. One has only to glance at the photographs of those primitive African peoples who are large eaters of starch, with their distended abdomens, to assure one on this point. There is undoubtedly an increasing amount of indifferent health to-day from digestive disturbances. In the main these disturbances are not yet of a serious character, often amounting to no more than periodical discomfort. Most doctors to whom I have spoken agree in attributing these symptoms to excessive starch intake. I have also heard from one specialist that certain defects, usually attributed to 6 excessive consumption of starch and previously of infrequent occurrence, have been much more common during the last few years. I think that a reasonable answer to the whole question is that the country's food supply is sufficient in quantity, but deficient in quality. Above all, people are individuals and have individual needs: stomachs cannot be standardised or nationalised. It is perfectly true that one man's meat is another man's poison and we cannot really hope for any arrest of the present unsatisfactory conditions until there is a larger supply of essential foods and a greater variety of foods to meet individual needs. The physical condition of the school children suggests that, by the assistance of extra milk and school dinners, their needs are catered for adequately. Those people who take a proportion of their major meals at restaurants, etc., receive benefits denied to others. Once more it is clear that those who suffer most from existing conditions are the mothers and housewives. Infectious Disease. With the exception of the outbreak of Infantile Paralysis in the summer months, the incidence of Infectious Disease was low. Repair of Premises. Every effort has been made throughout the year to remedy the many unhealthy conditions in dwelling houses in the Borough— conditions partly due to War Damage and partly to progressive dilapidation. Many of the problems with which Local Authorities and property owners are confronted produce a sense of frustration. Still, in spite of the restriction of materials, licence difficulties and, in the earlier part of the year, adverse weather conditions, a great deal has been done to recondition and render properly habitable many of our dwelling-houses. There still remains a large number which are urgently in need of attention. Action has been taken during the year under Sections 9., 11 and 12 of the Housing Act, 1936, as well as under the general provisions of the Public Health Acts. There can be no doubt that action under the Housing Act, 1936 produces far better results than action under the Nuisance Sections of the Public Health Act, 1936. The administrative work entailed in the former is considerably greater and regard has to be paid to the requirements of the Ministry respecting the restriction of building works and the issue of licences. Under existing conditions the problem seems to be insoluble: on the one hand it will be years before enough new houses are built to meet the needs of the people: on the other hand, the diversion of materials and labour to the erection of new houses results in the progressive and disastrous dilapidation of many others. The instructions given in the Ministry of Health's Circular LRL 6/47 relating to the control of civil building licences placed much additional work upon the Sanitary Inspectors. Broadly speaking, it has meant that licences for all work involving the labour of a bricklayer or a plasterer could only be issued in cases approved by this Department. 7 Social Welfare. This is the last complete year during which the Beckenham Borough Council will administer the personal Health Services. On the "appointed day"—piesumably 5th July, 1948—the Kent County Council will become the Local Health Authority to implement the provisions of Part III of the National Health Service Act, 1946. At some time in the future it will be of interest to study the record of Beckenham as a Welfare Authority: the present moment is not quite opportune, since one cannot with decency hold an inquest while the patient is still breathing. It is, however, not an inappropriate time to summarise the indirect effects of the Public Health Department's activities, which touch the lives of many of our people at so many different points. Over a number of years a body of experience and knowledge has been built up, which has secured the respect of residents, and they have looked to the Department as a place to which they could come for help and advice on problems which arose out of health and home conditions, but which did not lie within the scope of the actual services administered. It is not possible to catalogue exactly the number of interviews given to people who needed help and advice in many different problems concerned with housing difficulties, domestic problems, the care of the aged, the adoption of children, the provision of fosterhomes, the securing of convalescent treatment and other matters. By reason of its knowledge and contacts and of its outlook, the Health Department has been able to give this help and advice and to put people in touch with agencies through which help could be obtained when the official services could not meet the case. We have tried to avoid saying "that it is not our job"; we have always tried to find out whose job it is and to make sure that those who were in need of help received it. The Officers of the Department have always been ready to listen patiently and courteously to the troubles and worries of those who come to them and in so doing have built up a measure of trust and confidence. We do not claim to have been successful in all our efforts, but without protesting too much, I think we may say that a great deal of real Social Welfare work has been done. This is not due to any particular members of the Staff, but to the attitude adopted by all. Members of the Staff have promoted and organised two voluntary funds from which a great deal of financial help has been given. It is hoped that this local interest and enterprise will still be able to find an outlet, when the administration of the personal health services passes into other hands. In conclusion I should like to express my thanks to the members of the Health and Welfare Committee for their help and consideration, and to all of the members of my Staff for their loyal, efficient and whole-hearted support. T. PHILIPS COLE, Medical Officer of Health. 8 SUMMARY OF VITAL STATISTICS, 1947 Area of District in acres 5,935 Civilian Population as estimated by Registrar-General at 30th June, 1947 74,030 Civilian Population per acre 12.5 Rateable Value at 1/10/47 £845,392 Births Registered: Male Female Legitimate 677 601 Illegitimate 23 13 Total 1,314 Birth Rate per 1,000 of Civilian Population 17.749 Deaths Registered: Male Female 346 390 Total 736 Death Rate per 1,000 population 9.975 Infant Mortality Rate per 1,000 births 28.158 37 Deaths of Infants under 1 year of age: Male Female Legitimate 17 16 Illegitimate 3 Total 37 Deaths from Enteritis under 2 years of age—4 deaths. Still Births— Male Female Legitimate 16 20 Illegitimate 2 Total 39 Death Rate from Cancer (136 deaths) 1.775 Death Rate from Pulmonary Tuberculosis (19 Deaths) 0.256 VITAL STATISTICS FOR YFARS 1939 to 1947 The comparative rates given reveal some interesting tendencies Year Population as estimated at mid-June by RegistrarGeneral Live Births Registered Still Births Deaths of Infants under one year Legitimate Illegitimate Total Rate per 1,000 of population Legitimate Illegitimate Total Legitimate Illegitimate Total Rate per 1,000 live Births 1939 71,010 897 14 911 12.827 26 1 27 24 6 30 32.96 1940 64,500 757 22 779 12.079 20 - 20 22 1 23 30.06 1941 53,310 548 33 591 10.898 10 3 13 17 3 20 36.70 1942 56,300 890 44 934 16.589 27 - 27 24 1 25 26.77 1943 58,080 950 45 995 17.131 25 1 26 29 1 30 30.15 1944 55,540 848 40 888 15.988 21 3 24 24 2 26 29.28 1945 58,850 836 50 886 15.055 26 2 28 18 4 22 24.94 1946 70,330 1,273 62 1,335 18.413 28 - 28 34 3 37 27.71 1947 74,030 1,278 36 1,314 17.749 36 3 39 33 4 37 28.15 Year Deaths of Civilians from all causes (including enemy action) Deaths of Mothers in Childbirth Deaths from Pulmonary Tuberculosis Deaths from all forms of Cancer Number Rate per 1,000 of population Number Number Rate per 1,000 population Number Rate per 1,000 population 1939 677 9.771 1 26 0.366 110 1.580 1940 851 13.190 3 22 0.341 115 1.783 1941 726 13.637 NIL 28 0.525 92 1.725 1942 673 11.953 NIL 25 0.444 122 2.166 1943 663 11.071 NIL 17 0.292 121 2.083 1944 717 12.909 NIL 33 0.594 107 1.926 1945 650 11.045 NIL 31 0.520 109 1.852 1946 757 10.763 2 22 0.314 142 2.190 1947 736 9.975 3 19 0.256 133 1.775 INFANTILE MORTALITY 1947 The number of deaths of infants under the age of twelve months was 37 as compared with 36 in 1946. The Infantile Mortality Rate for the year was 25.158 per 1,000 live births. The following table shews the causes of death in 36 cases for which full records exist. Table of Causes of Infant Deaths in Beckenham. Cases in 1947. Age in Weeks Total under 1 mth Age in Months Total under 1 yr. 0-1 1-2 2-3 3-4 1-3 4-6 7-9 10-12 'A' Congenital Defects Mongolism - 1 - - 1 - - - - 1 Hydronephrosis 1 1 - - 2 - - - - 2 Spina bifida - - - - - 1 - - - 1 Imperforate Anus - 1 - - 1 - - - - 1 'B' Ante-Natal or Intranatal Conditions. Prematurity 10 1 1 - 12 - - - - 12 Atelectasis 3 - - - 3 - - - - 3 Intra-cranial hæmorrhage 1 - - - 1 - - - - 1 Asphyxia-antepartum hæmorrhage 1 - - - 1 - - - - 1 'c' Infections. Broncho-pneumonia - - - - - 5 - - 1 6 Gastro-enteritis - - - - - 1 1 1 1 4 Gen. Miliary Tuberculosis - - - - - - 1 - - 1 Abscess in the Lung - - - - - 1 - - - 1 'D' Other Causes. Intussusception - - - - - - - 1 - 1 Erythroblastosis foetalis 1 - - - 1 - - - - 1 Totals 17 4 1 - 22 8 2 2 2 36 Deaths Male 20 Female 16 NATURAL AND SOCIAL CONDITIONS No change has taken place from the details printed in previous reports. SANITARY CIRCUMSTANCES OF THE AREA Sewerage and Drainage. No major alterations or amendments require report. HOUSING SURVEY A reprint of this Report appears as an Appendix to this volume. 9 GENERAL PROVISION OF HEALTH SERVICES IN THE AREA (a) Provided by Public Authorities. 1. Fever Hospitals. The West Kent Joint Hospital Board provides Fever Hospital accommodation for Beckenham and a number of other districts. 2. Maternity Hospital. The Beckenham Borough Council and the Penge Urban District Council maintain a Joint Hospital at Stone Park Avenue, Beckenham. 3. General Hospital. The County Council provide General Hospitals at Farnborough and at Orpington for acute cases and the chronic sick. The Hospital at Farnborough includes a Maternity Block with 50 beds. 4. Tuberculosis. The Kent County Council are responsible for the provision of Sanatoria and Hospitals for Tubercular patients, and for the provision of Chest Clinics for diagnosis and treatment. The Chest Clinic for Beckenham and Penge is at 1, Westbury Road, Penge, and for Wickham at 2, Park Road, Bromley. 5. Day Nurseries. To meet war-time developments the Council opened two Nurseries, with places for 85 children in all. Details appear later in the Report. (b) Local Clinic Services Provided by the Local Authorities. The table on page 12 shows the Centres and Clinics in operation at the end of December, 1947. (c) Local Services Provided by Voluntary Organisations. 1. Beckenham Hospital. This Voluntary Hospital has accommodation for 78 patients. It is the General Hospital for the district for the treatment of acute medical and surgical cases and is supported by voluntary contributions and charges made to patients. The Hospital provides Consultant's Out-Patient Clinics at which patients can leceive the advice of a specialist by appointments which must be made through the patients' own doctors. 2. The South-Eastern Hospital for Children. This is situated just outside the Borough, but takes a great many cases from the northern part of the area. 3. Heart ease Hospital, Woodland Way, West Wickham. This is provided by the Invalid Children's Aid Association. (d) Homeless Children. There are several voluntary institutions in the district which provide excellent care for orphans and homeless children. 10 (e) Homes for the Aged. The arrangements made by the County Council for the care of old people in institutions have been severely curtailed by war-time difficulties, and it is now extremely difficult to obtain accommodation in any of the County Hospitals, even when advancing years and chronic illness make it essential that these old folk should have more care than it is possible to receive from relatives or those with whom they live. It is to be hoped that this problem will be dealt with before long. The S.O.S. Society opened a Hostel for old people at 75, Bromley Road, Beckenham, in 1944, and this has met a real need. The Beckenham Old People's Committee has helped in many ways to provide extra comforts and furnishings for the occupants of this Hostel. (f) Private Nursing Homes. Most of the premises used for this purpose were damaged by bombing and had to be closed. At the end of 1947 there were six private homes registered in the Borough and these provided a total of 58 beds. These premises were inspected under the Nursing Homes (Registration) Act, and 23 visits were made to the premises by the Assistant Medical Officer of Health. (g) Nursing Arrangements. Professional Nursing in the Home. (a) Midwifery. The County Council remains the supervising authority under the Midwives Acts, and repeated applications by the Borough Council for delegation of powers have been refused. The Kent County Council provide 5 midwives for this area, and in 1947 they attended 222 confinements. (b) General. For all general Nursing in the Home the services of the Queens Nurses are available. This service is organised by the Beckenham & Shortlands District Nursing Association, and the West Wickham & Hayes District Nursing Association. These Associations employ 5 nurses. A small fee is payable according to the citcumstances of the patient, or families can join as Annual Contributors. The number of visits made annually by these Nurses is about 10,000 and every type of case is undertaken with skill and kindness. (h) Ambulance Facilities. 1. For Infectious Diseases. The West Kent Joint Hospital Board provide motor Ambulances for the removal of Fever cases to Hospital and return cases to their homes when discharged. 11 2. For Non-Infectious and Accident Cases. The Beckenham and Penge Councils collaborate in a Joint Service administered by Beckenham, and this came into operation on 1st July, 1945. Facilities have been arranged for the vehicles to be stationed at the Beckenham and Penge Fire Stations and for all calls to be received over the N.F.S. telephone system. The following table shows the calls dealt with by the Joint Service in the year 1947. Calls operated Accid'ts Rem'v'ls. to Hospitals Mater'ty. Cases Calls Transferred to adjoining areas Mileage covered Day 1,556 250 1,048 258 154 18,892 Night 772 112 158 502 Total 2,328 362 1,206 760 154 18,892 LOCAL CLINIC SERVICES Arrangements in force at 31st December, 1947. Service Days and Times Premises in Usep Ante-Natal Fridays, 2—4 (3 times a month) Clinic Block, Town Hall Fridays, 2—4 (once a month) Clinic Block, Hawes Lane, W. Wickham Wednesdays, 10.30—12.30 (alternate) Hawes Lane Clinic Block Fridays, 10—12 (weekly) R.M.O. Maternity Hospital Thursdays, 10—12 (weekly) Practitioners' Mon., T'ues., Wed., 10—12 Matron's Clinic 1 Obstetric Consultant Mondays (weekly), 2—4 Maternity Hospital Child Welfare Monday, 2—4 Clinic Block, Hawes Lane, West Wickham Tuesday, 2—4 (a) Baths Annexe, Beckenham Rd. (b) Coney Hall Club, W. Wickham Wednesday, 2—4 (a) Church Hall, Langley Road, Elmers End (b) Church Hall, Valley Road, Short lands Thursday, 2—4 (a) Clinic Block, Town Hall (b) Church Hall, Lennard Road (c) Clinic Block, Hawes Lane, W. Wickham Friday, 2—4 Church Hall, Langley Road, Elmers End Immunisation Monday, 2—4 Clinic Block, Town Hall Thursday, 2—4 Hawes Lane Clinic Block 12 Service Days and Times Premises in Use Dental (Infant Welfare Cases) Fridays—By appointment Clinic Block, Town Hall By appointment Clinic Block, Hawes Lane, W. Wickham Ophthalmic Tuesday, 2.30—4.30 Clinic Block, Town Hall Wednesday (once a month) 2.30—4.30 Clinic Block, Hawes Lane, W. Wickham Aural Fridays, 2.30—4.30 (monthly) Clinic Block, Town Hall Wednesday, 2.30—4.30 (monthly) Orthopedic Surgeon: Mondays (3 times) Clinic Block, Town Hall Massage: Mondays (all day) Do. Wednesdays (all day) Do. Thursday, 2—4 Do. Friday, 10—12 Do. Chest Clinic Friday, 10.30—12.30 1, Westbury Road, Penge MATERNITY AND CHILD WELFARE This service is concerned with the care of the mother throughout her pregnancy and confinement and the supervision of nursing mothers and of children up to the age of five years. The provision made for this work thus falls into three sections: 1. Care of the expectant mother. 2. Arrangements for the confinement and lying-in period. 3. Supervision of mothers and infants. 1. Care of the Expectant Mother. (a) Observation of the progress of pregnancy, detection of abnormalities, and discovery and correction of any other physical defects which may exert a harmful effect on the process of gestation. This work is carried out by the routine attention of the medical practitioner or midwife who has been engaged for the confinement. In cases where a midwife only has been engaged it is necessary that the expectant mother should be examined at least twice during pregnancy by a medical practitioner. It is for this purpose that Ante-natal Clinics are established. The Ante-natal Clinics are conducted by a panel of medical practitioners practising in the Borough. Expectant mothers are invited to select from the names on the panel the practitioner whom they would wish to attend them in the event of the services of a doctor being needed at the confinement. Appointments for the necessary examinations at the Clinics by the doctor selected are then made by the Public Health Department. Ante-natal examinations of those mothers who have arranged to have their confinements in Institutions outside the Borough are carried out by the Assistant Medical Officer of Health. 13 All attendances at the Ante-natal Clinics are by appointment, by which means periods of waiting are reduced. Ante-natal Clinics for those mothers attending the Beckenham and Penge Joint Maternity Hospital are held at the Maternity Hospital : for all other mothers they are held at the Borough Clinics at the Town Hall and in Hawes Lane, West Wickham. During 1947, 222 births were attended by Midwives, and 155 of these mothers attended at the Clinics. Ante-natal Panel Assistant Medical Officer Sessions held 51 47 Number of expectant mothers attending 186 128 Number of attendances made 392 393 (b) Inspection of home conditions; advice as to general hygiene, securing extra nourishment, provision of extra clothing, etc. The Health Visitors pay visits to the homes of expectant mothers nd assist in all these matters—except in the cases of those mothers who have engaged the services of a medical practitioner. 2. Arrangements for the Confinement. (a) Institutions. (b) Mothers' own homes. (a) Institutions. The Institutions within the Borough are:— The Beckenham & Penge Joint Maternity Hospital. Two private Nursing Homes, registered under the Public Health Act, 1936. The Beckenham Hospital which takes a few maternity cases but only under certain special conditions. The demand for institutional accommodation for confinements has been steadily increasing for a number of years. This is shown by the following figures:— 1935 56% of the births took place in Institutions. 1938 67% of the births took place in Institutions. 1945 79% of the births took place in Institutions. 1946 81% of the births took place in Institutions. 1947 80% of the births took place in Institutions. The existing housing situation and the difficulty in securing adequate help in the home undoubtedly contributed to the high percentage of institutional births in recent years. During 1947 the County midwives attended 177 cases as Midwives and 45 as Maternity Nurses. Home Helps. The Council is empowered to engage suitable women to assist in the housekeeping and domestic work of homes where the mother is confined in her own home; in certain cases the Council pays all or part of the fees for this attendance. 14 A total of 252 applications were recorded for enquiry, many more were refused because it was impossible to get sufficient women to undertake domestic work. Advertisements and posters were used to get staff and the engagement of full-time "Helpers" was found to be unsatisfactory because it was difficult to use the afternoons. Help was given in 30 confinement cases and 106 cases of illness for from 15—48 hours a week for 2—4 weeks according to the need. It is evident that there is a real need for this service, but it is difficult to organise and in many cases the applicant only "wants someone to do the rough work." This is not the function of the "Home Help"—her job is to keep the home running whilst the mother is unfit, to do essential work, shopping and sometimes cooking. It is an important job—well worth doing—and every woman who does this work can be assured of the satisfaction which comes from giving help in cases where it is urgently needed. 3. Supervision of Mothers and Infants. (a) Post-Natal Clinics. Arrangements are made for the examination of mothers after their confinements. These examinations are carried out by the medical practitioners on the panel or by the Assistant Medical Officer, as the case may be. During 1947, 121 of these examinations were carried out. In addition, all mothers who engaged midwives for their confinements are invited to attend the Obstetric Consultant's Clinic for final examination and the correction of any abnormality caused by pregnancy and childbirth. See page 20. (b) Nursing Mothers and Infants. Supervision is carried out at the Infant Welfare Centres and by visits to the homes made by the Health Visitors. There are seven Infant Welfare Centres in the Borough and during the year nine sessions were held each week. A Medical Officer attended each centre weekly. The situations and other particulars of the centres appear in the Table of Local Clinic Services. The work of the Centres is summarised in the following table which shows that the attendances have increased by over 3,000. Infant Welfare Centre Attendances, 1947. Town Hall Alexandra Elmers End Wickham Conev Hall Baths Shortlands Total 1947 Total 1946 Total attendances 4,498 5,548 7,778 5,436 2,435 5,009 2,624 33328 30145 New Cases 214 188 257 260 91 205 118 1,333 1,367 Sessions Held 51 51 103 99 52 52 52 460 460 Aver. per Session 88 108 75 54 46 96 50 72 65 Doctors' Sessions 51 51 50 47 52 51 52 354 324 Cases seen by Drs. 813 1,132 965 514 361 913 531 5,229 5,248 Aver. per Session by Doctors 16 22 19 10 7 17 10 14 16 3,295 children made 33,328 attendances—an average of 10.1 each. 15 The following figures shew the attendances of children in agegroups. Year of Birth No. of Children Attendances made 1942 43 339 1943 251 878 1944 385 1,485 1945 590 2,705 1946 1,011 14,493 1947 1,015 13,128 3,295 33,328 Four Health Visitors were engaged in Home Visiting and at the Infant Welfare Centres and during the year 1,315 new cases were placed on the Health Visitors registers. Particulars of the visits made are shewn in the following table. Health Visitors' Home Visits. New Cases Routine Visits to Children under 1 Routine Visits Aged 1-5 Special Visits for Illness Other Visits No Reply Total Visits Miss Kendall 489 816 883 123 8 140 2,459 Miss Furse 49 66 100 43 - 49 307 Miss Baker 101 153 143 15 - 97 509 r Miss Williamson 41 95 206 9 4 120 475 Mrs. Walmsley 38 45 54 35 11 28 211 Miss Williams 191 92 96 157 3 75 614 Miss Gatherer 201 568 588 74 4 321 1,756 Mrs. French 260 689 407 56 11 300 1,723 Mrs. Anderson 96 146 125 97 - 86 550 Total 1,466 2,670 2,602 609 41 1,216 8,604 Comparison 1946 1,305 2,582 3,432 1,038 626 1,537 10,520 Several changes in staff took place during the Year; the two Bursary Students both passed their examinations and one took up duties in August and the other in January, 1948. 16 Unmarried Mothers. During the year the cases of 15 unmarried mothers were brought to the notice of the Department. Of these 13 were reported by the Social Worker of the Rochester Diocesan Moral Welfare Council and 2 by the Catholic Rescue Society. Arrangements were made for 13 of these cases to enter special Hostels maintained by Moral Welfare Societies, the remaining 2 making their own arrangements. Of the 13 babies born, 2 died, 1 was stillborn, 4 remained in the care of their mothers, 3 were adopted under the Adoption of Children Act, and 1 was boarded out with a foster mother under the Infant Life Protection Act. Two left the area. In addition there were 23 other illegitimate births not reported until the notification of birth was received. These cases create a considerable social problem and the present resources are not adequate to deal with them all. More Hostel accommodation is urgently required, where the mothers can remain long enough to have time to arrange for their future in the best interests of themselves and the children. Adoption Act, 1939. The Health Department receives notification under this Act for the proposed adoption of children. The Registered Adoption Societies ask the Department for a report on the home before placing any child and this is a very useful procedure. Any person who acts as a third party in arranging an adoption is required to give notice to the Health Department but in many cases arrangements are made direct between the parent and the adopter. Information was received from 5 registered Adoption Societies and 5 other bodies during the year relating to 28 children and all the homes were visited regularly. Adoption orders were made by the Courts in 24 cases; in three cases the applications were withdrawn and 10 were still under consideration at the end of 1947. One child died and one family left the area. Close liaison is maintained with the Education Officer in cases coming under the provisions of this Act. Provision of Milk, Milk Foods, Etc. A stock of dried milks and other foods is kept at the Centres and sold to the mothers at cost price. During the year foods to the value of approximately £3,500 were sold. The scheme organized by the Ministry of Food for the provision of Cod Liver Oil, Vitamin Tablets and Orange Juice to expectant mothers and children, has been steadily developed since its inception and it now entails a very large weekly distribution. The Local Food Office have made arrangements for volunteers to be in attendance at 13 distribution points in addition to the Corporation's Infant Welfare Centres. 17 The "take-up" of these issues varies very much in different districts, but the periodical statistics furnished by the Ministry of Food shew quite conclusively that Beckenham is among those areas with the highest percentage. The figures for the period ending November, 1947, shew that the issues were Cod Liver Oil 570 bottles representing 59.87% of the possible issues. Vitamin Tablets *129 packets representing 62.32% of the possible issues. Orange Juice *2,314 bottles representing 73.27% of the possible issues. *Highest in the London Division. The numerous volunteers who undertake this work are to be congratulated on their public spirit as all medical opinion is agreed upon the importance of these additions to our present dietary. Free Milk to Necessitous Cases. The supply of milk for children under 5 has been taken over by the Ministry of Food, and the Council retain only the option of supplementing supplies in special cases. The Milk Officer reports that since the Scheme came into operation, a very large number of permits have been issued. Voluntary Helpers. We are much indebted to the many ladies who give most valuable assistance at the Beckenham Welfare Centres. At all Centres there is a band of volunteers who attend regularly and undertake a great deal of work which makes it possible for the nurses to concentrate on giving advice and instruction to mothers. Some of the workers have been helping for periods of 10—20 years. A list of names of present volunteers is given below:— Town Hall Mrs. Buckley Mrs. Dungay Mrs. Hone Mrs. Susans Baths Mrs. Gummer Mrs. Lambert Mrs. Muttridge Mrs. Newman Mrs. Petrie Alexandra Mrs. Abbs Mrs. Clark Mrs. Davidson Mrs. Foster Mrs. Fry Mrs. Groves Mrs. MacWilliam Mrs. Morgan Elmers End Miss Bailey Miss Firmin Mrs. Holford Mrs. Shelley Mrs. McGillay Mrs. Uzzell Shortlands Mrs. Thorpe Mrs. Wilson Mrs. Yabsley West Wickham . . Mrs. A. E. Bennett Mrs. J. W. Bennett Mrs. Buckley Mrs. Carey Mrs. Lebban Mrs. Parham Coney Hall . . Mrs. Cadreman Mrs. Clark Mrs. Mowll 18 Premature Infants. During the year 54 infants were born in the Borough weighing less than five and a half pounds. Weight at birth cannot be regarded as the sole criterion of prematurity, but the Ministry of Health's Circular regarding the care of premature infants suggests that infants whose weight at birth is less than five and a half pounds should be regarded as premature and in need of the special methods of care recommended. Of these 54 infants, 8 were born at home and 46 in Institutions. Born at home 8 Nursed entirely at home 8 Died during the first 24 hours Nil Alive at the end of one month 8 Born in Institutions 46 Died during the first 24 hours 7 Alive at the end of one month 35 The Council have approved arrangements for the care of these cases. Special equipment has been provided and arrangements made for the admission to the Maternity Hospital of any premature infant requiring medical attention. Special Treatment. Anangements have been made for children from 1 to 5 years of age to participate in the special services available for school children and the use made is shewn by the following attendances:— Eye U.V. Ray Orthopae- Aural Clinic Clinic dic Clinic Clinic Masseuse Surgeon 1947, Infants 91 843 578 297 8 Boarded-Out Children. At the commencement of the year there were 9 registered foster mothers having charge of 14 children. At the end of the year there were 8 names still on the register with 12 children. The Health Visitors and the Assistant Medical Officer are Infant Life Protection Visitors amd made 77 visits to the homes. Public Health Act, 1936—Sections 206—220. Under these Sections the Council may grant exemption Certificates from provisions covering the necessity for notification of admission and discharge of children from residential homes and schools. Nine premises are exempted and two are not. 19 Obstetric Consultant's Service. The consultants clinics were held at the Maternity Hospital. Eighteen sessions were held; 137 ante-natal cases and 493 post-natal cases were examined. The total number of attendances at the Clinics was 743 compared with 428 in 1946. Mr. D. M. Lindsay, F.R.C.O.G., was asked to see 42 Beckenham cases during the year. The following summary indicates the reasons for the consultations:— (a) Ante-Natal Conditions. Toxaemia of Pregnancy 5 Ante-Partum haemorrhage 3 (Placenta Praevia 1: Accidental haemorrhage 2) Removal of Cervical Polypus 1 External Version 1 10 (b) During Labour. Generally Contracted Pelvis 12 Flattened Pelvis 1 Malpresentations 6 (Extended Breech 3 : Persistent occipito-posterior 2: Transverse lie 1) Uterine inertia, prolonged labour and minor disproportion 3 Placenta praevia 3 Fibroid in lower uterine segment 1 Eclampsia 2 Other conditions 2 30 (c) Post-Natal Conditions. Thrombo-phlebitis 2 2 Caesarean section was performed on 21 occasions the conditions necessitating the operation were:— Generally contracted Pelvis 9 Flattened Pelvis 1 Placenta Praevia 3 Extended Breech 3 Transverse Lie 1 Fibroid in lower uterine Segment 1 Toxaemia 1 Combined with operation for sterilisation to prevent further pregnancies 2 20 MATERNITY AND CHILD WELFARE DENTAL REPORT Sessions were haid each Friday afternoon and at such other times as circumstances demanded, the total number of sessions being 65. The attendances were 549, compared with 523 in 1947. Summary of Treatment. Adults. Infants. Attendances 315 234 Number treated 120 127 Extractions 273 67 Fillings 52 163 Dressings 75 95 Silver Nitrate - 47 Scalings 12 - Nitrous Oxide 65 21 Ethyl Chloride - 8 Local Injections 32 - Impressions, etc. 95 - Dentures 32 - Repairs to Dentures 2 - DAY NURSERIES Both Nurseries have been booked to capacity, and there have been waiting lists for admission, particularly for children under two years of age. Considerable difficulty has been experienced in keeping domestic staff, and the Matrons and the Nurses are to be congratulated on the way they have overcome these difficulties and the high standard of care and welfare they have maintained. The attendances have been affected from time to time by minor illnesses and during the outbreak of Poliomyelitis one Nursery was closed for three weeks. Dr. H. Mack has supervised the health of the children in attendance and has carried out immunisation against Diphtheria and Whooping Cough. As from the 1st April, 1946, the Kent Education Committee assumed financial responsibility for the children aged 2 to 5 years, at the Springfield Nursery, by establishing Nursery Classes for these 21 children under the care of trained teachers during the usual school hours. Outside these hours the children are looked after by the Nursery Staff. Month Springfield—45 Places Beckenham Rd.—40 Places Remark under 2 over 2 Total Days Open Under 2 Over 2 Total Days Open Jan 127 585 712 27 182 586 768 27 Feb 62 268 350 24 79 444 523 22 Cold Weather Mar 125 651 776 26 153 594 747 25 Apr 157 629 786 23 163 592 755 23 Easter May 194 718 912 25 182 622 804 25 Whitsun June 184 697 881 25 53 182 235 7 Closed -Polio July 240 763 1,003 27 212 667 879 27 Aug. 172 578 750 24 93 569 662 24 Sep 136 706 842 26 152 629 781 26 Oct 181 874 1,055 27 152 721 873 27 Nov 133 496 629 17 159 592 751 25 Closed Infect's Dec 189 802 991 24 149 530 679 24 Total 1,900 7,767 9,687 295 1,729 6,728 8,457 282 Notes, Beckenham Road Nursery was closed for two days during the cold spell and for 21 days in June because of Poliomyelitis. Springfield was closed for 10 days in November because of infection. Springfield is open all day on Saturdays. Beckenham Road only up to mid-day on Saturdays. 22 23 BECKENHAM AND PENGE JOINT MATERNITY HOSPITAL This Hospital is provided by the Borough of Beckenham and the Urban District of Penge, and is administered by a Joint Committee of members of the two authorities. Admissions. The number of admissions in 1947 was 982, by far the greatest number accommodated in any single year. It was only possible to deal with so large a number of patients by limiting the stay in hospital for the great majority, to a period of ten days. This shortening of the lying-in period places a considerable strain on the nursing staff, since every patient requires full nursing attention during the whole period of her stay in hospital. Ante-Natal Supervision. Ante-natal Clinics for routine examination of the expectant mothers are held on three mornings every week. These clinics are conducted by the Resident Medical Officer and the Matron. During the year 915 cases attended for examination and these cases made 6,106 attendances. An additional clinic is held each week by the Resident Medical Officer for the collection of blood samples, so that the Hospital Staff may know in advance all the essential facts for each individual patient in case blood transfusion is subsequently needed at any time during labour or in the puerperium. Gas-Air Analgesia. All members of the Nursing Staff are trained in the administration of gas-air analgesia, and courses of lectures, combined with practical experience in the operation of the various types of apparatus suitable for use by midwives, have been given by a specialist anaesthetist. Training of Pupil Midwives. Since 1944 the Hospital has been recognised by the Central Midwives' Board as a training school for pupil midwives for Part I of the Training Regulations of the Board. During the year 26 pupils were in training and 22 passed the examination for Part I. Consulting Staff. Mr. Douglas Lindsay, M.D., F.R.C.O.G., in his capacity of Obstetric Consultant, attends at the request of the Resident Medical Officer and of General Practitioners to give advice and treatment in all cases presenting special difficulties. He is also always ready to discuss any case with the Resident Medical Officer on the occasions of his weekly visits to Hospital to conduct the Ante- and Post-natal Clinics on behalf of the Beckenham Health & Welfare Committee, and this assistance has been very much appreciated. 24 Dr. N. M. Jacoby is the Consulting Paediatrician to the Hospital. Dr. Jacoby pays regular weekly visits to the Hospital and advises generally on the care of all infants, with particular reference to premature infants. His services are also available at any time for any emergency. Nursing Staff. The Nursing Staff of the Hospital consists of Matron, Deputy Matron, 8 Ward Sisters, 23 Pupil Midwives. Domestic Staff. There was a considerable improvement in the matter of domestic help during the year : this improvement was largely due to the arrival of three women from Latvia. Councillor Prince, of the Penge U.D.C., took a particularly active part in securing the services of these women and the hospital is grateful to him for his interest. Toxaemias of Pregnancies. As mentioned in the introduction of this Repoit, there was a considerable increase in the number of patients showing signs of toxaemia. In all, there were 99 cases of this condition, which gives an incidence of about 10%. Of these cases, six were severe, 33 were of moderate severity and 60 were mild cases. Though it is not possible to assign the increased presence of toxaemia to any one special cause, I feel that the continuous strain of conditions of living during the last eight or nine years, has contributed to the inability of the excretory systems of pregnant women to cope with the extra burden placed on them. ANNUAL STATISTICS FOR 1947 Relating to the Beckenham and Penge Joint Maternity Hospital. Information Required Particulars 1. Name and Address of Institution Beckenham and Penge Joint Maternity Hospital, Stone Park Avenue, Beckenham. 2. Number of maternity beds in the Institution (exclusive of isolation and labour beds) 34 2a. Number of such beds used for Ante-Natal cases 4 3. Number of Maternity cases admitted during the year Beckenham 702 982 Penge 280 3a. Number treated in Ante-Natal Beds 97 25 Information Required Particulars 3b. Average duration of AnteNatal Stay 6.52 days 4. Average duration of stay 10.99 days 5. Number of cases delivered by: (a) Midwives 759 (b) Doctors 220 6. Number of cases in which medical assistance was sought by a midwife in emergency 110 7. Number admitted after delivery (included in 3.) 3 8. Number of cases notified as: (a) Puerperal Fever Nil (b) Puerperal Pyiexia 18 9. Number of cases of Pemphigus Neonatorum Nil 10. (a) Number of Infants who have at any time received a supplementary feed while in the Hospital (excluding the first 3 or 4 days). 203 (b) Number of Infants wholly Breast fed on leaving the Hospital 746 » 11. (a) Number of cases notified as Ophthalmia Neonatorum (b) Result of treatment in each case Nil 12. Number of Maternal Deaths 3 13. Number of Still Births 21 14. Number of Infant Deaths 9 26 INFECTIOUS DISEASE. Diphtheria. Two cases were notified during the year—the same number as in the previous year. Diphtheria immunisation is undoubtedly the most important single factor in reducing the incidence of the disease. In the last three years, only nine cases have been notified. The table which gives the state of immunisation in children undei the age of 15 years shows that the percentage immunised undei the Council's scheme was, in 1947, 54.8 per cent. It must be borrne in mind that this table only includes those children whose immunisation was completed in Beckenham. For one reason or another, a number of children were treated in other areas. Medical Inspection in the schools shows that it is comparatively rare to meet with any school entrant who has not been immunised prior to entering school. This work has been done in Beckenham since 1928, and complete records have always been in the possession of the Public Health Department. After July 5th, the County Council will be responsible for carrying out this service, and, presumably the records will be kept in the County Health Department at Maidstone. Immunisation is an essential part of the control of infectious disease, and it seems to me that the authority which will remain responsible for this control should be in possession of all the information and records which relate to it. Diphtheria Immunisation. Annual Return for Year Ended 31 st December, 1947.—This return is required from every local Authority whether or not it is itself the Authority responsible for the carrying out of immunisation. 1. Immunisation in Relation to Child Population. Number of Children w ho had completed a full course of Immunisation at any time up to 31st December, 1947. Age at 31/12/47 i.e.— Under 1 1 2 3 4 5 to 9 10 to 14 ToTal Under Born in year 1947 1946 1945 1944 1943 1938 to 1942 1933 to 1937 No. Immunised 36 684 616 637 481 2,689 2,766 7,909 Estimated mid-year population. 1947 5,710 8,770 14,480 During 1947 a continued effort was made to protect children between the age of one and two years, and also to give reinforcing doses to children on reaching the age of 5 years. 869 new cases completed treatment and 490 old cases had extra doses, compared with 922 and 493 for 1946. 27 INFECTIOUS DISEASE The following table gives the number of cases notified during the year, the number removed to Hospital and the number of deaths. Cases of Tuberculosis are shown in a separate table. Disease Beckenham West Wickham Total 0 to 1 1 to 5 5 to 10 10 to 15 15 to 25 25 to 45 45 to 65 Over 65 Age Unknown Admitted to Hospital Deaths Measles 165 88 253 5 87 141 12 8 2 - Whooping Cough 63 24 87 10 41 31 1 1 1 1 1 - - - Chicken Pox 27 5 32 - 7 18 7 _ - - - - - - Mumps 22 1 23 - 4 16 2 1 - - - - - - German Measles 6 1 7 1 1 1 1 2 1 - - - - - Diphtheria - 2 2 - 1 - - - - 1 - - 2 - Scarlet Fever 21 33 54 1 9 27 12 4 1 - . - 32 - Poliomyelitis 26 7 33 1 3 6 9 8 5 1 - — 24 2 Paratyphoid B. - 1 1 - - 1 - - - - . - 1 - Cerebro Spinal Meningitis 4 - 4 - 1 2 - - - 1 - - 4 1 Dysentery - 1 1 - 1 - — — - - - - - - Erysipelas 3 1 4 — - - - - 2 1 - 1 - - Pneumonia 30 4 34 1 7 3 1 1 1 7 12 1 - - P. Pyrexia All Hospital Confinements 21 - - - - 10 9 - - 2 - - 28 The following figures shew the number of new cases in age groups:— 1939 6 1944 12 1940 4 1945 80 1941 12 1946 683 1942 24 1947 36 1943 12 Total 869 ACUTE POLIOMYELITIS. A serious outbreak of this disease occurred during the summer and autumn. The first case in Beckenham occurred on May 7th. Enquiries were not able to establish any likely source of infection. In most years a few sporadic cases of this disease are notified and it is seldom possible to discover whence the infections come. For three weeks, no further cases occurred ; then, in the fourth week, two more cases were notified. These cases were not in direct contact with each other, but there seemed to be a possible common source of infection through a child who had suspicious symptoms, but who did not at any time show any signs of paralysis. Soon after this, it became clear that, although unusually early in the season, a widespread outbreak of the disease was developing in all parts of the country. So far as Beckenham was concerned, in the earlier weeks the infection was confined to those parts of the Borough bordering on Lewisham, Penge and Croydon: later on it extended into most parts of the Borough. The medical practitioners in the district were informed of the situation and their assistance was sought in detecting " abortive " cases of the disease : (an "abortive" case is a case which shows many of the early symptoms of the disease, but which does not develop any form of paralysis). This assistance was generously given and many suspicious cases were isolated. The Saturday morning performance for children at one Cinema was discontinued for a month, and one Day Nursery in which a case had occurred was closed for three weeks: apart from these, no widespread methods of closure were adopted. It was considered to be neither wise nor necessary to close schools, cinemas or the Public Baths : this view was subsequently confirmed by Medical Officers of the Ministry of Health at a conference of Medical Officers of Health held in London. The incidence of the disease reached its peak in Beckenham in August : and only one case occurred after the end of September. There is no easy " short-cut " available to bring an outbreak of this disease to a speedy and dramatic ending. Wholesale closure of schools, cinemas, etc., only tends to cause " panic " and contributes nothing to the effort to control the outbreak. At such a time there must always be anxiety, particularly in homes where there are young children. Advice to parents to avoid crowded assemblies, and to 29 secure medical advice for any and every febrile illness, however slight; authoritative statements in the local press, giving exact figures (usually lower than those appearing in the National Press, and always very much lower than those distributed by public " rumour"); judicious closing of individual classes in schools for definite reasons ; addresses to associations of parents and teachers ; and, above all, the detailed and unremitting attention to every suspected case and its immediate contacts, together with an exploration of the neighbourhood for possible " missed " cases. These are the methods by which anxiety may be allayed, and by which reasonable attempts can be made to limit the extent of the outbreak. The co-operation of the medical practitioners in the district was invaluable, both in helping to limit the spread of infection and in re-assuring the public. The almost entire absence of " sniping," and the helpfulness and steadiness of the residents of Beckenham throughout a very trying time are things which the Staff of the Public Health Department will always remember with gratitude. Thanks are also due to the Local Press for theit co-operation in giving full publicity to all authoritative statements and to authoritative statements only. In all, thirty-three cases were notified. The dates of onset of the cases were as follows:— Week ending— Mav 10th (1) June 7th (2) July 5th (1) Aug. 2nd (3) Sept. 6th (2) „ 17th — „ 14th (2) 12th (1) „ 9th (3) „ 13th (5) „ 24th — „ 21st — „ 19th (1) „ 16th (4) „ 20th (1) „ 31st — „ 28th (1) „ 26th — „ 23rd (1) „ 27th (1) 30th (3) and the last case in the third week in November. The distribution of the cases was:— Ward May, June and July August September November Lawrie Park 1 - - - Kent House 4 2 1 - Manor House 2 1 3 - Copers Cope 1 1 — — Eden Park 1 6 - - Shortlands - 1 - 1 Langley Park 1 - 2 - West Wickham 1 1 3 — In the main, the infection spread gradually from the North of the Borough to the South. No cases were notified in the southern part of West Wickham (Coney Hall). Incidence in Schools, etc. Cases occurred in seven departments in the Local Authority's Schools. In two departments there were three cases. In one department there were two cases. In each of four departments there was a single case. One case occurred in the Beckenham Road Day Nursery. 30 More than one Case in any One House or Family. I have heard it said that in previous outbreaks in this country, it has been extremely rare to find more than one case in a house. This has certainly not been true in the severe and widespread outbreaks which have occurred in the Dominions. It was not strictly true of the present outbreak in Beckenham. From one house, three cases were notified, but two of these were " abortive " cases. From one house, two cases were notified, one of which was an " abortive " case. In addition to these, there were at least seven other houses in which, as well as the notified case, there were cases of illness of a suspicious nature though of verv short duration. Age and Sex Distribution. Of the thirty-three cases, sixteen were males and seventeen females. Age under 2-4 5-9 10-14 15-19 20-29 30-39 40 yrs. 2 yrs. yrs. yrs. yrs. yrs. yrs. yrs. and over No. of Cases 1 2 7 10 5 4 2 2 The disease is called Infantile Paralysis because in the earliest days, most of the cases occurred among children under the age of two years. In this recent outbreak in Beckenham, only one of the thirtythree cases was under two years old: on the other hand, thirteen cases (or 39% of the total number) were in persons aged fifteen years and over. Severity of Cases. To classify cases merely as " Severe," " Moderate " or " Slight " would not be very informative. I am not aware of any recognised definition of the various degrees of severity met with as the results of this disease, and so I have tried, by as accurate description as is possible, to indicate what facts I have taken into consideration in placing the cases in the different categories. Very Severe Cases with complete paralysis of one or more limbs. Severe Cases with paralysis of one or more groups of muscles, resulting in crippling or a severe degree of disability. Moderate Cases with marked weakness in a group of muscles, resulting in some degree of disability. Slight Cases with some weakness in single muscles' but with no real permanent disability. Abortive Cases with no residual paralysis or muscular weakness. 31 On the above basis, the classification of the cases is as follows :— Fatal Cases Two: this gives a case mortality rate of 6%. Both fatal cases, one in a boy aged twelve and the other in a woman aged twentyseven, had complete paralysis of all the muscles of respiration. Very Severe Three cases. Severe Six Cases. Moderate Two cases. Slight Nine cases. Abortive Eleven cases. It is hoped that the condition of all the cases with any residual paralysis will continue to improve as time passes: it is too soon yet to know what the final degree of disability will be. All of the cases are under the supervision of Orthopaedic Surgeons and are receiving appropriate treatment. General Notes. Five cases among young people between the ages of fourteen and twenty had various degrees of weakness of the soft palate and pharyngeal muscles: in four of these cases, these were the only muscles affected. Recovery in all these cases has been practically complete. It was noticeable that in over a third of the cases, one of the initial symptoms was naso-pharyngeal catarrh : in some cases this symptom preceded any other symptom by one or two days. In slightly less than a third of the cases, other contacts in the homes had had catarrhal attacks of very short duration accompanied by mild degrees of pyrexia, but none of these contacts showed any distinctive symptoms of the disease. Scarlet Fever. The incidence was low, the number of cases notified being 54 compared with 42 in 1946. The infection was mild in all cases. Paratyphoid Fever. Two cases were notified. Smallpox. No cases were notified during the year. 1,246 children under one year of age were vaccinated by the Public vaccinator during the year. Epidemic Diarrhoea. This disease becomes notifiable annually during the period 15th July to 15th October. No cases were notified. Puerperal Pyrexia. Twenty-one cases were notified. Of these, eighteen occurred in the Beckenham & Penge Joint Maternity Hospital, and three in other institutions. 32 Other Diseases Notified. Measles (253 cases), was most prevalent daring February and March. There is still no sign of a reappearance of the pre-war regular periodicity. Whooping Cough (87 cases) occurred mostly in June and July. Chickenpox (32 cases) and Mumps (23 cases) were very slight. Scabies. It has not been found necessary to continue the war-time arrangements for the treatment of scabies. Instructions and material are issued to any cases referred to the Department. Overseas Contacts. Information was received from Ports and Air Ports of the arrival of 21 persons from areas where Smallpox and or Typhus Fever existed. These cases were visited daily until we were satisfied that no infection existed. This necessitated 85 visits by the Sanitary Inspectors and by the M.O.H. Bacteriological Work. The number and results of the examinations made at the Public Health Department Laboratory during 1947 was:— Disease suspected Total 1947 Results Comparative Total for 1946 Positive Negative Diphtheria 95 95 117 Tuberculosis 39 3 36 41 Other Diseases 12 1 11 6 Total 146 4 142 164 Tuberculosis. The total of 81 cases compare with 78, 64, 79, 71 and 76 in the preceding five years. In addition to the new cases there were 14 definite cases transferred from other areas, and one old case restored to the register. 5 cases were not notified until after death. At the end of the year the number of notified cases in the area was:— 268 Pulmonary Males, 230 Pulmonary Females, 46 non-Pulmonary Males and 34 non-Pulmonary Females; a total of 578 cases, which compares with 532 last year. 55 cases were placed off the register for the following reasons: Died, 25; Cured, 12 ; Left area, 18 ; Notification.—In 5 cases notification was not made until after death. 33 New Cases attending the Tuberculosis Dispensaries for the first time during 1947 (Information from the Tuberculosis Officer) Adults Children under 15 years Male Female Male Female Pulmonary 32 16 2 5 Non-Pulmonary 2 1 2 — Negative 89 109 38 55 Negative Positive Contacts Examined 120 4 - - No. of patients admitted to Sanatoria during the year: 66 Tuberculosis Care Committee. The Voluntary Tuberculosis Care Committee which was formed in 1938 has continued to raise considerable sums of money and used them for the benefit of local patients. This voluntary fund gives assistance to patients in ways which supplement the official schemes, and I feel that a word of congratulation is due to the Hon. Secretary and Committee for their continued good work for the benefit of the Tuberculosis patient. I understand that since the Committee was formed an amount of over £1,300 has been raised from local sources, and a special activity of the Committee has been the boarding out of child contacts to minimise the risk of infecting young children. Public Health (Prevention of Tuberculosis) Regulations, 1925. No occasion has arisen during the year to exercise the powers conferred by these Regulations of prohibiting any person engaged in the milk trade from continuing his employment. Public Health Act, 1936 (Section 169). It has not been necessary to apply for an Order under this Section for the removal of a patient to hospital. 34 Tuberculosis—Table of Notifications and Deaths, 1947, from Local Records Sex Ages Wards m. F. Total 0 to 5 5 to 10 10 to 15 15 to 20 20 to 25 25 to 35 35 to 45 45 to 55 55 to 65 Over 65 l. PR. k.h. m.h. c.c. E.P. PR. l. Short w.w. Notifications (New Cases only) Pulmonary 39 30 69 - 2 2 9 9 16 13 9 3 6 4 11 9 5 16 6 7 11 Non-Pulmonary 6 3 9 - 2 - 1 1 1 1 1 2 - 1 - 2 - 3 1 1 1 Totals 45 33 78 - 4 2 10 10 17 14 10 5 6 5 11 11 5 19 7 8 12 Deaths . Pulmonary 14 12 26 - 1 - - 4 6 4 3 4 4 2 4 6 - 5 2 2 5 Non-Pulmonary 1 - 1 - - - 1 - - - - - - - - 1 - - - - - Totals 15 12 27 - 1 - 1 4 6 4 3 4 4 2 4 7 - 5 2 2 5 35 REPORT ON THE SANITARY INSPECTION of the DISTRICT FOR THE YEAR 1947 By G. A. Webber, Chief Sanitary Inspector, Beckenham Borough Council. So far as the work of the Council's Sanitary Inspectors was concerned with the removal of bad housing conditions, the year 1947 may fairly be described as one of constant endeavour, seriously hampered by many restrictions. Tired of the drab and insanitary conditions which they had suffered patiently during the war, the public greatly increased their demands on our services; but the control and shortage of materials, and, to a lesser degree, of labour, the need for obtaining licences and the always slow moving machinery of our legislation seriously interfered with our efforts: and our inability in so many instances speedily to provide the assistance sought—and so often urgently necessary—produced a sense of frustration which was at all times exceedingly depressing. In pre-emergency days, the notification or confirmation of a nuisance requiring remedy merely entailed the simple procedure of adding to the printed form of Notice the details of the nuisance, which could be handed to a builder for immediate attention. The procedure is now vastly altered. In nearly every case, the notice has to be accompanied by:— (a) a blank licence application form, with a suitable endorsement by the Sanitary Inspector. (b) a duplicate of the notice, to be attached to the licence application, when made, and (c) a letter explaining the purpose of these added enclosures. If our troubles ended there, we could, perhaps, hardly complain ; but very frequently the materials for the work demanded were only obtainable on " permit "—which meant more form filling by the owner or his agent; nor was this the end, for, having obtained the licence and the necessary material permits, the owner frequently found himself unable to find a supplier who had the required materials. The delays occasioned will be apparent, and complainants frequently added to one's difficulties by suggesting that insufficient attention was being paid to their particular matter. Nevertheless, it is pleasing to be able to report that certain occupied properties, which had reached such a condition of deterioration and dilapidation as almost to defy reconditioning, and which may be said to have formed the worst housing accommodation in Beckenham, were, in fact, reconditioned as a result of the Council's implementation of the provisions of the Housing Act, 1936. We always approach this problem of existing insanitary conditions whether they be due to war damage, to dilapidation, or to a combination of both, with the view that the remedy of such nuisances, by reconditioning, repair or renewal, is one answer to the housing problem which confronts us to-day. It has to be admitted that the renovation of house properties does not enable the housing of more 36 families, but it does place further off the day when the properties, with deterioration unchecked, would only be suitable for demolition, with a consequent increase of families without proper accommodation. It appears, however, that this view is not held, or at any rate not acted upon, by the higher administrative powers, for our ability to obtain licences and materials is restricted with increasing severity, and we are advised that we should only pay attention to those items of disrepair and dilapidation, the existence of which make a property quite uninhabitable ; in other words, to keep the property a fraction away from the state in which it would only be fit for demolition. This suggested interpretation of the Public Health Acts is completely at variance with that intended by our legislators, and accordingly, in the absence of a definite written instruction, or amendment of existing legislation, it is, presumably, still a Local Authotity's duty properly to implement the Health Statutes ; and, after giving due consideration to the obstructions occasioned by the restrictions referred to, we may say we have succeeded remarkably well in that duty. Work in connection with keeping house property free from conditions prejudicial to health or a nuisance, usually takes the Sanitary Inspector to those properties which are not owner-occupied. This position, too, has been considerably altered during 1947 by a Ministry of Health Circular controlling the issue of Civil Building Licences. Briefly, the issue of licences which cover work requiring the employment of plasterers and bricklayers is restricted to those cases where a Statutory Notice under the ' nuisance sections ' of the Public Health Acts could be served. The issue of such Statutory Notices is authorised by a Local Authority, following the recommendation either of its Medical Officer of Health or its Sanitary Inspector. Accordingly, the Circular meant that many Licences had to receive the approval of the Sanitary Inspector before issue was possible. In Beckenham. with its large proportion of owner-occupied properties, so many of which were severely damaged by enemy action, the Sanitary Inspector was called in to inspect and give authoritative opinion on quite a different class of property from that usually falling within his purview, and on nuisances, arising not from neglect or deterioration, but from war damage. Over five hundred such cases were dealt with during the year. It has been interesting and useful work, if only because it has enabled licences to be issued in some order of priority of need. The work had, too, many disturbing features, for we frequently could not reach agreement with a householder on an opinion as to the need for repair, and many licences sought were refused. Taking our inspections generally the greatest difficulty has been to separate the structural defects into categories (a) Due to dilapidation and (b) Due to war damage. This has applied, of course, more to the older, poorer, and ill-maintained properties, which number approximately, 2,500. It is from such properties that complaints normally rise, and there has been a great increase in the number received. The majority of these properties are rented and Notices calling for the remedy of structural defect must be served upon the Owners. This usually brought from the 37 recipients a statement that the "nuisances" were due to war damage. The Inspector has no authority to adjudicate on this query and can only refer the Owner to the War Damage Commission for a decision. This caused considerable and unavoidable delay, but it is proper for us to take as reasonable a view of an owner's assertions as we do of an occupier's complaint. Unfortunately it appears that the conditions and edicts which have restricted our activities in 1947 are likely to continue for some considerable time. In the midst of our concern over the increased need for reconditioning property, with decreased facilities for so doing, there descended upon us the most severe winter for many years. The number of sanitary appliances, particularly water closet pans, which were broken by the frost caused considerable inconvenience to many of our residents. The following table gives the startling comparisons between the winter months of 1946 and 1947:— Defective Sanitary Appliances found 1946 1947 January 5 28 February 8 65 March 6 97 Once again the materials position caused great difficulty, and many households were without adequate sanitary accommodation for many weeks, even, in a few cases, many months. Fortunately the position eased towards the end of the year. A table, giving statistical information of the Sanitary Inspectors work, so far as the removal of nuisances is concerned, is appended. 1946 1947 Number of complaints received and investigated 1,718 2,238 Number of initial visits 4,803 4,664 Number of re-visits 8,074 6,515 Number of Intimation Notices served 910 1,450 Number of Statutory Notices served 163 181 Nuisances iound and Remedied. Found Rem'd. Found Rem'd. Structural Defects: External 494 342 767 546 ,, ,, Internal 669 515 1,161 866 Insanitary conditions other than Vermin 83 60 67 78 Verminous conditions 12 12 15 15 Choked drains 416 410 283 284 Other drainage defects 309 340 260 271 Defective sanitary appliances 265 281 520 589 Insufficient and unsuitable water supply 19 23 79 78 Absence of Dustbins 55 50 54 49 Offensive accumulations 33 29 10 14 38 It will be observed that the number of complaints received by the Department increased by over 500 on 1946 figures. The decrease in the number of visits and revisits paid may be accounted for, in large measure, by the fact that for the first three months of the year there was one vacancy on the Inspectorial Staff, due to the resignation of Mr. R. C. Rogers. Mr. W. Woodard commenced duty as a District Sanitary Inspector on the 17th March, 1947, and has, since his appointment, obtained additional qualification by passing the examination of the Royal Sanitary Institute for Inspectors of Meat and Other Foods. The number of notices served has increased. It is a fair index of the co-operation of property owners with the Council when it is seen that although 500 more Intimation Notices were served than in 1946, it was only necessary to serve 18 more Statutory Notices. The figures for defects found and remedied may, perhaps, be confusing. For instance, it will be seen, taking the years 1946 and 1947 as a whole, that at the end of 1947, 373 structural defects (external) and 449 structural defects (internal) were still not remedied. There is always a " float " of outstanding work on property renovation such as this. The two figures, combined, give a total of 822 defects, and relate to approximately 160 properties. There are four District Sanitary Inspectors, and so each Inspector has approximately 40 properties on his district where there is outstanding work. This is usual and reasonable, and the figures given in the table are not so alarming as might at first be thought. Verminous conditions found and remedied show little increase and such conditions do not form a major problem in the Borough. The considerable decrease in the number of choked drains may, it is thought, be accounted for by the fact that in 1946 we had considerable trouble with war damaged and neglected properties, which condition did not prevail so much, in 1947. Housing—Inspection of Dwelling Houses During the Year. Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 3,165 Number of inspections made for the purpose 8,934 Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 10 Number of inspections made for the purpose 24 Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 1 Number of dwelling-houses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 1.450 Number of dwelling-houses in respect of which informal notices were served 1,450 Number of dwelling-houses in which defects were remedied after service of informal notices 1,205 Number of dwelling-houses in respect of which formal notices were served requiring defects to be remedied 181 Number of dwelling-houses in which defects were remedied after service of formal notices— (a) by owners 131 (b) by Local Authority in default of owners 39 Properties not Possessing Main Drainage Systems. There are still some domestic properties in Beckenham not connected to the main sewerage system. In the majority of these instances the properties drain to cesspools; there are, however, a few dwellings where earth closet sanitation only is available. The Council gave consideration to three such properties, where connection to main sewerage is possible, and agreed that appropriate action should be taken. The matter is receiving the attention of the Council's officers. So far as cesspool drainage is concerned there are twenty-one cesspools in the area which drain, in all, forty-four properties. Of these forty-four properties, thirty-three are domestic dwellings, and eleven are sports pavilions. Of the thirty-three domestic dwellings, twenty-three drain entirely to cesspools, i.e. water closets, sinks, etc., and ten only partially, i.e. sinks only. In the case of the sports pavilions, all drain entirely to cesspools. In the absence of any direction from the Ministry of Health, there appears to be no liability on the part of an Authority to cleanse cesspools, although they are empowered so to do by Section 72 of the Public Health Act, 1936. In accordance with Section 74 (i) of the same Act, an Authority may make such charge, if any, as they think fit for cleansing cesspools. Moveable Dwellings. Five families occupied moveable dwellings under licence from the Council during 1947. No nuisances arose from these occupancies. Four of the families used chemical closet sanitation, which, when properly used, is entirely satisfactory, and their water supply is obtained from a stand-pipe connected to Metropolitan Water Board mains. This water supply was examined by the County Pathologist on one occasion during the year and reported as " good watei." The fifth family occupied a caravan on extensive land adjacent to a dwelling house, wherein was provided, for their separate use, lavatory and washing accommodation connected to the main sewerage system. Legal Proceedings. Proceedings were taken against an owner of property for failure to comply with a Nuisance Order, which had been made by the Court in previous proceedings in 1946, and the defendant was fined the maximum penalty of £5. The owner subsequently complied with the Order. A Nuisance Order, subsequently complied with, was obtained against an owner of property after he had failed to comply with a Statutory Notice issued by the Council. A fine of £2 2s. Od., plus five shillings and sixpence costs, was imposed by the Bench. Statutory Notices served under Section 39 of the Public Health Act, 1936, in respect of defective drainage in two properties, were not complied with. Exercising its powers, the Council executed the work and successful legal proceedings were instituted for the recovery of the cost of works from the persons on whom the Notices were served. 40 Proceedings instituted against an owner for failure to comply with a Statutory Notice resulted in the making of an Order for the work required to be carried out within 28 days from the date of the hearing. A penalty of £5 0s. Od. was also imposed. The Nuisance Order was not complied with within the time allowed by the Court, and in further exercise of its powers the Council executed the work required at a cost of £12 0s. Od., which sum was recovered from the owner without recourse to further legal proceedings. Rat Repression. Routine measures for rat repression have continued throughout the year. Private Dwellings Scheme. A total of 11,782 visits and revisits have been paid to 9,127 private houses in the area. 789 infestations were discovered and dealt with. It will be seen that approximately 8.6 per cent of the properties visited were infested. Business Premises Scheme. 1,044 visits and revisits have been made to business premises in the area. 188 infestations were discovered and dealt with. Two operations to reduce rat infestation in Sewers were completed during the year, the first in March, and the second in November. In this work we have the co-operation of the Borough Engineer's Department and members of the Highways Section are actually engaged in the work of laying bait and poison in the sewers under the direction of the Chief Sanitary Inspector. This work is carried out in accordance with the Ministry of Agriculture and Fisheries Scheme, and grant aid was available on certain conditions with which we were able to comply. To assess the value of the operations it is necessary to refer to the first organized introduction of such measures embracing the whole of the Borough in October, 1946. It was then found that 30 per cent. of our sewers were infested. In March, 1947, 28 per cent. were still infested, and this was not a heartening result. The November operation, however, showed considerable improvement, only 14 per cent. being infested. The northern, north-eastern and north-western areas of the Borough are those mainly affected, the majority of the southern and central areas being, now, entirely free. Similar work will be carried on in 1948. The Rodent Operators brought to my notice, in August, 1947, reports of a very heavy infestation of the common brown rat in a residential area of the Borough. My subsequent visits to the area confirmed the alarming nature of the reports. During the course of my first visit, it is no exaggeration to say that numbers of rats were always visible, running to and from their nests, taking no notice at all of my colleagues and myself, and carrying on quite unconcernedly what I was to discover was their daily routine. The infestation appeared to centre in the extensive grounds of two houses, one occupied, the other a " blitzed " shell. The occupied house had a well-ordered, but heavily infested, garden, in the charge of a whole-time gardener. Chickens and geese were kept. The lay-out of the garden provided ample harbourage for rats. It included a rockery 12 yards wide rising to a height of 5 feet, literally 41. honeycombed with rat runs, the various plant growths providing ample cover. The derelict site beggars description. Here the neglected rockery, although not so wide, was built up to a height of 7 or 8 feet and was covered with weeds in some cases 6 feet high. It was a hive of industry so far as rats were concerned, and it undoubtedly housed scores. Further investigations showed that eleven other adjacent properties were infested, but, in all cases except one to a far lesser degree. The main infestation centred round the two houses already mentioned. The other infestations were off-shoots of a rapidly growing colony. The " blitzed " house presented a problem in ratproofing which must remain unanswered until war damage repair is complete. It was decided to commence a poisoning campaign on the 5th August, 1947, to embrace all the 13 properties affected. These properties, 12 of which were occupied, all had large grounds and some of the occupiers kept poultry and rabbits, etc. 180 prebait points were laid. Sausage rusk formed the prebait, about 3 ozs. to each point. Prebaiting was carried on for three days. On the third day of prebaiting 72 Full Takes, 62 Good Takes, 16 Small Takes and 30 No Takes were recorded. It was decided to lay 161 poison points and where prebait takes had been in close proximity to poultry runs, etc., Red Squill was used. This poison is harmless to domestic animals and poultry. At other points (which were the majority) Zinc Phosphide was used. Poison takes were as follows :— 7 Full Takes ; 92 Good Takes ; 32 Small Takes ; 38 No Takes. The number of bodies found was small, and obviously had no relation to the number of rats actually killed. Post bait was laid with the following resulting takes :— 0 Full Takes ; 18 Good Takes ; 28 Small Takes ; 87 No Takes. It was evident from these figures that we had reduced the infestation, but were still a long way from overcoming it. Incidentally, we had narrowed the concentration down to the original centre of infestation, namely, two houses. A second operation was commenced on the 25th August, 1947— bread mash was the prebait arsenic the poison. On the third day of prebaiting 79 points gave the following result:— 14 Full Takes ; 30 Good Takes; 24 Small Takes ; 11 No Takes. Poison points laid numbered 75 and produced this result:— 0 Full Takes; 31 Good Takes ; 24 Small Takes ; 20 No Takes. Post Bait Takes were as follows:— 2 Full Takes; 8 Good Takes; 15 Small Takes; 51 No Takes. The infestation was thus further reduced, but it was obvious that rats still remained, and the work could not be left. We had now used the three " routine " poisons, and it was decided to seek the Ministry's assistance to enable the use of " Antu " (Alpha-Naphthyl-Thio-Urea). This poison, known to be highly effective against the common rat, has only recently become available. It is recommended that treatments with the poison should be done 42 only in consultation with the Ministry of Agriculture and Fisheries. Arrangements were made and the operation commenced on 29th September, 1947. 66 Prebait points were selected, and eventually 30 poison points. The takes were as follows:— Prebait. First Day. Second Day. Third Day Full 15 15 14 Good6 6 6 Small9 9 9 No Takes 36 36 37 Poison. Full . 0 Good .. 8 Small 8 No Takes 14 Post Rait. Full 0 Good 0 Small 0 No Takes 30 We were now reasonably certain that the infestation was overcome. Sound bait was again laid three weeks after " Antu " poisoning, and only two very small takes noted. During the course of the operations much undergrowth was cut down and removed, and hundreds of burrows, closed. These burrows remained unopened. The following facts emerge from the investigation:— 1. The rapidity of the growth and the dense concentration of a rat colonv where there is provided ample harbourage, food and drink (baiting in 1946 on the same site produced evidence only of a very minor infestation). 2. The interesting off-shoots of a colony once it has become too large for its original habitat. 3. The regular habits of a colony, i.e., their greatest activity was found to be at the regular feeding times of the poultry, etc. 4. The existence of a surface infestation by the common brown or sewer rat, which apparently had no connection with infestation in the sewer. All the drainage of the " blitzed " property was properly sealed long before the infestation occurred. 1 he drainage of the adjacent properties was sound, and the sewers, which were baited in April, 1947, and again at the commencement of this operation, showed no comparable infestation. 5. The absolute need for skilled organized control in the hands of one team in cases of major infestations. No amount of indiscriminate baiting by householders could have overcome this infestation. 6. The absence of any attempt by rats to invade the houses, although in many instances opportunity was adequate. 7. The usefulness of the new poison " Antu," in finally disposing of a heavy infestation which has already called into use three " routine " poisons. 43 Food and Drugs Sampling. During 1947, 133 samples were purchased and submitted to the Public Analyst. Details are appended:— Formal Samples Informal Samples Milk 79 - Malt Vinegar 2 2 Zinc Ointment — - Liquorice Powder - 1 Glycerine - 1 Fig Syrup - 1 Cough Mixture — - Shredded Carrot Soup - 1 Banana Flavouring - 1 Jelly-making Gelatine - 1 Fish Paste — 7 Ground Ginger - 1 Aspirin - 1 Camphorated Oil - - Vita—Gravy - 1 Malted Milk Tablets - - Lemonade Powder - 1 Sphagetti in Sauce - 1 Macedoine - 1 Golden Raising Powder - 1 Pickled Gherkins - 1 Custard Powder - 1 Castor Oil - 1 Ice Cream - 3 Sausage Meat 9 - Liver Sausage 1 - Whalemeat Savouries 1 - Savoury Sausage 1 - Ham and Beef Press 1 — Cayenne Pepper - 1 Spice - 1 Black Pepper - 1 Ginger Wine - 1 94 39 One sample was found to be adulterated. This certification related to an informal sample of Heat Treated Milk, submitted for Heat Treatment Tests and found on chemical analysis to contain 8.35 per cent. solids—not—fat, instead of the prescribed 8.5 per cent. 3.7 per cent extraneous water was, therefore, presumed. It is not possible to consider legal proceedings on informal samples. A formal sample from the same dairyman, taken on the same day, was returned as genuine. There are, in the Borough, two milk pasteurising plants. Samples are submitted monthly for Heat Treatment and keeping quality tests, and failure to comply with the prescribed tests was occasional and in no case consistent. Such samples are actually taken on the request 44 of the Ministry of Food, Milk Division, and unsatisfactory results notified to them for appropriate action. Nevertheless, we too take up the matter of any failure with the Dairyman concerned and any apparent fault in the plant or recording instruments accounting for the failure is rectified. There were, at the commencement of 1947, four producers of specially designated milks in the Borough, three producing Tuberculin Tested milk and one Accredited. One of the producers of Tuberculin Tested milk discontinued business later in the year. As agents of the Kent County Council, we submit samples for bacteriological examination to the County Pathologist. The samples should comply with the tests outlined in the Milk (Special Designations) Order, 1936. 19 samples were submitted during the year, 14 satisfying the tests and 5 failing. The County Council, being the Licencing Authority for the product of Tuberculin Tested and Accredited Milk, take whatever action is considered necessary on the submission of an unsatisfactory sample. It should be explained that the tests are not concerned with the chemical analysis of the milk, e.g., for fat and solids—not—fat content, but with bacteriological examination, which gives an indication as to whether or not the milk is produced in clean conditions, free from sources of contamination. Food Unfit for Human Consumption. It was not necessary, during the year, to implement the provisions of the Food and Drugs Acts, 1938, regarding seizure of unsound food. Many tons of food, mainly of the tinned variety, were, however, surrendered by provision merchants, and, being unfit for human consumption, were destroyed. Unsound Food Complaints. There are brought to our notice, fortunately only on infrequent occasions, instances of alleged contaminated foods. A full investigation is made in each case, although it is not always possible to confirm the complaint, or to decide that the food alleged to cause the illness was in fact responsible. For instance, it was alleged that the eating of jam tarts purchased from a bakery caused sickness in two children. No remains of the actual tarts consumed were available. Investigations showed that the bakery made 200 daily, using the usual ingredients, i.e., flour, fat, sugar and jam. All had been sold and no other complaint had been received. It was quite impossible to build any case to substantiate the allegation. Often the complaints are a great help to us in our work, enabling us to put a finger on wrong or careless practices in food processing. A resident produced a bottle of milk for our inspection. On the inside of the bottle was a brown stain. It proved to be " old cream line " which the process of cleansing failed to remove and which had been charred. The milk was bottled outside Beckenham, but we were able to trace the farm concerned and the Sanitary Inspector of that District was informed, and enabled to require the farmer to overhaul his cleansing apparatus. 45 An interesting item was cheese which the purchaser thought was contaminated with mice excreta. It was, however, a Continental cheese, flavoured with dill seeds. The Ministry of Food agreed, after representation had been made, to withdraw any supplies which a vendor could not sell and to allow a vendor to change such cheese, already sold, for a cheese more commonly acceptable in this country. Cheese of poor odour was submitted as unfit. It was, however, certified as genuine by the Public Analyst. There were a few other instances of milk bottles with dirt and foreign bodies inside. We do not condone these instances of lack of care on the part of milk suppliers, but nevertheless, full appreciation is given to the fact that millions of bottles are filled each year for delivery in Beckenham, and the very few instances of a dirty bottle getting through is remarkable. Bottle washing in these days is usually done by automatic process, and a " watcher " is employed to view the bottles passing on the conveyor belt from the washing machine to the milk fillers. Anybody who has seen this process should appreciate the terrific strain imposed by the work. It would be remarkable indeed if isolated instances of failure were not met. It is, of course, an offence against Statute and prosecution could follow. If the failure was constant, such legal action would be recommended, but, where the instances are isolated, the institution of proceedings would perhaps be considered persecution rather than prosecution. The problem of the failure of the human element in milk bottle washing and filling is a great concern of the dairy industry, who have already spent large sums of money in endeavouring to perfect an automatic device for rejecting imperfectly washed bottles whilst travelling on the conveyor between the washing and the filling machines. It is understood that the work has progressed so far as to give reasonable hope that ultimate success will be achieved, but it will take a considerable time before it reaches commercial usage. A complaint of two flies in a pint bottle of milk was investigated. It was stated that the milk was delivered in this condition. The specimens were found, on examination, to be a " blow fly " and a "house fly." The flies were, however, entire, and were floating free in the liquid. This condition appeared to cast a doubt on the matter, for it is reasonable to assume that the high-pressure jets used in washing and filling would have mutilated the flies. The complainant was seen by a representative of the dairy and satisfied in the matter. Meat Inspection—Slaughtering. On only six occasions were animals slaughtered and dressed for food. The carcases and offals of three pigs and three calves were passed as fit for human consumption. 46 Factories Act, 1937. 95 visits of inspection were made to Factories in the area. The following nuisances discovered were remedied following the service of informal notices:— Unreasonable temperature 1 Insufficient sanitary accommodation 3 Unsuitable and defective sanitary accommodation 17 Miscellaneous offences 2 Shops Acts. 116 visits were paid in connection with the Shops Acts. 16 contraventions discovered were remedied following the service of Intimation Notices. Water Supply. The water supply of the area has been satisfactory in quality and quantity, all properties being supplied by the mains of the Metropolitan Water Board. Bacteriological examination of the supply has been regular. 36 samples have been taken during the year and reported as satisfactory by the County Pathologist. An encampment of caravan dwellers obtain their water supply from a stand pipe taken direct from the Metropolitan Water Board mains. The Ice Cream (Heat Treatment) Regulations, 1947. These regulations, which, with certain limitations, came into force on the 1st May, 1947, if they do not do all that Public Health Officers desired, do form an important legislative step in food hygiene. The Regulations, broadly speaking, require that, subject to certain qualifications, the ingredients of ice cream shall be Heat Treated after being mixed, and that the mixture shall then be cooled until the freezing process is begun. After freezing, the ice cream must not be sold unless it has been kept at a temperature of not more than 28 degrees Fahrenheit. If its temperature has risen above 28 degrees Fahrenheit it has again to be heat treated. The Regulations must be operated by, and to the satisfaction of, Local Authorities and there is a general requirement that ice cream, during its manufacture, storage and distribution shall at all times be protected from contamination, and also that all apparatus and utensils brought into contact with it shall be cleansed immediately after use and kept clean at all times. In Beckenham the number of Manufacturers is small, but there ate a large number of vendors, and so we are mainly concerned with the storage and distribution of ice cream. This is, of course, not the first step ever taken to control the Ice Cream Trade. Local Authorities have for many years had authority to register certain premises for such purposes. This power is given in the Food and Drugs Act, 1938, but does not apply to premises used primarily as a Club, Hotel, Inn, or Restaurant, or to theatres, cinematograph theatres, so far as sale and storage is concerned. It is 47 only those premises where ice cream is manufactured, stored, or sold for consumption off the premises that are registered. Registration in Beckenham is governed by Section 61 of the Beckenham Urban District Council Act, 1935, which has comparable powers to the Food and Drugs Act, with certain useful additions. The sale of unwrapped ice cream in the streets of Beckenham is receiving the attention of your Officers. For many reasons this is an undesirable method of sale. There is evidence (obtained outside Beckenham) that loose ice cream shows a very serious increase in bacteria counts of samples taken from the same batch at the beginning and end of the service, and it does seem somewhat futile that so much regulation should govern manufacture and storage, when the " loose " sale in the streets, which exposes the commodity to all types of contamination, is allowed to continue. It is not possible, at the present time, legally to prohibit the practice in Beckenham, but attention is drawn to the powers given to a Local Authority to make by-laws under Section 15 of the Food & Drugs Act, 1938, for securing the observance of sanitary and cleanly conditions and practices in connection with the handling, wrapping and delivering of food sold or intended for sale for human consumption. We are satisfied, so far, with the conditions of manufacture of loose ice cream, sold in Beckenham, and that generally the manner of sale is such that the prevalence of conditions liable to give rise to contamination are minimised, but it is intended to conduct a fairly large scale investigation into this matter by frequent sampling, and depending upon the results obtained, to make definite representations to the Council in the matter. The Heat Treatment Regulations do nothing other than control the conditions of preparation, etc. The Ministry of Food, although pressed by Local Authority and Health Officers' Associations, have so far not set any standard for the product. Ice Cream, in law, " includes water ices and any article, under whatever description it is sold, which is so similar to ice cream as to constitute a substitute therefore " and, another definition, " Ice Cream includes any similar commodity." How different from America where " Ice Cream is a frozen product made from cream and sugar with or without a natural flavouring and containing not less than 14 per cent. of milk fat " ! During the course of a special investigation carrried out by the Chief Sanitary Inspector of Blackpool in 1945, it was found that 29 per cent. of samples taken contained less than 1 per cent. of fat, and 50 per cent. less than 2 per cent. the Ministry's present decision is, of course, based on the regrettable absence of proper ingredients for allocation to all Manufacturers. I should again like to express my appreciation to the Medical Officer of Health who has, by his general direction of the work of Sanitary Inspectors, offered the greatest encouragement to myself and my colleagues, who have, in turn, given me every support in my duties as the Council's Chief Sanitary Inspector. Roffey Clark, Ltd., High Street, Croydon